Citation Nr: 21030860 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 15-26 490 DATE: May 19, 2021 ORDER Entitlement to service connection for a right shoulder disability is denied. Entitlement to service connection for a left shoulder disability is denied. Entitlement to service connection for a left knee disability is denied. Entitlement to service connection for a left foot disability is denied. FINDINGS OF FACT 1. The most probative evidence of record establishes that the appellant does not have a current right shoulder disability which is causally related to a disease or injury during a period of active duty for training (ACDUTRA), or an injury during a period of inactive duty training (INACDUTRA). 2. The most probative evidence of record establishes that the appellant does not have a current left shoulder disability which is causally related to a disease or injury during a period of ACDUTRA, or an injury during a period of INACDUTRA. 3. The most probative evidence of record establishes that the appellant does not have a current left knee disability which is causally related to a disease or injury during a period of ACDUTRA, or an injury during a period of INACDUTRA. 4. The most probative evidence of record establishes that the appellant does not have a current left foot disability which is causally related to a disease or injury during a period of ACDUTRA, or an injury during a period of INACDUTRA. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 101, 1110, 1131; 38 C.F.R. §§ 3.6, 3.303. 2. The criteria for entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 101, 1110, 1131; 38 C.F.R. §§ 3.6, 3.303. 3. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. §§ 101, 1110, 1131; 38 C.F.R. §§ 3.6, 3.303. 4. The criteria for entitlement to service connection for a left foot disability have not been met. 38 U.S.C. §§ 101, 1110, 1131; 38 C.F.R. §§ 3.6, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant was a member of the Army National Guard from August 1975 to March 2012. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas, which, inter alia, denied service connection for bilateral shoulder, left knee, and left foot disabilities. In an April 2019 Board decision, the Board, inter alia, denied service connection for bilateral shoulder, left knee, and left foot disabilities. The appellant appealed the April 2019 Board decision to the United States Court of Appeals for Veterans Claims (Court). While the matter was pending before the Court, the appellant and VA's General Counsel filed a joint motion for partial remand. In April 2020, the Court granted the parties' motion, vacated the portions of the April 2019 Board decision that denied entitlement to service connection for bilateral shoulder, left knee, and left foot disabilities and remanded the matter for actions consistent with the joint motion for partial remand. In July 2020, the Board remanded the claims for further evidentiary development, to include VA examinations, pursuant to the Joint Motion. Service Connection Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The term active military, naval, or air service means active duty, any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty. 38 U.S.C. § 101(24); Biggins v. Derwinski, 1 Vet. App. 474, 477 78 (1991). Certain evidentiary presumptions such as the presumption of sound condition at entrance to service, the presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service, and the presumption of service incurrence for certain diseases, including arthritis, which manifest themselves to a degree of 10 percent or more within a specified time after separation from service are provided by law to assist veterans in establishing service connection for a disability or disabilities. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.304(b), 3.306, 3.307, 3.309. However, the advantages of these evidentiary presumptions do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA. Paulson v. Brown, 7 Vet. App. 466, 470 471 (1995) (noting that the Board did not err in not applying presumptions of sound condition and aggravation to appellant's claim where he served only on ACDUTRA and had not established any service-connected disabilities from that period); McManaway v. West, 13 Vet. App. 60, 67 (1999). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to service connection for a right shoulder disability is denied. 2. Entitlement to service connection for a left shoulder disability is denied. The appellant contends that her shoulder disabilities were incurred in, caused by, or aggravated by her service. She contended in her July 2015 substantive appeal that during her military service, over time, her body sustained injuries due to physical training. She emphasized that her physical condition declined due to physical training that she undertook in order to maintain Army standards for the Army physical training test, and specified that she sustained rotator cuff damage from training for and performing pushups. She also contended that her conditions were severely aggravated by participation in Army Physical Fitness Training. In August 2002, the appellant was seen for an evaluation involving a problem with her right shoulder. She was diagnosed with right rotator cuff tendinitis. In December 2002, she was placed on a permanent physical profile for right shoulder tendinitis. In a January 2006 Report of Medical History, she reported having a painful shoulder, arthritis, and swollen or painful joints. The appellant, inter alia, specifically reported right rotator cuff tendinitis or impingement. In December 2007, she was seen for complaints of left shoulder pain for approximately 3 to 4 months. She was diagnosed with rotator cuff tendinitis/impingement in the left shoulder. In May 2008, she was placed on a permanent physical profile for left shoulder impingement and rotator cuff tendinitis and right shoulder rotator cuff repair. In an August 2020 private medical opinion, Dr. M.H. noted diagnoses of bilateral shoulder impingement with early left shoulder adhesive capsulitis, bilateral AC osteoarthropathy, and bilateral long head bicipital tendinitis. The physician opined in pertinent part, It is my opinion that the above orthopedic issues, more likely than not, were caused by or aggravated by [the appellant's] military physical training, especially running and pushups, the latter given her symptoms and shoulder anatomy, and usual mechanisms for injuries such as hers. See August 2020 Report of Medical Examination from Dr. M.H. A VA medical opinion was obtained in September 2020. After review of the claims file, the examiner determined that the appellant's right and left shoulder disabilities were at least as likely as not incurred in service as "noted in STR [service treatment record] dated 8/1/2002 [and] 12/17/2007." The examiner's rationale was as follows: "Right rotator cuff tendinitis, 8/2002. S/p right shoulder rotator cuff repair. Left rotator cuff tendinitis and impingement, 12/2007." The examiner also determined that the appellant's shoulder disabilities were aggravated beyond natural progression. The examiner opined, While enlistment exam dated 01/16/1981 and periodic medical exams that followed in 01/18/1984, 04/15/1989 and 01/01/1995 were silent for shoulder condition, "permanent restrictions" to running, pushups and limited to lifting 30 lbs was issued by Dr. G. of Kansas Ortho and Sports Medicine during assessment 8/19/2002 and then again in 2/19/2008. Review of recent consult with Dr. M.H. in 8/5/2020 documented "bilateral shoulder impingement with early left shoulder adhesive capsulitis, bilateral AC osteoarthropathy[,] bilateral and long head bicipital tendinitis. An additional VA medical opinion was obtained in February 2021. After review of the claims file, the examiner rendered a negative etiological opinion regarding the appellant's right and left shoulders. The examiner opined in pertinent part, Condition not caused by service or SC condition. Condition not caused by "the heavy physical training in the Army National Guard." While the Veteran is credible to report symptomatology, [s]he is not qualified to make medical diagnosis or to discuss medical nexus, nor aggravation for that matter. As per medical literature this is as likely age related: "Repetitive overhead activity, whether in sport or work, is a major risk factor for rotator cuff tendinopathy. Other risk factors include anatomic variants that predispose to rotator cuff impingement, scapular instability or dyskinesis, and older age." There is no objective evidence to support that condition was aggravated in any measurable way, beyond its natural progression by veteran['s] military service. Placement on light duty is not evidence that condition [w]as being aggravated but a measure to prevent further injuries. Examiner opinion on ACE C&P examination dated 24 Sept 2020, although full in advocacy was devoid of scientific data. After a review of the evidence, the Board finds that service connection is not warranted for right and left shoulder disabilities. With regard to the first element of a service connection claim, the evidence shows that the appellant has right and left shoulder disabilities. As noted above, the appellant has been diagnosed with bilateral shoulder impingement with early left shoulder adhesive capsulitis, bilateral AC osteoarthropathy, and bilateral long head bicipital tendinitis. See August 2020 Report of Medical Examination from Dr. M.H. In addressing the second element, the Board finds that although the appellant reported shoulder disabilities during the course of her membership in the Army National Guard, there is no indication that the appellant was disabled from a disease or injury incurred or aggravated in the line of duty while on ACDUTRA or an injury during a period of INACDUTRA. The Board finds it significant that the appellant never reported injuring her bilateral shoulders in the line of duty. There are no STRs from her periods of ACDUTRA or INACDUTRA showing complaints, treatment, or diagnosis for a bilateral shoulder disability. Instead, the appellant asserts that as a result of keeping herself physically fit, she developed the disabilities on appeal. Thus, there is no indication, including a line of duty determination, that any bilateral shoulder injury was incurred during a period of ACDUTRA or INACDUTRA. Even assuming arguendo that the appellant sustained a shoulder injury during a period of ACDUTRA or INACDUTRA, the claims nonetheless fail for lack of nexus. With respect to the third element, the nexus requirement, the Board finds that the preponderance of the evidence is against a finding that the appellant's right and left shoulder disabilities are causally related to or aggravated by a period of ACDUTRA or INACDUTRA. The Board assigns great probative weight to the February 2021 VA medical opinion, as the examiner reviewed the appellant's claims file in its entirety, including the appellant's reports about the nature of her military activities and the symptoms she developed. After considering the record, the examiner concluded that the appellant's right and left shoulder disabilities were not causally related to or aggravated by service, to include physical training in the Army National Guard. The examiner provided a reasoned conclusion and clear rationale to support his determination that the appellant's right and left shoulder disabilities were not causally related to a period of ACDUTRA or INACDUTRA, explaining that the nature of the current pathology was consistent with aging and not an in-service injury. He also explained that the appellant's right and left shoulder disabilities were not aggravated beyond their natural progression, as placement on light duty was not evidence that the appellant's shoulder disabilities had been aggravated but rather a measure to prevent further injuries. The Board assigns less probative weight to the August 2020 private opinion from Dr. M.H., as it is conclusory in nature and does not appear to have had the benefit of a review of the clinical evidence of record. The Board also assigns less probative weight to the September 2020 VA medical opinion, as the examiner's opinion was based on an inaccurate factual premise, namely that the appellant's shoulder injuries were identified during a period of active service. In addition, the Board assigns less probative weight to the appellant's statements indicating that her shoulder disabilities were caused or aggravated by her physical training. Although the appellant is competent to describe symptoms, she is not competent to determine the cause of her symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have had medical training or skills. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Questions of competency notwithstanding, the Board assigns more probative weight to the findings of the February 2021 VA examiner, given his clinical expertise and the rationale he provided. In reaching this decision, the Board has considered the fact that the appellant has been diagnosed as having bilateral AC osteoarthropathy, an enumerated disease under 38 C.F.R. § 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). However, as noted above, this evidentiary presumption does not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA, and therefore does not apply in this case. The appellant has not established Veteran status for any period of ACDUTRA or INACDUTRA. Based on the foregoing, as the probative evidence is against the appellant's claims of service connection for right and left shoulder disabilities, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the appellant's claims for right and left shoulder disabilities are denied. 3. Entitlement to service connection for a left knee disability is denied. The appellant contends that her left knee disability was incurred in, caused by, or aggravated by her service. She contended in her July 2015 substantive appeal that during her military service, over time, her body sustained injuries due to physical training. She emphasized that her physical condition declined due to physical training that she undertook in order to maintain Army standards for the Army physical training test, and specified that her knees sustained damage from training and from performing two-mile runs. She also contended that her condition was severely aggravated by participation in Army Physical Fitness Training. In August 2002, the appellant was seen for an evaluation involving a problem with her left knee. She described a long history of exertional and post-exertional pain and swelling in her bilateral knees, left knee more so than her right. She also denied any specific precipitating causes. She was diagnosed with bilateral knee chondromalacia with early degenerative disease. In December 2002, she was placed on a permanent physical profile for left knee chondromalacia. In a January 2006 Report of Medical History, she reported having arthritis, swollen or painful joints, and knee trouble. The appellant, inter alia, specifically reported early degenerative disease in both knees. In May 2008, she was placed on a permanent physical profile for bilateral knee chondromalacia patella. In an August 2020 private medical opinion, Dr. M.H., inter alia, noted diagnoses of bilateral patellofemoral knee pain, associated chondromalacia patella, bilateral mild anseri[ne] bursitis, by old reports osteoarthritis bilaterally with medial compartment most severely involved, and mild, bilateral iliotibial band syndrome or "runner's knee." The physician opined in pertinent part, It is my opinion that the above orthopedic issues, more likely than not, were caused by or aggravated by [the appellant's] military physical training, especially running and pushups . . . given . . . usual mechanisms for injuries such as hers. See August 2020 Report of Medical Examination from Dr. M.H. A VA medical opinion was obtained in September 2020. After review of the claims file, the examiner determined that the appellant's left knee disability was at least as likely as not incurred in service as "noted in STR dated 8/2002." The examiner's rationale was as follows: "Chondromalacia with early DJD, bilateral knees, 2002 (claimed left knee). Bilateral knee DJD, 12/30/2019." The examiner also determined that the appellant's left knee disability was aggravated beyond natural progression. The examiner opined, While enlistment exam dated 01/16/1981 and periodic medical exams that followed in 01/18/1984, 04/15/1989 and 01/01/1995 were silent for knee condition, "permanent restrictions" to running, pushups and limited to lifting 30 lbs was issued by Dr. [G.] of Kansas Ortho and Sports Medicine during assessment 8/19/2002 and then again in 2/19/2008. Review of recent consult with Dr. [M.H.] in 8/5/2020 documented "bilateral patellofemoral knee pain associated with chondromalacia patella, right knee baker's cyst, bilateral mild anserinal [sic] bursitis, by old report bilateral knee osteoarthritis with medial compartment most severely involved and bilateral iliotibial band or runners knee." An additional VA medical opinion was obtained in February 2021. After review of the claims file, the examiner rendered a negative etiological opinion regarding the appellant's left knee. The examiner opined in pertinent part, Condition not caused by service or SC condition. Condition not caused by "the heavy physical training in the [N]ational Guard" such a causative nexus cannot be supported by current peer review medical literature (see article above). While the Veteran is credible to report symptomatology, [s]he is not qualified to make medical diagnosis or to discuss medical nexus, nor aggravation for that matter. There is no objective evidence to support that condition was aggravated in any measurable way, beyond its natural progression by veteran['s] military service. Placement on light duty is not evidence that condition [w]as being aggravated but a measure to prevent further injuries. Examiner opinion on ACE C&P examination dated 24 Sept 2020, although full in advocacy was devoid of scientific data. Left knee x rays dated 12/30/2019 shows only changes that are essentially consistent with natural aging, no chondromalacia is documented. After a review of the evidence, the Board finds that service connection is not warranted for a left knee disability. With regard to the first element of a service connection claim, the evidence shows that the appellant has a current left knee disability. As noted above, the appellant has been diagnosed with bilateral patellofemoral knee pain, associated chondromalacia patella, bilateral mild anseri[ne] bursitis, by old reports osteoarthritis bilaterally with medial compartment most severely involved, and mild, bilateral iliotibial band syndrome or "runner's knee." See August 2020 Report of Medical Examination from Dr. M.H. In addressing the second element, the Board finds that although the appellant reported a left knee disability during the course of her membership in the Army National Guard, there is no indication that she was disabled from a disease or injury incurred or aggravated in the line of duty while on ACDUTRA or an injury during a period of INACDUTRA. The Board finds it significant that the appellant never reported injuring her left knee in the line of duty. There are no STRs from her periods of ACDUTRA or INACDUTRA showing complaints, treatment, or diagnosis for a left knee injury or disability. Instead, the appellant asserts that as a result of keeping herself physically fit, she developed the disability on appeal. Even assuming arguendo that the appellant sustained a left knee injury during a period of ACDUTRA or INACDUTRA in the form of trauma while performing physical training, the claim nonetheless fails for lack of nexus. With respect to the third element, the nexus requirement, the Board finds that the probative evidence is against a finding that the appellant's left knee disability is causally related to or aggravated by a period of ACDUTRA or INACDUTRA. The Board assigns great probative weight to the February 2021 VA medical opinion, as the examiner reviewed the appellant's claims file in its entirety, including the appellant's reports about the nature of her military physical training and symptoms. After considering the record, the examiner concluded that the appellant's left knee disability was not causally related to or aggravated by service, to include physical training in the Army National Guard. The examiner provided a reasoned conclusion and clear rationale to support his determination that the appellant's left knee disability was not causally related to a period of ACDUTRA or INACDUTRA, explaining that the nature of the current pathology was consistent with aging and not an in-service injury. He also explained that the appellant's left knee disability was not aggravated beyond its natural progression, as placement on light duty was not evidence that the appellant's left knee disability had been aggravated but rather a measure to prevent further injuries. The Board assigns less probative weight to the August 2020 private opinion from Dr. M.H., as it is more conclusory in nature and does not appear that he had the benefit of reviewing the clinical evidence of record in providing the opinion. The Board also assigns less probative weight to the September 2020 VA medical opinion, as the examiner's opinion was based on an inaccurate factual premise, namely that the appellant's left knee injury was incurred in and aggravated by a period of active service. In addition, the Board assigns less probative weight to the appellant's statements indicating that her left knee disability was caused or aggravated by her physical training. Although the appellant is competent to describe symptoms, she is not competent to determine the cause of her symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have had medical training or skills. See Jandreau, 492 F.3d at 1376-77. Questions of competency notwithstanding, the Board assigns more probative weight to the findings of the February 2021 VA examiner, given his clinical expertise and the rationale he provided. In reaching this decision, the Board has considered the fact that the appellant has been diagnosed as having osteoarthritis, an enumerated disease under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, as noted above, this evidentiary presumption does not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA, and therefore does not apply in this case. The appellant has not established Veteran status for any period of ACDUTRA or INACDUTRA. Based on the foregoing, as the probative evidence is against the appellant's claim of service connection for a left knee disability, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the appellant's claim for a left knee disability is denied. 4. Entitlement to service connection for a left foot disability is denied. The appellant contends that her left foot disability was incurred in, caused by, or aggravated by her service. She contended in her July 2015 substantive appeal that during her military service, over time, her body sustained injuries due to physical training. She emphasized that her physical condition declined due to physical training that she undertook in order to maintain Army standards for the Army physical training test. She also contended that her condition was severely aggravated by participation in Army Physical Fitness Training. In August 2002, the appellant was seen for an evaluation involving a problem with her left foot. She was diagnosed with left foot accessory navicular with some early posterior tibial tendinitis. In a January 2006 Report of Medical History, the appellant, inter alia, reported having arthritis and swollen or painful joints, and she specifically reported left foot accessory navicular with some early posterior tibial tendinitis. In an August 2020 private medical opinion, Dr. M.H., inter alia, noted diagnoses of probable left Morton's neuroma, osteoarthritis in the bilateral feet, left tibialis posterior tenosynovitis, right greater than left mildly symptomatic hallux valgus, and mild pes planus with mild hyperpronation. The physician opined in pertinent part, It is my opinion that the above orthopedic issues, more likely than not, were caused by or aggravated by [the appellant's] military physical training, especially running and pushups... given... usual mechanisms for injuries such as hers. See August 2020 Report of Medical Examination from Dr. M.H. A VA medical opinion was obtained in September 2020. After review of the claims file, the examiner determined that the appellant's left foot disability was at least as likely as not incurred in service as "noted in STR dated 8/1/2002." The examiner's rationale was as follows: "Accessory navicular with early posterior tibial tendinitis, left foot, 8/2002." The examiner also determined that the appellant's left foot disability was aggravated beyond natural progression. The examiner opined, While enlistment exam dated 01/16/1981 [and] periodic exams that followed in 01/18/1984, 04/15/1989 and 01/01/1995 were silent for foot condition, "permanent restrictions" to running, pushups and limited to lifting 30 lbs was issued by Dr. [G.] of Kansas Ortho and Sports Medicine during assessment in 2/19/2008. Review of recent consult with Dr. [M.H.] in 8/5/2020 documented "probable left Morton's neuroma, osteoarthritis generalized bilateral feet, left tibialis posterior tenosynovitis right greater than left, mildly symptomatic hallux valgus, mild pes planus with mild hyperpronation and bilateral foot x-ray showing "hallux valgus metatarsus primus varus and bunion formation bilaterally greater in the right foot." An additional medical opinion was obtained in February 2021. After review of the claims file, the examiner rendered a negative etiological opinion regarding the appellant's left foot. The examiner opined in pertinent part, Veteran's accessory navicular with early posterior tibial tendonitis is less likely than not the result of physical training in the Army National Guard. Dr. [V.] statement on C&P examination dated Sept 2020, although full of advocacy, is not based on scientific grounds. Identification of a condition does not equate to caused by. As per medical literature: "An accessory navicular bone is an extra bone or piece of cartilage located in the middle of the foot near the navicular bone, the bone that goes across the foot near the instep. It is present from birth (congenital) and is a common trait." Therefore a developmental condition cannot be caused by exercise performed later on in life. Regarding whether the appellant's left foot disability was aggravated beyond normal progression, the examiner opined in pertinent part, Veteran['s] condition is less likely than not aggravated by National Guard exercises. There is no objective evidence to support that veteran['s] condition was aggravated in any measurable way by veteran['s] physical activity while in the National Guard. Once more, Dr. [V.] statement on C&P examination dated Sept 2020, although full of advocacy, is not based on scientific grounds. X rays from 2020 demonstrate no traumatic osteoarthritis, in fact, the x ray does not even mention the accessory navicular bone as a prominent feature (after all this is a normal variant). As stated on ACE C&P examination dated 01 Feb 2021: "There is some evidence to suggest that higher-paced activities and higher exposure to vigorous exercise may increase the risk of OA [osteoarthritis]. A meta-anaylsis found an increased risk of OA with both elite and non-elite sport participation, although the quality of evidence was rated as very low. When limiting the data to elite athletes, there was also an increased risk of OA after sport exposure in elite sports people compared with a control group. However, when sensitivity analysis was performed in which only cohort studies were included, this association was no longer significant. The risk was higher in soccer and greater among elite soccer players, but lower and not significant in runners. After a review of the evidence, the Board finds that service connection is not warranted for a left foot disability. As a preliminary matter, as noted above, the presumption of sound condition at entrance to service and the presumption of aggravation during service of preexisting diseases or injuries which undergo an increase in severity during service do not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA, and therefore do not apply in this case as the appellant has not achieved Veteran status. With regard to the first element of a service connection claim, the evidence shows that the appellant has a current left foot disability. As noted above, the appellant has been diagnosed with left foot accessory navicular with some early posterior tibial tendinitis, probable left Morton's neuroma, osteoarthritis in the bilateral feet, left tibialis posterior tenosynovitis, right greater than left mildly symptomatic hallux valgus, and mild pes planus with mild hyperpronation. See August 2020 Report of Medical Examination from Dr. M.H. In addressing the second element, the Board finds that there is no indication that the appellant was disabled from a disease or injury incurred or aggravated in the line of duty while on ACDUTRA or an injury during a period of INACDUTRA. The Board finds it significant that the appellant never reported injuring her left foot in the line of duty. There are no STRs corresponding to her periods of ACDUTRA or INACDUTRA showing complaints, treatment, or diagnosis for a left foot disability. Instead, the appellant asserts that as a result of keeping herself physically fit, she developed the disability on appeal. Thus, there is no indication, including a line of duty determination, that any left foot injury or disease was incurred during a period of ACDUTRA or INACDUTRA. Even assuming arguendo that the appellant sustained a left foot injury during a period of ACDUTRA or INACDUTRA, the claim nonetheless fails for lack of nexus. With respect to the third element, the nexus requirement, the Board finds that the probative evidence is against a finding that the appellant's left foot disability is causally related to or aggravated by a period of ACDUTRA or INACDUTRA. The Board assigns great probative weight to the February 2021 VA medical opinion, as the examiner reviewed the appellant's claims file in its entirety. After considering the record, including the appellant's reports about her military activities and symptoms, the examiner concluded that the appellant's left foot disability was not causally related to or aggravated by service, to include physical training in the Army National Guard. The examiner provided a reasoned conclusion and clear rationale to support his determination that the appellant's left foot disability was not causally related to a period of ACDUTRA or INACDUTRA. He also explained that the appellant's left foot disability was not aggravated beyond its natural progression, as X-rays from 2020 did not demonstrate traumatic osteoarthritis. The Board assigns less probative weight to the August 2020 private opinion from Dr. M.H., as it is more conclusory in nature and he does not appear to have had the benefit of reviewing the clinical evidence of record in providing the opinion. The Board also assigns less probative weight to the September 2020 VA medical opinion, as the examiner's opinion was based on an inaccurate factual premise, namely that the appellant's left foot disability was incurred in and aggravated during a period of active service. In addition, the Board assigns less probative weight to the appellant's statements indicating that her left foot disability was caused or aggravated by her physical training. Although the appellant is competent to describe symptoms, she is not competent to determine the cause of her symptoms because it would involve medical inquiry into biological processes, anatomical relationships, and physiological functioning. Such internal physical processes are not readily observable and are not within the competence of the appellant in this case, who has not been shown by the evidence of record to have had medical training or skills. See Jandreau, 492 F.3d at 1376-77. Questions of competency notwithstanding, the Board assigns more probative weight to the findings of the February 2021 VA examiner, given his clinical expertise and the rationale he provided. In reaching this decision, the Board has considered the fact that the appellant has been diagnosed as having osteoarthritis, an enumerated disease under 38 C.F.R. § 3.309(a); Walker, 708 F.3d 1331. However, as noted above, this evidentiary presumption does not extend to those who claim service connection based on a period of ACDUTRA or INACDUTRA, and therefore does not apply in this case. Based on the foregoing, as the probative evidence is against the appellant's claim of service connection for a left foot disability, the benefit-of the-doubt rule is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102. Accordingly, the Board finds that the elements of service connection are not met, and the appellant's claim for a left foot disability is denied. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Ruddy, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.