Citation Nr: 21039963 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 15-45 055 DATE: July 1, 2021 ORDER Entitlement to service connection for obstructive sleep apnea (OSA), claimed as secondary to service connected psychiatric disabilities, is denied. Entitlement to service connection for gastroesophageal reflux disease (GERD), claimed as secondary to service connected psychiatric disabilities, is denied. Entitlement to service connection for hypertension, claimed as secondary to service connected psychiatric disabilities, is denied. Entitlement to service connection for erectile dysfunction (ED), claimed as secondary to service connected psychiatric disabilities, is granted. Entitlement to service connection for bone spurs of the right heel, claimed as bone spurs of the right ankle, is denied. Entitlement to service connection for bone spurs of the left heel, claimed as bone spurs of the left ankle, is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that diagnosed OSA is due to a disease or injury incurred in-service, or is caused or aggravated by service-connected psychiatric disorders. 2. The preponderance of the evidence of record is against finding that that diagnosed GERD is due to a disease or injury incurred in-service, or is caused or aggravated by service-connected psychiatric disorders. 3. The preponderance of the evidence of record is against finding that that diagnosed hypertension is due to a disease or injury incurred in service or within one year of service, or is caused or aggravated by service-connected psychiatric disorders. 4. Resolving doubt in the Veteran's favor, it as likely as not that ED is due to and a result of his service connected alcohol use disorder. 5. The preponderance of the evidence of record is against finding that bone spurs of the right heel were incurred during service or are otherwise related to disease, injury or event during service. 6. The preponderance of the evidence of record is against finding that bone spurs of the left heel were incurred during service or are otherwise related to disease, injury or event during service. CONCLUSIONS OF LAW 1. The criteria for service connection for OSA, claimed as secondary to service connected psychiatric disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for GERD, claimed as secondary to service connected psychiatric disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 3. The criteria for service connection for hypertension, claimed as secondary to service connected psychiatric disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 4. The criteria for service connection for ED have been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310. 5. The criteria for service connection for bone spurs of the right heel, claimed as bone spurs of the right ankle, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 6. The criteria for service connection for bone spurs of the left heel, claimed as bone spurs of the left ankle, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from March 1975 to July 1977. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision in June 2016 of a Department of Veterans Affairs (VA) Regional Office (RO). An August 2018 Board decision denied service connection for psoriasis, which was upheld by the United States Court of Veterans Claims (Court) in December 2019. That Board decision also remanded the claims addressed herein, as well as service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depression, and service connection for varicose veins of the right and left lower extremities. Thereafter, an October 2020 rating decision granted service connection for left lower extremity varicose veins and a December 2020 rating decision granted service connection for right lower extremity varicose veins. Also, a February 2021 rating decision granted service connection for PTSD, major depressive disorder, generalized anxiety disorder, and alcohol use disorder. Accordingly, these matters are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). A March 2021 rating decision found that service connection for frostbite of feet remained denied because the evidence submitted was not new and relevant. On March 26, 2021, VA Form 20-0996, Review Request: Higher Level of Review, was filed as to the March 2021 rating decision, which described the claim as one for a "Bilateral foot condition." In an attachment the Veteran's attorney stated that the Veteran desired to have his claim as to his feet broadly construed because at service separation he was noted to have mild pes planus, and he now has a diagnosis of tarsal tunnel syndrome and the latter diagnosis was sufficient to reopen the claim. In any event, the RO is in the process of conducting further development. Additionally, in the attachment the Veteran's attorney referenced to a "TDIU" rating [even though an April 5, 2021 VA outpatient treatment (VAOPT) record shows that he was "working the swing shift"]. However, no VA Form 21-8940, Application for Increased Compensation Based on Unemployability has been filed. This matter is drawn to the attention of the RO. Lastly, the Veteran claimed service connection for bone spurs of each ankle. However, the evidence shows that he actually has had bone spurs of the heels, and not the ankles. Thus, these claims have been recharacterized. Service Connection Compensation may be awarded for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131. Service connection basically means that the facts, shown by evidence, establish that an injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in- service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). However, not every manifestation of joint pain during service will permit service connection for arthritis first shown as a clear-cut clinical entity at some later date. 38 C.F.R. § 3.303(b). Certain chronic diseases, such as hypertension and arthritis, will be presumed related to service, absent an intercurrent cause, if shown as chronic in service; or, if manifested to a compensable degree within a presumptive period following separation from service; or, if noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection will be granted on a secondary basis for disability that is proximately due to or the result of, or permanently aggravated by, an already service-connected condition. 38 C.F.R. § 3.310(a) and (b). This requires (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence establishing a nexus between the service-connected disability and the claimed disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom., Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In essence, lay testimony is competent when it pertains to the readily observable features or symptoms of injury or illness and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also 38 C.F.R. § 3.159(a)(2). A determination as to whether medical evidence is needed to demonstrate that a Veteran presently has the same condition as that during service or during a presumptive period, or whether lay evidence will suffice, depends on the nature of the condition (e.g., whether the condition is of a type that requires medical expertise to identify it as the same condition as that during service or during a presumption period, or whether it can be so identified by lay observation). See Barr v. Nicholson, 21 Vet. App. 303, 310 (2007 The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. Reasonable doubt will be favorably resolved if there is an approximate balance of favorable and unfavorable evidence but if the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1365-66 (Fed. Cir. 2001) (holding that an approximate balance of evidence is more favorable than the evidence being in equipoise, i.e., equally balanced). Initial Considerations Information in August 2014 from the Social Security Administration (SSA) reflects that SSA records were unavailable, having been destroyed. In the March 26, 2021, VA Form 20-0996, Review Request: Higher Level of Review, as to the March 2021 rating decision, the Veteran's attorney cited extensive case law, including McLendon v. Nicholson, 20 Vet. App. 79, 81(2006) and caselaw addressing rating claims, e.g., DeLuca v. Brown, 8 Vet. App. 202 (1995), as well as caselaw addressing the adequacy of VA examinations and opinions. Here, the Veteran has been afforded VA nexus examinations as to the claims for bone spurs of the ankles, as requested in the 2018 Board remand. Moreover, VA medical opinions have been obtained as to the other claims now before the Board. Despite five (5) pages of boilerplate and broad-brushed references to VA obligations, there are no specific allegations as to the adequacy, or inadequacy, of the examinations or medical opinions which have been obtained. When assessing the probative value of a medical opinion, the access to claims files and the thoroughness and detail of the opinion must be considered. The opinion is considered probative if it is definitive and supported by detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A claims file review is not a requirement for private medical opinions but it may lend additional probative value to any opinion but, more importantly, "[i]t is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion." See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The March 2021 VA negative nexus opinions were based on a complete review of the record, including the lay statements and medical evidence, and the examiner explained the reasons for his conclusion based on an accurate characterization of the evidence of record. The April 2021 medical opinions as to the claimed bone spurs were rendered after both a physical examination and a complete review of the record, including the lay statements and medical evidence, and the examiner explained the reasons for the conclusions based on an accurate characterization of the evidence. Thus, the Board finds that the medical opinions are adequate to properly adjudicate the claims on appeal, particularly in light of the absence of any specific allegations that the medical opinions are inadequate, and in the absence of any favorable medical opinions against which the negative VA medical opinions could be weighed. The Board therefore places significant weight on the findings of the medical opinions rendered in March and April 2021 as to the claimed disabilities. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). The Board has considered that lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. Crucially, however, the Veteran's contentions in support of service connection, including continuing post-service symptomatology, are contradicted by the findings reflected in the March and April 2021 VA medical opinions, which considered the lay assertions and any such inferences contained in the record in rendering the negative nexus opinions. Moreover, the contemporaneous clinical evidence does not support his contentions of continuous symptoms of the claimed disabilities since service. Also, additional VA treatment records have been associated with the record as requested in the 2018 Board remand. Accordingly, the Board concludes that there has been substantial compliance with the 2018 Board remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). 1. Entitlement to service connection for OSA, claimed as secondary to service connected psychiatric disabilities The examination for service enlistment in March 1975 was negative; however, in an adjunct medical history questionnaire the Veteran reported having or having had frequent trouble sleeping, with minimal nervousness. In a medical history questionnaire dated December 1976, he reported having or having had frequent trouble sleeping. In a November 2013 statement in support of his claim for service connection for psychiatric disability, the Veteran reported having, among other symptoms, insomnia. A May 2014 statement from a service buddy also attested that the Veteran had experienced difficulty sleeping. On an August 2019 Sleep Apnea Disability Benefits Questionnaire (DBQ), the Veteran was examined, and his records reviewed. The examiner diagnosed OSA. This was confirmed by a polysomnography later in August 2016 which yielded impressions of severe OSA and obesity. On examination, the Veteran reported that beginning in 1978 he would snore and intermittently awaken gasping for air. At that time, he indicated that h experienced persistent daytime hypersomnolence. It was opined that the OSA was less likely as not due to or the result of his service connected psychiatric disorders, because there was no confirmed diagnosis of PTSD. A January 2021 Initial PTSD DBQ reflects that the Veteran reported that his psychiatric symptoms included insomnia. He reported that he continued to smoke cigarettes. After the grant of service connection for psychiatric disabilities, a March 2021 a VA medical opinion was obtained, after a review of the records, as to any nexus between the Veteran's OSA and his service connected psychiatric disabilities. The Veteran has stated that he had snored and would awaken gasping for air since his military service. While lay persons are competent to describe observable symptomology (e.g. pain), a lay person is not competent to opine on the etiology of such symptoms given that the Veteran's OSA is not otherwise shown to have existed during service and because a layperson lacks the requisite medical expertise to formulate a medical opinion on whether the condition had its onset in service or is related to an in-service injury or disease. Such matters are complex medical determinations beyond the range of experience or understanding of the lay person that cannot be answered based on observation or analysis of the lay person. Rather, the Veteran's OSA is an intricate and complex matter that requires specialized medical education and knowledge, separate from the training, education, or knowledge of a lay person, regarding the unseen and complex processes of the development of respiratory disabilities. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (although it is error to categorically reject a non-expert opinion as to etiology, or nexus, not all questions of nexus are subject to non-expert opinion; whether a layperson is competent to provide a nexus opinion depends on the facts of the particular case). Therefore, the Board finds that the opinions of the Veteran have no probative value in this matter. The examining VA clinician in March 2021 reported that OSA was diagnosed by polysomnography or a sleep study. Effectively, this rules out the possibility of a diagnosis by a layperson, particularly when sleep disturbance, e.g., insomnia, is a factor in assessing the severity of psychiatric disability, such that lay evidence of sleep disturbance is not competent to establish the existence or the diagnosis of OSA. The March 2021 VA examiner further opined that the conditions of OSA and the service connected psychiatric disorders were not medically related. The examiner commented that sleep apnea was an entirely separate entity from the service connected psychiatric disorders and thus, unrelated to them. A thorough review of medical literature failed to demonstrate a causal relationship. Noting that the Veteran was diagnosed with obstructive sleep apnea in 2019, it was observed that according to the American Sleep Apnea Association, OSA arises from what is basically a mechanical problem. It was noted that OSA could lead to depression. In this regard, any aggravation of a service connected disorder by a nonservice-connected disorder is not a basis for granting service connection for the nonservice-connected disorder. It was further stated that the available scientific and objective medical evidence did not support a conclusion that OSA was associated with the service connected psychiatric disorders. There was no established causal link establishing that OSA was due to or the result of the service connected psychiatric disorders and no objective medical evidence noted to confirm permanent aggravation beyond normal progression. The Veteran and his attorney have had the opportunity to obtain corroborating statements from the medical professionals that putatively rendered favorable, but verbal, medical opinions. Despite this opportunity, no such corroborating statements, reports or medical opinions have been submitted. This must be weighed against the written medical opinions which are actually of record. Unfortunately, all such written medical opinions of record weigh against the claim for service connection. Further, the evidence does not otherwise demonstrate that OSA originated during active service. Accordingly, the Board finds that the preponderance of the evidence is against that claim and, thus, the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. 2. Entitlement to service connection for GERD, claimed as secondary to service connected psychiatric disabilities At the outset, the Board notes that the Veteran's service clinical records are negative for GERD. On VA examination in June 2016, the examiner diagnosed GERD. It was noted that the Veteran was claiming service connection for GERD as caused by hearing loss and tinnitus. The opinion was that a review of current medical literature showed no evidence of an association between a sensorineural condition (hearing loss and tinnitus) and the physiologic condition of GERD (reflux). On gastrointestinal (GI) DBQ in August 2019 the Veteran was examined and his records reviewed. The diagnosis was GERD. The Veteran reported a 1978 onset of reflux and regurgitation, dysphagia, nausea, vomiting, and heartburn. He had begun taking medication in 1986. However, it was noted that a prior examination had stated that the date of the diagnosis was in 2007. It was opined that the GERD was less likely than not due to or the result of his service connected PTSD, because PTSD had not been diagnosed and, so, a nexus could not be established. After service connection was granted for psychiatric disabilities, in March 2021 a VA medical opinion was obtained as to any nexus between the Veteran's GERD and his service connected psychiatric disorders. After a review of the records, a VA clinician opined that the conditions of GERD and the Veteran's service connected psychiatric disorders were not medically related. It was stated that GERD was the result of stomach acid flowing back up into the esophagus, and was a separate entity entirely from the service connected psychiatric disorders and thus, unrelated to them. A thorough review of medical literature failed to demonstrate a causal relationship. The medical records demonstrated that GERD was diagnosed in January 2004, which was prior to the diagnoses of the Veteran's service connected psychiatric disorders. This effectively ruled out the possibility that psychiatric disabilities caused GERD. The opinion noted that many different factors could increase the risk of developing, or aggravating, GERD. However, the available scientific and objective medical evidence did not support a conclusion that GERD was associated with the Veteran's service connected psychiatric disorders. There was no established causal link for GERD due to or the result of the service connected psychiatric disorders and, so, a nexus had not been established. Also, there was no objective medical evidence to confirm permanent aggravation beyond normal progression. A nexus had not been established. Considering the overall evidence, including the post-service medical evidence, the VA medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran's claim that he has GERD that is due to or aggravated by his service connected psychiatric disorders. Further, the evidence does not otherwise demonstrate that GERD originated during active service. In sum, the preponderance of the evidence is against the claim and, so, there is no doubt to be resolved and the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. 3. Entitlement to service connection for hypertension, claimed as secondary to service connected psychiatric disabilities Under 38 C.F.R. § 4.104, Diagnostic Code 71014, Note (1) hypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days. The term hypertension means that the diastolic blood pressure is predominantly 90 mm. or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160 mm. or greater with a diastolic blood pressure of less than 90 mm. A February 1977 service clinical record shows that the Veteran denied having high blood pressure. All blood pressure readings during service were within normal limits, and in a medical history questionnaire at the service separation examination he reported not having or having had high or low blood pressure. The evidence is undisputed that the Veteran now has essential hypertension. However, the evidence is also undisputed that hypertension first developed many years after active service. The Board notes that an article from the Internet was submitted, which indicated that the prevalence of hypertension was greater in those with PTSD. On VA hypertension DBQ in August 2019, the Veteran was examined and his records reviewed. The diagnosis was hypertension. The Veteran reported that he was uncertain of the date of onset of hypertension but reported that he had been diagnosed with hypertension in 1986. He had not initially taken his medication as prescribed but was now doing so. It was opined that his hypertension was less likely as not due to or the result of PTSD because he had not been diagnosed as having PTSD and, so, a nexus could not be established. Following the grant of service connection for psychiatric disabilities, a March 2021 a VA medical opinion was obtained as to any nexus between the Veteran's hypertension and his service connected psychiatric disorders. With respect to causation, it was noted that hypertension had been diagnosed in January 2004, which was prior to the documented date of diagnoses for the service connected psychiatric disorders. In effect, this rules out the possibility that hypertension was caused by service connected psychiatric disabilities. On this basis, the evaluator opined that the objective medical evidence did not support a conclusion that the Veteran's hypertension was associated with his service connected psychiatric disorders. Thus, a nexus had not been established. With respect to aggravation of hypertension by the service connected psychiatric disorders, it was noted that an April 8, 2017, medical records noted "blood pressures under control, continue amlodipine." Medical records dated September 13, 2019 noted the Veteran's hypertension was not under optimal control and he was to continue his medication and weight loss diet. A September 5, 2018, medical records noted that the Veteran reported "my blood pressure was in the 180s, I had forgotten to take my BP med for the last 2-3 days, smoked a cigarette right before my physical." However, medical records dated September 13, 2018 noted his blood pressure was 132/83 and a November 26, 2019 record noted his blood pressure was 123/72. The available medical records did not note current medical evaluations for hypertension/high blood pressure. The evaluator found that there was evidence to indicate that the Veteran continued to suffer from hypertension, which was typical for that disorder. However, there was a lack of sufficient objective medical evidence to confirm permanent aggravation of the hypertension beyond normal progression. Thus, a nexus had not been identified. Considering the overall evidence, including the post-service medical evidence, the VA medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In sum, the preponderance of the evidence is against the Veteran's claim that he has hypertension which is related to his military service or which was caused or aggravated by his service-connected psychiatric disorders. Thus, the benefit-of-the-doubt rule is inapplicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. 4. Entitlement to service connection for ED, claimed as secondary to service connected psychiatric disabilities At that outset, the Board notes that the Veteran's service clinical records are negative for ED. On VA examination in June 2016, it was noted that the Veteran had never been diagnosed with any conditions of the male reproductive system. On physical examination, no abnormality was found. It was noted that the Veteran claimed ED as due to hearing loss and tinnitus. There was no diagnosis at that time. It was opined that ED was less likely as not caused by or a result of hearing loss and tinnitus. The rationale was that a review of the medical record shows no evidence of the diagnosis or treatment for ED. Moreover, a review of current medical literature showed no evidence of a causal relationship between a sensorineural condition (hearing loss and tinnitus) and the physiologic condition of ED. An article from the Internet was submitted which indicated that the prevalence of ED was greater in those with PTSD. Records of private chiropractic treatment for low back disability from 2018 to 2020, but these do not indicate that any low back pathology caused ED. On VA male reproductive organ conditions DBQ in August 2019 the Veteran's records were reviewed. He declined a physical examination of his reproductive organs. The diagnosis was ED. It was reported that he had been unable to achieve erection since 2009. It was opined that his ED was less likely as not due to or the result of PTSD because he had not been diagnosed as having PTSD and, so, a nexus could not be established. However, with respect to the etiology of the ED, the examiner recorded "Alcoholism." After service connection was granted for psychiatric disabilities, a March 2021 a VA medical opinion was obtained as to any nexus between the Veteran's ED and his service connected PTSD. After a review of the records a VA clinician opined that the conditions of ED and the Veteran's service connected PTSD were not medically related. The clinician was unable to confirm a current chronic diagnosis of ED from the current records and, so no nexus or plausible secondary relationship could be established. The medical records did not note medical evaluations, treatment or a diagnosis for ED. The symptoms per self-report only and were not confirmed in the claims file. The available objective medical evidence did not support a conclusion that the Veteran's ED was associated with his service connected PTSD. There was no established causal link for the Veteran's ED due to or the result of his service connected PTSD and there was a lack of objective medical evidence in the available medical records to confirm permanent aggravation beyond normal progression. Thus, a nexus had not been established. The Board finds that although there is no link between the Veteran's ED and his service-connected PTSD, he is service-connected for multiple psychiatric disorders. This includes an alcohol use disorder. The only medical opinion which addressed any potential link, i.e., nexus, between this disorder and the Veteran's ED is the August 2019 opinion which stated that the etiology of the ED was the Veteran's alcoholism. There is no medical opinion to the contrary or which even implicitly contradicts the opinion. Accordingly, with the favorable resolution of doubt, the Board finds that service connection for ED is warranted on the basis of being due to and the result of the Veteran's service connected alcohol use disorder. 5. Entitlement to service connection for bone spurs of the right ankle 6. Entitlement to service connection for bone spurs of the left ankle (Issues 5 and 6) In a medical history questionnaire during service in December 1976, the Veteran reported not having or having had foot trouble. The service treatment records are negative for any bone spurs of the Veteran's heels, or any part of his anatomy. An article from the Internet was submitted which discussed bone spurs and indicated that inflammation of the achilles tendon could lead to the formation of a bone spur at the back of the heel bone (calcaneus bone). While this addresses the possibly etiology of any heel spurs it provides no information of probative value linking such heel spurs to military service. An August 2019 VA ankle conditions DBQ reflects that the Veteran was examined and his records reviewed. The diagnosis was a bilateral ankle strain. It was reported that the onset of discomfort of the feet and ankles had been in 2007. It was noted that the claim for "ankle" spurs was actually a claim for heel spurs. Current X-rays were normal. It was commented that there was insufficient objective evidence to support Veteran's claim of bilateral ankle bone spurs, such that as to this matter no diagnosis was warranted. It was opined that the claimed ankle bone spurs were less likely than not incurred in or caused by in-service injury, event, or illness. The rationale was that the bone spurs were not diagnosed until many years after service and there was no indication in the records that the condition started in or was diagnosed during service and, so, a nexus was not established. On VA examination in April 2021, the Veteran's records were reviewed and after a physical examination the diagnosis was bilateral calcaneal spurs. The Veteran reported that he had the onset of pain in both heels in 1976 when walking or running. He believed that poorly fitting boots were part of the problem, which he had reported at the time. It was noted that he had some circulatory problems with his feet that were not caused by an actual foot problem. He now had pain in the heels and the top of each too when he walked, which had been partially resolved by using insoles. Left foot X-rays in July 2007 had demonstrated a left calcaneal spur. The examiner opined that it was less likely than not that the bilateral heel spurs were incurred in or caused by in-service injury, event, or illness. The rationale was that the first mention of a heel spur diagnosis was is in 2007, which was decades after the Veteran's separation from military service. There was no indication that he had had foot pain, heel spurs or any other foot condition during military service. Therefore, a nexus could not be established. The examiner also opined that it was less likely than not that bilateral ankle sprains were incurred in or caused by in-service injury, event, or illness. The rationale was that there was no record of ankle sprains in the records and there was no record of Veteran having a disease or injury in service "other than ankle fracture" and, thus, a nexus was not established. However, the comment of "other than ankle fracture" is clearly incorrect inasmuch as there if virtually no evidence that the Veteran has ever had any fracture in either ankle, and in fact this was actually noted by the examiner in the report of the examination findings in April 2021. Accordingly, this inadvertent comment does not detract from the probative value of that examiner's opinion and particularly so because it made only in reference to possible ankle "sprains" and the evidence, as noted by that examiner, shows that the Veteran has never had any ankle sprains, and because that comment was not replicated in rendering the medical opinion as to the heels spurs which are the actual disabilities being claimed. The Board has considered that lay evidence concerning the in-service onset and the continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence. In this case, the Veteran's assertions as to etiology, i.e., ill-fitting boot during service, concerns an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Cf. Jandreau, 492 F.3d at 1376. Crucially, however, the Veteran's contentions in support of service connection, including continuing post-service symptomatology, are contradicted by the findings reflected in the 2019 and 2021 VA medical opinions, which considered the lay assertions and any such inferences contained in the record in rendering the negative nexus opinions. Moreover, as set forth above, the contemporaneous clinical evidence does not support his contentions of continuous symptoms since service. Considering the overall evidence, including the post-service medical evidence, the VA medical opinion, and the lay evidence presented by the Veteran, the Board finds that the negative evidence is more persuasive and of greater probative value. In conclusion, the preponderance of the evidence is against the Veteran's claim that he now has heel spurs of the right heel and the left heel, which are related to his military service. Thus, the benefit-of-the-doubt rule is not applicable to the claim. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 54-56. Christopher J. O'Donnell Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Fussell, 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.