Citation Nr: 21041434 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 18-53 102A DATE: July 9, 2021 ORDER Service connection for a neck disorder, to include as secondary to the service-connected right foot disability, is denied. Service connection for a back disorder, to include as secondary to the service-connected right foot disability, is denied. Service connection for a right ankle disorder, to include as secondary to the service-connected right foot disability, is denied. Service connection for a left ankle disorder, to include as secondary to the service-connected right foot disability, is denied. Service connection for a right leg disorder manifested by blood clots is denied. Service connection for a left leg disorder manifested by blood clots is denied. REMANDED Service connection for a skin disorder, to include chloracne, is remanded. Service connection for hypertension is remanded. Service connection for a vision disorder is remanded. FINDINGS OF FACT 1. A neck disorder, including degenerative joint disease (DJD), was initially manifested many years after service, is not shown to be related to the Veteran's service or to have been caused or aggravated by a service-connected disability. 2. A back disorder, including DJD, was initially manifested many years after service, is not shown to be related to the Veteran's service or to have been caused or aggravated by a service-connected disability. 3. A right ankle disorder, including arthritis, was initially manifested many years after service, is not shown to be related to the Veteran's service or to have been caused or aggravated by a service-connected disability. 4. The preponderance of the evidence of record is against finding the Veteran has had a left ankle disorder at any time during or proximate to this appeal. 5. The preponderance of the evidence of record is against finding the Veteran has had right leg blood clots at any time during or proximate to this appeal. 6. The preponderance of the evidence of record is against finding the Veteran has had left leg blood clots at any time during or proximate to this appeal. CONCLUSIONS OF LAW 1. The criteria for service connection for a neck disorder, including arthritis, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. 2. The criteria for service connection for a back disorder, including arthritis, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. 3. The criteria for service connection for a right ankle disorder, including arthritis, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. 4. The criteria for service connection for a left ankle disorder have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310. 5. The criteria for service connection for right leg blood clots have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. 6. The criteria for service connection for left leg blood clots have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1964 to December 1968. These matters come before the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office/Agency of Original Jurisdiction (RO/AOJ). A September 2019 Board decision denied the claims of service connection for dental cavities, hemorrhoids, asthma and disorders of the neck, back and both ankles. The Veteran appealed the portion of the decision which denied the claims of service connection for disorders of the neck, back and both ankles to the United States Court of Appeals for Veterans Claims (Court) (he did not challenge the denial of service connection for dental cavities, hemorrhoids and asthma). In an August 2020 Order, the Court granted a Joint Motion for Partial Remand (Joint Motion), vacated the September 2019 Board decision to the extent it denied these claims and remand the appeal for action consistent with the terms of the Joint Motion. The Court dismissed the appeal as to the remaining issues. In December 2020, the Board remanded the matters of service connection for disorders of the neck, back and both ankles to the RO for additional development necessary to ensure compliance with the terms of the August 2020 Joint Motion. The additional development consisted of obtaining private treatment records from Dr. R. A. from October 2013, the date treatment was initiated, to the present and addendum opinions in connection with the remanded claims. Although addendum opinions based on the Veteran's updated medical records have been obtained, treatment records requested from Dr. R.A. have not been provided and are not available for review. Specifically, in December 2020, the Veteran authorized VA to obtain records from Dr. R.A. dated from January 1, 2019 to December 31, 2021 (rather than from October 2013, as requested by VA). In December 2020, VA advised the Veteran that the records from Dr. R.A. had been requested pursuant to his authorization; however, it was his responsibility to see that VA received these records. The requested records were not received and a December 2020 VA Form 21-0820, Report of Contact, shows Dr. R.A. stated "the records were provided directly to the Veteran." However, the Veteran has not submitted those records to VA and, in February 2021 correspondence (resubmitted in March 2021), indicated that he has "no other information or evidence to submit." Accordingly, the Board finds there has been substantial compliance with the December 2020 remand instructions. Stegall v. West, 11 Vet. App. 268 (1998). As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The September 2019 Board decision also remanded the claims of service connection for hypertension, a vision disorder, bilateral leg disorder manifested by blood clots, a skin disorder and a psychiatric disorder, to include posttraumatic stress disorder (PTSD) and depressive disorder. Upon consideration of additional evidence obtained pursuant to the September 2019 Board remand, an interim July 2020 rating decision granted service connection for PTSD with anxiety and assigned a 50 percent rating from July 28, 2011, the date of the Veteran's informal claim. As this represents a complete grant of the Veteran's claim of service connection for a psychiatric disorder, this issue is no longer on appeal before the Board. See generally Grantham v. Brown, 114 F.3d 116 (Fed. Cir. 1997); Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997). As to the claims of service connection for right and left leg disorders manifested by blood clots, after review of the development accomplished by the AOJ, the Board concludes there has been substantial compliance with the September 2019 Board remand instructions (the claims for service connection for a skin disorder, hypertension and vision disorder are addressed in the Remand portion of the decision, below) and no further development is necessary as to these matters. See Stegall, supra. Subsequent to the most recent adjudication of the claims by the AOJ (Supplemental Statement of the Case dated in August 2020 (hypertension, vision disorder, bilateral leg disorders manifested by blood clots and skin disorder) February 2021 (neck, back and bilateral ankles)), additional relevant evidence consisting of duplicates of previously submitted statements and treatment records were received. As these records are duplicative of evidence previously received, remand to the AOJ for issuance of a SSOC based on the receipt of this evidence is not necessary. 38 C.F.R. §§ 19.31, 20.1304(c). Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015). Accordingly, the Board will proceed with adjudication of his appeal. Service Connection Service connection may be granted for current disability arising from disease or injury incurred or aggravated by active service. 38 U.S.C. § 1110. Service connection may 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). Service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104(a); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). To substantiate a claim of secondary service connection there must be evidence of (1) a current chronic disability for which service connection is sought; (2) an already service-connected disability; and (3) that the already service-connected disability (a) caused or (b) aggravated the disability for which service connection is sought. See Allen v. Brown, 7 Vet. App. 439 (1995). 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; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Neck Disorder 2. Back Disorder 3. Right Ankle Disorder 4. Left Ankle Disorder The Veteran claims that his neck and back disorders, diagnosed as DJD; right ankle disorder, diagnosed as degenerative changes (arthritis); and left ankle disorder, diagnosed as strain, are secondary to his "ankle condition" (notably, a July 2013 rating decision granted service connection for status post left fifth metatarsal fracture also claimed as broken left foot and a subsequent December 2018 rating decision found clear and unmistakable error in granting service connection for fracture of the left foot fifth metatarsal instead of fracture of the right foot fifth metatarsal and changed the indicator of the left foot to the right foot, to reflect it was the right foot that was fractured.) See March 2016 VA Form 21-4138 and April 2016 VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits, claiming neck and back conditions are secondary to service-connected "feet." In addition, he claims that his back and ankle disorders are the result of injury sustained during his military service. See November 2018 VA back examination report, showing the Veteran reported his initial low back injury was sustained in 1968 while moving a heavy motor, and November 2018 VA ankle conditions examination report, noting he reported the onset of his bilateral ankle symptoms in 1966. Service connection for certain chronic diseases, including arthritis, will be presumed if they manifest to a compensable degree within one year following active military service. This presumption, however, is rebuttable by probative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. A nexus to service (for diseases listed in 38 C.F.R. § 3.309(a)) may be established by showing continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). The Veteran's service treatment records (STRs) from his period of active service from September 1964 to December 1968 do not show any complaints, findings or diagnoses of a neck or back disorder. The treatment records from his Reserve service show complaints of upper back and neck pain after a motor vehicle accident in June 2005. There are no further complaints during the remainder of his Reserve service ending in March 2006; however, as discussed below, the Veteran was in receipt of private treatment during this period and continued to receive private treatment after the end of his Reserve service. These private treatment records show continued treatment for neck and back symptoms. The STRs include December 1966 complaints of right ankle pain and stiffness. However, these symptoms were associated with a cast required for the service-connected right foot fracture, the Veteran underwent right ankle range of motion exercises and one week later was noted to be "doing well" with normal right ankle range of motion. These records are silent as to a right ankle injury and left ankle complaints or treatment. A November 2011 VA examination report notes no signs of edema, instability, abnormal movement, effusion, weakness, tenderness, redness, heat, deformity, malalignment, drainage, subluxation or guarding of movement of either ankle. The Veteran's posture and gait were within normal limits, bilateral ankle examination was normal and the Veteran had painless bilateral ankle range of motion. The examiner noted no limitation with standing and walking and no functional loss due to pain. In a September 2015 letter, Dr. R.A., from the Chiropractic Healing Center, stated that she had been treating the Veteran since October 2013. Dr. R.A. noted the Veteran reported a history of a broken right foot in 1966, favoring this foot since the injury and experiencing right foot numbness, tingling, chronic pain and edema. She noted examination findings of a "change in walking pattern, from the ankle to the knee, to the hip and then to the lower back." Dr. R.A. opined that the Veteran was experiencing chronic low back pain because of the 1966 injury. Dr. R.A. reiterated this opinion in correspondence dated in April 2016 (Physician's Statement noting she had reviewed the Veteran's STRs and that his neck and back disorders are due to his ankle problems) and August 2016 ("[a]s a consequence of a broken foot that was documented by X-ray in December 1966, arthritis develops in and around the joints that cause stiffness and swelling" and Veteran "compensates when walking, throwing his back out."). An April 2016 VA ankle conditions examination report includes a diagnosis of bilateral ankle sprain. The examiner opined that the Veteran's bilateral ankle disorder is less likely than not due to service because "there are no medical records" showing diagnosis or treatment for an ankle disorder or a condition related to an ankle disorder. On November 2018 VA back examination the diagnosis was DJD. The Veteran reported the initial onset of his back pain was 1968, when he was moving a heavy motor; he continued to work as a mechanic after service, which was "heavy work;" and his back got worse in 2013 when he began to see a chiropractor. The examiner opined that it is less likely than not that the Veteran's back condition is related to service because examination showed a "near normal back and xrays show multilevel DJD consistent with age 72." The examiner explained that there is no evidence of continued treatment for the back after the Veteran left service until 2013, when he started getting regular treatment. The examiner also noted the Veteran's 26 year post-service history of working at Lockheed Martin in a job which involved heavy lifting and pushing, activities which "would require a functioning back, neck and ankles." Regarding secondary service connection, the examiner opined that the Veteran's back condition is less likely than not related to his service-connected right foot fracture because the foot fracture has healed and there is no deformity or tenderness around the fracture site, the Veteran "walks without a limp relative to the fracture and the right "foot would not impose excess stress on other joints including the R ankle, back and neck." On November 2018 VA neck examination, the diagnosis was DJD cervical spine. The Veteran recalled he started to feel neck pain and tingling in the 1980s and saw a chiropractor in 2013. The examiner opined the Veteran's neck disorder is less likely than not related to service because he provided no history of neck pain in service and had a motor vehicle accident in 2005, which was after service. The examiner further explained the Veteran's loss of neck range of motion and multilevel DJD are consistent with his age of 72 years. The remainder of the opinion and explanation is identical to the November 2018 opinion and explanation provided for the back (no continuity of treatment since service, 26 year history of post-service employment at Lockheed Martin in job requiring heavy lifting and pushing and healed right foot fracture with no limp, deformity or tenderness.) On November 2018 VA ankle examination, X-ray study showed degenerative change of the right ankle. Left ankle examination was normal. The Veteran recalled experiencing right ankle pain because of his broken right foot in 1966 which continued after the right foot fracture healed. He reported continued right ankle pain after service to the present. He reported first noticing the numbness and tingling about 30 years ago; thus, after his separation from service in 1968. The examiner noted the examination of the right ankle was "near normal" and explained the X-ray report showed early DJD but the body of the report stated that the ankle is normal and review of the X-ray showed the right ankle to be "within the variation of normal." The examiner opined that the Veteran's right ankle condition is less likely than not related to service because examination revealed a "near normal" right ankle and X-rays "are normal" and there is no evidence of continued right ankle treatment after separation from service. The remainder of the opinion is identical to the November 2018 opinions and explanations provided for the neck and back (26 year history of post-service employment at Lockheed Martin in job requiring heavy lifting and pushing and healed right foot fracture with no limp, deformity or tenderness.) Although the treatment records from Dr. R.A., as requested in the December 2020 Board remand have not been provided and are not available for review (Dr. R.A. stated she provided the records to the Veteran; however, he has not provided them to VA); in a December 2020 letter, Dr. R.A. noted that, since breaking his right foot in 1966, the Veteran reported he "had a postural imbalance/instability and gate/mobility disorder. He has right foot pain, trouble with his balance and drags his feet." She noted that the Veteran also complains of a sharp low back pain and "has developed Baastrup's Disease, L4-L5 facet arthrosis with 15% degenerative spondylolisthesis at L4," right leg length inequality, segmental and somatic dysfunction of the lumbar spine and sacral region and "Intvt" disc disorders with radiculopathy. This statement also notes that the Veteran has neck pain and stiffness; has developed degenerative disc narrowing, arthrosis and discogenic retrolisthesis associated with chronic posterior disc protrusion; moderate degenerative disc narrowing in the mid thoracic spine and segmental and somatic dysfunction of the cervical spine. Dr. R.A. opined that "[a]bnormal foot function can be related to and worsen pain in the low back and spinal regions due to an imbalance in your foot and lower extremity structure as well as weakness and imbalance of tendons, ligaments, muscles, and joints from an old injury." She further states that the Veteran "developed a gait disorder caused by this foot injury and has thrown out his spine (misaligned vertebrae.) He favors this foot and has anterior weight bearing." She concluded that "[p]ost traumatic arthritis develops years after the healing process after someone ages, putting much weight and pressure on affected area leads to symptoms of arthritis." In January 2021, VA obtained an addendum medical opinion. After a detailed review of the record and consideration of the opinions provided by Dr. R.A., a VA physician responded: (1) it is less likely than not that the Veteran's back disability is proximately due to or aggravated beyond it natural progression by his service-connected right foot disability because, although the opinion from Dr. R.A. was considered, "VA medical records from 2013-2016 do not indicate gait impairment," the 2011 VA examination report noted normal gait and posture and November 2018 VA examination performed by an orthopedic physician noted that the Veteran walked without a limp relative to the fracture and such a foot would not impose excess stress on other joints including the back, (2) it is less likely than not that the Veteran's neck disorder is proximately due to or aggravated beyond its natural progression by the service connection right foot disability because the Veteran's cervical spine (neck) condition is in a distinctly separate anatomical location from the right foot condition and peer reviewed literature does not support the concept that a foot condition would cause or aggravate the neck condition and (3) it is less likely than not that the Veteran's bilateral ankle disorder is proximately due to or aggravated beyond its natural progression by the service-connected right foot disability because, although the opinion from Dr. R.A. was considered, "VA medical records from 2013-2016 do not indicate gait impairment," the 2011 VA examination report noted normal gait and posture and the November 2018 examination performed by an orthopedic physician noted the right foot fracture was healed, the Veteran walks without a limp relative to the fracture and such a foot would not impose excess stress on other joints including the ankles. Private treatment records include a March 2006 Patient Visit Record which notes the complaint of low back pain, for which the Veteran had been seen before; a December 2007 Patient Visit Record which notes the Veteran had been in a motor vehicle accident the day before and his symptoms included back and neck pain; a December 2007 report of cervical spine X-ray which notes a clinical history of pain following trauma and shows an impression of degenerative disc space disease C4-C5 through C7-T1, degenerative posterior spurring resulting in osseous compromise of the foramina at these levels, most pronounced at C4-C5 and C5-C6; and a September 2009 report of chest X-ray includes an impression of degenerative spurring mid thoracic vertebral bodies. The September 2009 treatment report notes no gait difficulties. VA treatment records throughout the appeal period (most recently updated in May 2020) also note no gait impairment and are consistent with the VA examination reports and private treatment records, which also note no gait impairment. See, e.g., December 2015, February 2016, April 2016, June 2016, and August 2016 VA treatment reports noting "normal gait and station." Upon consideration of the foregoing, it is not in dispute that the Veteran has diagnosed disorders of the neck and back (DJD), right ankle (degenerative changes/arthritis) and left ankle (strain) during the appeal period. What remains for consideration is whether the current neck, back and bilateral ankle disorders are etiologically related to his service or are caused or aggravated by his service connected right foot disability. As noted above, a chronic neck, back and/or disorder of either ankle was not noted in service (although the Veteran was treated for one instance of right ankle pain in service, the symptoms resolved with treatment) and cervical spine, lumbar spine and right ankle arthritis was not noted during the initial post-service year following the Veteran's December 1968 separation from service. Consequently, service connection for a neck, back and/or disorder of either ankle on the basis that such became manifest in service and has persisted or on a presumptive basis (for arthritis as a chronic disease under 38 U.S.C. §§ 1112, 1137, 38 C.F.R. §§ 3.309) is not warranted. See Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). In addition, to the extent the Veteran attempts to support his claims of service connection for disorders of the neck, back and ankles by his more recent accounts of continuity of symptoms since service, the Board finds such accounts to be inconsistent with contemporaneous clinical data as described in detail above, and not credible. See Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991); see also Seng v. Holder, 584 F.3d 13, 19 (1st Cir. 2009) (noting that, notwithstanding a declarant's intent to speak the truth, the witness's statement may lack credibility because of faulty memory due to passage of time). What remains then is the question of whether, in the absence of a showing of onset in service and continuity since, the Veteran's neck, back and/or disorder of either ankle may otherwise be related to his service or his service-connected right foot disability. Whether there is a nexus between his current neck, back and/or disorder of either ankle and his in-service injury (absent evidence of continuity) or his service-connected disability, is a medical question that requires medical expertise, which the Veteran has not been shown to possess. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428 (2011). Therefore, the Veteran's opinions that his current neck, back and bilateral ankle disorders are related to injuries sustained during service or as a result of his service-connected right foot disability are merely lay speculations and are not competent evidence. They are without probative value in this matter. The only medical opinions as to whether there is a nexus between the Veteran's current disorders of the back and/or ankles and his in-service injury are the opinions contained in the April 2016 and November 2018 VA examination reports and they are against the Veteran's claims. Although the April 2016 opinion that the Veteran's bilateral ankle disorder is unrelated to service provides an insufficient explanation of rationale (because it is based on an absence of medical records showing treatment in service and does not appear to take into consideration the Veteran's report of inservice injury and treatment); the November 2018 opinions that the Veteran's back, neck and ankle disorders are less likely than not related to service because there is no evidence of continued treatment for these disorders after the Veteran's separation from service, X-ray findings of DJD as to the neck and back were consistent with his age of 72 years, right ankle examination was "near normal," right ankle X-ray findings were "within the variation of normal" and left ankle examination was normal warrant substantial probative weight because the opinions incorporate statements made by the Veteran throughout the pendency of his claims as well as his STRs and explain why the complaints and findings shown do not support a nexus between any currently diagnosed disorder of the back and/or ankles and his service. The November 2018 opinions are based on detailed examinations and a thorough review of the record and include rationales that point to factual data, including the Veteran's self-reports provided in clinical settings. These opinions are probative evidence as to whether the Veteran's claimed disorders of the back and ankles are related to service and, in the absence of probative evidence to the contrary, are persuasive. Regarding the secondary service connection theory of entitlement, the Board acknowledges there are contrasting medical opinions September 2015, April 2016, August 2016 and December 2020 opinions from Dr. R.A. favorable to the Veteran's claims and November 2018 and January 2021 opinions unfavorable to his claims. While the Board may not reject a favorable medical opinion based on its own unsubstantiated medical conclusions, see Obert v. Brown, 5 Vet. App. 30, 33 (1993), the Board does have the authority to "discount the weight and probity of evidence in the light of its own inherent characteristics and its relationship to other items of evidence." See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). The guiding factors in evaluating the probative value of a medical opinion include whether the opinion is based upon sufficient facts, whether the opinion is the product of reliable principles, and whether the opinion applied valid medical analysis to the significant facts of the case in order to reach the conclusion submitted in the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). Greater weight may be placed on one medical opinion over another depending on factors such as reasoning employed by the medical professional, and whether or not, and to what extent, they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The opinions provided by Dr. R.A. are premised on a finding that the Veteran's service-connected right foot has resulted in an altered gait (he has "favoring" this foot since the injury, he has had a "change in walking pattern, from the ankle to the knee, to the hip and then to the lower back," he "compensates when walking, throwing his back out," and he "developed a gait disorder caused by this foot injury and has thrown out his spine (misaligned vertebrae.)); thereby, causing his ankle, back and neck problems. However, the treatment records on which Dr. R.A. has based her opinions are not available for review. As discussed above, although VA requested treatment records from Dr. R.A. with the Veteran's authorization, such records were provided directly to the Veteran and he did not provide them to VA. Accordingly, there is no record of any gait impairment which Dr. R.A. might have noted while treating the Veteran. As described above, the VA examination reports note the Veteran's right foot injury has healed, there is no deformity, his gait has been normal and he has had no limp and the VA and private treatment records note a normal gait and posture and are silent as to any gait disturbance. As such, the opinions provided by Dr. R.A. are based on an inaccurate factual premise (the premise that the Veteran has favored his right foot and has had an altered gait is contradicted by his contemporaneous treatment records) and are of no probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (concluding that a medical opinion is only as good and credible as the history on which it was based, and if based on an inaccurate factual premise it has no probative value); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely."). In the present case, the Board finds the November 2018 neck, back and ankle opinions combined with the January 2021 addendum opinion (because, as noted in the Joint Motion, the November 2018 VA examiner did not provide opinions addressing the issue of aggravation) is more probative and persuasive as to the question of a nexus between any current disorder of the neck, back and/or ankles and the Veteran's service-connected right foot disability. These opinions, combined, show consideration of the Veteran's assertions and the opinions provided by Dr. R.A. as well as the clinical evidence of record. In contrast, the opinions from Dr. R.A. do not show consideration of the Veteran's complete claims file, including the clinical evidence of normal gait and posture. As such, the November 2018 neck, back and ankle opinions combined with the January 2021 addendum opinion are probative evidence in the matter and, in the absence of equally or more probative evidence suggesting that a service-connected disability may have been an etiological factor for the Veteran's development of neck, back and/or disorders of either ankle, they are persuasive. The preponderance of the evidence is against the claims of service connection for disorders of the neck, back and ankles, including arthritis; therefore, the benefit of the doubt rule does not apply and the appeal as to these claims must be denied. Gilbert v. Derwinski, 1 Vet. App. at 54-56. 5. Right Leg Blood Clots 6. Left leg Blood Clots The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104, F.3d 1328 (Fed. Cir. 1997). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement for a current disability is satisfied if the disability is shown at any time proximate to or subsequent to filing the claim, even if not shown currently. McClain v. Nicholson, 21 Vet. App. 319 (2007); Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). The initial threshold matter that must be addressed here (as in any claim seeking service connection) is whether there is competent evidence that the Veteran currently has (or proximate to or during the pendency of the claim has had) right and/or left leg blood clots. An August 2011 Physician's Statement includes the opinion that the Veteran's blood clots, bilateral legs, "could have as likely as not been caused or aggravated by the Veteran's active duty service." However, this statement does not indicate that the Veteran was diagnosed with blood clots of either extremity by the opining physician and the treatment records received from the physician's practice are silent as to complaints, findings or treatment for blood clots. A July 2013 VA medical advisory opinion includes the finding that the "Veteran does not have a current diagnosis of blood clots in the legs. His service records show no on-going chronic treatment or condition for blood clots in the legs. He was seen briefly for thrombophlebitis, but [he] does not have a current diagnosis of blood clots in the legs." A December 2019 VA artery and vein conditions examination report includes a diagnosis of acute superficial thrombosis, diagnosed in June 2005, resolved. (Notably, the 2005 diagnosis was during the Veteran's Reserve service.) The examiner opined that the claimed disorder was less likely than not related to service because onset of the Veteran's superficial thrombophlebitis "was acute and resolved." The examiner further explained that there is no evidence noted in current records of an ongoing superficial thrombophlebitis condition for any right or left lower extremity. The examiner subsequently supplemented the opinion, explaining that the "Veteran's records are silent for an ongoing and/or continued superficial thrombophlebitis condition" and, according to literature, superficial thrombophlebitis condition is a relatively acute condition and resolved with treatment. VA and private treatment records do not reflect any evidence suggestive of blood clots in either leg. After careful review of the record, the Board concludes that the most probative evidence does not reach the level of equipoise as to whether the Veteran has a current disorder of either leg manifested by blood clots resulting in functional impairment of earning capacity that had its onset during or is etiologically to military service. The Board is cognizant of the holding in Saunders v. Wilkie, 886 F.3d 1356, 1363 (Fed. Cir. 2018). In Saunders, the Federal Circuit held that pain alone, in the absence of a diagnosed condition, may constitute a disability if it results in functional impairment of earning capacity. However, subjective complaints of pain in the absence of objective evidence of functional impairment are not sufficient to show a current disability for VA purposes. Id. at 1367-68. In the present case, the Veteran has not claimed symptoms of leg pain (or functional loss due to leg pain) and there is no evidence of functional impairment of earning capacity due to a disorder of either leg manifested by blood clots. The December 2019 VA artery and vein conditions examination report notes no functional impact due to the Veteran's claimed condition. As the finding was based on physical examination by a medical professional, the Board finds the conclusion to be worth significant probative weight (and there is no evidence to the contrary). See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g., experiencing leg pain). Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, as a lay person, he is not competent, by his own opinion, to establish a diagnosis of a disorder of either leg manifested by blood clots. Such an opinion is a medical question beyond the scope of lay observation, and requires medical expertise. Jandreau v. Nicholson, 429 F.3d 1372 (Fed. Cir. 2007). The Veteran lacks such expertise, and does not cite to any supporting medical treatise evidence. The preponderance of the evidence is against the claim of service connection for a disorder of either leg manifested by blood clots. Therefore, the benefit of the doubt rule does not apply and the appeal as to these matters must be denied. Gilbert v. Derwinski, 1 Vet. App. at 54-56. REASONS FOR REMAND 7. Skin Disorder The Veteran claims service connection for a skin disorder, including chloracne. His service personnel records show (and the AOJ as conceded) he served in the Republic of Vietnam, thus his exposure to Agent Orange is presumed. See 38 U.S.C. § 1116. The Veteran's skin symptoms have not been diagnosed as chloracne and none of his skin disorders diagnosed during the appeal period are presumptively linked to in-service Agent Orange Exposure. See 38 C.F.R. § 3.309(e). However, where the evidence does not warrant presumptive service connection, an appellant is not precluded from establishing service connection for disability due to exposure to herbicides with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran has been afforded VA skin examinations in November 2018 and August 2020 ; however, the opinions provided do not include explanations as to why the Veteran's skin disorders diagnosed during the appeal period are not related to his presumed in-service Agent Orange exposure. As such, remand for an addendum opinion is necessary. 8. Hypertension The Veteran underwent VA hypertension examination in December 2019 and the examination report includes the opinion that the Veteran's onset of benign hypertension was February 2006, more than one year after his separation from active duty service (an initial opinion provided a positive nexus opinion; however, the examiner did not consider the Veteran's dates of active duty service.) In this regard, the Board takes judicial notice that in Veterans and Agent Orange: Update 11 (2018), the National Academies of Sciences, Engineering and Medicine (NAS) found "sufficient" evidence of an association for hypertension and exposure to herbicides, an upgrade from its previous classification of limited or suggestive" evidence of an association. https://www.nap.edu/read/25137/chapter/1. The December 2019 VA opinion does not address this study. As such, remand for an addendum opinion is necessary. 9. Vision Disorder As noted in the September 2019 Board remand, in a November 2013 notice of disagreement, the Veteran stated that he has visual distortion due to his hypertension. As the remand of the above claim for service connection for hypertension could affect the claim for a vision disorder, the Board finds that the claims are inextricably intertwined and a decision on the vision disorder claim at this time would be premature. The matters are REMANDED for the following action: 1. Please obtain any updated VA and non-VA treatment records. 2. After the development in paragraph 1 has been completed to the extent possible, please obtain an addendum medical opinion as to the nature and etiology of the Veteran's skin disorder(s). Based on review of the record (and, if necessary and deemed feasible, interview and examination of the Veteran, and using telehealth techniques if possible), the clinician should respond to the following: (a) Identify all skin disorders present throughout the appeal period, including tinea cruris, hidradenitis suppurativa, and onychomycosis. (b) For each identified skin disability, is it at least as likely as not (50 percent probability or greater) that such had its onset in service or is otherwise related to service, to include as a result of exposure to herbicide agents and/or Agent Orange during service? In providing the requested opinions, the examiner should consider as necessary: (1) STRs noting cyst in groin area, cyst to right thigh, sebaceous cyst and cyst to back of head; (2) May 1978 Reserve records showing treatment for acne vulgaris and dermatitis; (3) post service private treatment records noting lesion on right foot in March 2009 and hidradenitis suppurative and tinea cruris in October 2019, and (4) November 2018 and July 2020 VA examination reports and opinions. A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit the requested opinion to be made. 3. After the development in paragraph 1 has been completed to the extent possible, please obtain an addendum medical opinion as to the nature and etiology of the Veteran's hypertension. Based on review of the record (and, if necessary and deemed feasible, interview and examination of the Veteran, and using telehealth techniques if possible), the clinician should respond to the following: Is the Veteran's hypertension at least as likely as not (a 50 percent or greater probability) related to presumed in service exposure to an herbicide agent? In addressing this question, the clinician should consider and address the National Academy of Science's Agent Orange: Update 11 (2018), which upgrades hypertension from the category of "limited or suggestive" evidence of an association with herbicide exposure to the category of "sufficient" evidence, stating, "[t]he sufficient category indicates that there is enough epidemiologic evidence to conclude that there is a positive association" between hypertension and herbicide agent exposure. The clinician is advised that the sole basis of a negative opinion cannot be that hypertension is not on the list of diseases subject to presumptive service connection based on exposure to herbicide agents. (Continued on the next page) A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resorting to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit the requested opinion to be made. 4. After completing the above, and any other development deemed necessary (including obtaining a VA eye examination if deemed warranted based on the resolution of the claim for service connection for hypertension), readjudicate the inextricably intertwined issue of entitlement to service connection for a vision disorder, including as secondary to hypertension. If any benefit sought on appeal is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. M. Mills Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K Hughes 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.