Citation Nr: 21042363 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 12-36 142 DATE: July 12, 2021 ORDER Entitlement to service connection for bronchitis is denied. Entitlement to service connection for asthma/emphysema is denied. Entitlement to service connection for allergic rhinitis is denied. Entitlement to service connection for bilateral foot disabilities is denied. Entitlement to service connection for a right knee disability is denied. Entitlement to service connection for a left knee disability is denied REMANDED Entitlement to service connection for gastroesophageal reflux disease (GERD) is remanded. FINDINGS OF FACT 1. The evidence of record demonstrates that the Veteran's has not had chronic bronchitis during or contemporaneous to the appeal period. 2. The evidence of record demonstrates that the Veteran's allergic rhinitis, asthma, emphysema are not related to his first period of military service, to include his presumed exposure to herbicide agents or his exposure to asbestos. 3. The evidence of record demonstrates that the Veteran's allergic rhinitis and asthma preexisted his military service in 1990 and 1991, but did not increase in disability during that period of service; and the evidence demonstrates that his emphysema is not related to his military service in the Persian Gulf. 4. The evidence of record is against a finding that the Veteran's currently-diagnosed bilateral foot disabilities are due to his military service. 5. The evidence of record is against a finding that the Veteran's currently-diagnosed bilateral knee disabilities are due to his military service or secondary to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for bronchitis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for the Veteran's asthma/emphysema are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for the Veteran's allergic rhinitis are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. The criteria for service connection for the Veteran's currently-diagnosed bilateral foot disabilities are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for the Veteran's currently-diagnosed right knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for the Veteran's currently-diagnosed left knee disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from January 1963 to January 1967. He also served on active duty in the Air Force Reserves from December 1990 to March 1991, and from October 2001 to December 2001 with periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA). The Veteran testified before the undersigned Veterans Law Judge during an April 2018 hearing. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). "When no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry. The burden then falls on the government to rebut the presumption of soundness by clear and unmistakable evidence that the veteran's disability was both preexisting and not aggravated by service." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). When an entrance examination has been conducted and is unavailable, the veteran is presumed sound. Quirin v. Shinseki, 22 Vet. App. 390 (2009) (citing Lee v. Brown, 10 Vet. App. 336, 339 (1997) (holding that the presumption of soundness applies even when the record of a Veteran's entrance examination has been lost or destroyed while in VA custody)). With regard to the Veteran's first period of active duty service, service treatment records from that period have been deemed as unavailable for review. See January 2011 VA Memo. While there is no entrance examination associated with the record, there is no reason to indicate that the examination did not take place. Because it appears that the entrance examination has either been lost or destroyed, the Board will presume that Veteran's was sound at entry into service. In order to rebut the presumption of soundness, there must be clear and unmistakable evidence that a claimed disability existed prior to service and was not aggravated by service. See VAOPGCPREC 3-2003; Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). If VA is unable to rebut the presumption of soundness; then the claim becomes one for service connection based on incurrence of disability in service. With regard to his other periods of active duty service, although the reports of certain periodic examinations are of record, it does not appear the Veteran was administered examinations upon entry into active duty service in 1990 and 2001. As such, the presumption of soundness does not attach for those two periods. See Smith v. Shinseki, 24 Vet. App. 40, 45 (2010); Crowe v. Brown, 7 Vet. App. 238, 245 (1994) (holding that the presumption of sound condition "attaches only where there has been an induction examination in which the later-complained-of disability was not detected"). A pre-existing disease or injury will be considered to have been aggravated by military service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence is required to rebut the presumption of aggravation where the preservice disability underwent an increase in severity during service. 38 C.F.R. § 3.306(b). Aggravation may not be conceded where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and after service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). Further, temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted with symptoms, has worsened. See Davis v. Principi, 276 F.3d. 1341, 1346-46 (Fed. Cir. 2002) ("[E]vidence of temporary flare-ups symptomatic of an underlying preexisting condition, alone, is not sufficient for a non-combat veteran to show increased disability under 38 U.S.C. § 1153 unless the underlying condition is worsened"). Notably, it is the veteran who bears the burden of establishing aggravation under 38 U.S.C. § 1153. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). In other words, the Veteran must submit, or the record must contain, some evidence demonstrating that the pre-existing disability increased in severity during service for the presumption of aggravation to attach. See Verdon v. Brown, 8 Vet. App. 529, 538 (1996) (stating that the question of whether a preexisting defect or injury underwent an increase in severity "must be answered in the affirmative before the presumption of aggravation attaches"). Once the presumption attaches, it may be rebutted only by clear and unmistakable evidence. See Cotant v. Principi, 17 Vet. App. 116, 123-30 (2003); 38 C.F.R. § 3.306 (b). 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for allergic rhinitis, bronchitis, and asthma The Veteran claims entitlement to service connection for allergic rhinitis, bronchitis, and asthma as a result of his military service, to include his presumed exposure to herbicide agents in the Republic of Vietnam. During his hearing, the Veteran indicated that although he had some problems with his sinuses prior to his deployment in 1990, he was exposed to the environmental factors during Operation Desert Storm, including burning oil fields and titanium from vehicles. In essence, he asserts that his breathing problems were permanently exacerbated during his service in the Persian Gulf War due to exposure to environmental hazards. He reported that his symptoms progressed, required more treatment, and led to a diagnosis of allergic rhinitis. He also indicated that he had more episodes of bronchitis and his asthma became emphysema. See April 2018 Hearing Transcript, pp. 3-5. He also referred to asbestos exposure from the tile flooring in his sleeping quarters during his first period of active duty. See id. at pp. 5-7. In addition to the general requirements for service connection, a "veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the Veteran was not exposed to any such agent during that service." 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307(a)(6)(iii). The Veteran's personnel records demonstrate that he served in the Republic of Vietnam during the pertinent time period; thus, he is presumed exposed to herbicide agents. If a veteran was exposed to a herbicide agent during active military, naval, or air service, certain diseases shall be service connected if the requirements of 38 U.S.C. § 1116 and 38 C.F.R. § 3.307(a)(6)(iii) are met, even though there is no record of such disease during service, provided further that the rebuttable presumption provisions of 38 U.S.C. § 1113; 38 C.F.R. § 3.307(d) are also satisfied. 38 C.F.R. § 3.309(e). The Board notes the Veteran does not have one of the diseases listed as being presumptively associated to herbicide agents; nonetheless, the United States Court of Appeals for the Federal Circuit has held that a claimant is not precluded from establishing service connection for a disease averred to be related to herbicide exposure, as long as there is proof of such direct causation. See Combee v. Brown, 34 F.3d 1039, 1043-1044 (Fed. Cir. 1994). As noted above, service treatment records from the Veteran's first period of service have been deemed as unavailable for review. See January 2011 VA Memo. When service records are unavailable through no fault of a veteran, VA has a heightened duty to assist, as well as an obligation to explain its findings and conclusions and carefully consider the benefit-of-the-doubt rule. Washington v. Nicholson, 19 Vet. App. 362, 369-70 (2005), Cuevas v. Principi, 3 Vet. App. 542, 548 (1992); O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991). A December 1973 report of medical examination was silent for any diagnoses related to Veteran's allergies, sinuses, or respiratory system. In fact, the Veteran's sinuses, lungs, and chest were all marked as normal. Although a June 1984 civilian report of medical history noted a history of sinusitis and asthma, the Veteran's sinuses, lungs, and chest were all marked as normal upon examination. The examiner noted that the Veteran had sinus drainage at times with no medications or hospitalizations. He also had asthma as a child with no problems, medications, or hospitalizations. A June 1984 electrocardiogram noted that the Veteran used antibiotics. A January 1986 dental patient medical history form indicated that the Veteran took sinus pills. A January 1988 report of medical history noted a history of sinusitis, but he denied a history of asthma and hay fever. A January 1988 pulmonary function laboratory report as well as dental patient medical history forms dated in December 1990, August 1991, and September 1991 indicated that the Veteran smoked 12 cigarettes per day. A hearing conservation examination around 1991 indicated that the Veteran had allergies and sinus problems. An April 1996 dental patient medical history form noted a history of being under the care of a physician during the past year and taking medications, particularly allergy shots. Notably, the Veteran did not indicate that he had a history of asthma, hay fever, or emphysema. A July 1998 pre-deployment health assessment questionnaire indicated that the Veteran had allergies. The examiner noted that the Veteran had seasonal allergies that were treated with allergy shots. In an April 2001 dental patient medical history, the Veteran indicated a history of asthma; notably, the Veteran did not circle hay fever or emphysema. In a June 2001 pre-deployment health assessment, the Veteran indicated that he was in very good health, and that he did not have any medical problems. An April 2001 report of medical examination indicated that the Veteran's sinuses, lungs, and chest were normal. In connection with the Board's June 2020 remand, a VA medical opinion was obtained in February 2021. First, with regard to the estimated onset of the Veteran's asthma, the examiner concluded that it was a historical diagnosis that existed during his childhood; however, the examiner noted that it did not manifest itself during, or in the years immediately following, his active duty service in the Persian Gulf. The examiner then noted that the Veteran's June 1984 report of medical history and examination documented a history of sinusitis and asthma since childhood. The examiner continued that, while in-service and post-service treatment record documented a history of asthma, there were no active complaints, diagnoses, or treatment for asthma specifically notated, and the Veteran's use of an inhaler was related to the radiographic appearance of emphysema. The examiner also noted that an active diagnosis of asthma during adulthood was not supported by the available medical documentation. Citing to pertinent medical literature, the examiner noted that the Veteran's longstanding smoking history with over twenty pack years was noted in his treatment records, and the mild obstructive defect and the reduction in diffusing capacity for carbon monoxide was consistent with a diagnosis of emphysema/chronic obstructive pulmonary disease (COPD), and smoking was a known major cause of emphysema and/or COPD. With regard to the Veteran's allergic rhinitis, the examiner again noted that that such was a condition that also existed prior to the Veteran's entrance to active duty in 1990. Citing service treatment records from June 1984, January 1986, and January 1988 documenting the Veteran's treatment or sinus related problems, the examiner noted that it was not uncommon for a lay person's self-reported "sinus" symptoms to actually be allergic rhinitis. Nevertheless, the examiner noted that the Veteran denied problems associated with hay fever, asthma, chronic/frequent colds, sinusitis, shortness of breath, or chronic cough in an August 1991 report of medical history. Furthermore, while treatment records dating back to 1995 document chronic active diagnosis and treatment for perennial allergic rhinitis (PAR), there is nothing to indicate that the Veteran's pre-existing PAR worsened or progressed during his active duty service in the Persian Gulf from December 1990 to March 1991. With regard to the Veteran's claimed bronchitis, the examiner noted that, while a January 2015 VA treatment record listed bronchitis as a presenting problem, the actual medical assessment and diagnosis at the time was PAR. The examiner went on to note that there was no indication from the available treatment records that the Veteran has or has had chronic bronchitis during or since his active duty service periods. Insofar as the Veteran experienced coughing, the examiner noted that such was nonspecific and could be due to his GERD, asthma, emphysema/COPD, and/or post-nasal drip from his PAR. Thus, in the absence of supportive medical documentation, the examiner concluded that a diagnosis of chronic bronchitis could not be substantiated by the evidence of record. With regard to the Veteran's emphysema, the examiner noted that such was medically documented dating back to 2003; however, the examiner indicated that there was no evidence of emphysema during, or in the years immediately following, his active duty service in 1990-1991. Insofar as the examiner determined that the Veteran's asthma and PAR preexisted his military service from December 1990 to March 1991, the examiner went on to note that the Veteran denied problems with asthma and hay fever (allergic rhinitis) in an August 1991 report of medical history, and there were no record of active treatment during or immediately following his deployment to suggest that progression or worsening of these conditions occurred while on deployment. Addressing the Veteran's April 2018 regarding the onset and continuity of his symptoms, the examiner indicated that his testimony was contradicted by the August 1991 report of medical history, which was just five months after his discharge. Furthermore, the examiner noted that there was no documentation of sustained or recurrent treatment until 1995, four years after his separation from active duty. Thus, the examiner concluded that it was less likely than not that the Veteran's asthma and/or allergic rhinitis worsened during his active duty service in 1990-1991. With regard to the Veteran's emphysema initially noted in 2003, the examiner concluded that such was less likely than not related to the Veteran's exposure to environmental hazards during his service in the Persian Gulf, including exposure to titanium and oil fumes/smoke. The examiner noted that medical literature indicated that emphysema was a pathological term that described some structural changes sometimes associated with COPD. The examiner went on to note that the most important risk factor for COPD was cigarette smoking, but environmental/occupational history may also disclose risk factors for COPD. With specific regard to the Veteran, the examiner noted that his treatment records documented a 20+ year smoking history from the 1970s to the 1990s, which far exceeded the three months of environmental exposure that would be applicable to his Persian Gulf service. Thus, the impact of his daily smoking outweighed the potential environmental exposure in the development of his emphysema. With regard to the Veteran's contention that his disabilities were related to his in-service exposure to asbestos, the examiner noted that the Veteran's treatment record provided no basis upon which to base a claim for asbestos-related lung disease. Indeed, the Veteran's clinical presentation, imaging studies, and pulmonary function tests failed to provide the characteristic features of asbestosis. Finally, with regard to his contention that his disabilities are related to his in-service exposure to herbicide agents, the examiner noted that there was no evidence of lung cancer (a presumptive disability), and the evidence was lacking in support of a direct or causal association between herbicide agents and noncancerous chronic lung/respiratory diseases, including asthma, emphysema, and allergic rhinitis. As will be explained in more detail below, the Board concludes that the preponderance of the evidence weighs against a finding that the Veteran has had a diagnosis of chronic bronchitis at any point during the appeal period. Furthermore, the Board concludes that the preponderance of the evidence weighs against a finding that the Veteran's allergic rhinitis, asthma, and/or emphysema had their onset during, or is otherwise related to, his active duty service, to include his alleged in-service exposure to herbicide agents and/or environmental exposures in the Persian Gulf, or that such were aggravated by his military service. a. Bronchitis As it relates to the Veteran's claim for service connection for bronchitis, the Board concludes that he does not have a current diagnosis of chronic bronchitis and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Review of the Veteran's post-service treatment records does not reflect any diagnosis of and/or treatment for bronchitis. Furthermore, the February 2021 VA opinion provider noted that while a January 2015 VA treatment record listed bronchitis as a presenting problem, the actual medical assessment and diagnosis at the time was PAR, and that there was no indication from the available treatment records that the Veteran has or has had chronic bronchitis during or since his active duty service periods. While the Veteran may believe that he suffers from chronic bronchitis, he is not competent to provide a diagnosis in this case. Specifically, whether his observable symptoms are manifestations of chronic bronchitis is a complex medical matter that falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, his lay statements are not entitled to probative value as to whether he suffers from chronic bronchitis. b. Asthma, Emphysema, and Allergic Rhinitis With regard to the Veteran's claim that his asthma, emphysema, and/or allergic rhinitis are due to his first period of active duty service from 1963 to 1967 and his exposure to asbestos and herbicide agents, as noted above, the Veteran is entitled to the presumption of soundness for this period. Furthermore, given the lack of any service treatment records from the period of service, the Board finds that the presumption of soundness has not been rebutted. Thus, the question for the Board is whether the Veteran has a current disability manifested as asthma, emphysema, and/or allergic rhinitis that began during service or is at least as likely as not related to an in-service injury, event, or disease, to include the Veteran's exposure to asbestos or herbicide agents. On that question, the most probative evidence is the February 2021 VA medical opinion, as it reflects consideration of the Veteran's pertinent military and medical history, to include his in-service exposure to asbestos and herbicides. Moreover, it makes clear the basis for the conclusions reached, namely that there was no basis upon which to conclude that the Veteran's disabilities were asbestos-related, and that the evidence was lacking in support of a direct or causal association between herbicide agents and noncancerous chronic lung/respiratory diseases, including asthma, emphysema, and allergic rhinitis. See Nieves-Rodriguez, supra. With regard to the Veteran's claim that his asthma, emphysema, and/or allergic rhinitis are due to, or aggravated by, his active duty service in the Persian Gulf in 1990 and 1991, the Veteran is not entitled to the presumption of soundness for this period of service. Furthermore, both the Veteran's service treatment records and the February 2021 VA medical opinion clearly indicate that the Veteran's allergic rhinitis and asthma preexisted his military service. Thus, the question for the Board is whether the Veteran's allergic rhinitis and asthma increased in disability during his service in 1990 and 1991, and if so, whether it is undebatable such increase we due to the natural progression of the disease. On that question, the most probative evidence is the August 1991 report of medical history, as well as the February 2021 VA medical opinion. With regard to the August 1991 report of medical history, contrary to what he claimed during the April 2018 hearing that his symptoms were worse after his return from the Persian Gulf, the Veteran actually denied problems with his ear, nose, and throat; chronic or frequent colds; hay fever; asthma; and shortness of breath. Given that this report was approximately five months after the Veteran's discharge in March 1991, the Board finds that this is more probative as to the nature of the Veteran's symptoms following his service in the Persian Gulf. As for the February 2021 VA medical opinion, the Board finds that such is probative as it reflects consideration of the Veteran's pertinent military and medical history, to include his service in the Persian Gulf. Moreover, it makes clear the basis for the conclusions reached, namely that it was less likely than not that his asthma and allergic rhinitis were aggravated by his service in the Persian Gulf. See Nieves-Rodriguez, supra. The Board accordingly finds that the probative evidence does not demonstrate a worsening of symptoms during his period of service in the Persian Gulf, and the presumption of aggravation does not attach. Although the Veteran is competent to attest to worsening symptoms during this period of service, the Board finds such recent assertions not credible given his denial of the same shortly after his deployment. Finally, as for the Veteran's emphysema, the examiner noted that such was first diagnosed in 2003; thus, it does not appear that such preexisted the Veteran's service in 1990/1991 or his service in 2001. Nevertheless, the examiner concluded that such was not related to his military service; instead, the examiner explained that such was likely related to his 20+ pack year history of smoking. The February 2021 VA medical opinion is probative as it reflects consideration of the Veteran's pertinent military and medical history, to include his service in the Persian Gulf. Moreover, it makes clear the basis for the conclusion reached, namely that it was less likely than not that the Veteran's emphysema was related to his military service in the Persian Gulf, but rather his long history of smoking. See Nieves-Rodriguez, supra. There are no medical opinions of record that favor the Veteran's claims. The Board acknowledges the Veteran's contention that his asthma, allergic rhinitis, and/or emphysema are related to his military service; however, he is not competent to opine on the complex medical causation questions raised in this appeal, and the Board does not find the Veteran's assertions of aggravation credible. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claims for service connection for bronchitis, asthma, allergic rhinitis, and emphysema, and his claims must be denied. The Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as no competent and probative evidence supports the required elements of his claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. 2. Entitlement to service connection for bilateral foot disorders The Veteran claims entitlement to service connection for bilateral foot disorders as a result of his military service. During his hearing, the Veteran indicated that he began to have pain in his feet in the 1960s, which developed into corns and required foot surgeries in the 1980s. See April 2018 Hearing Transcript, pp. 15-24. More specifically, he described pain in his feet beginning during his first period of active service as a result of being issued the wrong size shoe and standing for prolonged periods of time as a security office and continuing through his surgeries and into the present. As noted above, service treatment records from the Veteran's first period of service have been deemed as unavailable for review. See January 2011 VA Memo. June 1984, January 1988, and August 1991 reports of medical history note the Veteran's denial of foot trouble. A January 1988 dental patient medical history form noted foot surgery in 1984. An undated adult preventative and chronic care flowsheet noted foot operations in 1983 and 1984. The Veteran underwent a VA examination in October 2020, and he was diagnosed with bilateral pes planus, right-sided hammer toes, bilateral hallux valgus, and bilateral degenerative arthritis. The examiner then noted the Veteran's report of bone spurs beginning in 2005 that have gotten worse over time, as well as his history of pain and surgical removal of corns from the fifth toes. He also stated that he was unsure when his left-sided hallux valgus began. The Veteran then reported having to wear ill-fitting boots during his military service, as well as prolonged standing as a guard. As for his flat feet, the Veteran indicated that such was first noted three to four years prior. Ultimately, the examiner concluded that the Veteran's currently-diagnosed bilateral foot problems were less likely than not related to his military service. With regard to the Veteran's hallux valgus, the examiner noted his June 1984, January 1988, and August 1991 reports of medical history wherein he denied foot trouble, as well as his history of foot surgeries in 1983 and 1984. The examiner then noted that there was no objective evidence to support that the Veteran's hallux valgus began during or soon after his active duty service. As for his post-service surgeries in 1983 and 1984, the examiner noted that, while ill-fitting military boots could cause bunion formation in susceptible individuals, it would not occur seventeen years later. With regard to the Veteran's right hammer toes, the examiner again noted his June 1984, January 1988, and August 1991 reports of medical history wherein he denied foot trouble, as well as his history of foot surgeries in 1983 and 1984. After discussing his post-service treatment records, the examiner noted that there was no objective evidence to support that the Veteran's hammer toes began during or soon after his active duty service. With regard to the Veteran's pes planus, the examiner again noted his June 1984, January 1988, and August 1991 reports of medical history wherein he denied foot trouble, as well as his history of foot surgeries in 1983 and 1984. After discussing his post-service treatment records, the examiner noted that there was no objective evidence to support that the Veteran's pes planus began during or soon after his active duty service. The examiner also noted that risk factors for pes planus in adult were aging, obesity, foot trauma, rheumatoid arthritis, or diabetes, and the Veteran's specific risk factor was his progressive age. With regard to the Veteran's arthritis, the examiner also noted that such was asymptomatic, and that it was age-related as the Veteran was seventy-eight years old. The question for the Board is whether the Veteran's currently-diagnosed bilateral foot disabilities had their onset in, or are otherwise related to his military service, to include having to stand and wearing ill-fitting boots. On that question, the most probative evidence is the June 1984, January 1988, and August 1991 reports of medical history wherein the Veteran repeatedly denied foot trouble, as well as the October 2020 VA medical opinion. The Board finds that the October 2020 is probative as it reflects consideration of the Veteran's pertinent military and medical history, as well as his theory of entitlement. Nevertheless, it makes clear the basis for the conclusions reached, namely that it was less likely than not that the Veteran's bilateral foot disorders were caused by any aspect of his military service. See Nieves-Rodriguez, supra. There are no medical opinions of record that favor the Veteran's claim. The Board acknowledges the Veteran's contention that his bilateral foot disorders were are related to his service in the 1960s; however, he is not competent to opine on the complex medical causation questions raised in this appeal, and the Board does not find the Veteran's assertions of continuous symptoms since that period of service credible, given his prior conflicting reports of history. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for his bilateral foot disabilities, and his claim must be denied. The Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as no competent and probative evidence supports the required elements of his claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. 3. Entitlement to service connection for bilateral knee disabilities The Veteran claims entitlement to service connection for bilateral knee disabilities as a result of his military service. During his hearing, the Veteran reported that as a security police officer in the military, he was required to stand for long periods during his 12-hour post during which his feet and knees would bother him. See April 2018 Hearing Transcript, pp. 20-27. He claimed that practicing drills and dropping to his knees, including during periods of active duty, ACDUTRA, and INACDUTRA resulted in repetitive use and trauma over a long period of time and had an accumulative affect to his knees. He also reported that he overcompensated for his foot pain beginning during his first period of service, which led to problems with his knee. Id. June 1984, January 1988, and August 1991 reports of medical history note the Veteran's denial of "trick" or locked knee. The Veteran underwent a VA examination in October 2020, and he was diagnosed with bilateral knee degenerative arthritis. The examiner noted the Veteran's reports of doing drills during service, as well as falling on his knees after getting out of a truck. The examiner also noted his history as a security guard standing on concrete guarding airplanes. The Veteran then indicated that his left knee pain began when he was 55 years old, and his right knee pain started five years after that. Ultimately, the examiner concluded that the Veteran's bilateral knee disabilities were less likely than not related to his military service. The examiner noted that the Veteran's June 1984, January 1988, and August 1991 reports of medical history were negative for any knee trouble. The examiner then noted that the earliest notation of knee problems was in 1997 when the Veteran report that his knee were tired, which was a nonspecific complaint with a wide range of possible etiologies. The examiner also reasoned that degenerative joint disease of the knee was related to the aging process. The examiner then stated that drills involving dropping to one's knees produced direct pressure on the kneecaps, not the knee joint, and that such would not have a causative effect in the development of knee joint problems. Also, the examiner stated that degenerative joint disease was related to the aging process from everyday use of the knee, not from standing stationary for prolonged periods of time. The question for the Board is whether the Veteran's currently-diagnosed bilateral knee disabilities had their onset in, or are otherwise related to his military service, to include having to stand for long periods of time, as well as repetitive use and trauma. On that question, the most probative evidence is the June 1984, January 1988, and August 1991 reports of medical history wherein the Veteran denied problems with is knees, as well as the October 2020 VA medical opinion. The Board finds that the October 2020 opinion is probative as it reflects consideration of the Veteran's pertinent military and medical history, as well as his theory of entitlement that his knees are due to his having to stand for long periods of time, as well as repetitive use and trauma. The opinion makes clear the basis for the conclusion reached, namely, that it was less likely than not that the Veteran's bilateral knee disabilities were caused by any aspect of his military service. See Nieves-Rodriguez, supra. There are no medical opinions of record that favor the Veteran's claims. The Board acknowledges the Veteran's contention that his bilateral knee disabilities are related to his military service; however, he is not competent to opine on the complex medical causation questions raised in this appeal. Finally, insofar as the Veteran claims that his bilateral knee disabilities are secondary to his bilateral foot disabilities, as service connection has not been awarded for his bilateral foot disabilities, the Veteran's claims for service connection for his bilateral knee disabilities on a secondary basis is without legal merit and must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426 (1994). In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claims for service connection for his bilateral knee disabilities, and his claims must be denied. The Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as no competent and probative evidence supports the required elements of his claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. REASONS FOR REMAND Entitlement to service connection for GERD The Veteran claims entitlement to service connection for GERD as a result of his military service. During his hearing, the Veteran indicated that he began to experience heartburn and pain while doing physical training during an annual tour around 1990 or 1991, after he returned from his tour in the Middle East. He self-treated the symptoms with Tums, Rolaids, or antacids. He asserts his GERD, although first diagnosed in 1996, began during or shortly after service in the Persian Gulf, and is otherwise related to his exposure to environmental hazards. Service personnel records reflect that, after he returned from the Middle East, he served on a special tour or ACDUTRA in May and June 1991 as well as an annual tour from July to August 1992. An August 1991 report of medical history noted the Veteran's denial of problems associated with frequent indigestion and stomach troubles. In June 2015 correspondence, Dr. W. Y. reported that the Veteran had GERD, and associated treatment records beginning in 1996 show treatment for gastroesophageal-related problems. In the June 2020 remand, the Board determined that an April 2019 VA medical opinion was insufficient to adjudicate the Veteran's claim as the examiner did not offer an opinion as to whether GERD can be directly related to environmental exposures in the Persian Gulf. The Board thus directed the agency of original jurisdiction (AOJ) to obtain a VA medical opinion that addressed (a) the approximate onset of the Veteran's GERD given the Veteran's testimony regarding the onset of his symptoms following his deployment to the Persian Gulf; (b) whether his GERD was related to his military service in the Persian Gulf, to include any hazardous environmental exposures; and (c) whether his GERD was aggravated beyond its nature progression by his active duty service from October 2001 to December 2001. A VA medical opinion was obtained in December 2020; however, as will be explained the opinion is once again insufficient to adjudicate the Veteran's claim. First, while the examiner opined that the Veteran's GERD was less likely than not related to his military service, the examiner did not provide a clear answer to the question of when the Veteran GERD began. Moreover, in opining against a relationship between GERD and hazardous exposures in the Persian Gulf, the examiner provided an incomplete rationale. To ensure an adequate record upon which to decide the Veteran's claim, a remand is necessary to afford the Veteran a new VA examination. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). On remand, the Veteran should be given the opportunity to identify any outstanding pertinent records. The matters are REMANDED for the following action: 1. Give the Veteran an additional opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 2. The Veteran should be afforded an examination to determine whether any currently-diagnosed GERD had its onset during, or is otherwise related to his military service, to include his service in the Persian Gulf and any possible hazardous environmental exposure therein. The record must be made available to, and reviewed by the examiner. The examiner should take a history from the Veteran as to the progression of his claimed disability. Following a review of the entire record, to include the lay statements from the Veteran concerning the onset and continuity of symptomatology, the examiner should address the following inquiries: (a) Please provide a best estimate as to date of onset for the Veteran's GERD. The Veteran contends his GERD symptoms began shortly after completion of his deployment to the Persian Gulf in March 1991, and post-service treatment records reflect that he began to received treatment for gastroesophageal-related problems in 1996. Please discuss what in the record helps inform your estimate, and specify whether it is at least as likely as not (50 percent or greater probability) that GERD had its onset during the Veteran's period of active duty service from December 1990 to March 1991, while serving in the Persian Gulf. (b) If it is concluded that the Veteran's GERD did not have its onset during his period of active duty service from December 1990 to March 1991, is it at least as likely as not (50 percent or greater probability) that such is otherwise related to the Veteran's Persian Gulf service, to specifically include hazardous environmental exposures? (c) Notwithstanding the above, is it at least as likely as not that GERD underwent an increase in disability during his subsequent period of active duty service from October 2001 to December 2001. If so, please also indicate whether it is clear and unmistakable (i.e., undebatable) that the increase in disability was due to the natural progression of the disease. In rendering each requested opinion, the examiner must specifically consider the service treatment records and post-service treatment records, as well as the Veteran's assertions regarding the onset and nature of symptoms, including his assertions that he began to experience heartburn and pain while doing PT during an annual tour (ACDUTRA) shortly after he returned from his tour in the Middle East/Persian Gulf, and that he self-treated his symptoms with Tums, Rolaids, or antacids to try to relieve his symptoms until he ultimately sought treatment. A clearly-stated rationale for any opinion offered should be provided. 3. Thereafter, readjudicate the issue on appeal. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James R. Springer, 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.