Citation Nr: 23003537 Decision Date: 01/19/23 Archive Date: 01/19/23 DOCKET NO. 17-20 042 DATE: January 19, 2023 ORDER 1. Service connection for a headache disability is denied. 2. Service connection for irritable bowel syndrome (IBS) is denied. 3. Service connection for gastroesophageal reflux disease (GERD) is denied. 4. Service connection for a left knee disability, to include as secondary to service-connected right ankle scar, service-connected tinnitus, and service-connected posttraumatic stress disorder (PTSD), is denied. 5. Service connection for a right heel disability, to include as secondary to service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD, is denied. 6. Service connection for a right ankle disability, to include as secondary to service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD, is denied. FINDINGS OF FACT 1. The probative evidence of record is not at least in relative equipoise as to whether a headache disability was incurred in, aggravated by, or otherwise attributable to, active-duty service. 2. The probative evidence of record is not at least in relative equipoise as to whether IBS was incurred in, aggravated by, or otherwise attributable to, active-duty service. 3. The probative evidence of record is not at least in relative equipoise as to whether GERD was incurred in, aggravated by, or otherwise attributable to, active-duty service. 4. The probative evidence of record is not at least in relative equipoise as to whether a left knee disability was incurred in, aggravated by, or otherwise attributable to, active-duty service. The probative evidence is not at least in relative equipoise as to whether a left knee disability (arthritis) manifested to a compensable degree within one year of the Veteran's separation from service. The probative evidence is not at least in relative equipoise as to whether the Veteran's left knee disability was proximately caused by or aggravated beyond its natural progression by service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD. 5. The probative evidence of record is not at least in relative equipoise as to whether a right heel disability was incurred in, aggravated by, or otherwise attributable to, active-duty service. The probative evidence is not at least in relative equipoise as to whether the Veteran's right heel disability was proximately caused by or aggravated beyond its natural progression by service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD. 6. The probative evidence of record is not at least in relative equipoise as to whether a right ankle disability was incurred in, aggravated by, or otherwise attributable to, active-duty service. The probative evidence is not at least in relative equipoise as to whether the Veteran's right ankle disability was proximately caused by or aggravated beyond its natural progression by service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD. CONCLUSIONS OF LAW 1. The criteria for service connection for a headache disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for service connection for IBS have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 3. The criteria for service connection for GERD have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304 4. The criteria for service for left knee disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307. 3.309, 3.310. 5. The criteria for service for right heel disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 6. The criteria for service for right ankle disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1978 to September 1981. These matters come before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2019, the Veteran testified at a Board hearing before a Veterans Law Judge (VLJ) who is no longer at the Board. In response to the Board's correspondence about the status of this VLJ and the opportunity of another Board hearing, the Veteran indicated that he did not wish to appear at another Board hearing, selecting to have his case considered on the evidence of record. By way of relevant procedural history, the Board remanded the above-captioned issues for additional evidentiary development in December 2019, which regrettably required an additional remand because all of the requested development had not been performed. Consequently, in March 2022, the Board again remanded these issues to effectuate the development that had not occurred in December 2019. Upon review of record subsequent to the March 2022 remand, there has been substantial compliance with the Board's remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998) (Board remand confers a right on a claimant to compliance with the remand order); Dyment v. West, 13 Vet. App. 141, 147 (1999) (clarifying that substantial compliance with Board remand is required). The Board has reviewed the relevant evidence comprehensively. Although the Board has an obligation to provide reasons and bases to support a decision, there is no requirement to discuss, in detail, all the evidence submitted by or on behalf of a Veteran. Gonzales v. West, 218 F. 3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record; however, the Board does not have to discuss each piece of evidence). The analysis below focuses on the most salient and the most relevant evidence about what this evidence shows, or fails to show, about the issues on appeal. The Veteran must not assume that the Board has overlooked pieces of evidence that are not discussed explicitly. Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). SERVICE CONNECTION The Veteran seeks service connection for the above-captioned claimed disabilities. Additionally, the Veteran has advanced that his claimed left knee disability, right ankle disability, and right heel disability are secondary to his service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD. 1. Service connection for a headache disability is denied. 2. Service connection for irritable bowel syndrome (IBS) is denied. 3. Service connection for gastroesophageal reflux disease (GERD) is denied. 4. Service connection for a left knee disability is denied, to include as secondary to service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD, is denied. 5. Service connection for a right heel disability, to include as secondary to service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD, is denied. 6. Service connection for a right ankle disability, to include as secondary to service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD, is denied. For the reasons articulated below, the Board finds that service connection is not warranted for these 6 claimed disabilities. When contemplated under the evidentiary standards laid out in Lynch v. McDonough, 21 F. 4th 776, 781-82 (Fed. Cir. 2021), the evidence is not at least in relative equipoise as to whether these 6 claimed disabilities were incurred in, aggravated by, or otherwise attributable to, active-duty service (to include for the left knee, right heel, and right ankle on secondary bases). See id. (only in situations when the evidence persuasively favors one side, or another is the benefit-of-the-doubt doctrine not for application). In order to establish service connection on a direct basis, the record must contain competent evidence of: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). In the absence of proof of a present disability there can be no valid claim. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F. 3d 1039, 1043 (Fed. Cir. 1994). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). If the evidence is competent, the Board must then determine if the evidence is credible. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511 (1995). Some chronic diseasesto include arthritismay be presumed to have been incurred in service when they manifest to a degree of ten percent or more within the applicable presumptive period of one year following separation from service. 38 U.S.C.§§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). A disability which is proximately due to, or the result of, a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310. Secondary service connection is permitted based on aggravation; compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the relative weight of evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107. Evidence and Analysis The Veteran's service treatment records (STRs) provide initial guidance in these matters. In a May 1979 STR, a clinician indicated that Veteran sought treatment for a laceration of the right ankle. At this time, the clinician also noted that the Veteran complained of right heel. The Veteran conveyed that he sustained this injury when a door collided into his right ankle and right heel. In October 1979, the Veteran sought treatment for vomiting and diarrhea. A clinician indicated that the Veteran had consumed two large glasses of whiskey the prior evening. As an assessment, the clinician provided gastritis probably due to alcohol. In November 1979, a clinician wrote that the Veteran reported for a follow-up appointment to assess his status after an "alcohol incident with a severe hangover". In an undated emergency room (ER) encounter note from 1979, a clinician reported that the Veteran sought treatment for his right heel. In a January 1980 physical profile serial report, a clinician at Cannon Air Force (New Mexico) reported that the has sustained an abrasion/avulsion of the left knee. At this time the clinician indicated restrictions on marching; prolonged standing; and/or walking use of the lower extremities. In a subsequent report (two days post left knee abrasion/avulsion), a clinician reported that the Veteran endorsed increased pain. Upon examination, the wound appeared to be healing, albeit with a mild infection. Also, in January 1980, the Veteran complained of a bout of diarrhea. A clinician prescribed a bland diet and Kaopectate. In a February 1980 STR, a clinician reported that the Veteran complained of left knee pain. According to this clinician that Veteran gave two accounts of how he injured his left knee (involving a door collision and/or a hooked shoelace). February 1980 X-ray imaging of the left knee disclosed that the bony structures were unremarkable, without any signs of acute fracture. Likewise, soft tissues were unremarkable. In a June 1980 report of medical examination, a clinician indicated normal evaluations of the Veteran's lower extremities; abdomen and viscera; neurological status; and anus and rectum. In his contemporaneous report of medical history, the Veteran reported that he had not had and did not have swollen or painful joints; frequent or severe headache; frequent indigestion; stomach, liver, or intestinal problems; broken bones; piles or rectal disease; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; 'trick' or locked knee; and/or foot trouble. In June 1981, the Veteran sought treatment for chest pains and a headache. A clinician provided an assessment of viral syndrome. In a July 1981 STR, a clinician opined that the Veteran sought treatment for dizziness, fatigue, diarrhea, and diminished appetite. The clinician noted that there was no evidence of icterus, noting an assessment of a gastric malady. In the Veteran's August 1981 discharge report of medical examination (labeled as such), the clinician indicated normal evaluations of the Veteran's lower extremities; abdomen and viscera; neurological status; and anus and rectum. In his contemporaneous report of medical history, the Veteran reported that he had not had and did not have swollen or painful joints; frequent or severe headache; frequent indigestion; stomach, liver, or intestinal problems; broken bones; piles or rectal disease; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; 'trick' or locked knee; and/or foot trouble. Throughout the course of these claims, VA has received hundreds of pages of treatment records from Kaiser P., spanning over two decades. Such records disclose that the Veteran sought private treatment for dyspepsia; fecal maladies; gout; abdominal pain; nephrolithiasis; hyperlipidemia; bloody stools; sinusitis; osteoarthritis; GERD; eye problems; transaminase elevation; eyelid ptosis; mild non visually significant dermatochalasis; back pain; muscle spasm of the back; hemorrhoids; and upper respiratory infections. While these records disclose the on-going statuses of these multiple disease entities and their courses of treatment, they do not provide guidance as to any etiological association with the Veteran's service. The Veteran's 2015 VA progress notes reveal active problems of gout; hyperlipidemia; shoulder pain; abdominal pain; impotence; and benign prostatic hypertrophy without outflow obstruction. In January 2016, the Veteran submitted a lay statement concerning his claimed disabilities. As to GERD, the Veteran conveyed that his "irregular" schedule (and erratic meals) in service caused digestive distress. The Veteran indicated that he had self-treated. The Veteran also posited that his GERD progressed into IBS. As to the claimed left knee disability, the Veteran reported that his many hours in motor vehicles during service contributed to left knee pain. As to the right ankle and right heel, the Veteran noted a motorcycle accident and a dormitory parking lot event, which led to these claimed disabilities. Here too, the Veteran indicated that he self-treated. The Veteran's 2019 VA progress notes disclose active problems of tinnitus; environmental allergy; sleep apnea; low pain back pain; pain in the left knee; GERD; gout; hyperlipidemia; shoulder pain; abdominal pain; impotence; and benign prostatic hypertrophy without outflow obstruction. At the August 2019 Board hearing, the Veteran conveyed that he sought treatment for his claimed disabilities after he separated from active-duty service. Prior to this, the Veteran reported that he self-treated his respective symptoms. The Veteran emphasized his bouts of diarrhea, of which, he contended were indicative of IBS. The Veteran also conveyed accounts of his in-service claimed orthopedic disabilities, noting that he had undergone a left knee replacement at Kaiser P. The Veteran underscored the role that his in-service operation of "heavy equipment" played in the acquisition and aggravation of these claimed disabilities. Here, the Veteran offered testimony as to several dump truck incidents. As to his claimed headache disability, the Veteran indicated that it began "long ago"again the Veteran reported that he self-medicated at the early stage of this claimed disability. In a November 2019 VA treatment record, a clinician indicated that the Veteran reported for an upper GI endoscopy. The endoscopy disclosed the following impressions: an irregular Z-line; a medium amount of food (residue) in the stomach; and a normal duodenal bulb and second portion of the duodenum. This clinician did not provide any guidance as to the etiology of these impressions. In November 2020, the Veteran reported for a battery of VA examinations. In each instance, the clinician reviewed the claims file; considered the Veteran's lay complaints of his medical history; and conducted an appropriate evaluation. Upon a headache examination, the clinician provided a current diagnosis of tension headache (2020). Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. As a rationale, the clinician opined that, [I] have reviewed all of the medical records including testimony and January 2016 correspondence. Even after reviewing this there is no clear evidence that the veteran's headaches occurred while in [...] service. [While] the Veteran stated in the hearing that symptoms started during service, the records don't support this. Also, [the] Veteran's responses from the hearing were noted to be inaudible numerous times. The lay statement[s] [also indicate] that the Veteran did not seek care. Upon a left knee examination, the clinician provided a current diagnosis of status post total replacement, left knee, with residual pain (2019). Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. As to direct service connection, the clinician articulated that, [A]lthough the Veteran stated in the hearing that [left knee] symptoms started during [active duty] service, the records don't support this. Also, [the] Veteran's responses from the hearing were noted to be inaudible numerous times. The lay statement[s] [also indicate] that the Veteran did not seek care. As to secondary service connection (proximate causation), the clinician stated that, [T]here is evidence in the records supporting [that] the veteran had a wound to the right heel, but this RIGHT ANKLE/HEEL SCAR would not contribute to left knee degenerative arthritis requiring a total knee replacement. As to secondary service connection (aggravation), the clinician stated that, [T]his veterans records were extensively reviewed. His service-connected RIGHT ANKLE/HEEL SCAR was due to a wound [;] and would have not contributed to the development of left knee osteoarthritis leading to a total knee replacement nor right [Achilles' tendonitis]. As stated previously, this veteran does not have objective findings to render [a] diagnosis [...] related to the right foot. Therefore, this [veteran's] claimed left knee disability is less likely than not aggravated beyond its natural progression by the [veteran's] service-connected RIGHT ANKLE/HEEL SCAR. Upon a right ankle examination, the clinician provided a current diagnosis of right ankle tendonitis (2020). Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. As to direct service connection, the clinician stated that, [I] have reviewed all of the medical records including testimony and January 2016 correspondence. Even after reviewing this [,] there is no clear evidence that the veteran's [Achilles' tendonitis] occurred while in the service. There was evidence of a right ankle wound, but it is highly unlikely that this caused and led to [Achilles' tendonitis]. Although the Veteran stated in the hearing that symptoms started during service, the records don't support this. Also, [the] Veteran's responses from the hearing were noted to be inaudible numerous times. The lay statement[s] [also indicate] that the Veteran did not seek care. As to secondary service connection (proximate causation), the clinician stated that, [T]here is evidence in the records supporting at the veteran had a wound to the right heel, but this RIGHT ANKLE/HEEL SCAR would not contribute to developing left knee degenerative arthritis requiring a total knee replacement. The RIGHT ANKLE/HEEL SCAR is due to a wound sustained during the veteran's time in the Air Force. This wound, which has healed would not have led to [Achilles' tendonitis]. [Achilles' tendonitis] is caused by repetitive injuries, wear and tear, and repetitive strain and stress on the joint. As to secondary service connection (aggravation), the clinician conveyed that, This [veteran's] records were extensively reviewed. His service-connected RIGHT ANKLE/HEEL SCAR was due to a wound [;] and would have not contributed to the development of left knee osteoarthritis leading to a total knee replacement nor right [Achilles' tendonitis]. As stated previously, this veteran does not have objective findings to render [a] diagnosis [...] related to the right foot. Therefore, this [veteran's] claimed RIGHT ANKLE DISABILITY is less likely than not aggravated beyond its natural progression by the [veteran's] service-connected RIGHT ANKLE/HEEL SCAR. Upon a right heel (foot conditions) examination, the clinician provided no current diagnosis relating to the right heel. However, the Veteran endorsed that he experiences occasional pain in his right heel. Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. As to direct service connection, the clinician remarked that, [The Veteran's claimed] right heel condition, with no objective evidence to render right foot condition diagnosis, is less likely than not incurred in or caused by the specific in-service illness, event, or injury. As to both the proximate causation and the aggravation prongs of secondary service connection, the clinician wrote that, As stated previously, this veteran does not have objective findings to render [a] diagnosis [...] related to the right foot. Therefore, this [veteran's] claimed RIGHT HEEL DISABILITY is less like than not due to the [service-connected] RIGHT ANKLE/HEEL SCAR. [Moreover, the claimed] RIGHT HEEL DISABILITY is less likely than not aggravated beyond its natural progression by the [veteran's] service-connected RIGHT ANKLE/HEEL SCAR. Upon a GERD examination, the clinician provided a current diagnosis of GERD (2020). Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. According to the clinician, GERD is less likely than not incurred in or caused by the specific in-service illness, event, or injury. I have reviewed all of the medical records [,] including testimony and January 2016 correspondence. Even after reviewing this there is no clear evidence that the veteran's GERD occurred while in the service. [Even though] the Veteran stated in the hearing that symptoms started during service, the records don't support this. Also, [the] Veteran's responses from the hearing were noted to be inaudible numerous times. The lay statement[s] indicate that the Veteran did not seek care [for GERD]. Upon an IBS examination, the clinician provided a diagnosis of chronic diarrhea (2020). Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. According to the clinician, This veteran's claimed [...] IBS [,] diagnosed as chronic diarrhea [,] is less likely than not incurred in or caused by the specific in-service illness, event, or injury. There was evidence of [a one-time] episode of diarrhea in 1980, but it is highly likely that this is related to his current diagnosis of chronic diarrhea. Although the Veteran stated in the hearing that symptoms started during service, the records don't support this. As noted above, the Board remanded these issues for additional evidentiary development in March 2022. Pursuant to the remand, the Veteran reported for another battery of VA examinations in June 2022. In each examination instance, the clinician reviewed the claims file; considered the Veteran's lay complaints of his medical history; and conducted an appropriate evaluation. Upon a right ankle examination, the clinician provided a current diagnosis of a right collateral ligament sprain. Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. According to this clinician, The claimed right ankle condition diagnosed as right ankle strain is less likely than not proximately due to or the result of the Veteran's right ankle scar. A thorough review of medical literature failed to show any causal relationship between ankle strain and right ankle scar. Upon a right heel examination, the clinician did opine that the Veteran had bilateral pes planus (however there was no current diagnosis specific to the right heel). Nevertheless, upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. According to this clinician (as to direct and secondary causation and aggravation), Right heel pain is less likely than not related to or aggravated by the status post right ankle/heel scar that was incurred during active duty. The claimed scar is stable without cause of limitation in movement or immobilization of the ankle; thus, not causing changes in ambulation or weight bearing line. In addition, the Veteran has moderate flat [feet] which also causes heel pain. [...] The condition is less likely than not caused, incurred, or aggravated during service as there is no evidence of heel or foot pain during active duty and [the Veteran's] separation exam did not indicate any ankle and foot condition and health concerns at the time of discharge. AND Right heel disability is less likely than not aggravated beyond its natural progression by his [service-connected] disability for PTSD. The conditions of right heel disability and [service-connected] PTSD are not medically related. The claimed right heel disability is a separate entity entirely from the PTSD and unrelated to it. A thorough review of medical literature failed to demonstrate a causal relationship. A nexus has not been established. Upon a GERD examination, the clinician provided a current diagnosis of GERD. Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. According to this clinician, The diagnosis for GERD is less likely than not incurred during active-duty service. [STRs] and [the Veteran's] separation exam did not indicate any diagnosis or ongoing health concerns for GERD during active duty and at the time of discharge. Upon an IBS examination, the clinician did provide a current diagnosis of IBS. Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. According to this clinician, The diagnosis for irritable bowel syndrome is less likely than not incurred in or caused by [...] service. [STRs] and [the] separation exam did not indicate any diagnosis or ongoing health concerns for IBS during active duty [or] at the time of discharge. During service, [the] veteran has reported diarrhea and was diagnosed with gastroenteritis [that] was acute only. There is no evidence of chronicity of care and symptoms are subjective only. Upon a headache examination, the clinician provided a current diagnosis of tension headache. Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. According to this clinician (as to direct and secondary causation and aggravation), During service, there was no evidence of diagnosis and ongoing treatment for headaches and [the Veteran's] separation exam did not indicate any headache condition and health concerns at the time of discharge. Upon a left knee examination, this clinician provided a current diagnosis of status post total knee replacement, left knee, with residual pain. Upon careful contemplation of the totality of evidence, to include findings from the instant evaluation, the clinician rendered a negative etiological opinion, suffused with both evidence and medical expertise. According to this clinician (as to direct and secondary causation and aggravation), Status post total knee replacement, left knee, with residual pain is less likely than not incurred in or caused by the left knee disability during service. During service, left knee condition was acute only. Veteran reports injury to the left knee and was diagnosed with deep knee abrasion during active duty. X-ray was normal. Separation exam did not indicate any left knee health concerns or ongoing treatment at the time of discharge. In addition, Kaiser encounter notes dated 01/19/2018 states "Patient now retired from UCSD as an electrician, has history of left knee osteoarthritis states he will have left knee replacement thru the UCSD workman's comp." In August 2022, a clinician provided an addendum, again underscoring the negative etiological opinion as to the Veteran's right ankle disability. This clinician supported this negative etiological opinion with a lengthy and comprehensive rationale, replete with both evidence and highly specialized medical findings. According to the clinician, There is no evidence of an ankle condition of either ankle while in service. There is no evidence of a right ankle condition in particular. The separation exam dated 8/20/81 was negative for signs or symptoms of a chronic ankle condition. These exams are notably thorough and include a history, physical, records review to assess conditions arising in service, and a veteran answered [his] RMH (report of medical history), which was specifically negative for signs or symptoms of joint injuries, including the ankles and lower extremities. The veteran unequivocally did not have a right ankle condition at separation. The veteran was diagnosed with nonspecific tendonitis on 10/23/20 and a lateral collateral ligament sprain on 6/28/22. These are completely different injuries and neither has an apparent nexus [to] service. Regardless of the actual diagnosis, whether it be tendonitis or a lateral collateral ligament sprain, it is less likely than not due to service or events in service. Though an absence of records does not disqualify from service connection itself, it is medically implausible that an individual would have gone a span of 25+ years without seeking care for an ankle condition having its nexus in service. The obvious limitations due to a chronic ankle condition and its impact on ambulation, prolonged standing, walking on uneven ground, strenuous activity, etc. would almost certainly require evaluation and treatment. It is not due to the superficial laceration of the right heel occurring in service and there was no residual deficit attributed to the scar at separation. There was no evidence of a sprain or tendonitis associated with the laceration. They would not be caused by a laceration or scar. Tendonitis is an overuse or acute strain injury [,] and a lateral collateral ligament sprain is an acute injury due to eversion of the ankle. Both of the conditions diagnosed on the DBQs (disability benefits questionnaires) would not be caused by a heel laceration. Obviously, the laceration would have no bearing on a collateral ligament sprain, which is an acute injury. Therefore, it is less likely than not that the veteran's right ankle conditions, regardless of the accepted or actual diagnoses, are due to or incurred in service, and they are unrelated to the laceration occurring in service. Any claim of onset in service with continuity of symptoms since service is not supported by clear medical evidence to the contrary, including the respective pathophysiologies of either condition [,] and the absence of a chronic [right] ankle condition at the separation exam in 1981. No nexus is established in service, at separation, within one year of service, or for greater than 25 years post-service. Tendonitis is an overuse injury, acute or chronic. Ankle sprains are acute injuries. There was no evidence of either in service, including at the time of the laceration. The heel laceration is unrelated anatomically to either diagnosed condition. The Veteran has not been provided VA examinations or requests for medical opinions focalized on the issues of service connection for left knee disability, right heel disability, or right ankle disability as secondary to service-connected tinnitus. Likewise, the Veteran not been provided VA examinations or requests for medical opinions focalized on the issues left knee disability or right ankle disability as secondary to service-connected PTSD. The Court has held that VA is not required to provide a medical examination when there is not credible evidence. Bardwell v. Shinseki, 24 Vet. App. 36 (2010). Additionally, conclusory generalized lay statements that a service event or illness caused a claimant's current condition (or lack thereof) are insufficient to require the Secretary to provide examinations. Waters v. Shinseki, 601 F. 3d 1274, 1278 (2010). Here, the Veteran might sincerely believe in these theories of secondary causation and/or aggravation; however, the evidence of record does not contain any evidence, even to suggest that possibility. The Veteran believes that his 6 disabilities were incurred in or aggravated by service (and in the case of the left knee disability, right heel disability, and right ankle disability secondary to service-connected right ankle scar, service-connected tinnitus, and service-connected PTSD). While the Veteran is competent to report discernable symptoms and report etiological opinions of competent clinicians (Jandreau, 492 F. 3d 1372; Kahana, 24 Vet. App. 428), the evidence of record fails to disclose that the Veteran has training or expertise in neurology, gastroenterology, or orthopedics to render complex etiological opinions. 38 C.F.R. § 3.159(a)(1). Indeed, the Board recognizes that the Veteran has sought treatment for a host of disabilities and disease entities at Kaiser P. for several decades. While these records follow the Veteran's clinical status and treatment protocols, these many hundreds of pages of medical records do not provide affirmative guidance as to whether any of the Veteran's claimed disabilities has an etiological association (at any level) with the Veteran's active-duty service or service-connected disabilities. Thus, upon an exhaustive review of the record, neither the Veteran nor his representative has offered any competent clinical or scientific evidence to support these 6 service connection claims. A Veteran still ultimately bears some burden of production. 38 U.S.C. § 5107(a); Cromer v. Nicholson, 455 F. 3d 1346 (Fed. Cir. 2006). Furthermore, a claimant, such as the Veteran, has some responsibility to cooperate in the development of all facts pertinent to his claim and that the duty to assist is not a one-way street. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board recognizes that the Veteran believes the theories of entitlement that he advances; however, lay beliefs do not rise to the level of affirmative competent medical or scientific evidence. 38 C.F.R. § 3.159(a)(1). As already articulated, arthritis (of the left knee prior to replacement) is a presumptive disease under the provisions of 38 C.F.R. §§ 3.307(a), 3.309(a). However, the evidence of record fails to disclose that this left knee arthritis was either diagnosed or manifested to a compensable degree within one year of the Veteran's separation from active-duty service. Hence, service connection is not possible for the left knee disability presumptively. The present disability elements of these 6 disabilities are established. However, the persuasive weight of competent and probative evidence fails to establish in-service incurrences, predicates, or causes upon which nexuses can be drawn. Saunders, 886 F. 3d 1356. Stated differently, other than the Veteran's conjecture, there is no evidence that these disabilities were incurred in active-duty service. Again, the Board identifies the Veteran's August 1981 discharge report of medical examination, in which the clinician reported normal evaluations of the Veteran's lower extremities; abdomen and viscera; neurological status; and anus and rectum. Indeed, by the Veteran's own reporting in his August 1981 discharge report of medical examination, he had not had and did not have swollen or painful joints; frequent or severe headache; frequent indigestion; stomach, liver, or intestinal problems; broken bones; piles or rectal disease; arthritis, rheumatism, or bursitis; bone, joint, or other deformity; 'trick' or locked knee; and/or foot trouble. As to the Veteran's claims to entitlement on a secondary basis, as discussed above, neither the Veteran nor his representative have not submitted any evidence to support these contentions. Consequently, the possibility or granting service connection for these two disabilities is foreclosed. Allen, 7 Vet. App. 439. The Board assigns substantial weight to the many VA examinations of record. As articulated above, the clinicians reviewed the claims file; considered the Veteran's lay complaints of his medical history; and conducted appropriate evaluations. Perhaps most importantly, these clinicians provided robust evidence-based and medically informed rationales to support each and every negative etiological opinion. Therefore, the persuasive weight of probative evidence is against the Veteran's 6 service connection claims. As such, there are no doubts to resolve. 38 U.S.C. § 5107. John R. Doolittle, II Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. J. Komins, 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.