Citation Nr: 1209703 Decision Date: 03/15/12 Archive Date: 03/28/12 DOCKET NO. 08-16 792 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been presented to reopen a previously denied claim for entitlement to service connection for pes planus. 2. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease of the lumbar spine. 3. Entitlement to service connection for erectile dysfunction as secondary to a service connected disability. ATTORNEY FOR THE BOARD Katie K. Molter, Associate Counsel INTRODUCTION The Veteran served on active duty from October 1976 to March 1985. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a May 2007 rating decision in which the RO denied the Veteran's petition to reopen a previously denied claim for entitlement to service connection for pes planus and an August 2009 rating decision in which the RO granted service connection for lumbar spine degenerative joint disease associated with right total knee replacement history of right knee injury and assigned an initial 10 percent rating and denied entitlement to service connection for erectile dysfunction. The Veteran perfected a timely appeal with respect to both rating decisions. As a final preliminary matter, the Board notes that a review of the Virtual VA paperless claims processing system does not reveal any additional documents pertinent to the present appeal. FINDINGS OF FACT 1. A September 2004 rating decision denied the Veteran's claim for entitlement to service connection for pes planus. 2. The evidence associated with the claims file since the September 2004 rating decision includes evidence that is cumulative or redundant and, therefore, does not raise a reasonable possibility of substantiating the claim of entitlement to service connection for pes planus. 3. Since service connection, the Veteran's degenerative joint disease of the lumbar spine, even with consideration of the Veteran's complaints of pain, has not caused forward flexion of the thoracolumbar spine to 30 degrees or less or favorable ankylosis of the entire thoracolumbar spine. There is no evidence of incapacitating episodes. 4. The Veteran's erectile dysfunction is casually related to his service-connected Posttraumatic stress disorder (PTSD). CONCLUSIONS OF LAW 1. The September 2004 rating decision, denying service connection for pes planus is final. See 38 U.S.C.A. § 7105 (West 2002); 38 C.F.R. §§ 3.104, 20.204, 20.302, 20.1103 (2011). 2. New and material evidence has not been received to reopen the claim of service connection for pes planus. 38 U.S.C.A. §§ 5108, 7104, 7105 (West 2002 & Supp. 2011); 38 C.F.R. §§ 3.156, 20.1105 (2011). 3. The criteria a disability rating in excess of 10 percent for degenerative joint disease of the lumbar spine have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 4.1-4 .16, 4.71a, Diagnostic Codes 5242 (2011). 4. The criteria for establishing entitlement to service connection for erectile dysfunction as secondary to service-connected PTSD disability are met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA's duties to notify and assist claimants in substantiating a claim for VA benefits are found in part at 38 U.S.C.A. § 5103 (West 2002 & Supp. 2011) and 38 C.F.R. §3.159 (2011). VA's notice requirements apply to all five elements of a service connection claim: veteran status, existence of a disability, a connection between the veteran's service and the disability, degree of disability, and effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). Compliant notice must be provided to a claimant before the initial unfavorable decision on a claim for VA benefits by the agency of original jurisdiction (in this case, the RO and the AMC). See Pelegrini v. Principi, 18 Vet. App. 112 (2004); see also Disabled American Veterans v. Secretary of Veterans Affairs, 327 F.3d 1339 (Fed. Cir. 2003). However, the notice requirements may, nonetheless, be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Id. Collectively, in March 2007, April 2009, May 2009, and June 2009 pre-rating letters, the Veteran was given the notice required by the VCAA, to include that required by Dingess. Specific to a claim to reopen a previously denied claim for service connection, the VCAA requires that VA provide a notice letter that describes the basis of the previous denial, as well as the evidence necessary to substantiate the element or elements of service connection found to be unsubstantiated in the previous denial. The failure to provide this notice prior to the adjudication of a veteran's claim generally constitutes prejudicial error by VA. See Kent v. Nicholson, 20 Vet. App. 1, 10 (2006). The March 2007 letter was consistent with the requirements in Kent. There is no additional notice that should be provided, nor is there any indication that there is additional existing evidence to obtain or development required to create any additional evidence to be considered in connection with the claims herein decided. Consequently, any error in the sequence of events or content of the notice is not shown to prejudice the Veteran or to have any effect on the matters decided on appeal. Any such error is deemed harmless and does not preclude appellate consideration of the matters herein decided, at this juncture. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (holding that a party alleging defective notice has the burden of showing how the defective notice was harmful). All relevant evidence necessary for an equitable resolution of the issue remaining on appeal has been identified and obtained, to the extent possible. The evidence of record includes VA examination reports, VA treatment records, service treatment records, identified private treatment records, and statements from the Veteran and his representative. The Board has carefully considered the provisions of the VCAA in light of the record on appeal, and for the reasons expressed above; it finds that the notice and development of the claim has been consistent with these provisions. Accordingly, the Board will proceed to a decision on the merits. II. Analysis A. Petition to reopen claim In general, rating decisions that are not timely appealed are final and binding based on the evidence then of record. See 38 U.S.C.A. § 7105; 38 C.F.R. §§ 3.104, 20.1103. A claim which has been denied in an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. § 7105(c) (West 2002). The exception to this rule is 38 U.S.C.A. § 5108 (West 2002), which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. Here, the claim to reopen was received in May 2006; therefore, the current version of the law, which is set forth in the following paragraph, is applicable in this case. New evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). A VA adjudicator must follow a two-step process in evaluating previously denied claims. First, the adjudicator must determine whether the evidence added to the record since the last final decision is new and material. If new and material evidence is presented or secured with respect to a claim that has been finally denied, then the claim will be reopened and decided upon the merits. Once it has been determined that a claimant has produced new and material evidence, the adjudicator must evaluate the merits of the claim in light of all of the evidence, both new and old, after ensuring that VA's statutory duty to assist the claimant in the development of his claim has been fulfilled. See 38 U.S.C.A. § 5108; Elkins v. West, 12 Vet. App. 209 (1999); Vargas-Gonzalez v. West, 12 Vet. App. 321, 328 (1999). For the limited purpose of determining whether new and material evidence has been submitted, the credibility of the newly submitted evidence is presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Board must decide whether new and material evidence has been received to reopen the Veteran's claim for entitlement to service connection for pes planus. While there is some evidence the Veteran has submitted that is new, it must also be considered material. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. In the current matter, the Board finds the newly submitted evidence by the Veteran is cumulative and redundant and does not provide anything material regarding a positive association between the Veteran's pes planus and his active duty service. In rating decisions dated in December 1985 and September 2004, the RO denied service connection for pes planus, respectively. These decisions were predicated on the finding (in December 1985) that the Veteran's pes planus preexisted military service and was not aggravated by his period of active duty. The September 2004 rating decision continued a denial on the basis that no new and material evidence had been presented to show that the Veteran's pes planus was aggravated by his military duty. The evidence of record at the time of the September 2004 rating decision consisted of the Veteran's induction examination report, service treatment records, a medical board report and various VA treatment records. At the time of induction, in September 1976 mild pes planus was noted. The Veteran complained of arch pain in January 1978 and was prescribed arch supports. A July 1978 service treatment record shows that the Veteran presented for continuing evaluation of painful flat feet. Present for approximately 4 months in duration. Objectively, the Veteran was found to have pes planus foot type and was assessed with plantar fasciitis aggravated by standing. In September 1981 flat arches of the feet were noted. In January 1985 the medical board assigned a 10 percent evaluation for left calcaneal fasciitis. The evidence added to the record since the September 2004 rating decision includes various VA and private treatment records. However, none of this evidence pertains to the Veteran's claim for pes planus. Accordingly, the newly submitted records and contentions do not provide any new evidence that would indicate that the Veteran's pes planus was aggravated during his period of active duty service. Rather, the evidence is cumulative and redundant, already received and considered by the RO in its final September 2004 decision. Since there is no new non-redundant evidence that shows that the Veteran's preexisting pes planus was aggravated by his active duty military service, the evidence does not raise a reasonable possibility of substantiating the claim and thus is not material to the Veteran's claim. Consequently, the Board finds that new and material evidence has not been received since the September 2004 final RO decision and reopening the claim for service connection for pes planus is not warranted. B. Lumbar Spine The Veteran has alleged that his service connected lumbar spine disability warrants an initial rating in excess of 10 percent. Disability evaluations are determined by the application of a schedule of ratings which is based on average impairment of earning capacity. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4 (2011). Separate diagnostic codes identify the various disabilities. When a question arises as to which of two ratings apply under a particular diagnostic code, the higher rating is assigned if the disability more nearly approximates the criteria for the higher rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2011). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3 (2011). A veteran's entire history is to be considered when making disability evaluations. See generally 38 C.F.R. 4.1 (2011); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where entitlement to compensation already has been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). This does not, however, preclude the assignment of a "staged rating" (i.e., assignment of different ratings for distinct periods of time, based on the facts found). See Hart v. Mansfield, 21 Vet. App. 505 (2007); see also Fenderson v. West, 12 Vet. App. 119, 126 (1999). The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. Rating factors for a disability of the musculoskeletal system include functional loss due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion, weakness, excess fatigability, incoordination, pain on movement, swelling, or atrophy. 38 C.F.R. §§ 4.40, 4.45; DeLuca v. Brown, 8 Vet. App. 202 (1995). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). In evaluating musculoskeletal disabilities, the VA must determine whether pain could significantly limit functional ability during flare-ups, or when the joints are used repeatedly over a period of time. See DeLuca 8 Vet. App. at 206. The General Rating Formula for Diseases and Injuries of the Spine for Diagnostic Codes 5235 to 5243 provides for the rating of disabilities of the spine. Under the General Rating Formula, 100 percent evaluation is appropriate for unfavorable ankylosis of the entire spine; a 50 percent evaluation is appropriate for unfavorable ankylosis of the entire thoracolumbar spine; a 40 percent evaluation is appropriate for favorable ankylosis of the entire cervical spine; or, forward flexion of the thoracolumbar spine of 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 30 percent evaluation is appropriate for forward flexion of the cervical spine 15 degrees or less; or, favorable ankylosis of the entire cervical spine. A 20 percent evaluation is appropriate where there is forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or, forward flexion of the cervical spine greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 10 percent evaluation is appropriate where there is forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. 38 C.F.R. § 4.71a, DC 5237. Intervertebral disc syndrome may be evaluated either under the General Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher evaluation when all disabilities are combined under 38 C.F.R. § 4.25. Under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, a 10 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months; a 20 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months; a 40 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months; and a 60 percent disability evaluation is warranted for incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, DC 5243. Under Note (1), for purposes of evaluation under DC 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. For VA compensation purposes, normal forward flexion of the cervical spine is zero to 45 degrees, extension is zero to 45 degrees, left and right lateral flexion are zero to 45 degrees, and left and right lateral rotation are zero to 80 degrees. Normal forward flexion of the thoracolumbar spine is zero to 90 degrees, extension is zero to 30 degrees, left and right lateral flexion are zero to 30 degrees, and left and right lateral rotation are zero to 30 degrees. The combined range of motion refers to the sum of the range of forward flexion, extension, left and right lateral flexion, and left and right rotation. The normal combined range of motion of the cervical spine is 340 degrees and of the thoracolumbar spine is 240 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, DC 5235-43, Note (2). Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. The Board will consider whether separate ratings may be assigned for separate periods of time based on facts found, a practice known as "staged ratings," whether it is an initial rating case or not. Fenderson v. West, 12 Vet. App. 119, 126-27 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The record evidence shows that during a July 2009 VA examination the Veteran denied any incapacitating episodes. He stated that the pain radiates not to his legs but up his back and to the midback. He has no numbness or tingling in his legs, but he does complain of bilateral lower extremity weakness. The Veteran stated that he can stand for fifteen to twenty minutes and this is primarily limited by his back. He reported difficulties with bending and prolonged sitting, along with walking and standing. Daily flare-ups were also reported. He denied any bowel or bladder incontinence. No history of surgery. Upon physical examination the Veteran had no tenderness to palpation over his lumbar spine or paraspinal muscles. He had flexion from zero to 70 degrees, extension from zero to 10 degrees. He can bend to the right from zero to 20 degrees and bend to the left from zero to 25 degrees. He can rotate to the right from zero to 20 degrees and rotate to the left from zero to 25 degrees. There was no change with repetition and there was pain at the end ranges for all ranges tested. The Veteran was diagnosed with lumbar spine degenerative joint disease. Various VA treatment records show that the Veteran sought treatment for lower back pain. A January 2010 letter from the Veteran's treating physician at VA submitted a letter which indicated that the Veteran has a long history of chronic lower back pain, and plain film imaging in 2009 indicated degenerative disease with the space narrowing at L4-5, and mild anterior osteophytes at L2-4. His back pain has increased in intensity over the last several years as the arthopathy in his knees worsened. He recently underwent MRI of his lower back and this revealed degenerative changes at L4-5 with mild bilateral lateral recess stenosis as well as multilevel fact joint degenerative disease. This is reflective of osteoarthritis, or wear-and-tear, on these joints. Given the evidence of record, the Board finds that an initial disability rating greater than 10 percent is not warranted for the Veteran's degenerative joint disease of the lumbar spine under the schedular criteria. The Veteran's range of motion did not meet the criteria for a 20 percent rating under DC 5242 as his forward flexion was greater than 60 degrees with pain. During the July 2009 VA examination, the Veteran reportedly had 70 degrees of flexion. Further, combined range of motion was greater than 120 degrees. There is also no evidence of any incapacitating episodes relating to intervertebral disc syndrome during the past 12 months. During the July 2009 VA examination the Veteran specifically denied any such incapacitating episodes. Thus, an initial disability rating greater than 10 percent under either DC 5242 or DC 5243 is not warranted. Furthermore, there are no other alternative diagnostic codes under 38 C.F.R. § 4.71a that could apply to the Veteran's back disability. The Board also finds that an initial disability rating greater than 10 percent is not warranted for the Veteran's low back disorder under DeLuca. The July 2009 VA examiner specifically noted that there was no change in the Veteran's range of motion after repetition. Pain on repetitive use was the primary functional impact on the Veteran's lumbar spine. As such, the evidence does not warrant a higher rating pursuant to DeLuca. The above determination is based upon consideration of applicable rating provisions. The Board also finds that there is no showing that the Veteran's lumbar spine disability has reflected so exceptional or unusual a disability picture as to warrant the assignment of any higher evaluation on an extra-schedular basis. See 38 C.F.R. § 3.321(b)(1) (2011). The symptoms of his disability have been accurately reflected by the schedular criteria. Without sufficient evidence reflecting that the Veteran's disability picture is not contemplated by the rating schedule, referral for a determination of whether the Veteran's disability picture requires the assignment of an extra-schedular rating is not warranted. See Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). C. Erectile Dysfunction (ED) Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury; or, for any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progression of the nonservice-connected disease. 38 C.F.R. § 3.310(a), (b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran does not contend, nor does the record show, that his erectile dysfunction was incurred in service. Rather, the Veteran contends that this condition is proximately due, or was aggravated by, the medication prescribed to treat his service connection PTSD. The record evidence contains a June 2008 progress note from Dr. H. J., showing that the Veteran reported erectile dysfunction, possibly due to the Celexa. A June 2008 letter from Dr. H. J. indicates that he has been treating the Veteran psychiatrically for service-connected PTSD since November 7, 2006, and he has been treated with the medication Celexa for his condition and that resulted in erectile dysfunction due to the treatment of previous symptoms. An academic article dated in August 2008 was submitted which discusses the positive correlation between PTSD and sexual dysfunction. A May 2009 VA examination report shows that the Veteran reported having ED since 1985 and as secondary to his PTSD. He reported currently using injections for an erection and hydrocone for pain with success. The examiner diagnosed the Veteran with ED and opined that he could not opine as to whether the Veteran's current ED was related to his PTSD without resorting to mere speculation. The examiner explained that the Veteran stated that he began to have ED in 1985 when he was discharged from service. He was not on Cymbalta when he was discharged from service. The Veteran stated that he has not lost interest in having sex. He states he cannot have sex more than once a month. The PDR states use of Cymbalta only caused impotence in 3 percent of the study cases of the drug. He does not think that his hormone levels have been evaluated in the past. Veteran can have successful sex with the injection of his penis about once a month. The examiner said he could not speculate as to why the Veteran had ED. At his June 2009 VA examination, the Veteran indicated that his erectile dysfunction began about 20-25 years ago. Record notes ED with a prescription for Viagra in 2002. Previous examination notes ED since 1985. The Veteran reported that the ED gradually developed over several years. He stated that he developed testicular pain in the late 1980's and attributed it to parachute straps. He also noted a decreased libido over the past 10 years. The examiner opined that there was no evidence of PTSD in the VA electronic record and that the Veteran has had ED for many years, preceding the diagnosis of PTSD and prescription for Celexa in 2006. He concluded by saying, in his opinion, there was no evidence that the PTSD or its treatment caused the ED. There are three medical opinions of record which speak to the issue of whether the Veteran's ED is etiologically related to his service-connected PTSD. It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). In assessing the various opinions of record the Board notes that the May 2009 VA opinion is of little probative value. In Jones v. Shinseki, 23 Vet. App. 382 (2009), the Court held that, before the Board can rely on an examiner's conclusion that an etiology opinion would be speculative, the examiner must explain the basis for such an opinion or the basis must otherwise be apparent in the Board's review of the evidence. Id. at 390. It must also be clear that the physician has considered "all procurable and assembled data." Id (citing Daves v. Nicholson, 21 Vet. App. 46 (2006)). Finally, the physician must clearly identify precisely what facts cannot be determined. Id. In this case it appears that the physician considered all of the evidence of record. He made reference to the fact that Veteran's hormone levels had not been evaluated but did not indicate whether those missing facts were indeed the reason why could not opine as to the etiological relationship between the Veteran's ED and his PTSD. Furthermore, the Board finds this opinion to be of little probative value because the examiner based his opinion, in part, on the fact that the Veteran was not on Cymbalta when he was discharged from service and the PDR states use of Cymbalta only caused impotence in 3 percent of the study cases of the drug. However, the Veteran's private doctor indicated that the Veteran had been taking Celexa and not Cymbalta. Thus, it appears that his opinion is premised on incorrect facts and misconstrued evidence and is therefore of significantly diminished probative value. The Board also finds the June 2009 VA examiner's opinion to be of diminished probative value. In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49. The June 2009 examiner indicated in his report that he did not review the Veteran's claims file and though he indicated that he reviewed available local VA notes and remote data, he seemed to be uncertain of the Veteran's PTSD diagnosis as he noted in his opinion that there was no evidence of PTSD in the VA electronic record. In addition, since the examiner was not able to review the claims file he did not review or comment on the June 2008 private opinion which stated that the Veteran's ED was caused by the Celexa he has been taking since 2006. For these reasons, it appears that the June 2009 VA examiner's opinion was not based on all of the relevant and available information and medical history of the Veteran and for that reason it is of diminished probative value. The third medical opinion of record is a June 2008 opinion from the Veteran's private doctor. The opinion indicates that the Veteran's current ED is caused by the Celexa he has been taking since 2006 for his service-connected PTSD. The doctor also provided literature which showed that in his opinion, sexual dysfunction is an almost uniform feature of PTSD sufferers. Given that the two VA opinions are of diminished probative value and that the Veteran's private doctor has indicated that the Veteran's erectile dysfunction is related to his service-connected PTSD, the Board finds that after considering all of the evidence of record, the preponderance of the evidence is not against the Veteran's claim, it is in relative equipoise, and all reasonable doubt should be resolved in favor of the Veteran. Therefore, service connection for erectile dysfunction, as secondary to service-connected PTSD, is granted. ORDER New and material evidence not having been received, the appeal to reopen a claim for service connection for pes planus is denied. Entitlement to an initial rating in excess of 10 percent for degenerative joint disease of the lumbar spine is denied. Entitlement to service connection for erectile dysfunction, as secondary to a service-connected disability, is granted. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs