Citation Nr: 1315165	
Decision Date: 05/08/13    Archive Date: 05/15/13

DOCKET NO.  08-20 624	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Lincoln, Nebraska


THE ISSUES

1.  Entitlement to service connection for hypertension, including as due to service-connected posttraumatic stress disorder (PTSD).

2.  Entitlement to service connection for a bilateral foot disorder other than bilateral pes planus, bilateral hammertoes, and bilateral hallux valgus, to include as secondary to these service-connected foot disabilities.

3.  Entitlement to an initial rating in excess of 30 percent for bilateral pes planus.


REPRESENTATION

Appellant represented by:	Veterans of Foreign Wars of the United States


ATTORNEY FOR THE BOARD

D.J. Drucker, Counsel
INTRODUCTION

The Veteran had active military service from December 1966 to September 1968.

This matter initially came to the Board of Appeals' (Board) on appeal from rating decisions of the Department of Veterans (VA) Regional Office (RO) in Lincoln, Nebraska.

In a July 2010 decision, the Board granted the Veteran's request for an increased rating from his service-connected PTSD.  At that time, the Board remanded his claims for service connection for a foot disorder, other than his service-connected foot disorders, and hypertension, including as due to service-connected PTSD, and an increased rating for bilateral pes planus, to the RO for further evidentiary development.

In December 2012, the Board requested a medical opinion, pursuant to 38 U.S.C.A. § 7109 and as set forth in a designated Veterans Health Administration (VHA) Directive, in response to the appellant's claim of entitlement to service connection for hypertension, including as due to service-connected hypertension.  See 38 U.S.C.A. § 7109(a) (West 2002) and 38 C.F.R. § 20.901 (2012).  See generally Wray v. Brown, 7 Vet. App. 488, 493 (1995).  A VHA medical opinion was rendered in January 2013.  In February 2013, the appellant was given an opportunity to present additional argument and his representative presented further written argument in April 2013. 

Finally, the Board observes that, on June 8, 2007, the RO received the Veteran's original claim for service connection for bilateral pes planus that was granted by the RO in a June 2008 rating decision and assigned an initial 10 percent disability evaluation, effective from June 8, 2007.  The Veteran submitted a timely notice of disagreement with that evaluation and, in an October 2008 rating, the RO granted a 30 percent evaluation, effective from June 8, 2007.  Although the title page of the Board's July 2010 decision/remand characterized the issue on appeal as entitlement to an increased rating for bilateral pes planus, rated as 10 percent disabling prior to June 8, 2007 and 30 percent disabling thereafter, the Board is of the opinion that the issue as presently set forth on the decision title page more accurately represents the current status of the Veteran's claim.


FINDINGS OF FACT

1.  The evidence of record preponderates against a finding that hypertension had its onset in service, is otherwise related to the Veteran's military service, or was manifest to a compensable degree within one year of his discharge from active service; it is not proximately due to service-connected PTSD.

2.  The evidence of record preponderates against a finding that a foot disorder other than bilateral pes planus, hammertoes, or hallux valgus, had its onset in service, is otherwise related to the Veteran's active military service; it is not proximately due to foot service-connected disabilities.

3.  The Veteran's bilateral pes planus is manifested by symptoms and physical conditions producing no more than severe impairment, primarily by foot pain accentuated on use and objective evidence of callosities on both feet. 


CONCLUSIONS OF LAW

1.  The criteria for service connection for hypertension, including as due to service-connected PTSD, have not been met.  38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1137, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2012).

2.  The criteria for service connection for a bilateral foot disorder, other than bilateral pes planus, hammertoes, and hallux valgus, have not been met.  38 U.S.C.A. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310.

3.  The criteria for a rating in excess of 30 percent for bilateral pes planus have not been met.  38 U.S.C.A. §§ 1155, 5103, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 4.71a, Diagnostic Code 5276 (2012).


REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

I. Duty to Notify and Assist

As provided for by the Veterans Claims Assistance Act (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits.  38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012).  

Proper notice from VA must inform the claimant of any information and medical or lay evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide.  38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183 (2002).  

VCAA notice must be provided prior to an initial unfavorable decision on a claim by the RO.  Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Pelegrini v. Principi, 18 Vet. App. 112 (2004).  Where complete notice is not timely accomplished, such error may be cured by issuance of a fully compliant notice, followed by readjudication of the claim.  See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006).

In addition, the notice requirements of the VCAA apply to all elements of a service-connection claim, including the degree of disability and the effective date of the disability.  See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006).  Further, this notice must include information that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded.  Id. at 486.  

The United States Court for Veterans Appeals (court) had held that at a minimum, adequate VCAA notice in an increased rating claim required that VA notify the claimant that, to substantiate such a claim: (1) the claimant must provide, or ask VA to obtain, medical or lay evidence demonstrating a worsening or increase in severity of the disability and the effect that worsening has on the claimant's employment and daily life; (2) if the diagnostic code under which the claimant is rated contains criteria necessary for entitlement to a higher disability rating that would not be satisfied by the claimant demonstrating a noticeable worsening or increase in severity of the disability and the effect of that worsening has on the claimant's employment and daily life (such as a specific measurement or test result), the Secretary must provide at least general notice of that requirement to the claimant; (3) the claimant must be notified that, should an increase in disability be found, a disability rating will be determined by applying relevant diagnostic codes; and (4) the notice must also provide examples of the types of medical and lay evidence that the claimant may submit (or ask VA to obtain) that are relevant to establishing entitlement to increased compensation.  Vazquez-Flores v. Peake, 22 Vet. App. 37 (2008).

The Federal Circuit vacated the court's decision, overturning the requirement that VA provide notice that the claim could be substantiated by evidence of a disability's impact on daily life and that VA provide notice with regard to potential diagnostic code criteria (element 2).  Vazquez-Flores v. Shinseki, 580 F.3d 1270 (Fed. Cir. 2009).  The generic first, third, and fourth elements (contained in the court's decision) were not disturbed by the Federal Circuit's decision.

Here, the Veteran was sent letters in June 2007, and February, March and April 2008, that provided information as to what evidence was required to substantiate the claim and of the division of responsibilities between VA and a claimant in developing an appeal.  The April 2008 letter provided notice as to how VA assigns an appropriate disability rating or effective date, curing any timing defect, and notice consistent with the remaining portions of the court's holding in Vazquez-Flores.  Accordingly, no further development is required with respect to the duty to notify.

Next, VA has a duty to assist the Veteran in the development of his claims.  This duty includes assisting him in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary.  38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159.  All reasonably identified and available VA and non-VA medical records were obtained.  A review of the Veteran's Virtual VA electronic file does not reveal any additional evidence regarding the claims for service connection for hypertension, including as due to service-connected PTSD and a bilateral foot disorder, other than bilateral pes planus, bilateral hammertoes, and bilateral hallux valgus, to include as secondary to these service-connected foot disabilities.

The Veteran was afforded VA examinations in March 2008 and the examination reports are of record.

As noted above, in July 2010, the Board remanded the Veteran's case to the RO for further development that included obtaining records from High Plains Podiatry and scheduling him for VA examinations.  There has been substantial compliance with the Board's 2010 remand as he was scheduled for VA examinations of his feet and for hypertension in September 2010, and records from High Point Podiatry, dated in October 2008, were obtained.

Thereafter, upon review of the record and the September 2010 VA hypertension examination report, the Board obtained a VHA opinion regarding the Veteran's claim for service connection for hypertension, including as due to service-connected PTSD.  A copy of the VHA report was provided to the Veteran and his representative in February 2013 and, in April 2013, the representative submitted written argument on the Veteran's behalf.

The Board finds that the January 2013 VHA report is adequate for rating purposes as the claims file was reviewed, the examiner reviewed the pertinent history, provided clinical findings and diagnoses, and offered an etiological opinion with rationale from which the Board can reach a fair determination.  The records satisfy 38 C.F.R. § 3.326 (2012).  The February 2013 VHA report makes up for the deficiencies in the March 2008 and September 2010 VA hypertension examination reports as to this matter.  

The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the appellant.  See Bernard v. Brown, 4 Vet. App. 384 (1993).  The claims file contains the Veteran's service treatment records, as well as post-service reports of VA non-VA treatment and examinations.  The Board has carefully reviewed such statements and concludes that no available outstanding evidence has been identified.  The Board has also perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims.  

For the above reasons, no further notice or assistance to the appellant is required to fulfill VA's duty to assist the appellant in the development of the claims.  Smith v. Gober, 14 Vet. App. 227 (2000), aff'd, 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002).

II. Factual Background and Legal Analysis

The Board notes that it has thoroughly reviewed the record in conjunction with this case, including the Veteran's service treatment records, VA and non-VA medical records and examination reports, dated from 1995 to 2013, and the Veteran's written statements in support of his claims.  Although there is an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the appellant or on his behalf.  See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence).  Rather, the analysis below will focus specifically on what the evidence shows, or fails to show, on the claim.  See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant). 



A. Service Connection

Under 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303, a veteran is entitled to disability compensation for disability resulting from personal injury or disease incurred in or aggravated by active military service.  

Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service either has not been established or might reasonably be questioned.  38 C.F.R. § 3.303(b); but see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a)).  

Nevertheless, the regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service.  38 C.F.R. § 3.303(d).  Moreover, case law has established that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007).  When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the appellant's particular disability is the type of disability for which lay evidence may be competent.  Kahana v. Shinseki, 24 Vet. App. 428 (2011).

To establish a right to compensation for a present disability, a veteran must show: "(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" - the so-called "nexus" requirement."  Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  This is a direct service connection theory of entitlement.

Certain chronic diseases, such as cardiovascular renal disease including hypertension, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from active service.  See 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309.  This is also a direct service connection theory of entitlement.

In addition, secondary service connection may be granted for a disability that is proximately due to, or the result of, a service-connected disease or injury.  38 C.F.R. § 3.310(a).  With regard to the matter of establishing service connection for a disability on a secondary basis, the court has held that there must be evidence sufficent to show that a current disability exists and that the current disability was either caused or aggravated by a service-connected disability.  See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).  Additionally, when aggravation of a non-service-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation.  Id.; see also 38 C.F.R. § 3.310(b).  With regard to a claim for secondary service connection, the record must contain competent evidence that the secondary disability was caused by the service-connected disability.  See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). 

A service connection claim must be accompanied by evidence which establishes that the claimant currently has the claimed disability.  See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992).

Where the determinative issue involves medical causation or a medical diagnosis, there must be competent evidence to the effect that the claim is plausible.  

However, although the Veteran is competent in certain situations to provide a diagnosis of a simple condition such as a headache, varicose veins, or tinnitus, the Veteran is not competent to provide evidence as to more complex medical questions, such as the etiology of hypertension and foot pathology, as is the case here.  See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). 

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 a preponderance of the evidence is against the claim, in which case the claim is denied.  38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

In this regard, the Board must assess the credibility and probative value of evidence, and, provided that it offers an adequate statement of reasons or bases, the Board may favor one medical opinion over another.  See Owens v. Brown, 7 Vet. App. 429, 433 (1995); Wood v. Derwinski, 1 Vet. App. 190 (1991).  While the Board is not free to ignore the opinion of a treating physician, it is free to discount the credibility of that physician's statement.  See Guerrieri v. Brown, 4 Vet. App. 467, 471-73 (1993); Sanden v. Derwinski, 2 Vet. App. 97, 101 (1992). 

1. Hypertension, Including as Due to Service-Connected PTSD

In written statements in support of his claim, the Veteran asserts that he has hypertension that is due to his military service or to his service-connected PTSD.  Service connection for PTSD was granted by the RO in a January 2008 rating decision.

Upon review of the evidence of record, and after considering the laws and regulations applicable to the Veteran's claim, the Board finds that service connection is not warranted.

Service treatment records do not discuss complaints or diagnosis of, or treatment for, hypertension.  When examined for separation in August 1968, the Veteran's blood pressure reading was 120/80.

Post service, elevated blood pressure readings of 150/90 and 150/86 were noted in March and December 1995 private medical records, respectively.  

A diagnosis of hypertension was reported in private treatment records dated in March 2004.

In March 2008, the Veteran underwent VA examination.  The examiner noted that the Veteran was diagnosed hypertension six years earlier, for which he took prescribed medication.  Upon clinical evaluation, the diagnosis was essential hypertension.  The VA examiner stated that "[i]t does not appear to be" at least as likely as not that the Veteran's hypertension was due to his service-connected PTSD.  The VA physician said that "the current medical literature does not state any nexus between PTSD specifically causing hypertension.  The vas[t] majority of cases of hypertension are essential in nature, which means they were going to happen regardless of whether one has PTSD or not.  Therefore, as there is no documentation in the literature to support PTSD specifically causing hypertension, this [V]eteran's hypertension was NOT caused by his PTSD, and is likely essential in nature.  I cannot determine any aggravation issues either."

In September 2010, the same VA examiner reevaluated the Veteran and again diagnosed him with essential hypertension.  The VA examiner stated that,

[b]ased on a review of all records...it is impossible to determine whether PTSD specifically aggravated/permanently worsened his hypertension.  There is no specific manner in which to do so.  In addition, [the Veteran] states when he is in crowds or with larger numbers of people, he does have more stress.  Unfortunately, the blood pressures are never taken.  Even so, there is no specific method available to modern medicine today that tells us whether blood pressures are permanently worsened due to other medical comorbidities.  Therefore, it is impossible to determine whether [the Veteran's] hypertension was made permanently worse by any PTSD.  This would be speculation.  The reasoning is because there is no specific method to measure this or determine this, nor any manner to delineate or separate this out any further."

In December 2012, the Board requested a VHA opinion as to whether it was at least as likely as not ( a 50 percent or higher degree of probability) that hypertension had its clinical onset during, or is otherwise related to, the Veteran's active duty.  The Board also asked if it was at least as likely as not (a 50 percent or higher degree of probability) that hypertension was proximately due to or the result of service-connected PTSD?  If not, was at least as likely as not aggravated by the service-connected PTSD?  The VHA examiner was further asked that, if aggravated, what permanent measurable increase in current hypertension pathology was attributable to the service-connected PTSD?  The VHA examiner was particularly requested to address the opinions rendered by the VA examiner in March 2008 and September 2010.

In the January 2013 VHA report, a VA psychiatrist opined that it was not at least as likely as not that hypertension had its clinical onset during, or was otherwise related to, the Veteran's active duty.  The VHA physician explained that the Veteran "clearly did not" have a diagnosis of hypertension in 1968 when he was discharged from active service and, hence, hypertension did not appear to be the result of his active military experience.  

The VHA medical specialist further opined that hypertension was not likely aggravated by PTSD.  The VA physician stated that "[a] person may have blood pressure spikes as a result of [a]nxiety/PTSD.  Stressful situations could cause blood pressure to spike temporarily, but there is no evidence between" chronic anxiety/PTSD causing long term high blood pressure (hypertension).

According to the VHA psychiatrist, just as behaviors linked to chronic anxiety, such as overeating, drinking alcohol, and poor sleeping habits, may cause hypertension (in) the same way, adapting healthy life-style habits will decrease the risk of developing hypertension.

The VHA examiner also commented that it was possible that mental health conditions related to stress, such as anxiety, depression, and isolation from friends and family, may be linked to heart disease, but there was no evidence that they were linked to high blood pressure.  Rather, it may be that the hormones produced when one was emotionally stressed may damage one's arteries, leading to heart disease.  It may also be that being depressed may cause self-destructive behavior, such as neglecting to take one's medication to control high blood pressure or other heart conditions.

The VHA examiner agreed with the comments made by the VA examiner in March 2008 that the most common etiology for hypertension was essential (more than 90 percent) and that the Veteran's hypertension was not caused by his PTSD and was likely essential in nature.

Where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion.  Wray v. Brown, 7 Vet. App. at 493.  The Board does, in fact, adopt the VHA specialist's opinion on which it bases its determination that service connection for hypertension, including as due to service-connected PTSD, is not warranted. 

Since the VHA physician's opinion was based on a review of the pertinent medical history, and was supported by sound rationale, it provides compelling evidence against the appellant's claim.  The Board emphasizes that the VHA medical expert provided a valid medical analysis to the significant facts of this case in reaching his conclusion.  In other words, the VHA physician did not only provide data and conclusions, but also provided a clear and reasoned analysis that the court has held is where most of the probative value of a medical opinion comes is derived.  See Nieves-Rodriguez v. Peake, 22 Vet App 295 (2008); see also Wray v. Brown, 7 Vet. App. at 493.  Moreover, there is no medical opinion of record to contradict the VHA examiner's opinion.  

In sum, the record is against the Veteran's claim of service connection for hypertension.

2. A Bilateral Foot Disorder Including as Due to Service-Connected Bilateral Pes Planus, Hammertoes, and Hallux Valgus

In written statements in support of his claim, the Veteran asserts that he has a foot disorder, other than service-connected bilateral pes planus, hammertoes, and hallux valgus, that is due to his military service or to his service-connected foot disabilities.  In his October 2008 substantive appeal, he stated that his foot disorder affected the ball of his foot and produced a core or center that caused pain and affected his gait.  As noted, the June 2008 rating decision granted service connection for bilateral pes planus.  Service connection for bilateral hammertoes and bilateral hallux valgus was granted by the RO in an October 2008 rating decision.

Upon review of the evidence of record, and after considering the laws and regulations applicable to the Veteran's claim, the Board finds that service connection is not warranted.

Service treatment records do not reference a foot disorder other than flat feet.  When examined for induction into service in August 1966, the Veteran was noted to have second degree pes planus.  On a Report of Medical History completed in August 1968, prior his discharge, the Veteran checked yes to having foot trouble and the examiner noted that the Veteran had flat feet.  

Post-service, a March 2008 VA examination report indicates that the physician-examiner found that the Veteran's flat feet existed prior to service and had been aggravated beyond natural progression by military service.

An October 2008 private medical record from R.H., D.P.M., includes an impression of posterior tibial tendon dysfunction, bilaterally, and hallux valgus and hammertoe, bilateral; pes planus, hallux valgus, bilateral.  Capsulitis was also noted.  Dr. R.H. opined that it was at least as likely as not that the Veteran's pes planus, posterior tibial tendon dysfunction, and hallux valgus were increased as a result of his military service.  The podiatrist was unable to determine if this was an acquired deformity.  Conservative nonsurgical treatment was advised.

In a September 2008 opinion, the March 2008 VA examiner opined that the Veteran's bilateral hammertoes and hallux valgus were at least as likely as not due to his service-connected bilateral pes planus.

In September 2010, the Veteran underwent another VA examination of his feet.  According to the examination report, the physician-examiner reviewed the Veteran's medical records and performed a clinical evaluation.  X-rays taken at the time showed bilateral hallux valgus as well as the hammertoe deformities.  The clinical impression included bilateral mild pes planus deformity; hammertoe deformities of digits 2-4, bilaterally; bilateral hallux valgus, right greater than left; and bilateral first metatarsophalangeal (MTP) joint degenerative joint disease.  

In the VA physician-examiner's opinion, the Veteran's current bilateral pes planus disorder was the result of his posterior tibial tendon dysfunction.  According to the VA physician, this was not a separate disorder and the symtoms resulting from posterior tibial tendon dysfunction were equal and were the same symtoms that were resultant from bilateral pes planus.  The VA examiner explained that the dysfunction of the posterior tibial tendon was actually the cause of the Veteran's resultant bilateral pes planus and was "well-described" in the literature.  The VA examiner reiterated that this was "not a distinct disorder, nor are these symptoms separate."  The VA examiner opined that "there is no additional disorder manifested in [the Veteran's] bilateral feet."


Again, the Veteran seeks service connection for bilateral foot disorder, other than bilateral pes planus, hammertoes, and hallux valgus.  In his October 2008 written statement, he reported that his foot condition affected his gait and caused pain in the ball of his foot.  The Board recognizes that, in October 2008, Dr. R.H., opined that the Veteran's pes planus, posterior tibial tendon dysfunction, and hallux valgus were increased as a result of his military service although the podiatrist was unable to determine if this was an acquired deformity.

However, as discussed above, in September 2010, the VA physician-examiner expressly stated that the Veteran's posterior tibial tendon dysfunction was not a separate foot disorder distinct from his service-connected bilateral pes planus.  Rather, the VA examiner explained that the dysfunction of the posterior tibial tendon was actually the cause of the Veteran's resultant bilateral pes planus and that the Veteran had no additional foot disorder.

Where a medical expert has fairly considered all the evidence, his opinion may be accepted as an adequate statement of the reasons and bases for a decision when the Board adopts such an opinion.  Wray v. Brown, 7 Vet. App. at 493.  The Board does, in fact, adopt the VA specialist's opinion on which it bases its determination that service connection for a foot disorder, other than service-connected bilateral hammertoes, pes planus, and hallux valgus, is not warranted. 

Since the 2010 VA physician's opinion was based on a review of the pertinent medical history and clinical evaluation, and was supported by sound rationale, it provides compelling evidence against the appellant's claim.  The Board emphasizes that the VA examiner provided a valid medical analysis to the significant facts of this case in reaching his conclusion.  In other words, the VA physician did not only provide data and conclusions, but also provided a clear and reasoned analysis that the court has held is where most of the probative value of a medical opinion comes is derived.  See Nieves-Rodriguez v. Peake, 22 Vet App at 295; see also Wray v. Brown, 7 Vet. App. at 493

The Board therefore places greater weight on the VA opinion that finds that the Veteran did not have a foot disorder other than service-connected pes planus, hammertoes, and hallux valgus, that was incurred in or aggravated by active military service, including service-connected foot disabilities, than on the October 2008 opinion rendered by Dr. R.H., to the effect that the Veteran's pes planus, posterior tibial tendon dysfunction, and hallux valgus were increased as a result of his military service although the podiatrist was unable to determine if this was an acquired deformity.  See Owens v. Brown, 7 Vet. App. at 433 (holding that VA may favor the opinion of one competent medical expert over that of another when decision makers give an adequate statement of reasons and bases); Guerrieri v. Brown, 4 Vet. App. at 473 ("the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches").  

As such, with respect to the Veteran's claim of service connection for a bilateral foot disorder other than bilateral pes planus, hammertoes, and hallux valgus, in the absence of proof of a current disability, there can be no valid claim.  Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. at 225.  Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability.  Brammer, 3 Vet. App. at 225.  In the absence of any competent evidence of a foot disorder, other than bilateral pes planus, hammertoes, and hallux valgus, the Board must conclude the Veteran does not suffer from such a disability currently or at any time during the rating period on appeal.  

Both Claimed Disorders

In denying service connection as to the claims on appeal, the Board has considered the Veteran's contention that a relationship exists between his current hypertension and claimed foot disorder, and military service including his service-connected hypertension and foot disabilities.  In adjudicating these claims, the Board must assess the Veteran's competence and credibility.  See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). 

In Barr v. Nicholson, 21 Vet. App. 303 (2007), the court emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witnesses personal knowledge.  See also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means 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 the facts or circumstances and conveys matters that can be observed and described by a lay person). 

The Veteran is competent to describe his observable symptoms, such as increased heart rate and foot pain.  However, he is not competent to make a statement of causation that is a medical determination.  Barr v. Nicholson, 21 Vet. App. at 303; Buchanan v. Nicholson, 451 F.3d at 1331.  To the extent he is claiming that foot and hypertension problems have persisted since service, this is inconsistent with the overall record, which reflects that his foot and hypertension symptomatology manifested after service. 

The Board has considered the Veteran's statements as to his incurrence during service, in light of his service treatment records, post-service medical evidence, and March 2008 and September 2010 VA examiners' opinions and the January 2013 VHA medical opinion (regarding hypertension and PTSD).  However, the record fails to reflect that the Veteran was treated on even one occasion for hypertension difficulty during military service or for a foot difficulty other than bilateral pes planus.  The post service records show that hypertension was diagnosed in approximately 2002 or 2004, over 30 years after his discharge from service.  In this regard, the gap in time between military service and the first post-service medical evidence of hypertension is, in itself, significant, and weighs against the appellant's claim.  See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (to the effect that a lengthy period of absence of medical complaints for condition can be considered as a factor in resolving claim); see also Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming the Board's denial of service connection where veteran failed to account for lengthy time period between service and initial symptoms of disability).  In short, no competent medical opinion or other medical evidence relating the Veteran's hypertension or claimed foot disorder to service or any incident of service has been presented. 

The Board recognizes that the absence of documented post-service treatment cannot, by itself, invalidate the Veteran's claims of continuous symptomatology.  Buchanan v. Nicholson, 451 F.3d 1331  (Fed. Cir. 2006).  However, to the extent that the Veteran is claiming continuity of foot and hypertension symptoms since service, he is not a reliable historian.  He made no mention of hypertension problems, or foot problems other than flat feet, during his 1968 service examination, and examination of his cardiovascular system and lower extremities at those times was normal.  He has not explained why he failed to mention pertinent difficulty when examined pursuant to service requirements.  The Board does not find that there is credible evidence of continuity of symptomatology present in this case. 

Moreover, while the Veteran is competent to state that he experienced hypertension and foot problems in service, he is not competent to state that he has hypertension or another cardiovascular disease, or a foot disorder other than pes planus, hammertoes, or hallux valgus.  The clinical pathology of hypertension and foot disorders is not readily recognizable by a layman, such as varicose veins or acne.  See Jandreau v. Nicholson.  Even medical professionals rely on laboratory test results, x-rays, and other diagnostic tools to diagnose hypertension and foot disorders.  

Further, the January 2013 VHA examiner, who reviewed the in-service treatment records and the post service medical records, concluded that the Veteran had hypertension that was not due to military service or to service-connected PTSD.  This opinion is entirely consistent with that of the March 2008 VA examiner.  The September 2010 VA examiner, who reviewed the Veteran's in-service treatment records and reviewed his post service medical records and performed a clinical evaluation, concluded that he did not have an foot disorder, other than service-connected bilateral pes planus, hammertoes, and hallux valgus.  The Veteran's contentions as to etiology are not deemed competent and thus are not probative.  

Thus, the Board is left with no documented complaints of hypertension or foot problems other than bilateral pes planus in service, no documented complaints or findings of a diagnosed hypertension disorder after service until approximately 2004, two VA medical opinions to the effect that the Veteran's diagnosed hypertension was not caused or aggravated by military service or service-connected PTSD, and one VA medical opinion to the effect that the Veteran did not have a diagnosed foot disorder other than service-connected bilateral hammertoes, hallux valgus, and pes planus.  The questions involved regarding causation are medical in nature.  As discussed above, the medical opinions of the March 2008 and September 2010 VA examiners and the January 2013 VHA examiner (based on a review of the claims file and with knowledge of the Veteran's in-service duties and in-service complaints), deemed the most reliable evidence of record, were negative.  

In sum, a clear preponderance of the objective and probative medical evidence of record is against the Veteran's claims for service connection for hypertension, including as due to service-connected PTSD, and a bilateral foot disorder, other than bilateral pes planus, hammertoes, and hallux valgus, including as due to service-connected bilateral foot disabilities and his claims must be denied.  The benefit-of-doubt rule does not apply when the Board finds that a preponderance of the evidence is against the claim.  Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001).

B. Increased Rating For Bilateral Pes Planus

The Veteran also seeks a rating in excess of 30 percent for his service-connected bilateral pes planus.  In his June 2008 substantive appeal, he reported that his foot disorder caused moderate to severe pain with each step he took.

Disability evaluations are determined by the application of a schedule of ratings which is based, as far as can practically be determined, on the average impairment of earning capacity.  38 U.S.C.A. § 1155; 38 C.F.R. § 4.1.  Each service-connected disability is rated on the basis of specific criteria identified by Diagnostic Codes.  38 C.F.R. § 4.27.

In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of the Veteran's condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991).  However, where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability.  Francisco v. Brown, 7 Vet. App. 55 1994).  

In Fenderson v. West, 12 Vet. App. 119, 126 (1999), the court noted that where the question for consideration is propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection and consideration of the appropriateness of a "staged rating" is required.  Id.  

Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made.  Hart v. Mansfield, 21 Vet. App. 505 (2007).  The analysis in the following decision is therefore undertaken with consideration of the possibility that different ratings may be warranted for different time periods. 

When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied.  Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 

Where there is a question as to which of two evaluations is to be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating.  Otherwise, the lower rating will be assigned.  38 C.F.R. § 4.7 (2012).

In view of the number of atypical instances it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified.  Findings sufficiently characteristic to identify the disease and the disability therefrom, and above all, coordination of rating with impairment of function will, however, be expected in all instances.  38 C.F.R. § 4.21 (2012).  

Competent medical evidence means 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 mean 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 means 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 the facts or circumstances and conveys matters that can be observed and described by a lay person.  38 C.F.R. § 3.159(a)(2).

The Veteran's statements describing the symptoms of his service-connected bilateral pes planus disability are deemed competent evidence.  However, these statements must be considered with the clinical evidence of record and in conjunction with the pertinent rating criteria in order to assess their credibility. 

For disabilities evaluated on the basis of limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment.  The court has instructed that in applying these regulations VA should obtain examinations in which the examiner determined whether the disability was manifested by weakened movement, excess fatigability, incoordination, or pain.  Such inquiry is not to be limited to muscles or nerves.  These determinations are, if feasible, be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, flare-ups, or pain.  Mitchell v. Shinseki, 25 Vet App 32 (2011); DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59 (2012).

VA's policy is treated actually painful, unstable, or malaligned joints as warranting at least the minimum compensable rating for the joint.  38 C.F.R. § 4.59.  This regulation applies to any service connected joint disability, not just arthritis.  When § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, VA should address its applicability.  Burton v. Shinseki, 25 Vet. App. 1 (2011). 

The "pain must affect some aspect of 'the normal working movements of the body' such as 'excursion, strength, speed, coordination, and endurance,'" as defined in 38 C.F.R. § 4.40, before a higher rating may be assigned.  This is because "pain alone does not constitute a functional loss under the VA regulations that evaluate disability based upon range-of-motion loss."  Mitchell v. Shinseki, 25 Vet. App. at 33, 43.

The record reflects that the Veteran's service-connected bilateral pes planus disability is currently assigned a 30 percent rating, from June 8, 2007, under Diagnostic Code 5276, that evaluates pes planus.  38 C.F.R. § 4.71a, Diagnostic Code 5276. 

Under Diagnostic Code 5276, for a severe disability, a 20 percent rating is assigned if unilateral and a 30 percent rating is assigned if bilateral.  Id.  A severe disability is characterized by objective evidence of marked deformity (pronation, abduction, etc.), accentuated pain on manipulation and use, indication of swelling on use, and characteristic callosities.  Id.  A maximum 30 percent rating is awarded for a unilateral and a maximum 50 percent rating is awarded for a bilateral disability that is pronounced.  Id.  A pronounced disability is manifested by marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliance.

According to the March 2008 VA examination report, the physician-examiner reviewed the Veteran's medical records and performed a clinical evaluation.  The Veteran complained of progressively worsening flat, painful feet that he treated with rest and occasional Advil.  He always wore soft shoes and occasionally used inserts.  The Veteran denied a history of foot surgery.  He complained of bilateral foot pain, stiffness, fatigability and lack of endurance, while standing and walking, and said he had pain over his entire foot.  He denied foot swelling, heat, redness, weakness.  He had flare-ups of foot joint disease and was functionally limited in that he was able to stand up to one hour and walk 5 to 6 blocks.  He used orthotic inserts with fair results.

Physical examination revealed evidence of bilateral abnormal weight bearing by callosities with no objective evidence of bilateral painful motion, tenderness, or weakness.  There was no evidence of muscle atrophy.  The Veteran's gait was normal.  There was no forefoot or midfoot malalignment.  Achilles tendon alignment was difficult to correct with manipulation, but there was no pain on doing so.  The Veteran had moderately severe hammertoes and bilateral hallux valgus.  Dorsiflexion and plantar flexion of the big toes were to 20 degrees and 30 degrees, respectively.  DeLuca examination findings revealed that five additional exercises to the above-mentioned limits produced mild pain and moderate to severe weakness and fatigue, but no incoordination.  The Veteran had a difficult time trying to stand on his toes and heels.  The major functional impact was pain with repetitive use.  The examiner was unable to determine additional limitation following repetitive use during flare ups as that would be speculation but noted that the Veteran did not have additional limitation following repetitive use on current examination.  There was minimal painful motion reported.  

The Veteran denied having lost any time from work during the past 12 months due to his flat feet.  The diagnosis was severe bilateral pes planus that caused flat, painful feet, and had no significant effects on the Veteran's occupation.  

The VA examiner reported that the Veteran's flat feet prevented his participation in sports, had a moderate effect on his ability to participate in recreational activities, had a mild effect on his ability to shop, and had no effect on his ability to do chores, travel, drive, or other activities of daily living.  The VA examiner commented that the Veteran complained of night pain on the plantar surfaces of both feet that occurred daily after walking or standing.  Comfortable shoes helped as did occasional aspirin or over-the-counter medications.  Flares occurred with standing long periods and wearing boots that may last over night.  Tennis shoes helped, and he was functionally impairment during such episodes in that he avoided some activities.  It was noted that the Veteran saw a foot specialist 20 years ago in his hometown.  He used no other devices other than occasional inserts that helped.  He was able to walk 5 to 6 blocks and did not fall.  He worked full time in a coop.

The October 2008 private podiatry record from Dr. R.H. shows that the Veteran was evaluated for bilateral ankle pain and instability that he had for an extended duration and related to his foot problems in service.  Ambulation worsened his problem and he described having severe constant, pain that worsened at the end of the day.  Physical examination revealed that dorsalis pedis and posterior tibial pulses were palpable, bilaterally, and CFT (capillary refill time?) was immediate.  Edema and varicosities were not observed and there was no skin rash, lesions, or ulcers observed.  Skin temperature was warm to warm proximal to distal, bilaterally, and pedal hair growth, skin elasticity, texture, and turgor were all within normal limits, bilaterally.  Neurological examination findings were within normal limits. 

Examination of the Veteran's posterior tibial tendon revealed abduction of the forefoot at the Chopart joint, bilaterally, loss of height of the medial longitudinal arch, moderate pain, bilaterally, valgus deflection of the heel, and weak and painful inversion of the foot against resistance, bilaterally.  Muscle strength was essentially normal (5/5), as was muscle tone and inspection and palpation of the bones, joints, and muscle was unremarkable.  Range of motion of the left and right ankles showed normal plantar flexion without pain and decreased dorsiflexion without pain.  Left and right subtalar joint range of motion was excessive.  Left and right metatarsal joint (MTJ) range of motion was within normal limits.  Left and right 1st MTP joint range of motion showed normal flexion without pain and decreased extension without pain.  The forefoot showed rigid toe hammering of the digit 2, 3, 4, and 5 of severe degree and a severe hallux valgus deformity.

The September 2010 VA examination report reflects the Veteran's report that he developed calluses on the plantar surface of his feet in service due the amount of walking he did in military-issued boots.  The callosities continued and he had to have them shaved off in the past.  Over the past 15 years, he tried using tennis shoes that were much more helpful and had the corns and callosities shaved.  Over the past 30 years, he worked as a farmer and noted that he had not had any foot surgeries.  He currently just symptomatically treated his feet.  He took an occasional aspirin for pain but did not use any type of a brace.  He tried arch supports in the past, that helped somewhat, but did not currently use any, and found tennis shoes worked best for him.

On examination, in a standing position, the Veteran was observed to have bilateral moderate pes planus with a slight calcaneus valgus, bilaterally, on the right moderately, and on the left, mildly.  All the calcaneus valgus was correctable on toe rise.  There were some callosities over the second metatarsal head on the plantar surface of his foot.  His subtalar joint was mobile and stable with good motion.  Range of motion of the Veteran's ankle was from 5 degrees of dorsiflexion and from 45 degrees of plantar flexion, bilaterally.  The Veteran was intact neurovascularly, with positive dorsalis pedis and posterior tibial pulses.  Sensation was intact to light tough.  He had hammertoes on both feet, toes 2-4 that were correctable on manual manipulation.  He also had hallux valgus deformities, bilaterally, right more severe than left with bunions and a pinch callus on his right first toe on the medial aspect.  The medial aspect of the bunion was mildly tender to palpation.  He had decreased motion of his first MTP joint bilaterally.  DeLuca testing of the Veteran's bilateral ankles did not demonstrate increased pain, weakness, tenderness, or balance issues.  X-rays taken at the time showed bilateral hallux valgus and hammertoe deformities, most specifically the second and third digits able to be seen on x-ray as well at bilateral first MTP joint degenerative joint disease.  There were no obvious bony abnormalities.  The clinical impression included "bilateral mild pes planus deformity."

Upon review of the evidence of record, the Board finds that a rating in excess of the currently assigned 30 percent evaluation is not warranted for the Veteran's service-connected bilateral pes planus.  The March 2008 VA examiner described the Veteran as having severe and painful pes planus, although the September 2010 VA examiner reported moderate bilateral pes planus and diagnosed only mild bilateral pes planus.  Both examiners noted the Veteran's complaints of foot pain and observations of callosities on both feet.  However, the Board does not find symptoms such as marked pronation, extreme tenderness of the plantar surfaces of the feet, marked inward displacement such as to warrant a rating in excess of 30 percent.

Furthermore, as the clinical evidence demonstrates that the Veteran is able to obtain some measure of relief from the use of orthotics, the Board cannot concede that he obtains no improvement of his podiatric condition from prescribed orthopedic appliances.  Even considering the provisions of DeLuca v. Brown, and Mitchell v. Shinseki, supra, the aforementioned criteria for a 50 percent evaluation are not more closely approximated simply from flare-ups of elevated bilateral foot pain with curtailed capacity to walk or stand for extended periods of time, as the clinical record does not demonstrate that the Veteran's foot pain, in itself, somehow produces the orthopedic deformities contemplated in the rating criteria.  

The Board has also considered whether additional disability may be assigned under 38 C.F.R. §§ 4.40 and 4.45.  The March 2008 VA examiner reported that five additional exercises caused mild pain and moderate to severe weakness and fatigue with no incoordination.  While the examiner was unable to determine additional limitation following repetitive use during flare ups, he observed that the Veteran did not have additional limitation following repetitive use during the current examination.  In essence, the symptomatology associated with the Veteran's service-connected bilateral pes planus is exactly that described in the schedular criteria, namely no more than severe bilateral pes planus with accentuated pain on use and objective evidence of marked foot deformity.  See 38 C.F.R. § 4.71a, Diagnostic Code 5276.

While the examiner did not expressly state why it would require speculation to identify any additional limitation of motion, expressed in degrees, during periods of flare-up, it is obvious from the context of the report that the question required speculation because the examiner was not physically present to observe the Veteran's motion during episodes of flare-up.  The Board finds that further development in this regard would not yield a more specific finding and thus the examination report is deemed adequate, even in consideration of Mitchell v. Shinseki, 25 Vet. App. 32, 33, 43 (2011).

As the preponderance of the probative medical and other evidence of record is against the claim for an increased rating for bilateral pes planus, the benefit-of-the-doubt rule does not apply, and the claim must be denied.  38 U.S.C.A. § 5107(b).

The Board has also considered whether the Veteran's bilateral pes planus disability presents an exceptional or unusual disability picture as to render impractical the application of the regular schedular standards such that referral to the appropriate officials for consideration of an extra-schedular rating is warranted.  See 38 C.F.R. § 3.321(b)(1) (2012); Bagwell v. Brown, 9 Vet. App. 337, 338-39 (1996).  

Pursuant to § 3.321(b)(1), the Under Secretary for Benefits or the Director, Compensation and Pension Service, is authorized to approve an extraschedular evaluation if the case "presents such an exceptional or unusual disability picture with such related factors as marked interference with employment or frequent periods of hospitalization as to render impractical the application of the regular schedular standards."  38 C.F.R. § 3.321(b)(1) (2012).  Although the Board may not assign an extraschedular rating in the first instance, it must specifically adjudicate whether to refer a case for extraschedular evaluation when the issue either is raised by the claimant or is reasonably raised by the evidence of record.  Barringer v. Peake, 22 Vet. App. 242 (2008).

When it is not possible to separate the effects of a non-service-connected condition from those of a service-connected disorder, reasonable doubt should be resolved in the claimant's favor with regard to the question of whether certain signs and symptoms can be attributed to the service- connected disability.  See Mittleider v. West, 11 Vet. App. 181, 182 (1998).  Here the Board has considered Mittleider and attributed all potentially service-connected symtoms to his service-connected pes planus disability before considering if the Veteran is entitled to an extra-schedular rating.

If the evidence raises the question of entitlement to an extraschedular rating, the threshold factor for extraschedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the available schedular evaluations for that service-connected disability are inadequate.  Therefore, initially, there must be a comparison between the level of severity and symptomatology of the claimant's service-connected disability with the established criteria found in the rating schedule for that disability.  Thun v. Peake, 22 Vet. App. 111 (2008).

Under the approach prescribed by VA, if the criteria reasonably describe the claimant's disability level and symptomatology, then the claimant's disability picture is contemplated by the rating schedule, the assigned schedular evaluation is, therefore, adequate, and no referral is required. 

In the second step of the inquiry, however, if the schedular evaluation does not contemplate the claimant's level of disability and symptomatology and is found inadequate, the RO or Board must determine whether the claimant's exceptional disability picture exhibits other related factors such as those provided by the regulation as "governing norms."  38 C.F.R. 3.321(b)(1) (related factors include "marked interference with employment" and "frequent periods of hospitalization").  

The Veteran's symptomatology does not represent an exceptional or unusual disability picture as his symptomatology is clearly that envisioned by the criteria for rating his disability.  Accordingly, further consideration of an extraschedular rating is not warranted.  

In sum, the preponderance of the evidence of record is against a rating in excess of 30 percent for the Veteran's bilateral pes planus.  Moreover, as the preponderance of the probative medical and other evidence of record is against the claim for an increased rating for bilateral pes planus, the benefit-of-the-doubt rule does not apply, and the claim must be denied.  38 U.S.C.A. § 5107(b).

Additionally, in view of the holding in Fenderson and Hart, and, based upon the record, the Board finds that at no time since the Veteran filed his original claim for service connection has the disability on appeal been more disabling than as currently rated under the present decision of the Board. 

Finally, the Board observes that if the claimant or the record reasonably raises the question of whether the Veteran is unemployable due to the disability for which an increased rating is sought, then part and parcel to that claim for a higher rating is whether a total rating based on individual unemployability (TDIU) as a result of that disability is warranted.  See Rice v. Shinseki, 22 Vet. App. 447 (2009).  The Board notes, however, that in this case the Veteran and the record have not indicated that he is unemployable due to his bilateral pes planus. 



ORDER

Service connection for hypertension, including as due to service-connected PTSD, is denied.

Service connection for a bilateral foot disorder, other than bilateral pes planus, bilateral hammertoes, and bilateral hallux valgus, including as due to service-connected foot disabilities is denied.

A rating in excess of 30 percent for bilateral pes planus is denied.



____________________________________________
ERIC S. LEBOFF
Veterans Law Judge, Board of Veterans' Appeals



Department of Veterans Affairs