Citation Nr: 1325243 Decision Date: 08/09/13 Archive Date: 08/13/13 DOCKET NO. 09-19 449 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to an initial compensable evaluation for the service-connected bilateral pes planus. 2. Entitlement to service connection for a seizure disorder. 3. Entitlement to service connection for a disability manifested by bilateral calf pain. 4. Entitlement to service connection for pectoral region muscle strain, claimed as chest pain. 5. Entitlement to service connection for a right foot cicatrix. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K. L. Wallin, Counsel INTRODUCTION The Veteran served on active duty from October 1961 to September 1963. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from an October 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan. The claims have been recharacterized as they appear on the cover page of the instant decision. The Veteran originally requested a Board hearing to be held at his local RO. See VA Form 9 received in May 2009. In June 2009, he requested the Board hearing be held via videoconference. In November 2009, the Veteran opted for a hearing before a Decision Review Officer (DRO) in lieu of Board hearing. The matter was re-scheduled multiple times by request of the Veteran. The last scheduled DRO hearing was set in August 2010. Notice of the hearing was sent to the address of record and regularity of the mail is presumed. The Veteran failed to appear and as such, his hearing request is deemed withdrawn. A claim of entitlement to service connection for a fracture of the right great toe has been raised by the record. A claim of entitlement to service connection for three myocardial infarctions and two heart stents was filed in November 2006. See VA Form 21-526. These matters have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are, referred to the AOJ for appropriate action. The claims for a right foot cicatrix and pectoral region muscle strain are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. FINDINGS OF FACT 1. The Veteran's bilateral pes planus has been shown to be productive of weight-bearing line over the great toe and inward bowing of the tendo achillis; while there has been evidence of marked pronation, there has been no manifestation of pain on manipulation of the feet, pain on use accentuated, swelling on use, or characteristic callosities. 2. The competent and probative medical evidence of record preponderates against a finding that the Veteran's seizure disorder is due to events in active service or manifested to a compensable degree within one year after the Veteran's separation from service in September 1963. 3. It is not shown that the Veteran has, or during the pendency of this claim has had, a disability manifested by bilateral calf pain. CONCLUSIONS OF LAW 1. The criteria for the assignment of an initial 10 percent evaluation, but not greater, for the service-connected bilateral pes planus have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 4.3, 4.7, 4.71a, including Diagnostic Code 5276 (2012). 2. The criteria for service connection for a seizure disorder have not been met. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2012). 3. The criteria for service connection for disability manifested by bilateral calf pain have not been met. 38 U.S.C.A. §§ 1110, 1112, 5107 (West 2002); 38 C.F.R. §§ 3.159, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Notice and Assistance Upon receipt of a complete or substantially complete application for benefits and prior to an initial unfavorable decision on a claim by an agency of original jurisdiction, VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The RO provided the Veteran pre-adjudication notice by letters dated in January 2007 and August 2007. The Veteran indicated in February 2007 and August 2007 that he had no additional evidence to submit in support of his claims. The claim pertaining to the Veteran's bilateral pes planus arises from the Veteran's disagreement with the initial noncompensable evaluation following the grant of service connection. Courts have held that once service connection is granted the claim is substantiated, additional notice is not required, and any defect in the notice is not prejudicial. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). No additional discussion of the duty to notify is therefore required. VA also has a duty to assist the Veteran in the development of the claims. The duty to assist regarding the claim for bilateral pes planus is not abrogated by the granting of service connection. VA has obtained service treatment records, assisted the Veteran in obtaining evidence, provided the Veteran VA examinations, and afforded the Veteran the opportunity to give testimony before the Board, which he withdrew, and before a DRO, which he failed to appear. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. VA has substantially complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claims at this time. II. Analysis The Board has reviewed all the evidence in the Veteran's paper claims file and virtual record (including Virtual VA and Veteran's Benefits Management System (VBMS)). Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis will focus specifically on what evidence is needed to substantiate each claim and what the evidence in the claims file shows, or fails to show, with respect to each claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). A. Increased Rating Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities (Rating Schedule) and are intended to represent the average impairment of earning capacity resulting from disability. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. Disabilities must be reviewed in relation to their history. 38 C.F.R. § 4.1. VA should interpret reports of examination in light of the whole recorded history, reconciling the various reports into a consistent picture so that the current rating may accurately reflect the elements of disability. 38 C.F.R. § 4.2. Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations apply, the higher of the two should be assigned where the disability picture more nearly approximates the criteria for the next higher rating. 38 C.F.R. § 4.7. When considering functional impairment caused by a service-connected disorder, evaluations should be based on an assessment of the lack of usefulness, and adjudicators should consider the effects of the disabilities upon the person's ordinary activity. 38 C.F.R. § 4.10. See also Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In order to evaluate the level of disability and any changes in condition, it is necessary to consider the complete medical history of a veteran's disability. Schafrath, 1 Vet. App. at 594. In general, the degree of impairment resulting from a disability is a factual determination and generally the Board's primary focus in such cases is upon the current severity of the disability. Francisco v. Brown, 7 Vet. App. 55, 57-58 (1994); Solomon v. Brown, 6 Vet. App. 396, 402 (1994). The Board also acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation at any stage since the effective date of service connection. See Fenderson v. West, 12 Vet. App 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The analysis in the following decision is undertaken with consideration of the possibility that different ratings may be warranted for different time periods. The Court has held that functional loss, supported by adequate pathology and evidenced by visible behavior of the veteran undertaking the motion, is recognized as resulting in disability. DeLuca v. Brown, 8 Vet. App. 202 (1995); 38 C.F.R. §§ 4.10, 4.40, 4.45. Disability of the musculoskeletal system is primarily the inability, due to damage or inflammation in parts of the system, to perform normal working movements of the body with normal excursion, strength, speed, coordination and endurance. Functional loss may be due to pain supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. 38 C.F.R. § 4.40. The factors of disability affecting joints are reduction of normal excursion of movements in different planes, weakened movement, excess fatigability, swelling and pain on movement. 38 C.F.R. § 4.45. Ratings shall be based as far as practicable, upon the average impairments of earning capacity with the additional proviso that the Secretary shall from time to time readjust this schedule of ratings in accordance with experience. To accord justice, therefore, to the exceptional case where the schedular evaluations are found to be inadequate, the Under Secretary for Benefits or the Director, Compensation and Pension Service, upon field station submission, is authorized to approve on the basis of the criteria set forth in this paragraph an extra-schedular evaluation commensurate with the average earning capacity impairment due exclusively to the service-connected disability or disabilities. The governing norm in these exceptional cases is: A finding that 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). Historically, service connection was awarded for bilateral pes planus in an October 2007 rating decision. An initial noncompensable evaluation was made effective from November 2006. The Veteran disagreed with the initial noncompensable rating and initiated the instant appeal. The Board will now consider whether a higher evaluation is warranted for the disability at any stage since the effective date of service connection. See Fenderson, supra. The Veteran's bilateral pes planus has been assigned a noncompensable rating for mild flatfoot (pes planus), symptoms relieved by built-up shoe or arch support. 38 C.F.R. § 4.71a, Diagnostic Code 5276. A 10 percent rating is assigned for moderate pes planus, weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. Id. A 20 percent is assigned for unilateral and 30 percent for bilateral, severe pes planus, objective evidence of marked deformity (pronation, abduction, etc), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. Id. Having carefully considered all the evidence of record in light of the pertinent law and regulations, the Board finds that an initial 10 percent rating, and no higher, is warranted under the rating criteria for pes planus. 38 C.F.R. § § 4.7, 4.71a, Diagnostic Code 5276. The Board considered other applicable criteria for rating the feet in order to assign a higher rating; however, the Board observes that no other code provisions can be applied for a higher rating based on the evidence of record. There was no evidence of claw foot (Diagnostic Code 5278), malunion of or nonunion of the tarsal or metatarsal bones (Diagnostic Code 5283), or moderately severe foot injury (Diagnostic Code 5284). Id. The pertinent evidence is as follows. An August 2007 private treatment note simply contains complaints of intermittent right foot pain and bilateral flat feet. X-rays confirmed mild pes planus. Upon VA examination in April 2007, the Veteran denied foot pain, but endorsed swelling and stiffness in the feet. Treatment included shoe inserts. He denied seeing a podiatrist within the last couple of years. He had flare-ups of foot pain most often after walking for about one mile and standing too long. Pain was alleviated by soaking his feet. X-rays showed minimal loss of longitudinal arch of both feet. Upon VA examination in August 2009, the Veteran presented with subjective complaints of periodic right foot cramps, swelling, fatigability, redness, stiffness, weakness, and lack of endurance. Treatment included shoe inserts. He denied seeing a podiatrist. Flare-ups of pain occurred with walking 30 to 40 feet and standing too long, alleviated by soaking the feet. He denied any foot surgery. Physical examination showed no evidence of painful motion, swelling, tenderness, instability, weakness, or abnormal weight bearing. There was inward bowing of the Achilles alignment, partially correctable with manipulation. There was no midfoot or forefoot malalignment. There was marked pronation. There was no pain on manipulation. The weight-bearing line was over the great toe bilaterally. X-rays showed stable, mild, relative flattening of the plantar calcaneal angle. The examiner noted the Veteran's pes planus had significant effects on the Veteran's job in that he was assigned different duties; however, the Veteran retired in 1992. There was no indication the Veteran retired due to his pes planus; the cause of retirement was listed as unknown. In sum, the evidence shows the Veteran's bilateral pes planus has been productive of the weight-bearing line over the great toe and inward bowing of the tendo achillis, which warrants a 10 percent rating. While there was marked pronation on the August 2009 examination, which is listed in the criteria for a 30 percent rating, there was no evidence of pain on manipulation of the feet, pain on use accentuated, swelling on use, or characteristic callosities. Thus, the disability picture more nearly approximates the criteria for a 10 percent rating and no higher. 38 C.F.R. § 4.7. The Board has noted the Veteran's complaints of pain experienced in his feet and thus, considered functional loss due to flare-ups of pain, fatigability, incoordination, pain on movement, and weakness. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202, 206-7 (1995). However, neither the lay nor medical evidence reflects the functional equivalent of symptoms required for a finding of severe, bilateral pes planus as to warrant a higher rating under Diagnostic Code 5276. "Staged" ratings are not warranted for any period of the appeal. 38 C.F.R. § 4.71a; see Fenderson, supra. Should the Veteran's disability picture change in the future, he may be assigned a higher rating. See 38 C.F.R. § 4.1. Finally, the Board has considered whether extraschedular consideration is warranted. The symptoms and resulting impairment demonstrated with regard to the bilateral pes planus falls within the schedular criteria. The rating criteria contemplates a higher rating for bilateral pes planus, but as explained above, there has been no objective evidence of the necessary criteria to warrant such a rating. See Diagnostic Codes 5276-5284. The effects of pain and functional impairment have been taken into account and are considered in applying the relevant criteria in the rating schedule. The effects of the Veteran's disability have been fully considered and are contemplated in the rating schedule; hence, referral for an extraschedular rating is unnecessary at this time. Consideration of whether the Veteran's disability picture exhibits other related factors such as those provided by the regulations as "governing norms" is not required and referral for an extraschedular rating is unnecessary. Thun v. Peake, 22 Vet. App. 111 (2008). A total rating for compensation based on individual unemployability (TDIU) is an element of all appeals of an initial rating. Rice v. Shinseki, 22 Vet. App. 447 (2009). Entitlement to TDIU is raised where a Veteran : (1) submits evidence of a medical disability; (2) makes a claim for the highest rating possible; and (3) submits evidence of unemployability. Roberson v. Principi, 251 F.3d 1378 (Fed. Cir. 2001). However, TDIU is not raised in an increased rating claim unless the Roberson requirements are met. Jackson v. Shinseki, 587 F.3d 1106 (Fed. Cir. 2009). The evidence of record shows the Veteran retired in 1992. He has not made any assertions of unemployability during the appeal period. Hence, further consideration of TDIU is not warranted. B. Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some 'chronic diseases,' such as organic diseases of the nervous system, presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With 'chronic disease' shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term 'chronic disease', whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331, Fed. Cir. 2013). In this decision, the Board has considered all lay and medical evidence as it pertains to the issue. 38 U.S.C.A. §§ 5107(b), 7104(a); 38 C.F.R. § 3.303(a). In rendering a decision on appeal, 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. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify"). In determining whether statements submitted by a veteran are credible, the Board may consider internal consistency, facial plausibility, consistency with other evidence, and statements made during treatment. Caluza v. Brown, 7 Vet. App. 498 (1995). (i) Seizure Disorder The Veteran claims that he has a seizure disorder as result of active military service. The Veteran has not set forth a specific incident of service incurrence. After review of the evidence, the Board finds service connection must be denied because the competent, probative evidence does not suggest a seizure disorder had an onset in service or is causally related to service A seizure disorder is a "chronic disease" under 38 C.F.R. § 3.309(a). It is considered an organic diseases of the nervous system. Thus, consideration under 38 C.F.R. § 3.303(b) is warranted. Where a combination of manifestations sufficient to identify a 'chronic disease' in service, and establish chronicity at the time are present, any later manifestation of the same 'chronic disease' is subject to service connection unless attributable to an intercurrent cause. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. The service treatment records reflect no histories or treatment for a seizure disorder, to include the July 1963 separation medical examination.. The Veteran was diagnosed with a seizure disorder in 1984, which dates 21 years after separation. The long time lapse can be considered, along with other factors, as evidence of whether an injury or disease was incurred in service which resulted in any chronic or persistent disability. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Veteran has not claimed that he has had seizures since his discharge from service. A July 2000 private treatment record notes the Veteran had been taking seizure medication for the past 10 years. He informed providers at that time that he had been having black outs and memory loss for many years and had been evaluated multiple times and the physicians did not know what was causing these episodes. The September 2007 VA examiner noted that seizures were diagnosed in 1984. The Board finds that the probative evidence does not suggest the existence of a chronic seizure disorder manifested during service or within a year of discharge, or until 21 years after service; in other words, there is no continuity of symptomatology. Any current assertions of such a continuity would be of diminished credibility given these facts. 38 C.F.R. § 3.303(b); Layno v. Brown, 6 Vet. App. 465 (1994); see also Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Service connection may be granted when the evidence establishes a medical nexus between active duty service and current complaints. The Board finds that the preponderance of the competent evidence is against a finding of a nexus between the Veteran's seizure disorder, and his active service, despite his contentions to the contrary. In that regard, private treatment records dated in November 2008 show the Veteran sustained a skull fracture at age 19, prior to service, and was left with a lasting seizure disorder. In December 2006 Dr. AS, indicated he had known the Veteran for four months and he had seizures for over 20 years. Dr. AS also indicated there were no records dated in the 1970s, but seizures were noted in old records prior to 1985. This statement is in keeping with other evidence of record showing a seizure disorder being diagnosed in 1984. Dr. AS did not indicate the seizure disorder was related to the Veteran's active duty service. The Board is cognizant that Dr. RVG opined the Veteran had a seizure disorder, which required treatment shortly after being discharged from service and was service related. The Board does not find this opinion probative of the matter on appeal. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)); see also Guerieri v. Brown, 4 Vet. App. 467, 470-471 (1993) (the probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches, as is true of any evidence, the credibility and weight to the attached medical opinions are within the province of the Board). First, there is no indication Dr. RVG reviewed the Veteran's service treatment records, which were negative for a seizure disorder. Second, there was no mention of the head injury prior to service. Moreover, a statement by Dr. AS revealed there were no records dating in the 1970s, which would contradict Dr. RVG's statement that a seizure disorder was treated shortly after service (i.e. no objective evidence of such treatment and based on the Veteran's statements alone). Thus, Dr. RVG's opinion as to etiology of the Veteran's seizure disorder is not probative of the matter on appeal. See Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record; bare conclusions, even those made by medical professionals, which are not accompanied by a factual predicate in the record, are not probative medical opinions). In Kowalski v. Nicholson, 19 Vet. App. 171, 179 (2005), the Court, citing its decisions in Swann v. Brown, 5 Vet. App. 229 (1993), and Reonal v. Brown, 5 Vet. App. 458 (1993), reaffirmed that in evaluating medical opinion evidence, the Board may reject a medical opinion that is based on facts provided by the veteran that have been found to be inaccurate or because other facts present in the record contradict the facts provided by the veteran that formed the basis for the opinion. The Board may not, however, simply disregard a medical opinion solely on the rationale that the medical opinion was based on a history given by the veteran. Here, an in-service seizure disorder has not been verified and thus, to the extent that a medical provider's diagnosis can be read as an opinion of a nexus to service, it is not competent evidence. Id.; See also Coburn v. Nicholson, 19 Vet. App. 427, 432 (2006) (reliance on a veteran's statement renders a medical report incredible if the Board rejects the statements of the veteran). The Board acknowledges that the Veteran is competent to give testimony about what he experienced; for example, he is competent to report his in-service experiences. See, e.g., Layno, supra. Competency, however, must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. See Rucker, supra. The Veteran has not presented any lay statements of any credibility to identify the onset of a seizure disorder while he was serving on active duty. A VA medical opinion is not necessary in order to decide the claim for a seizure disorder in this case because the record does not contain any competent or probative evidence that the Veteran suffered an injury, disease, or event in service or that the claimed seizure disorder may be associated with service. 38 C.F.R. § 3.159(c)(4)(i); Duenas v. Principi, 18 Vet. App. 512, 517 (2004), citing Paralyzed Appellants of Am. V. Sec'y of Appellants Affairs, 345 F.3d 1334, 1355-57 (Fed. Cir. 2003). Based upon the evidence that has been submitted in this case, the weight of which does not establish that the Veteran's seizure disorder had its onset during service, the Board finds that the evidence is not in relative equipoise; thus, the Veteran may not be afforded the benefit of the doubt and his claim must be denied. 38 U.S.C.A. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). (ii) Bilateral Calf Pain The Veteran contends that he is entitled to service connection for bilateral calf pain. He informed the April 2007 VA examiner that he had bilateral pain in his lower legs during heavy activity. Service treatment records show the veteran reported leg cramps after exertion on his October 1961 enlistment medical history; however, there was no disability manifested by calf pain diagnosed upon the corresponding physical examination. As such, a disability manifested by calf pain did not pre-exist active service. During service, there was a complaint of calf pain in June 1963. The Veteran also reported calf pain on his July 1973 separation medical history. Again, no bilateral calf disability was diagnosed. The examiner indicated that cramps occurred on over exertion, but were not considered significant. Post-service, the Veteran denied leg cramps upon VA examination in April 2007. He also denied any current treatment for leg cramps, which is reflected in the other evidence associated with the claims file. The threshold matter that must be addressed here (as in any claim seeking service connection) is whether or not there is competent evidence that the Veteran actually has the disability for which service connection is sought (a disability manifested by bilateral calf pain). In the absence of proof of such disability there is no valid claim for service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The only competent evidence in the record specifically addressing whether or not the Veteran has a disability manifested by bilateral calf pain, is the report of the April 2007 VA examination. As that examination found no bilateral calf disability, the Board must find that such disability is not shown. Because the Veteran has not shown he now has, or during the pendency of this claim has had, a disability manifested by bilateral calf pain, he has not presented a valid claim of service connection for such disability. See 38 U.S.C.A. § 1131; See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Accordingly, his appeal in this matter must be denied. ORDER Entitlement to an initial 10 percent rating, and no higher, for the service-connected bilateral pes planus is granted subject to the controlling regulations governing monetary awards. Entitlement to service connection for a seizure disorder is denied. Entitlement to service connection for a disability manifested by bilateral calf pain is denied. REMAND The Veteran claims entitlement to service connection for a right foot cicatrix and pectoral region muscle strain. A preliminary review of the record discloses the matters are not ready for appellate disposition. The claim for a right foot cicatrix must be remanded for new VA examination. The Veteran was afforded a VA examination in April 2007. The examiner found that a scar (cicatrix) on the right foot pre-existed the Veteran's military service. The examiner opined the scar was not related to military service as it was due to a childhood foot muscle injury. The examiner did not provide an opinion as to whether the pre-existing cicatrix was aggravated during the Veteran's military service beyond the natural progression of the disease. The Veteran was also afforded a VA examination in August 2009. The examiner noted the Veteran had a severe laceration to the right foot as a child and this condition was superimposed on the Veteran's pes planus. There was no opinion as to whether the right foot cicatrix was aggravated by the service-connected bilateral pes planus. There is insufficient competent medical evidence on file for the VA to make a decision on the claim for a right foot cicatrix; a new VA examination is necessary. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The examiner is asked to answer the specific questions set forth in the numbered paragraphs below. The claim for pectoral region muscle strain, claimed as chest pain, must be remanded to satisfy the duties to notify and assist. The RO provided the Veteran pre-adjudication notice by letters dated in January 2007 and August 2007; however, these letters addressed the Veteran's claim for a heart condition, among other disabilities, but did not address a claim for pectoral region muscle strain or chest pain denied by the RO in October 2007. VA is required to notify the appellant of the information and evidence not of record that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159; Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). The notice should also address the rating criteria or effective date provisions that are pertinent to the appellant's claim. Dingess v. Nicholson, 19 Vet. App. 473 (2006). As noted in the Introduction, the Veteran filed a formal claim for three myocardial infarctions and two stent placements in November 2006. Thereafter, the Veteran amended his claim to include left side chest pain. See VA Form 21-4138 received in December 2006. The RO sent the Veteran preadjudication letters regarding the claim for heart condition in 2007; however, to date has not adjudicated the claim for a heart condition. The RO instead denied a claim for pectoral region muscle strain, claimed as chest pain, in October 2007. It is clear, the Veteran's claim for pectoral region muscle strain and chest pain is part and parcel of his claim for a heart condition. Thus, these claims are inextricably intertwined. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991)(issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). Hence, the Board may not proceed with appellate review of the pectoral muscle strain and chest pain issue until the RO had adjudicated the heart condition claim. The RO should also give the Veteran another opportunity to present information and/or evidence pertinent to the claims on appeal. 38 U.S.C.A. § 5103A (b) (West 2002). Accordingly, the case is REMANDED for the following action: 1. Send the Veteran a letter notifying him of the information and evidence not of record that is necessary to substantiate the claim for pectoral region muscle strain and chest pain. The notice should also address the rating criteria or effective date provisions that are pertinent to his claim. 2. Schedule the Veteran for a VA examination to ascertain the nature and etiology of the claimed right foot cicatrix. The Veteran's entire claims file (i.e. the paper claims file and any medical records contained in Virtual VA, VBMS, CAPRI, and AMIE) must be available for review by the examiner. If the examiner does not have access to Virtual VA or VBMS, any relevant treatment records in Virtual VA or VBMS that are not available on CAPRI or AMIE must be printed and associated with the paper claims file so they can be available to the examiner for review. All indicated tests or studies must be completed. The examiner should describe all findings in detail. The examiner should be notified that the October 1961 enlistment examination showed a healed laceration of the right instep. During service, the Veteran complained of tightness and pain under the sole of his foot when walking and pain while standing. The July 1963 separation examination showed a one inch cicatrix on the arch of the right foot. A complete rationale must be provided for all opinions expressed. If the requested opinions cannot be made without resorting to speculation, the examiner must state this and specifically explain why an opinion cannot be provided without resort to speculation. Based on the examination and review of the record, the examiner should answer the following questions: a) Is it at least as likely as not (50% probability or greater) that the pre-existing right foot cicatrix was aggravated beyond the natural progression of the disease during active duty service? b) Is it at least as likely as not (50% probability or greater) that the right foot cicatrix has increased in severity due to or the result of the service-connected bilateral pes planus? In answering this question, the examiner must make specific reference to the August 2009 VA examiner's notation that the Veteran had a severe laceration to the right foot as a child and this condition was superimposed on the Veteran's pes planus. The examiner is informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of right foot disability (i.e., a baseline) before the onset of the aggravation. 3. The RO must adjudicate the Veteran's claim for a heart condition. The RO must notify the Veteran and his representative of the determination and furnish notice of appellate rights and procedures so that the Veteran may have the opportunity to initiate an appeal on the heart condition issue if he so desires. 4. In the interest of avoiding further remand, ensure that the requested actions have been accomplished (to the extent possible) in compliance with this REMAND. 5. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should readjudicate the claims for service connection for pectoral region muscle strain (chest pain) and a right foot cicatrix in light of all evidence of record, to include any pertinent evidence contained within Virtual VA or VBMS. If any benefit sought on appeal remains denied, the RO must furnish to the Veteran and his representative with an appropriate supplemental statement of the case and afford a reasonable opportunity for response. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ MILO H. HAWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs