Citation Nr: 1327032 Decision Date: 08/23/13 Archive Date: 08/29/13 DOCKET NO. 11-12 659 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Whether new and material evidence has been received in order to reopen a claim of service connection for bilateral pes planus and, if so, whether service connection for bilateral pes planus is warranted. 2. Entitlement to service connection for a low back disability, to include as secondary to bilateral pes planus. REPRESENTATION Appellant represented by: Marshall O. Potter, Jr., Attorney ATTORNEY FOR THE BOARD Jennifer Hwa, Counsel INTRODUCTION The Veteran served on active duty from August 1994 to April 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In February 2012, the Veteran submitted additional evidence in support of his claims on appeal with a waiver of initial RO consideration of the evidence. See 38 C.F.R. § 20.1304 (2012). The Board notes that, in addition to the paper claims file, there is a paperless, electronic (Virtual VA) claims file associated with the Veteran's claims. A review of the documents in such file reveals that they are either duplicative of the evidence in the paper claims file or are irrelevant to the issues on appeal. In his March 2010 notice of disagreement, the Veteran alleged that he had a bilateral leg disability that was secondary to his low back disability. This issue has not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over it, and it is referred to the AOJ for appropriate action. FINDINGS OF FACT 1. In a final decision dated in August 2002 and issued in August 2002, the RO denied the Veteran's claim of entitlement to service connection for bilateral pes planus. 2. Evidence added to the record since the final August 2002 denial is not cumulative or redundant of the evidence of record at the time of the decision and raises a reasonable possibility of substantiating the Veteran's claim of entitlement to service connection for bilateral pes planus. 3. Medical findings at entrance into service reveal preexisting bilateral pes planus, and the evidence is at least in relative equipoise on the question of whether such disability underwent a permanent worsening beyond normal progression during the Veteran's active service. 4. Resolving all reasonable doubt in favor of the Veteran, the competent evidence shows that the Veteran's low back disability is due to his service-connected bilateral pes planus. CONCLUSIONS OF LAW 1. The August 2002 rating decision that denied the Veteran's claim of entitlement to service connection for bilateral pes planus is final. 38 U.S.C.A. § 7105(c) (West 1991) [(West 2002)]; 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2001) [(2012)]. 2. New and material evidence has been received to reopen the claim of entitlement to service connection for bilateral pes planus. 38 U.S.C.A. § 5108 (West 2002); 38 C.F.R. § 3.156(a) (2012). 3. The criteria for establishing service connection for bilateral pes planus have been met. 38 U.S.C.A. §§ 1110, 1153, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304(b), 3.306 (2012). 4. The criteria for establishing service connection for a low back disability have been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1117, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309(a), 3.310(a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS As the Board's decision to reopen and grant the Veteran's claim of entitlement to service connection for bilateral pes planus and to grant the Veteran's claim of entitlement to service connection for a low back disability is completely favorable, no further action is required to comply with the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations. New and Material Evidence Rating actions are final and binding based on evidence on file at the time the claimant is notified of the decision and may not be revised on the same factual basis except by a duly constituted appellate authority. 38 C.F.R. § 3.104(a). The claimant has one year from notification of an RO decision to initiate an appeal by filing a notice of disagreement with the decision, and the decision becomes final if an appeal is not perfected within the allowed time period. 38 U.S.C.A. § 7105(b) and (c); 38 C.F.R. §§ 3.160(d), 20.200, 20.201, 20.202, and 20.302(a). Generally, a claim which has been denied in an unappealed Board decision or an unappealed RO decision may not thereafter be reopened and allowed. 38 U.S.C.A. §§ 7104(b), 7105(c). The exception to this rule is 38 U.S.C.A. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the Secretary shall reopen the claim and review the former disposition of the claim. New evidence means existing evidence not previously submitted to agency decisionmakers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). The United States Court of Appeals for Veterans Claims (Court) has held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. See Shade v. Shinseki, 24 Vet. App. 110 (2010). The Court further held that new evidence would raise a reasonable possibility of substantiating the claim if, when considered with the old evidence, it would at least trigger the Secretary's duty to assist by providing a medical opinion. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). Service connection for bilateral pes planus was originally denied by rating decisions in July 1996 and December 1997. At such times, the Veteran failed to report to any VA examinations. Therefore, the RO denied service connection for bilateral pes planus based on the Veteran's failures to report to the scheduled examinations, without good cause. Most recently, service connection was again denied in a rating decision dated and issued in August 2002. The Veteran failed again to report to a VA contract examination that had been scheduled for May 2002. As the evidence of record was otherwise insufficient for rating purposes to determine the current nature and extent of the Veteran's claimed bilateral pes planus, the RO again denied service connection for the Veteran's disability. In August 2002, the Veteran was advised of the decision and his appellate rights. However, no further communication regarding his claim of entitlement to service connection for bilateral pes planus was received until March 2009, when VA received his application to reopen such claim. Therefore, the August 2002 rating decision is final. 38 U.S.C.A. § 7105(c) (West 1991) [(West 2002)]; 38 C.F.R. §§ 3.104, 20.302, 20.1103 (2001) [(2012)]. In this regard, the Board has considered the applicability of 38 C.F.R. § 3.156(b), which provides that, when new and material evidence is received prior to the expiration of the appeal period, it will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period. However, in the instant case, such regulation is inapplicable as no evidence pertaining to the Veteran's claim for service connection for bilateral pes planus was received prior to the expiration of the appeal period stemming from the August 2002 rating decision. See also Bond v. Shinseki, 659 F.3d 1362, 1367 (Fed. Cir. 2011); Roebuck v. Nicholson, 20 Vet. App. 307, 316 (2006); Muehl v. West, 13 Vet. App. 159, 161-62 (1999). In March 2009, the Veteran filed his request to reopen the claim for service connection for bilateral pes planus. The evidence received subsequent to the August 2002 rating decision includes, in relevant part, a VA examination report dated in July 2009. As pertinent here, the examination report shows that the Veteran has bilateral pes planus that is at least as likely as not to have had its etiology during his period of service. The Board finds that the new evidence relates to an unestablished fact necessary to substantiate the claim. In this regard, as the Veteran had failed to report to any VA examinations, his claim had essentially been previously denied, in part, because there was no evidence of a current diagnosis of any foot disorder. Indeed, there had been insufficient evidence to even decide his claim for service connection. Therefore, based on the foregoing reasons, the Board finds that new and material evidence has been received and, accordingly, the claim of entitlement to service connection for bilateral pes planus is reopened. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. 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). 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). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). Moreover, where a veteran served continuously for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one 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. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). The Board has reviewed all of the evidence in the Veteran's claims file. 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 below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Bilateral Pes Planus A veteran will be considered to have been in sound condition when examined and accepted for service, except as to disorders noted on entrance into service, or when clear and unmistakable evidence demonstrates that the disability existed prior to service and was not aggravated by service. Only such conditions as are recorded in examination reports are to be considered as noted. 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304(b). A preexisting injury or disease will be considered to have been aggravated by service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306. Whether a preexisting disorder underwent an increase in severity during service is determined based on evidence of the manifestations of the disorder before, during, and after service. 38 C.F.R. § 3.306. For a disorder to be considered aggravated in service, there must be worsening of the underlying condition, not just temporary or intermittent flare-ups of the symptoms of the condition. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). A review of service treatment records reveals that the Veteran's service entrance examination dated in March 1994 noted that he had severe, asymptomatic bilateral pes planus. A September 1995 treatment report shows that the Veteran had plantar fasciitis secondary to pes planus. In a January 1996 Medical Evaluation Board report, the Veteran was noted to have underwent a November 1995 examination for his symptomatic bilateral pes planus. The report indicated that at his March 1994 entrance examination, the Veteran was well-documented to have severely pronated foot type with bunion deformities and contracted digits. The Veteran complained of bilateral foot pain with standing, walking, running, marching, and all field activities, and although he was prescribed various arch supports, pads, rest, light duty, and nonsteroidal anti-inflammatory drugs, they did not relieve his symptoms. His commanders reported that the Veteran had unsatisfactory military field activity and physical performance, and related the performance deficiencies to the Veteran's complaints of bilateral foot pain. Examination revealed loss of the normal longitudinal osseous arch, excessive heel valgus, pronated forefeet, supple mid tarsal and hind ankle joint spaces, excessive plantar callous formation, and moderate clawing of the second to fifth toes, bilaterally. The Veteran had stage II-III bunion deformities of the first metatarsophalangeal joint. He had pain upon palpation of the medial tubercle of the calcaneus and along the plantar fascial bands at the plantar aspect of his bilateral feet. An x-ray of both feet and ankles indicated that the Veteran had marked decrease in the longitudinal osseous arch, lipping and spurring at and about the talonavicular joint that was symptomatic of degenerative joint changes, marked decrease in calcaneal inclination angle, and talonavicular fault which was characteristic of a severely pronated foot type. The Veteran was diagnosed with pes planus, bilateral stage II-III bunion deformities, plantar fasciitis heel spur syndrome, and bilateral degenerative joint disease at the talar navicular joint. His pes planus was noted to have existed prior to service. A February 1996 decision of the Physical Evaluation Board indicated that the Veteran was unfit for further duty On VA examination in July 2009, the Veteran complained of constant, burning, sharp pain in the bottom of his feet that traveled throughout the feet and ankles and was a 5/10 in severity. He reported that the pain was exacerbated by physical activity and relieved by rest. He stated that he had fatigue while at rest and stiffness while standing and/or walking. His functional impairment included difficulty with prolonged standing or walking. Upon examination, the Veteran was diagnosed with bilateral pes planus and bilateral calcaneal spurs. The examiner opined that it was at least as likely as not that the Veteran's currently diagnosed bilateral foot condition was related to his period of service. He explained that there was evidence of medical records as well as a pathophysiologic relationship to support this rationale. At a January 2010 VA examination, the Veteran complained of constant, burning, sharp pain in the bottom of his feet that traveled to the ankles and was a 10/10 in severity. He reported that the pain was exacerbated by physical activity and relieved by rest. He stated that he had stiffness while at rest, and pain and swelling while standing and/or walking. His functional impairment included being unable to perform normal daily routines and being unable to stand or walk for long periods of time without discomfort. Upon examination, the Veteran was diagnosed with bilateral pes planus deformity with left foot calcaneal spur. The examiner opined that the Veteran's bilateral pes planus was not caused by or aggravated by military service. She noted that the Veteran's enlistment examination in March 1994 clearly stated that the severe pes planus was a preexisting condition at the time of enlistment. However, she also noted that the pes planus had been asymptomatic, or not painful, on enlistment. The examiner acknowledged the Veteran's experiences of foot pain throughout service due to his preexisting foot condition and that he had been found unfit for duty in July 1995, just 16 months later. The examiner indicated that the Veteran's pre-service condition had been painful during service, but that his military service had not permanently aggravated or worsened his foot condition, which had already been specifically documented as severe bilateral pes planus. The examiner concluded that the Veteran's current condition of pes planus and calcaneal spurs was most likely a natural progression of this condition and had been unchanged by his 16 months of active duty. The Veteran submitted lay statements dated in July 2011 from his family and friends in support of his claim. These statements show, in pertinent part, that prior to entering service, the Veteran had been able to engage in activities that involved walking and running, such as playing basketball, without complaining that his feet were hurting him. After going through basic training in service, the Veteran began complaining that his feet were aching and painful, and when he came home after discharge from service, he asserted that his feet ached when he moved or was just standing. The Veteran began to limp and started walking very carefully. He stopped playing basketball due to foot pain and restricted his activities more and more. He also stumbled on occasion and had problems with balance. His complaints about his flat feet had become more severe as time passed, and he had a difficult time even walking and standing for any length of time. Sometimes he even complained about his feet while he was sitting down and at rest. In a December 2011 private medical report, the physician indicated that she had reviewed the Veteran's entire claims file. She noted that the Veteran's pes planus had been noted on enlistment but had only become painful during basic training. Subsequent to the Veteran complaining of severe foot pain and burning sensation on the bottom of his feet, he was placed on light duty for a few days. Once the Veteran returned to normal service, his foot pain returned just as severely as before, as it became unbearable for him to keep his boots on for any period of time, and he was limping due to pain. The Veteran cycled between being placed on light duty or bed rest, where his foot pain would subside slightly, and going back to normal duty, where his foot pain would return to the severity it had been in prior to light duty. Since the Veteran's discharge from service, he had experienced intractable pain in both feet, a limp when he walked, loss of balance, and pins and needles in his feet. After examination, the physician diagnosed the Veteran with pronounced bilateral pes planus. She found that it was a deterioration of his condition, as compared to his entrance examination, which had noted severe but asymptomatic bilateral pes planus. She explained that the Veteran's pes planus had markedly increased in severity since service, as was evidenced by limping, awkward gait, burning sensation in the feet, and pain greater in the right foot than the left foot. She opined that the Veteran's flat feet had been asymptomatic when he was first admitted to service, but that the military training activities that he had performed while wearing combat boots had aggravated his pes planus well beyond what would have been an expected course during his time of service. The physician explained that boot camp was a time of constant and strenuous physical activity that was usually performed in combat fatigues and boots. She noted that the Veteran's foot pain had always increased after he had worn his combat boots for long periods of time and engaged in strenuous activities of long duration. She also found that the Veteran's foot pain had at first resolved with rest during service, but that it had subsequently reached the point of being constant and chronic. The Veteran began limping all the time and could not even bear to put on his boots due to the foot pain. The physician explained that the necessity to wear, hike, and run in combat boots for long periods of time, often while carrying excessive weight, had been the initial trigger to the entire process leading to the Veteran's structural abnormalities in his feet. She acknowledged that the Veteran's pes planus had been asymptomatic for many years prior to his period of active service even though he had been very active by running and playing basketball for many years. However, she explained that because the Veteran had needed to wear combat boots while walking and running in service, this had placed his feet in an alignment that had resulted in chronic heel spur formation and plantar fasciitis, given his condition of pes planus. The initial determination is whether the Veteran's bilateral pes planus was present prior to service. In Crowe v. Brown, 7 Vet. App. 238 (1994), the Court indicated that the presumption of soundness attaches only where there has been an induction medical examination, and where a disability for which service connection is sought was not detected at the time of such examination. The Court added that the regulation provides expressly that the term "noted" denotes only such conditions as are recorded in examination reports, and that history of pre-service existence of conditions recorded at the time of examination does not constitute a notation of such conditions. 38 C.F.R. § 3.304(b)(1) (2012). In this case, the evidence of record indicates that the Veteran's bilateral pes planus was noted on entrance examination. Thus, the presumption of soundness does not attach in this case. 38 C.F.R. § 3.304(b). If a preexisting disorder is noted upon entry into service, a veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case, 38 U.S.C.A. § 1153 applies and the burden falls on the veteran to establish aggravation with regard to his bilateral pes planus. See Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation under 38 U.S.C.A. § 1153 arises, the burden shifts to the government to show a lack of aggravation by establishing "that the increase in disability is due to the natural progress of the disease." 38 U.S.C.A. § 1153 (West 2002); see also 38 C.F.R. § 3.306 (2012); Jensen, 19 F.3d at 1417. It must now be determined whether the preexisting disability was aggravated by service. In this case, the Board finds that the evidence of record is in equipoise on the question of whether the Veteran's bilateral pes planus underwent a permanent worsening beyond normal progression during his active service. An evaluation of the probative value of medical opinion evidence is based on the medical expert's personal examination of the patient, the examiner's knowledge and skill in analyzing the data, and the medical conclusion reached. The credibility and weight to be attached to such opinions are within the province of the Board as adjudicators. Guerrieri v. Brown, 4 Vet. App. 467 (1993); Gabrielson v. Brown, 7 Vet. App. 36 (1994). Greater weight may be placed on one physician's opinion over another depending on factors such as reasoning employed by the physicians and whether or not and the extent to which they reviewed prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The probative value of a medical opinion is generally based on the scope of the examination or review, as well as the relative merits of the expert's qualifications and analytical findings, and the probative weight of a medical opinion may be reduced if the examiner fails to explain the basis for an opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). The Board assigns no probative weight to the July 2009 VA opinion. While the examiner opined that the Veteran's bilateral pes planus was directly related to his period of service, he made no reference to the March 1994 enlistment examination in which the Veteran was already noted to have severe bilateral pes planus that was asymptomatic. Indeed, the examiner did not indicate why the Veteran's bilateral pes planus had its etiology during his period of service when the Veteran already had a preexisting bilateral pes planus disability prior to enlistment. Therefore, the Board finds that the July 2009 VA medical opinion is internally inconsistent due to a misreading of the Veteran's service treatment records. Thus, as the July 2009 VA examiner's opinion is based on an inaccurate factual premise, this limits its probative value. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Swann v. Brown, 5 Vet. App. 229, 233 (1993); Black v. Brown, 5 Vet. App. 177, 180 (1993). Regarding the issue of whether the Veteran's preexisting bilateral pes planus was permanently aggravated by service, the Board acknowledges the January 2010 VA examiner's opinion that the Veteran's bilateral pes planus was not aggravated by military service, but was instead most likely a natural progression of his foot condition and unchanged by his 16 months of active duty. She explained that although the Veteran's pre-service bilateral pes planus had been painful during service, his military service had not permanently aggravated or worsened his foot condition, as it had already been specifically documented as severe bilateral pes planus. However, the December 2011 private physician opined that the Veteran's bilateral pes planus had been asymptomatic when he was first admitted to service, but that the military training activities that he performed while wearing combat boots had aggravated his pes planus well beyond what would have been an expected course during his time of service. She explained that because boot camp was a time of constant and strenuous physical activity that was usually performed in combat boots, the Veteran's foot pain had increased after he had worn his combat boots for long periods of time and engaged in strenuous activities of long duration. She indicated that this foot pain had become constant and chronic, and the need to wear combat boots while walking and running in service had placed the Veteran's feet in an alignment that had resulted in additional chronic heel spur formation and plantar fasciitis, secondary to his condition of pes planus. The Board notes that in the January 2010 and December 2011 opinions, the physician and examiner both reviewed the Veteran's claims file, considered his lay statements regarding onset and symptomatology of his disorder, performed thorough physical examinations, discussed the Veteran's pertinent medical history, and provided detailed and adequate rationale for the differing conclusions of whether the Veteran's preexisting bilateral pes planus had been permanently aggravated by his period of service. For these reasons, the Board cannot find the negative July 2009 VA opinion to be more probative than that of the positive December 2011 private opinion. Similarly, the Board cannot find that the positive December 2011 private opinion is more probative than the negative July 2009 VA opinion. Thus, the overall record is in relative equipoise as to whether the Veteran's preexisting bilateral pes planus had been permanently aggravated by his period of service. In sum, the Board finds that the most probative evidence indicates that the Veteran's bilateral pes planus existed prior to his entry into service and was noted on his entrance examination. Additionally, the Board concludes that the balance of positive and negative evidence is at the very least in relative equipoise on whether the Veteran's bilateral pes planus underwent a permanent worsening beyond normal progression during his active service. Where the evidence supports the claim or is in relative equipoise, the appellant prevails. Reasonable doubt is resolved in favor of the Veteran, and the Board finds that service connection for bilateral pes planus is warranted. 38 U.S.C.A. 5107 (b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Low Back Disability Service connection may also be established for disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2012). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran contends that he has a current low back disability that is secondary to his bilateral pes planus. The Board notes that as a result of the above decision, service connection has been granted for bilateral pes planus, and therefore, the theory of secondary service connection can be considered in the Veteran's claim for a low back disability. Service treatment records are negative for any complaints, treatment, or diagnoses of a low back disability. At his January 1996 Medical Evaluation Board examination, the Veteran was not found to have any abnormalities of the spine. On VA examination in December 2009, the Veteran reported that his low back disability had existed for 14 years. He complained that he experienced stiffness, spasms, numbness, limitation in walking, and severe localized pain that occurred 4 times a day and lasted for 0.5 hours. He stated that his back and foot condition had caused such severe pain that he could barely go back and forth to class. He could not lift much, walk far, do yard work, or participate in sports. Upon examination, the Veteran was diagnosed with chronic lumbar strain with low back pain, secondary to chronic foot pain and abnormal gait that was secondary to pes planus and calcaneal spurs. The examiner opined that the Veteran's low back disability was at least as likely as not secondary to his bilateral foot condition. He explained that there was evidence that painful pes planus increased the risk of low back pain by as much as twofold. The examiner also noted that the Veteran did not have back pain prior to entering service and that his pes planus only became symptomatic during service. He indicated that the Veteran subsequently developed low back pain without any other intervening factors to account for it. The Veteran submitted lay statements dated in July 2011 from his family and friends in support of his claim. These statements show, in pertinent part, that the Veteran started complaining of back pain and stiffness about 2 to 4 years ago, but that prior to that time, he had never complained about his back. The Veteran's posture was noted to be different because he was not as straight as he used to be. He also appeared to get tired and did not have the stamina that he once had. He did not appear to be able to do a lot of strenuous activity and had limitation in his range of motion. He sometimes wore back support and would get back massages. In a December 2011 private medical report, the physician indicated that she had reviewed the Veteran's entire claims file. She noted that during the Veteran's period of service, after he started limping due to his foot pain, he began to experience back pain. After discharge from service, the Veteran had a period of prolonged limping and subsequently developed back pain that had progressed in severity. The back pain was so intense at times that he could not bend over and get back up, get down on his knees and get back up, run, play basketball, or do tasks at home like cutting the grass. After examination, the physician opined that the Veteran's chronic back pain, balance, and gait problems were clearly secondary to his pes planus. She explained that when an individual leaned more heavily into one leg than the other, the biomechanical result was that one iliac crest or side of the pelvis was elevated and laterally rotated in relation to the other. In the Veteran's case, his right leg was noticeably laterally rotated and his left hip elevated. She indicated that the elevation on one side of his hip involved a chronic tightening of the quadratus lumborum of that side of the back and usually a tightening of the lateral rotators of the hip on that side as well, as the spine tried to compensate for the hip height variation by rotating to one side. She reported that the tightening of the quadratus muscle and chronic rotation of the spine would eventually cause a chronic pain pattern in the low back on the side where the hip was elevated, due to the iliac crest rotating externally and moving close to the sacrum bone. The physician found that the Veteran's constant severe foot pain and abnormal gait had also caused a chronic back pain condition. She explained that the altered gait and alignment had caused dysfunctional movement in the lower extremities. Additionally, the right leg external rotation at the hip and shift of body weight away from the right side of the body onto the left leg had caused chronic back pain due to the stress at the sacroiliac joint. Therefore, the physician concluded that it was as likely as not that the Veteran's back pain was secondary to his altered gait that resulted from his bilateral foot pain. Regarding service connection for a low back disability on a direct basis, the Board reiterates that service treatment records are negative for any complaints, treatment, or diagnoses for any low back disability, and no arthritis was shown to have manifested within one year of the Veteran's discharge from service. Additionally, at no time did any treating provider relate the Veteran's low back disability to his period of service. With respect to service connection for a low back disability as secondary to the Veteran's service-connected bilateral pes planus, a December 2009 VA examiner found that the Veteran's low back disability was at least as likely as not secondary to his bilateral foot condition. He explained that there was evidence that painful pes planus increased the risk of low back pain by as much as twofold. The examiner also noted that the Veteran did not have back pain prior to entering service and that his pes planus only became symptomatic during service. He indicated that the Veteran subsequently developed low back pain without any other intervening factors to account for it. Additionally, a December 2011 private physician also found that the Veteran's back problems were secondary to the altered gait that resulted from his bilateral pes planus. She explained that the Veteran's constant severe foot pain and abnormal gait had caused a chronic back pain condition because the altered gait and alignment had caused dysfunctional movement in the lower extremities. She also indicated that the right leg external rotation at the hip and shift of body weight away from the right side of the body onto the left leg had caused chronic back pain due to the stress at the sacroiliac joint. As the medical evidence of record indicates that the Veteran has a low back disability that is due to bilateral pes planus, and there is no contrary competent evidence of record, the Board resolves all reasonable doubt in favor of the Veteran and finds that he currently has a low back disability that is due to his service-connected bilateral pes planus. In sum, the Board finds that the competent evidence of record shows that the Veteran's low back disability was related to his service-connected bilateral pes planus. Thus, the criteria for secondary service connection for a low back disability have been met. Therefore, reasonable doubt is resolved in favor of the Veteran, and the Board finds that service connection for a low back disability is warranted. 38 U.S.C.A. 5107 (b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER New and material evidence having been received, the claim of entitlement to service connection for bilateral pes planus is reopened. Entitlement to service connection for bilateral pes planus is granted. Entitlement to service connection for a low back disability is granted. ____________________________________________ DEBORAH W. SINGLETON Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs