Citation Nr: 1329138 Decision Date: 09/11/13 Archive Date: 09/17/13 DOCKET NO. 09-23 953 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New York, New York THE ISSUES 1. Entitlement to a rating in excess of 30 percent for posttraumatic stress disorder (PTSD). 2. Entitlement to service connection for a right foot disorder. 3. Entitlement to service connection for a left foot disorder. 4. Entitlement to service connection for hypertension. REPRESENTATION Appellant represented by: New York State Division of Veterans' Affairs WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T. S. Kelly, Counsel INTRODUCTION The Veteran served on active duty from April 1970 to December 1971. He is the receipt of the Combat Infantryman Badge. He also had additional service in the New York Army National Guard. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The Veteran testified before the undersigned Veterans Law Judge at a Travel Board hearing in April 2011. A transcript of the hearing is associated with the claims file. At the hearing, he submitted additional evidence with a waiver of RO consideration. Following the hearing, the Board remanded this matter for further development. The requested development was completed insofar as possible and the matter is now ready for appellate review. FINDINGS OF FACT 1. The Veteran's PTSD is manifested by, among other things, complaints of moodiness, irritability, forgetfulness, distraction, isolation, intrusive thoughts, flashbacks, and avoidance; findings include appropriate behavior, ability to communicate, clear and well-organized thought process, intact cognitive functioning, intact memory, good insight and judgment, but deficits in social functioning. 2. A right foot disorder is related to an injury sustained in June 1987 while on ACDUTRA. 3. A left foot disorder has been aggravated by a now service-connected right foot disorders. 4. Hypertension was not shown in service or for many years thereafter and is not related to service or to a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for a 50 percent rating, but no more, for PTSD have been met. 38 U.S.C.A. §§ 1155, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.321(b)(1), 4.3, 4.7, 4.130, Diagnostic Code (DC) 9411 (2012). 2. A right foot disorder was incurred during a period of ACDUTRA. 38 U.S.C.A. §§ 101, 1110, 1131, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.102, 3.303 (2012). 3. A left foot disorder was aggravated by a now service-connected right foot disorder. 38 U.S.C.A. §§ 101, 1110, 1131, 5103(a), 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.102, 3.310 (2012). 3. Hypertension was not incurred in or aggravated by active service nor may it be presumed to have been incurred therein, nor is it proximately due to or the result of a service-connected disability. 38 U.S.C.A. §§ 101, 1101, 1110, 1112, 1131, 1137, 5103(a), 5103A (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.6, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board has reviewed all of the evidence in the Veteran's claims folder. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to his claims. Increased Rating for PTSD Disability evaluations are determined by the application of the Schedule for Rating Disabilities, which assigns ratings based on the average impairment of earning capacity resulting from a service-connected disability. 38 U.S.C.A. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. It is the defined and consistently applied policy of VA to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. Any reasonable doubt regarding the degree of disability is resolved in favor of the Veteran. See 38 C.F.R. § 4.3. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Staged ratings are, however, appropriate for an increased rating claim when the factual findings show distinct time periods where the service-connected disability exhibits symptoms that would warrant different ratings. The relevant focus for adjudicating an increased rating claim is on the evidence concerning the state of the disability from the time period one year before the claim was filed until VA makes a final decision on the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). 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). 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 condition. Schafrath v. Derwinski, 1 Vet. App. 589, 594 (1991). The provisions of DC 9411 provides that a 30 percent rating is assigned for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). A 50 percent evaluation requires occupational and social impairment with reduced reliability and productivity due to such symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired abstract thinking; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships. A 70 percent evaluation is assigned for occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); inability to establish and maintain effective relationships. The criteria for a 70 percent rating are met if there are deficiencies in most of the areas of work, school, family relations, judgment, thinking, and mood. Bowling v. Principi, 15 Vet. App. 1, 11-14 (2001). A 100 percent evaluation is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; memory loss for names of close relatives, own occupation, or own name. The symptoms cited above follow the phrase "such symptoms as" which indicates that the symptoms after that phrase are not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Accordingly, the Board has not required the presence of all or most of the enumerated symptoms for any particular rating. The list of symptoms merely provides guidance as to the severity of symptoms contemplated for each rating, in addition to permitting consideration of other symptoms, particular to each veteran and disorder, and the effect of those symptoms on the claimant's social and work situation. The Board must consider all symptoms of a veteran's condition which affect the level of occupational and social impairment. If the evidence demonstrates that a claimant suffers symptoms or effects that cause occupational or social impairment equivalent to what would be caused by the symptoms listed in the diagnostic code, the appropriate, equivalent rating will be assigned. Mauerhan v. Principi, 16 Vet. App. 436, 441-443 (2002). The Global Assessment of Function (GAF) is a scale reflecting the "psychological, social, and occupational functioning in a hypothetical continuum of mental health-illness." American Psychiatric Association: DIAGNOSTIC AND STATISTICAL MANUAL OF MENTAL DISORDERS (DSM), 32 (4th ed.) (1994) (DSM IV); 38 C.F.R. §§ 4.125, 4.130 (2012). Relevant to this claim, GAF scores ranging from 51 through 60 reflect moderate symptoms (e.g., flat affect and circumstantial speech, occasional panic attacks) or moderate difficulty in social, occupational, or school functioning (e.g., few friends, conflicts with peers or co-workers). Scores ranging from 41 through 50 reflect serious symptoms (e.g., suicidal ideation, severe obsessional rituals, frequent shoplifting) or any serious impairment in social, occupational or school functioning (e.g., no friends, unable to keep a job). A GAF score of from 31 through 40 contemplates some impairment in reality testing or communication (e.g., speech at times illogical, obscure, or irrelevant) or major impairment in several areas, such as work or school, family relations, judgment, thinking, or mood (e.g., depressed man avoids friends, neglects family, and is unable to work). See Carpenter v. Brown, 8 Vet. App. 240, 242 (1995). In October 2006, the Veteran indicated that the symptomatology associated with his PTSD had increased in severity, warranting an increased evaluation. In conjunction with his claim, he was afforded a VA examination in October 2007. At the time of the examination, he was noted to be working full-time as a union representative. He stated that over the past few months he had been missing work more frequently, approximately one to two days per month because of his mood and irritability. He reported having problems on the job, including with his co-workers. He also stated that he was more forgetful and easily distracted and found himself thinking more of Vietnam. The Veteran reported living with his wife and indicated that the relationship was strained. He noted sleeping on the living room floor because he was fearful of an attack. His wife disapproved of this and this had caused conflict with his marriage. His wife and children had noticed a change in him, which included his being more grumpy, moody, and prone to arguments over the past six months. His son and daughter both lived at home and he frequently had arguments with both of them. He stated that after work, he enjoyed taking care of his motorcycle and reading. He reported that he only socialized with Vietnam veterans, which was quite limited, and that he isolated from others and stayed away from family at family gatherings. The Veteran reported having daily intrusive thoughts and flashbacks about Vietnam and weekly nightmares where he would wake up screaming. He reported reliving traumatic events daily. He had some avoidance behavior. He stated that he was estranged and detached from his wife and children and had no friends outside of his occasional contacts with his Vietnam buddies. He reported that his affect was sad, restricted and tearful. He noted having trouble sleeping and waking frequently through the night. He indicated that his children described him as quite angry and irritable. He stated that he was hypervigilant, constantly on the lookout for things that were out of place with his environment. He stated that this interfered with his ability to focus at work. He also described startle response to loud noises. Mental status examination revealed he was dressed in a plaid shirt and jeans. He was cooperative, well-related, and friendly. He reported having foot pain. His behavior was generally appropriate and his ability to communicate was intact. His affect was tearful and sad, though appropriate to content. His thought process was clear and well-organized. He denied suicidal or homicidal tendencies and perception was unremarkable. Cognitive functioning was intact and he was oriented and attentive. Memory was intact and insight and judgment were good. The examiner rendered a diagnosis of chronic PTSD and assigned a GAF score of 42. The examiner stated that the Veteran met the criteria for PTSD and his current symptoms were exaggerated startle response, hypervigilance, irritability, insomnia, restricted affect, detachment from others, avoidance behavior, distressed by triggers, reliving traumatic events, nightmares, and intrusive thoughts or flashbacks. The symptoms had worsened since the last examination and had a moderate to severe impact on social and occupational functioning. He had deficiencies in social functioning including relationships with his wife and children. He also had reduced reliability or productivity in occupational functioning due to his symptoms, which made it difficult for him to focus on his work, describing that intrusive thoughts interrupted him, that he was irritable and less patient with coworkers, and was preoccupied with his thoughts about Vietnam. He noted that his boss commented on his "memorial" to Vietnam in his office, which spoke to the Veteran's preoccupation. The examiner stated that these symptoms had impacted the Veteran's functioning by way of his inability to adapt to stress, poor performance in his employment setting, inability to maintain family role functioning, a deficit in social and interpersonal relationships, and difficulty regulating his mood. The examiner indicated that the Veteran's ability to work was impaired by his psychiatric condition and might be in jeopardy if he did not pursue appropriate PTSD treatment. Drugs and alcohol were not factors in the Veteran's condition. At the time of a July 2008 outpatient visit, mental status examination revealed that the Veteran had normal grooming and hygiene. He was slightly guarded but cooperative. Attention was normal and eye contact was fair. Motor activity was sedate and speech was normal. His mood was irritable and his affect was constricted but congruent. Concentration was normal and he was oriented times three. Recent and remote memory were normal and thought process and content were linear, spontaneous, and unremarkable. He did not have any hallucinations or suicidal or homicidal plans. Judgment and impulse control were good and insight was described as fair. The examiner rendered Axis I diagnoses of PTSD, chronic; depression, NOS; and alcohol abuse, and assigned a GAF score of 51. At the time of a March 2011 visit, mental status examination revealed the Veteran to be appropriately attired and to have normal grooming and hygiene. He engaged and related well and was pleasant. Attention was normal, eye contact was fair, and motor activity was sedate. Speech was normal and the Veteran's mood was irritable. His affect was reactive to reported mood and thought content. Concentration was normal and he was oriented to time, person, and place. Recent and remote memory were normal. Thought process was linear and spontaneous while thought content was unremarkable He did not have suicidal or homicidal plans or ideations. He had pan-insomnia and a good appetite. Judgment and impulse control were good and insight was described as fair. The examiner rendered Axis I diagnoses of chronic PTSD, depression, NOS, and alcohol abuse. A GAF score of 51 was assigned. At the time of his April 2011 hearing, the Veteran reported that he was receiving treatment for his PTSD at a local Vet Center. Following the hearing, the Board remanded this matter for additional development to include a VA examination and to obtain treatment records from the Vet Center; however, he did not provide the requested written authorizations to obtain the treatment records. At the time of a May 2011 VA outpatient visit, mental status examination revealed that the Veteran was appropriately attired with normal grooming and hygiene. He engaged and related well and was pleasant. Attention was normal, eye contact was fair, and motor activity was relaxed. His speech was normal and his mood was described as "better." Affect was appropriately reactive to reported mood and thought content. Concentration was normal and he was oriented to time, person, and place. Recent and remote memory were normal. Thought process was linear and spontaneous and thought content was unremarkable. There were no suicidal or homicidal ideations or plans. He had insomnia and there were no feelings of hopelessness. His appetite was good and judgment and impulse control were described as good while insight was fair. The examiner rendered Axis I diagnoses of PTSD, chronic; depression, NOS; and alcohol abuse. A GAF score of 55 was assigned. The Veteran was afforded another examination in December 2012. At that time, the examiner diagnosed PTSD. The Veteran reported that he had been married for 34 years and that he had two children. He stated that he and his wife did not sleep together and that he did not sleep well. He reflected that he stayed downstairs to protect the house. He also noted that his wife complained about him forgetting things and that he did not listen, that he was irritable all the time, and that he was depressed all the time. He indicated that his son also confirmed this. He noted that he was easily angered and that he stayed in the basement alone when at home. He indicated that he worked 40 hours per week. He stated that he stayed to himself and avoided others. He reported that his co-workers complained of his low frustration tolerance. He noted having no legal problems, no physical fights, and no confrontations. He had two beers with dinner. The Veteran had symptoms of depressed mood, anxiety, suspiciousness, panic attacks more than once a week, chronic sleep impairment, mild memory loss, disturbances of motivation and mood, and difficulty in establishing and maintaining effective work and social relationships. He denied having current suicidal or homicidal ideations. He was particularly vigilant checking his environment for safety. He did have impaired impulse control such as unprovoked periods of irritability but there were not periods of violence. He denied any persistent delusions or hallucinations. He also had intermittent inability to perform activities of daily living, including maintenance of personal hygiene. His wife needed to remind him to bathe frequently. The examiner stated that the Veteran's service-connected symptoms had increased since the last evaluation and his psychological and occupational functioning had decreased. There was now the presence of panic attacks more than once a week. He also had difficulty establishing and maintaining effective work and social relationships. He was far more isolative and had a flattened affect with disturbances in motivation and mood. The examiner assigned a GAF score of 40. Resolving reasonable doubt in favor of the Veteran, the Board finds that the criteria for a 50 percent rating for PTSD have been met throughout the course of the appeal. The Veteran has been shown to have intermittent periods of anger and fluctuations of mood, as well as depression throughout the appeal period. He has also been found to have mild memory impairment during this time. Disturbances of motivation and mood have also been found to be present during the time period in question. Although he has a relationship with his wife and children, it is somewhat strained. He has also indicated that he prefers isolation and that he does not like to talk to others. Therefore, the criteria for a 50 percent evaluation for PTSD have been met since the initial grant of service connection for PTSD. After a review of all the evidence, lay and medical, the Board finds that the criteria for a disability evaluation in excess of 50 percent have not been met or nearly approximated at any time during the appeal period. The Veteran's PTSD symptoms and the severity of his symptoms did not more nearly approximate the criteria for a 70 percent disability (occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood) at any time. Specifically, the Veteran has not been shown to have suicidal plans or intentions. There were no findings or assertions of suicidal or homicidal plans or intentions at the time of either VA examination or in VA outpatient treatment records which have been associated with claims folder. Speech has not been found to be intermittently illogical, obscure, or irrelevant at any time during this period, including at the time of both VA examinations. While depression has been diagnosed throughout the appeal, it has not been found to be near-continuous. Next, although he has reported being irritable and easily provoked there have been no physical altercations reported, and the Veteran still remains working on a full-time basis. He has been found to be alert and oriented to time, place, and person all times and while there was a notation that his wife had to remind him to bathe at the most recent VA examination, he continues to maintain adequate hygiene. As to relationships, while the Veteran has reported that he tends to isolate and prefers to be alone, he still remains married and continues to have a relationship with his children, although these relationships are strained. While he has been found to have obsessive rituals which interfere with routine activities, the symptomatology associated with his PTSD is more akin to that for the 50 percent evaluation. The Board recognizes that the Court in Mauerhan, 16 Vet. App. 436, stated that the symptoms listed in VA's general rating formula for mental disorders is not intended to constitute an exhaustive list, but rather are to serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating; however, the Court further indicated that without those examples, differentiating between rating evaluations would be extremely ambiguous. Id. at 442. With this in mind, the evidence shows that the Veteran's overall PTSD picture is adequately contemplated by the existing 50 percent rating. He does suffer from sleep problems, but this is specifically listed under the criteria for a 30 percent rating, a lower rating than the current 50 percent rating. Flattened affect, disturbance of motivation and mood, and difficulty in establishing and maintaining relationships are specifically contemplated in the 50 percent rating criteria. The same is true with the Veteran's depression, which is a symptom contemplated under the 30 percent PTSD disability rating. A 50 percent PTSD disability rating also considers "disturbances of motivation and mood" which would include his reported depression symptoms. Despite his contention that his PTSD symptoms warrant an evaluation in excess of 50 percent, the Board finds that the evidence of record does not support this contention. The Board does note that the Veteran was assigned GAF scores in the 40's at the time of the VA examinations; however, the GAF scores are only one criteria to be considered when deciding the appropriate disability evaluation to be assigned. The objective findings made at the time of the examinations, when compared to the symptoms set forth in the rating criteria, demonstrate that his symptoms more closely approximate the criteria for a 50 percent rating throughout the rating period. For these reasons, the Board finds that a preponderance of the evidence warrants a 50 percent rating but no more. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321 (2012). 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"). When the rating schedule is inadequate to evaluate a claimant's disability picture and that picture has related factors such as marked interference with employment or frequent periods of hospitalization, then the case must be referred to the Under Secretary for Benefits or the Director of the Compensation and Pension Service for completion of the third step-a determination of whether, to accord justice, the claimant's disability picture requires the assignment of an extraschedular rating. Id. In this case, the schedular rating criteria contemplate the impairments and symptoms associated with the Veteran's PTSD. The symptomatology and impairment caused by the Veteran's PTSD is specifically contemplated by the schedular rating criteria, and no referral for extraschedular consideration is required. The schedular rating criteria, DC 9411, specifically provides for ratings based on a combination of history and clinical findings. In this case, considering the lay and medical evidence, the Veteran's PTSD has manifested flashbacks, nightmares, depression, difficulty sleeping, avoidance of large crowds, difficulty associating with others other than his immediately family, obsessional rituals, and irritability. These symptoms are either explicitly part of the schedular rating criteria or are "like or similar to" those symptoms and impairment explicitly listed in the schedular rating criteria. Mauerhan at 443. The levels of occupational and social impairment are also explicitly part of the schedular rating criteria. In the absence of exceptional factors associated with this disability, the Board finds that the criteria for submission for assignment of an extraschedular rating pursuant to 38 C.F.R. § 3.321(b)(1) are not met. See Bagwell v. Brown, 9 Vet. App. 337 (1996); Shipwash v. Brown, 8 Vet. App. 218, 227 (1995). Service Connection Claims Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The conditions at issue, with the exception of hypertension, are not "chronic diseases" listed under 38 C.F.R. § 3.309(a) ; therefore, the presumptive provisions of 38 C.F.R. § 3.303(b) do not apply to the non-chronic diseases. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled from a disease or injury incurred in the line of duty. 38 U.S.C.A. § 101(21),(24); 38 C.F.R. § 3.6(a). Active military, naval, or air service also includes any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled from an injury incurred in the line of duty. Id. Accordingly, service connection may be granted for disability resulting from disease or injury incurred in, or aggravated, while performing ACDUTRA or from injury incurred or aggravated while performing INACDUTRA. 38 U.S.C.A. §§ 101(24), 106, 1110, 1131. As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, at 448 (1995) (holding that service connection on a secondary basis requires evidence sufficient to show that the current disability was caused or aggravated by a service-connected disability). To establish secondary service connection, the law states that there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between a service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Right and Left Foot Disorders The Veteran maintains that his current right and left foot disorders are related to his period of service, resulting from an injury incurred in June 1987, while on ACDUTRA. Records obtained as part of the Board's July 2012 remand reveal that an actual photocopy of the DA Form 1379 listed the ACDUTRA as having taken place for a two week period in June 1987. Thus, for purposes of the appeal, the Board finds that the right ankle injury, which occurred in mid-June 1987 was during a period of ACDUTRA, which allows for the grant of VA benefits for disabilities arising out of this injury. At the time of a July 1987 follow up visit, the Veteran was seen with complaints of stiffness of the right ankle for one month. It was noted that he had sprained his ankle in June 1987. He reported that he heard a funny noise in his ankle when he landed. At a follow-up visit, he indicated that he was given an Ace wrap. Pain and swelling were reported as being present. X-rays taken at that time were reported to have revealed no fracture or dislocation. A diagnosis of a sprained right ankle was made at that time. At his April 2011 hearing, the Veteran testified as to falling into a hole when on a training mission in Canada. He stated that he fell into the hole and heard a real crunch. The ankle was wrapped in an Ace bandage. He indicated that the left foot problems were as a result of damage to the right ankle. He testified that he subsequently received treatment for his ankle/foot problems. In a June 2011 letter, the Veteran's private podiatrist, L. L., DPM, indicated that the Veteran had been a patient of his since 2000. He reported that the Veteran had been treated for several problems over the years. The most pertinent condition was his flat feet with severe pronation. This condition caused him to walk differently. He did not have proper heel to toe gait. Dr. L. stated that the Veteran walked with an inward rotation of the ankle and foot that caused more strain on the ligaments and tendons. He noted that the Veteran's history included an injury to the right ankle over 20 years ago. He sustained a partial tear of his tibial tendon which was confirmed by an MRI. Dr. L. indicated that an injury like this would weaken the posterior tibial tendon which would cause more pronation of the right foot. This would increase the strain and pressure around the right ankle causing more discomfort. He noted that as a result of the injury to the right ankle, the Veteran placed more pressure on his left foot while ambulating. He indicated that the Veteran did not have an injury to the right ankle but stated that the compensatory pressure would place extra strain on the ligaments around the left ankle. It was his opinion that it was at least as likely as not that the diagnosed condition of the right foot/ankle, to include partial tear of the posterior tibial tendon, was related to the injuries described in the service medical records when the Veteran injured his right ankle. He also indicated that it was his opinion that it was at least as likely as not that the diagnosed conditions of the left foot, to include pes planus and severe pronation, were compensatory and related to the service-connected damage to the right ankle. In conjunction with the July 2012 Board remand, the Veteran was afforded a VA foot examination in January 2013. The examiner diagnosed bilateral flat foot, metatarsalgia, hammer toes, hallux rigidus, mild osteoarthritis of the right first metatarsophalangeal joint, and small bilateral calcaneal spurs. The examiner indicated that the claims folder was not available for review. In a March 2013 addendum report, the examiner indicated that the claims folder was available and had been reviewed. The examiner again reported that the Veteran had bilateral pes planus, metatarsalgia, hallux valgus, mild osteoarthritis of the right first metatarsophalangeal joint, and small bilateral calcaneal spurs. The examiner opined that for each diagnosed foot disorder, it was not as least as likely as not that it was related to the Veteran's period of service, including the June 1987 right foot injury. In the rationale section of the report, it was indicated that the Veteran's service treatment records and the June 2011 opinion from Dr. L.M.L. had been reviewed. The examiner noted that service treatment records showed evidence of right ankle sprain in 1980 after a fall into a 3 foot hole with negative x-rays. The examiner stated that he did not find any evidence of right ankle problems in the claims folder until 1996. He noted that in 1996, the Veteran had an MRI of the right ankle which showed posterior tibial tendon tear. The examiner indicated that he could not find the reason that the MRI was done for the right ankle (whether there was any trauma in 1996). As to bilateral pes planus, he stated there was no indication in the claims folder of the condition until 2003. The other diagnoses of bilateral feet were found on the previous examination. The examiner indicated that hence it was less likely as not that the current bilateral foot conditions listed above were related to the right ankle sprain while in service. As the positive and negative evidence are in equipoise, the Board will resolve reasonable doubt in the Veteran's favor and find that his current right foot disorders are related to the injury sustained to his right ankle in June 1987 while on ACDUTRA. The record reveals evidence of an in-service injury to the right ankle during a period of ACDUTRA. The Veteran has currently been found to have right foot disorders, namely pes planus, partial tear of the posterior tibial tendon, metatarsalgia, hallux valgus, mild osteoarthritis of the right first metatarsophalangeal joint, and small calcaneal spurs. As to the relationship between the current right foot disorders and the right ankle injury sustained by the Veteran while on ACDUTRA, the Board finds that the medical opinions rendered by the VA examiner and the Veteran's private physician are also in equipoise. Both examiners provided detailed rationale for their opinions. The private examiner cited to the Veteran's in-service injury and the subsequent disorders resulting from this injury. He provided detailed rationale as to why the Veteran's right foot disorder could have caused his current right foot disabilities and opined that it was at least as likely as not that the current foot disorders were related to the Veteran's in-service injury. The January/March 2013 VA examiner also provided detailed rationale as to why it was less likely than not that the Veteran's current right foot disorders were related to the June 1987 injury. However, the Board notes that there are some discrepancies in the report, including the examiner indicating that the ankle injury occurred in 1980. The Board finds these opinions equally persuasive. In such a case, reasonable doubt must be resolved in favor of the Veteran. As the Veteran has been noted to have sustained a right ankle injury during a period of ACDUTRA, as he has been shown to have current right foot disabilities, and as the required medical nexus opinions provided have been shown to be at least in equipoise, reasonable doubt must be resolved in favor of the Veteran. As such, service connection for a right food disorder is warranted. As to the left foot, as noted above, service connection has now been granted for a right foot disorder. To establish secondary service connection, the law states that there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between a service-connected disability and the current disability. The Board notes that the Veteran has not maintained that he injured his left foot during active duty or during a period of ACDUTRA. Rather, he asserts that his current left foot disorders arise from his right foot disorders. As demonstrated above, he has been found to have current left foot disabilities, namely pes planus, metatarsalgia, hallux valgus, and small calcaneal spurs. Service connection is also now in effect for right foot disorders. Finally, the June 2011 private examiner indicated that it was as likely as not that the diagnosed conditions of the left foot, to include pes planus and severe pronation, were compensatory and related to the service-connected damage to the right ankle. The private physician provided detailed rationale for his opinion and there is no other opinion of record contradicting the physician's statement. As a result, the Board finds that the Veteran has met the criteria required for granting service connection for the left foot disorders of pes planus, metatarsalgia, hallux valgus, and small calcaneal spur, as secondary to his service-connected right foot disorders. Hypertension Hypertension is a "chronic disease" listed under 38 C.F.R. § 3.309(a); therefore, 38 C.F.R. § 3.303(b) applies. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of "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. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases, such as hypertension, become manifest to a degree of 10 percent or more within one year after the date of separation from 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 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. The service treatment records do not demonstrate nor has the Veteran indicated that his hypertension had its onset in service or during a period of ACDUTRA. Rather, he has attributed hypertension to his service-connected diabetes mellitus. Post-service treatment records associated with the claims folder reveal that the Veteran's private physician, M.S., M.D., in an August 2005 letter, indicated that the Veteran was under her care for diabetes, hypertension, hyperlipidemia, and obesity. At his April 2011 hearing, the Veteran testified that his hypertension did not start in service. He stated that his hypertension was diagnosed in the 2000's. It was noted that the earliest reference for the hypertension in the file was in March 2005. He testified that his diabetes and hypertension were almost diagnosed simultaneously. In a June 2011 letter, Dr. M.S., indicated that the Veteran had been evaluated for hypertension, diabetes, and hyperlipidemia. She noted that the Veteran had suffered from these conditions for many years and had symptoms of diabetes retinopathy and neuropathy. She opined that the Veteran's hypertension was residual to and aggravated by his longstanding diabetes. Dr. S. provided no rationale for her opinion. In July 2012, the Board remanded this matter for further development, to include obtaining an opinion as to whether it was at least as likely as not (a 50 percent or greater probability) that the Veteran's hypertension was either caused or aggravated by (increased in severity due to) his service-connected diabetes. The Board noted that if the opinion was to the effect that the diabetes did not cause, but aggravated, the hypertension, the examiner was to also specify, so far as possible, the increased disability (pathology/impairment) resulting from such aggravation. The examiner was requested to explain the rationale for all opinions. The Veteran was afforded the requested examination in December 2012. The examiner indicated that the claims file and medical records were reviewed and that the Veteran was interviewed and examined. Following examination, the examiner opined that it was less likely as not that the Veteran's hypertension was either caused or aggravated by (increased in severity due to) his service-connected diabetes. As to rationale, the examiner indicated that the Veteran stated his hypertension and diabetes were diagnosed about the same time. The examiner further noted that the Veteran's blood pressure was controlled by his medication and his kidney function was normal. As it relates to the claim of service connection for hypertension on a direct basis or presumptive basis, the Board notes that the Veteran's service treatment records do not reveal any findings of hypertension and he has not provided any statements to support this claim and has not testified that his current hypertension started in service. There have also been no treatment records associated with the claims folder demonstrating the development of hypertension in close proximity to the Veteran's separation from service or during a period of ACDUTRA. Treatment records associated with the claims folder reveal that the earliest finding of hypertension was in 2005. For the above reasons, in-service injury or disease or aggravation during service has not here been established, either through the clinical evidence of record or by the statements from the Veteran. As to the Veteran's belief that his current hypertension is caused or aggravated by his service-connected diabetes, the Board applies the holding of the U.S. Court of Appeals for the Federal Circuit in Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Here, however, the question of causation extends beyond an immediately observable cause-and-effect relationship and, as such, he is not competent to address etiology in the present case. He has not been shown to have the requisite training or expertise to render an opinion as to the etiology of any hypertension and its relationship, if any, to his service-connected diabetes. Moreover, there are many complex factors/contributors to hypertension which he also does not have the requisite training to address. Next, service connection may be granted when the evidence establishes a medical nexus between a claimed disability and the service-connected diabetes. When evaluating the weight of medical evidence, the Board is guided by the principle that the probative value of a medical opinion largely rests upon the extent to which such opinion is based upon a thorough evaluation of a veteran's medical history, including but not limited to the medical evidence contained in the claims file. See, e.g. Miller v. West, 11 Vet. App. 345, 348. The Board may examine the factual foundation of a medical opinion, including whether the physician had access to relevant information of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 303-304 (2008). It is the accuracy of the facts that are important, rather than the source of the information. A significant factor to be considered for any opinion is the accuracy of the factual predicate, regardless of whether the information supporting the opinion is obtained by review of medical records or lay reports of injury, symptoms and/or treatment. See Harris v. West, 203 F.3d 1347, 1350-51 (Fed. Cir. 2000) (examiner opinion based on accurate lay history deemed competent medical evidence in support of the claim); Kowalski v. Nicholson, 19 Vet. App. 171, 177 (2005) (holding that a medical opinion cannot be disregarded solely on the rationale that the medical opinion was based on history given by the veteran); Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). In this regard, the Board notes that the Veteran has supplied an opinion from Dr. S. indicating that the Veteran's hypertension was residual to and aggravated by his diabetes. However, Dr. S. provided no rationale to support her opinion. The Board notes that the weight of a medical opinion is diminished where that opinion is ambivalent, based on an inaccurate factual premise, based on an examination of limited scope, or where the basis for the opinion is not stated. See Reonal, 5 Vet. App. at 461; Sklar v. Brown, 5 Vet. App. 140 (1993). The Board further notes that the Court has repeatedly declined to adopt a "treating physician rule" that would require giving additional evidentiary weight to the opinion of a physician who treats the veteran regularly. See White v. Principi, 243 F.3d 1378 (Fed. Cir. 2001); Harder v. Brown, 5 Vet. App. 183, 188 (1993); Van Slack v. Brown, 5 Vet. App. 499, 502 (1993); Chisem v. Brown, 4 Vet. App. 169 (1993). The Board is assigning greater probative value to the December 2012 VA examiner's opinion that it was less likely as not that the Veteran's hypertension was either caused or aggravated by his service-connected diabetes. The examiner's opinion was based upon a more thorough review of the evidence, including from the claims folder, and a comprehensive examination of the Veteran. The examiner provided detailed rationale to support his opinion. The entire claims file, which at the time included the service treatment records, private and VA treatment records, and statements from the Veteran, was reviewed. Based on all the evidence, the examiner rendered an opinion that was supported by detailed and complete rationale. There was no indication that the VA examiner was not fully aware of the Veteran's past medical history or that he misstated any relevant fact, or relied on any inaccurate fact. Thus, the Board finds the December 2012 VA examiner's opinion to be the most probative evidence of record. In sum, the preponderance of the evidence weighs against a finding that the Veteran's hypertension developed in service or during a period of ACDUTRA, in the one year following active service, or was caused or aggravated by his service-connected diabetes. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. Finally, the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1) . For claims pending before VA on or after May 30, 2008, 38 C.F.R. § 3.159 has been amended to eliminate the requirement that VA request that a claimant submit any evidence in his or her possession that might substantiate the claim. 73 Fed. Reg. 23,353 (Apr. 30, 2008). As the Board is granting the full benefit sought on appeal as it relates to the claims of service connection for right and left foot disorders, those claims are substantiated, and there are no further VCAA duties. Wensch v. Principi, 15 Vet App 362, 367-368 (2001); see also 38 U.S.C.A. § 5103A(a)(2) (VA Secretary not required to provide assistance "if no reasonable possibility exists that such assistance would aid in substantiating the claim"); VAOPGCPREC 5-2004 (the notice and duty to assist provisions of the VCAA do not apply to claims that could not be substantiated through such notice and assistance). As to the issues of service connection for hypertension and an increased evaluation for PTSD, the Board notes that the Veteran's status has been substantiated. The Board observes that in a September 2007 letter, the RO provided the Veteran with notice that informed him of the evidence needed to substantiate his claims. The letter also told him what evidence he was responsible for obtaining and what evidence VA would undertake to obtain. The letter further told him to submit relevant evidence in his possession. The Court has also held that that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) veteran status; 2) existence of a disability; 3) a connection between the veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). The September 2007 letter provided the Veteran with notice as to the disability rating and effective date elements of the claim. VA has a duty to assist a Veteran in the development of the claim. This duty includes assisting the Veteran in the procurement of service medical records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. All pertinent treatment records, service, VA, and private, have been obtained and associated with the claims folder insofar as possible. No other relevant records have been identified. The Veteran was requested to provide written authorizations to obtain treatment records from the Vet Center as part of the July 2012 Board remand and has not provided the requested authorizations. As such, no further assistance is required as it relates to obtaining these records. As it relates to the claim of service connection for hypertension, the Veteran was afforded a VA examination in December 2012. The examination provided the necessary opinion along with detailed rationale to properly assess the Veteran's claim. Thus, the examination was sufficient for VA rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). As it relates to the claim of for an increased evaluation for PTSD, the Veteran was afforded VA examinations in October 2007 and December 2012. The examinations provided sufficient detail to properly assess the Veteran's claim. Thus, the examination was sufficient for VA rating purposes. See Barr v. Nicholson, 21 Vet. App. at 312. The Veteran has been afforded a meaningful opportunity to participate effectively in the processing of the claim, including by submission of statements and arguments presented by his representative. The Veteran also appeared at a Travel Board hearing before the undersigned Veterans Law Judge in April 2011 in support of his claim. For these reasons, it is not prejudicial to the appellant for the Board to proceed to finally decide the appeal. Based upon the foregoing, the duties to notify and assist the Veteran have been met, and no further action is necessary to assist the Veteran in substantiating this claim. ORDER A 50 percent rating, but no more, for PTSD, is granted subject to the laws and regulations. Service connection for a right foot disorder is granted. Service connection for a left foot disorder is granted. Service connection for hypertension is denied. ____________________________________________ L. HOWELL Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs