Citation Nr: 1552011 Decision Date: 12/11/15 Archive Date: 12/16/15 DOCKET NO. 09-20 660 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUES 1. Entitlement to service connection for degenerative disc disease of the cervical spine (claimed as a neck condition), to include as secondary to service-connected bilateral plantar fasciitis and bunion disabilities. 2. Entitlement to service connection for lumbar paravertebral myositis (claimed as back pain), to include as secondary to service-connected bilateral plantar fasciitis and bunion disabilities. 3. Entitlement to an initial increased rating for adjustment disorder with depressed mood, evaluated as noncompensably disabling from June 25, 2007 to July 20, 2008, and 10 percent disabling from July 21, 2008. 4. Entitlement to an initial evaluation in excess of 10 percent for plantar fasciitis associated with flatfoot, claimed as both feet arches, from October 2, 2002 to August 16, 2010. 5. Entitlement to an initial evaluation in excess of 10 percent for right plantar fasciitis associated with flatfoot, claimed as both feet arches, effective August 16, 2010. 6. Entitlement to an initial evaluation in excess of 10 percent for left plantar fasciitis associated with flatfoot, claimed as both feet arches, effective August 16, 2010. ATTORNEY FOR THE BOARD A-L Evans, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1980 to January 1983. This matter is before the Board of Veterans' Appeals (Board) on appeal of a February 2009 rating decision of the San Juan, Puerto Rico, Regional Office (RO) of the Department of Veterans Affairs (VA). In December 2010, the Board remanded the case for further development. Thereafter, in an April 2013 Board decision and remand, the issues currently on appeal were denied. Subsequently, the Veteran appealed, in part, the April 2013 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a Joint Motion for Remand (JMR) of February 2014, the Court, in part, vacated the Board's decision regarding the issues currently on appeal and remanded the matter to the Board for compliance with the terms of the JMR. In July 2014, the Board remanded the issues for further development. The issues of entitlement to an initial increased rating for adjustment disorder with depressed mood, evaluated as noncompensably disabling from June 25, 2007 to July 20, 2008, and 10 percent disabling from July 21, 2008; entitlement to an initial evaluation in excess of 10 percent for plantar fasciitis associated with flatfoot, from October 2, 2002 to August 16, 2010; entitlement to an initial evaluation in excess of 10 percent for right plantar fasciitis associated with flatfoot, effective August 16, 2010; and entitlement to an initial evaluation in excess of 10 percent for left plantar fasciitis associated with flatfoot, effective August 16, 2010 are addressed in the REMAND portion of the decision below and are REMANDED to the RO. FINDINGS OF FACT 1. A degenerative disc disease of the cervical spine disability is not etiologically related to service, and is not caused or aggravated by service-connected bilateral plantar fasciitis and bunion disabilities. 2. A lumbar paravertebral myositis disability is not etiologically related to service, and is not caused or aggravated by service-connected bilateral plantar fasciitis and bunion disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for a degenerative disc disease of the cervical spine disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 2. The criteria for service connection for a lumbar paravertebral myositis disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist VA has a duty to provide notice of the information and evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103(a) (West 2014); 38 C.F.R. § 3.159(b) (2015). A standard December 2008 letter satisfied the duty to notify provisions. VA also has a duty to provide assistance to substantiate a claim. 38 U.S.C.A. § 5103A (West 2014); 38 C.F.R. § 3.159(c). The Veteran's service treatment records have been obtained. Post-service VA treatment records have also been obtained. VA examinations were conducted in January 2009 with a medical opinion addendum in March 2011. In addition, the Board sought advisory medical opinions from the Veterans Health Administration (VHA) in June 2012 and November 2012. When considered together, these examinations are adequate to address the Veteran's claims on a direct basis because they are based on a review of his service treatment records, consider his contentions, and are supported by a sufficient rationale. As discussed below, these opinions are considered either inadequate or not specific to the claims remanded by the Court with regard to the theory of service connection on a secondary basis. (See February 2014 JMR). Additional VA examinations were obtained in September 2014, with an opinion provided in October 2014, and the Board sought an expert medical opinion from the VHA in June 2015. The June 2015 opinion is adequate to adjudicate the claims on a secondary basis because it is based on claim file review and because the expert considered the relevant medical and lay evidence of record, supported the conclusions reached with a thorough rationale, and addressed the question at issue - whether the claimed disabilities were caused or aggravated by service-connected disabilities. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007); Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); 38 C.F.R. § 3.159(c)(4). There is no indication in the record that any additional evidence, relevant to the issues decided, is available and not part of the claims file. Thus, VA's duty to assist has been met. II. Analysis Service Connection 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). A second way to establish direct service connection is set forth in § 3.303(b). The Court of Appeals for the Federal Circuit (Federal Circuit) found that, unlike subsection (a), which is not limited to any specific condition, subsection (b) is restricted to chronic diseases. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). "If a veteran can prove a chronic disease 'shown in service,' and there are no intercurrent causes, the manifestations of the chronic disease present at the time the veteran seeks benefits establish service connection for the chronic disease. By treating all subsequent manifestations as service-connected, the veteran is relieved of the requirement to show a causal relationship between the condition in service and the condition for which disability compensation is sought. In short, there is no 'nexus' requirement for compensation for a chronic disease which was shown in service, so long as there is an absence of intercurrent causes to explain post-service manifestations of the chronic disease." Id. In addition, the Federal Circuit found that subsection (b) provides a second route by which service connection can be established for a chronic disease, which is if "evidence of a chronic condition is noted during service or during the presumptive period, but the chronic condition is not 'shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned,' i.e., 'when the fact of chronicity in service is not adequately supported,' then a showing of continuity of symptomatology after discharge is required to support a claim for disability compensation for the chronic disease. Proven continuity of symptomatology establishes the link, or nexus, between the current disease and serves as the evidentiary tool to confirm the existence of the chronic disease while in service or a presumptive period during which existence in service is presumed." Id. Furthermore, the Federal Circuit held that that the term "chronic disease" as set forth in subsection (b) is properly interpreted as being constrained by § 3.309(a) in that the regulation is only available to establish service connection for the specific chronic diseases listed in § 3.309(a) regardless of the point in time when a veteran's chronic disease is either shown or noted. Id. Certain chronic diseases, including arthritis, may be presumed to have been incurred during service if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307(a)(3); 3.309(a). Service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). In order to establish entitlement to secondary service connection, there must be competent evidence of a current disability and competent evidence establishing a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Facts and Background The Veteran is currently service connected for plantar fasciitis and bunion formation associated with plantar fasciitis and contends that his current low back and neck disorders arose as a result of these service-connected disorders. See December 2008 claim. Although he appears to primarily contend that his low back and neck disorders are secondary to a service-connected disorder, the Board will address his claim on both a direct and secondary basis. The Veteran's service treatment records do reflect complaints of neck and back pain in service. In February 1980, the Veteran presented at the military clinic with complaints of cervical neck pain of one year duration. According to the Veteran, the pain came about only when he was under stress. Upon examining the Veteran, the treatment provider observed signs of tenderness to the right and left sternocleidomastoid muscles. The treatment provider further noted that the Veteran's neck and shoulder muscles were tense, but clear for signs of spasms. An April 1980 Health Record reflects the Veteran's complaints of pain at the base of the neck between the shoulder blades, and a physical evaluation of the Veteran revealed signs of myalgia in the left shoulder area. Lastly, in May 1982, the Veteran presented at the military clinic with complaints of pain at the base of his neck. Upon physical evaluation, the treatment provider noted that the Veteran exhibited pain on forced extension and rotation of the neck bilaterally. The Veteran was diagnosed with a probable muscle strain. The Veteran's February 1983 entrance examination pursuant to his enlistment in the U.S. Army National Guard is also clear for any signs, notations, complaints or treatment for the spine, to include the back and neck region. Indeed, the clinical evaluation of the Veteran's spine was shown to be normal, and the Veteran denied a history of musculoskeletal problems, to include a history of recurrent back pain, in his medical history report. In addition, the Veteran had a physical profile of 'P1' at the time of this examination. See Odiorne v. Principi, 3 Vet. App. 456, 457 (1992) (observing that the 'PULHES' profile reflects the overall physical and psychiatric condition of the Veteran on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)). The first post-service diagnoses were found in the January 2009 VA examination report. During the January 2009 VA examination, the Veteran reported cervical and lumbar spine pain shortly after developing a bunion deformity on his left foot. He noted constant cervical pain on his left side which was worse during physical activity. He also noted a sharp, local pain in his low back. He reported that the pain for both his neck and back was moderate and occurred daily. Flare-ups occurred every two to three weeks. The Veteran stated that he could walk with corrective shoes. The Veteran was diagnosed with cervical degenerative disc disease and left lumbar paravertebral myositis. The examiner opined that the Veteran's cervical degenerative disc disease and left lumbar paravertebral myositis were not caused by or a result of bunion formation associated to plantar fasciitis. The examiner noted that both of the spine conditions belong to different anatomical regions with different pathophysiological processes unrelated to bunion formation associated with his plantar fasciitis. He also noted that cervical degenerative disc disease and left lumbar paravertebral myositis do not cause bunion formation associated to plantar fasciitis. A July 2010 VA treatment record noted chronic low back which was probably secondary to degenerative joint disease. Pursuant to a December 2010 Board remand, a VA medical opinion was obtained in March 2011 from the January 2009 VA examiner. The VA doctor indicated that the Veteran's cervical degenerative disc disease and left lumbar paravertebral myositis conditions were less likely as not caused by or a result of the Veteran's military service. The examiner noted a review of the claims file, including the specified in-service treatment records reflecting the Veteran's complaints of muscle pain in the neck region, as well as assessments of myalgia and possible muscle strain, but opined that none of the documented findings correlated with the current diagnosis of cervical degenerative disc disease which was an expected finding related to the normal process of aging. The examiner also noted that the Veteran's claims file was silent for a lumbar spine condition. While this medical opinion is sufficient with respect to the Veteran's cervical spine disability, the VA examiner's conclusion with respect to the Veteran's low back disability was based on an inaccurate factual premise, as the Veteran's claims file does reflect documentation of a lumbar spine disability - as reflected by the diagnosis of lumbar paravertebral myositis in January 2009. In addition, while the VA examiner had previously addressed whether the Veteran's neck and back condition were related to his service-connected disorders, he did not specifically state whether the Veteran's back and/or neck conditions were aggravated by his service-connected plantar fasciitis and/or bunion formation. A VHA was received in June 2012. Based on his review of the claims file, Dr. K. opined that it is not at least as likely as not that the Veteran's cervical spine disability, had its onset in, or is otherwise causally related to his military service. Dr. K. based his opinion on the February 1980 service treatment note reflecting the Veteran's reported history of neck pain which reportedly began one year prior. According to Dr. K., if the Veteran's current symptoms and cervical spine condition are attributed to a condition that was identified during his military service, then this condition was a pre-existing one, and not one that had its onset in, or is otherwise causally related to military service. With respect to Dr. K's line of reasoning, the Board notes that the Veteran's October 1979 entrance examination is completely negative for any complaints or previous diagnoses of a cervical spine disability. Indeed, the only evidence indicating that the Veteran's cervical spine disability pre-existed his enlistment consists exclusively of statements made by the Veteran during an in-service treatment consultation. The Board observes that lay statements, standing alone, are insufficient to rebut the presumption of soundness which arose when the Veteran was accepted for service. See Crowe v. Brown, 7 Vet. App. 238 (1994) (supporting medical evidence is needed to establish the presence of a pre-existing condition). As such, the Board is not persuaded that there is objective evidence demonstrating that the Veteran's current cervical spine disability existed prior to service. Turning back to the June 2012 medical opinion, Dr. K. further determined that it is not at least as likely as not that the Veteran's lumbar paravertebral myositis had its onset in service or is causally related to his military service. According to Dr. K., "[t]here is no substantiation that this [V]eteran had any lumbar spine condition during his period of military service." In reaching this conclusion, Dr. K. referenced the Veteran's February 1983 examination report pursuant to his enlistment in the U.S. Army National Guard, wherein the Veteran indicated that he was in good health, and denied a history of musculoskeletal concerns, to include any complaints of recurrent back pain. With respect to whether the Veteran's lumbar and cervical-spine disabilities were secondary to his service-connected plantar fasciitis and/or bunion formation, Dr. K. determined that neither disability was caused and/or aggravated by these service-connected disabilities. However, Dr. K. appears to have only addressed the direct theory of entitlement when providing the medical reasoning for this conclusion. In his explanation, Dr. K. referenced the Veteran's service treatment records, noting that the records were devoid of any evidence indicating that either condition originated in, and/or was exacerbated during the Veteran's period of military service. He also referenced the February 1983 examination report, noting that the Veteran denied having a "bone, joint, or other deformity" in his medical history report. However, Dr. K., went on to explain that a literature review conducted on PubMed, the National Institute of Health's search engine of published literature (http://www.ncbi.nlm.nih.gov) did not provide "any substantiated causality or linkage between the conditions of plantar fasciitis or hallux valgus (bunion) with lumbar paravertebral myositis or cervical degenerative disc disease." According to Dr. K., while the Veteran's personal history has led him to attribute his lower back and neck deterioration to his bilateral foot condition, "there is no substantiation that any causal linkage between these conditions has a mechanical explanation or has either a medical or scientific basis." As mentioned above, establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by, or (b) proximately aggravated by, a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). While Dr. K. discussed whether the Veteran's cervical and lumbar spine condition were caused by his service-connected bilateral foot disabilities, he did not discuss whether the claimed disorders were aggravated by the service-connected disabilities. In light of the fact that additional clarification was necessary with regard whether the Veteran's cervical spine disability originated in service, and whether the Veteran's cervical and lumbar spine disabilities were secondary to his service-connected disorders, the Board referred the claims file to Dr. K. for an additional advisory opinion. In the November 2012 request, the Board specifically instructed Dr. K to presume that the Veteran was in sound condition and had no pre-existing cervical spine condition at the time he entered service, when rendering his opinion. An additional advisory opinion was issued by Dr. K. in November 2012. In this opinion, Dr. K. explained that any previous comparison he made between the Veteran's in-service symptoms and symptoms he (the Veteran) may have experienced prior to service was not an attempt to classify the Veteran's condition as a pre-existing one, "but to simply report that these symptoms were not likely attributable to a traumatic or degenerative process that was obtained as a result of military service any more than from a natural degenerative process that is expected to occur with normal aging and use over an individual's lifetime." Dr. K. referenced the Veteran's service treatment records, and noted that any in-service complaints of neck pain were "always associated with stress and not with a specific or injury mechanism or activity attributable cause." He went on to explain that stress, whether physical or emotional, is not expected to cause a structural change in bone, disc, ligament, muscle or tendon that would lead to a disability in the future. According to Dr. K., as the nature of the Veteran's current complaints were not known to him, "it is not possible to determine any causal link between [the Veteran's] current condition and 'stress related' neck pain that was noted in the medical record in the absence of a specific injury mechanism." With respect to the secondary theory of entitlement, Dr. K. concluded that the Veteran's cervical spine and lumbar spine disabilities were neither caused, nor aggravated by his service-connected disabilities. In reaching this conclusion, he reiterated the previous explanation provided in the June 2012 medical advisory opinion. Pursuant to the February 2014 JMR, the Board remanded the issues in a July 2014 and the Veteran was afforded a new VA examination in September 2014. The examination report reflects that the Veteran reported localized pain in his neck and back. The examiner noted functional limitations of the Veteran's conditions. In a subsequent October 2014 VA medical opinion, the VA examiner who had conducted the January 2009 provided the same opinion and rationale. The VA examiner again stated that the Veteran's cervical degenerative disc disease and left lumbar paravertebral myositis belonged to different anatomical regions with different pathophysiological process unrelated to bunion formation associated to plantar fasciitis. Accordingly, another VHA was obtained in June 2015. The VA doctor, Dr. P.L., Chief of Neurosurgery, stated that there was nothing in the medical records that objectively linked the Veteran's foot complaints with his spine issues or that his foot problems caused the spine problems, other than his contentions that the two were related. The VA doctor noted that the cervical and lumbar spine are anatomically, spatially and functionally isolated from the pathology of the feet, except in rare circumstances. The most common of the circumstances are hip, knee, ankle and other unilateral conditions of the lower extremities that result in one leg becoming a different length than the other. The result was known a limb length discrepancy. A limb length discrepancy could cause the pelvis to become tilted, resulting in an abnormal gait and posture. Over time, this would frequently result in not only spine problems but hip and knee problems. The diagnosis of the condition was simple and could be made by standing x-rays and measuring the lower extremity. The VA doctor reported that there was nothing in the Veteran's claims file that described a limb length discrepancy and that plantar fascitis and bunions themselves did not lead to such discrepancies. The VA doctor noted that the potential associations between foot problems and spine conditions in medical literature was summarized in an article in the Journal of Back and Musculoskeletal Rehabilitation. The article pointed out that foot problems could, in rare cases, be associated with specific low back problems such as paravertebral myositis, but this was the most common condition that lead to limb length discrepancies. The VA doctor noted that this theory did not apply to the Veteran. In addition, the article noted that this type of association was the exception and not the rule and that the medical literature did not support a direct relationship between foot problems and the development of cervical spine pathology. Therefore, the causal relationship between foot problems and the causation of low back pathology was far below the 50% probability criteria, and was even less likely between foot problems and cervical spine pathology. The VA doctor also noted that degenerative disc disease in both the cervical and lumbar spine are natural occurrences in the aging of the spine that begins in our late 20's and 30's. The degenerative changes could and frequently did progress in both radiographic appearance and symptomatology as each decade goes by. He noted that there was nothing in the medical literature to support the contention that plantar fasciitis and bunion formation contributed to this process. The VA doctor opined that there was less than a 50% probability that the currently identified degenerative disc disease of the cervical spine was caused by the Veteran's service-connected bilateral bunion formation associated with plantar fasciitis associated with flatfoot. In addition, there was less than a 50% probability that the currently identified degenerative disc disease of the cervical spine was aggravated by the Veteran's service-connected bilateral bunion formation associated with plantar fasciitis associated with flatfoot. The VA doctor also opined that there was less than a 50% probability that the currently identified left lumbar paravertebral myositis was caused by the Veteran's service-connected bilateral bunion formation associated with plantar fasciitis associated with flatfoot. In addition, there was less than a 50% probability that the currently identified left lumbar paravertebral myositis was aggravated by the Veteran's service-connected bilateral bunion formation associated with plantar fasciitis associated with flatfoot. Discussion In considering the evidence of record under the laws and regulations as set forth above, the Board concludes that the Veteran is not entitled to service connection for the low back disability and the cervical spine disability. The Board finds that the weight of the evidence demonstrates that during the Veteran's service there was no combination of manifestations sufficient to identify a cervical or lumbar spine disability so as to establish chronicity of such claimed disorders during service. 38 C.F.R. § 3.303(b). While service treatment records reflect findings of myalgia and probable muscle strain in the neck on various occasions, there were no actual clinical findings of a chronic cervical or lumbar spine disability. Thus, while the Veteran underwent a few episodes of neck pain while on active duty service, the service treatment records do not indicate that he was diagnosed with a chronic neck disorder. In addition, there is no evidence that the first manifestation of degenerative changes of the cervical and lumbar spine occurred within the first post-service year after the Veteran's discharge from service in January 1983, nor has the Veteran so contended. The remainder of the service treatment records associated with the Veteran's period of service in the U.S. Army National Guard is clear for any complaints of, or treatment for, back and/or neck problems. Additionally, VA treatment records dated in July 1985 (while the Veteran was still serving in the U.S. Army National Guard) are negative for any complaints of, or treatment for, neck and/or back problems. As such, service connection on a presumptive basis is not warranted for either disability. Indeed, the Board further observes that the post-service record on appeal is similarly negative for any findings of complaints, treatment or diagnosis of a back or neck disorder until several decades after service. In fact, the first post-service medical evidence of record pertaining to the Veteran's back and neck condition is the January 2009 VA examination report. This examination report is dated twenty-six years after the Veteran's separation from service. In the absence of any objective evidence to support complaints of continuity of symptomatology in the passing years since service, the initial demonstration of the disabilities at issue, twenty-six years after service, is too remote from service to be reasonably related to service and diminishes the reliability of the Veteran's current recollections. Maxson v. Gober, 230 F.3d 1130 (Fed. Cir. 2000) (holding, in an aggravation context, that the Board may consider a prolonged period without medical complaint when deciding a claim). Moreover, the Board notes that the Veteran had the opportunity to file a claim for these disabilities given the fact that he filed a claim for other noted disabilities in October 2002, however he chose not to. The fact that the Veteran underwent medical examinations and evaluations closer in time to his discharge from service, but failed to mention his neck and back trouble weighs against any possible contentions of continuing symptoms since service. Accordingly, and based on this evidentiary posture, the Board concludes that service connection for the back and cervical spine disability based on continuity of symptomatology is not warranted. With respect to direct service connection, the competent medical evidence of record does not relate the Veteran's cervical spine and lumbar spine disabilities to his service. Indeed, in the March 2011 VA medical opinion, the VA examiner acknowledged the in-service notations reflecting the Veteran's complaints of neck pain, and determined that these documented findings did not correlate with the current diagnosis of cervical degenerative disc disease. According to the VA examiner, this particular finding (cervical degenerative disc disease) is related to the normal aging process. A collective review of the June 2012 and November 2012 advisory opinions further supports the March 2011 VA medical opinion; namely that the Veteran's cervical spine disability was not incurred in service. In the June 2012 medical opinion, Dr. K. determined that the Veteran's cervical spine disability was not incurred in service. In the November 2012 medical opinion, Dr. K. provided a medical explanation as to why it was difficult to relate the Veteran's cervical spine disability to an in-service cause. According to Dr. K., it is not possible to determine any causal link between the Veteran's current condition and "stress related" neck pain noted in the medical record in the absence of a "specific injury mechanism." While Dr. K. added that not knowing the nature of the Veteran's current complaints was one of the reasons it was not possible to determine a causative link between the Veteran's current condition and notations of stress-related pain in service, the Board notes that the March 2011 VA examiner did have an opportunity to examine the Veteran in January 2009, and was made aware of the nature of his current cervical spine complaints, and still concluded that the Veteran's cervical spine disability was not incurred in service, or related to an in-service cause. In addition, Dr. K. did not relate the Veteran's lumbar paravertebral myositis to his service (see June 2012 medical advisory opinion), referencing the Veteran's service treatment records, as well as the February 1983 enlistment examination, which were clear for any indications or signs of back trouble, when reaching this opinion. The Board finds these opinions highly probative as to the issue of direct service connection, as they, when viewed collectively, considered the relevant facts, are based on medical principles, and are supported by sufficient rationale. The Board now turns to the focus of the JMR, whether the Veteran's claimed disorders are secondary to his service-connected disorders. Given the evidence of record, the Board finds that service connection is not warranted on a secondary basis for the Veteran's current degenerative disc disease of the cervical spine and lumbar paravertebral myositis disabilities as they were not caused or aggravated by his service-connected bilateral plantar fasciitis and bunion disabilities. The only opinion that can be considered adequate regarding entitlement on a secondary basis, due to the Court's JMR and the redundant opinion provided by the October 2014 VA examiner, weighs against the claims. The opinion of the June 2015 VA doctor is persuasive evidence, which opposes rather than supports the claims. The VA doctor concluded that the causal relationship between foot problems and the causation of low back pathology was far below the 50% probability criteria, and was even less likely between foot problems and cervical spine pathology. The VA doctor noted that the cervical and lumbar spines were anatomically, spatially and functionally isolated from the pathology of the feet, except in rare circumstances, which resulted in one leg becoming a different length than the other. In this situation a limb length discrepancy would occur. After a review of the medical evidence of record, the VA doctor opined that nothing in the Veteran's claims file described a limb length discrepancy and noted that plantar fascitis and bunions themselves did not lead to such discrepancies. In addition, the examiner noted that while documentation in medical literature pointed out that foot problems could, in rare cases, be associated with specific low back problems such as paravertebral myositis, the most common condition that it lead to was limb length discrepancies. Again, this did not apply to the Veteran's current disability. Importantly, the examiner stated that these associations are the exception, not the rule. Further, medical literature did not support a direct relationship between foot problems and the development of cervical spine pathology. Thus, the examiner concluded that the Veteran's service-connected foot disability did not cause his cervical or lumbar spine disabilities. On the contrary, the VA doctor stated that cervical and lumbar spine degenerative disc disease are natural occurrences in the aging of the spine, which can and do frequently progress in symptomatology as each decade goes by. The VA doctor summarized that there is nothing in the medical literature to support the contention that plantar fasciitis and bunion formation contribute to this process. In other words, the VA doctor found nothing in the medical literature to support the theory that the Veteran's service-connected disabilities aggravated his cervical or lumbar spine, either. The VA doctor's opinion offered rationale and plausible explanations for concluding that there was less than a 50% probability that the currently identified degenerative disc disease of the cervical spine and lumbar paravertebral myositis were caused by or aggravated by the Veteran's service-connected bilateral bunion formation associated with plantar fasciitis associated with flatfoot. The opinions provided were based on a comprehensive review of the claims file and contained adequate rationales that considered the Veteran's lay contentions and reported history. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Furthermore, there are no opinions in conflict with that opinion. While the Veteran has alleged that his current neck condition and back pain are related to his service-connected bilateral bunion formation associated with plantar fasciitis associated with flatfoot, there is no indication that he has specialized training in diagnosing these disorders or determining their etiology. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the diagnoses of spine disabilities require medical testing, and such disabilities can have many different causes, thereby requiring medical expertise to determine the etiology. Thus, the Veteran's own opinions regarding the etiology of his current neck condition and back pain are not competent medical evidence. The Board accords significantly greater weight to the opinions of the June 2015 VA doctor than to the Veteran's lay assertions. In sum, the preponderance of the evidence is against the claim for service connection for degenerative disc disease of the cervical spine and for service connection for a lumbar paravertebral myositis disability, to include as a secondary basis to service-connected disorders. Thus, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b) (West 2014); Ortiz v. Principi, 274 F.3d 1361, 1364, 1365 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Entitlement to service connection for a degenerative disc disease of the cervical spine disability, to include as secondary to a service-connected disability, is denied. Entitlement to service connection for a lumbar paravertebral myositis disability, to include as secondary to a service-connected disability, is denied. REMAND It does not appear that the directives of the April 2013 remand have been complied with. The Board errs as a matter of law when it fails to ensure compliance. Stegall v. West, 11 Vet. App. 268 (1998). The reasons for remand are restated below. In the May 2008 rating decision, service connection was granted for plantar fasciitis associated with flatfoot (claimed as both feet arches), and evaluated as 10 percent disabling, effective October 2, 2002. Service connection was also granted for adjustment disorder with depressed mood, and evaluated as noncompensably disabling, effective June 25, 2007. In a July 2008 statement, the Veteran submitted what can be construed as a notice of disagreement (NOD) with the disability ratings assigned for both these service-connected disorders. A subsequent rating decision was issued in November 2008 continuing the 10 percent disability rating assigned for the plantar fasciitis, and increasing the disability rating for the service-connected adjustment disorder to 10 percent, effective July 21, 2008. In a November 2010 rating action, the RO decided to bifurcate the Veteran's service-connected plantar fasciitis associated with flatfoot into two separate claims. As such, the Veteran was awarded separate 10 percent disability ratings for the right and left plantar fasciitis associated with flatfoot, effective August 16, 2010. The Board notes, with respect to increased ratings, the Court has held that on a claim for an original or increased rating, the appellant will generally be presumed to be seeking the maximum benefit allowed by law or regulations, and it follows that such a claim remains in controversy where less than the maximum benefit is allowed. AB v. Brown, 6 Vet. App. 35, 38 (1993). The Court further held that, where a claimant has filed a NOD as to a RO decision assigning a particular rating, a subsequent RO decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the appeal. Id. As the Veteran has not expressed satisfaction with any of these rating, the claims for (1) entitlement to an initial increased rating for adjustment disorder with depressed mood, evaluated as noncompensably disabling from June 25, 2007 to July 20, 2008, and 10 percent disabling from July 21, 2008; (2) entitlement to an initial evaluation in excess of 10 percent for plantar fasciitis associated with flatfoot, from October 2, 2002 to August 16, 2010; (3) entitlement to an initial evaluation in excess of 10 percent for right plantar fasciitis associated with flatfoot, effective August 16, 2010; and (4) entitlement to an initial evaluation in excess of 10 percent for left plantar fasciitis associated with flatfoot, effective August 16, 2010 remain before the Board on appeal. See AB v. Brown, 6 Vet. App. 35 (1993). However, a Statement of the Case (SOC) has not been issued addressing this claim. The Court has held that, when an appellant files a timely NOD as to a particular issue and no SOC is furnished, the Board should remand, rather than refer, the claim for issuance of an SOC. See Manlicon v. West, 12 Vet. App. 238 (1999). Under these circumstances, an SOC concerning the issues of (1) entitlement to an initial increased rating for adjustment disorder with depressed mood, evaluated as noncompensably disabling from June 25, 2007 to July 20, 2008, and 10 percent disabling from July 21, 2008; (2) entitlement to an initial evaluation in excess of 10 percent for plantar fasciitis associated with flatfoot, effective from October 2, 2002 to August 16, 2010; (3) entitlement to an initial evaluation in excess of 10 percent for right plantar fasciitis associated with flatfoot, effective August 16, 2010; and (4) entitlement to an initial evaluation in excess of 10 percent for left plantar fasciitis associated with flatfoot, effective August 16, 2010, should be issued. However, these issues will be returned to the Board after issuance of the SOC only if perfected by the filing of a timely substantive appeal. See Smallwood v. Brown, 10 Vet. App. 93, 97 (1997); Archbold v. Brown, 9 Vet. App. 124, 130 (1996). Accordingly, the case is REMANDED for the following action: Furnish the Veteran an SOC regarding the claims for (1) entitlement to an initial increased rating for adjustment disorder with depressed mood, evaluated as noncompensably disabling from June 25, 2007 to July 20, 2008, and 10 percent disabling from July 21, 2008; (2) entitlement to an initial evaluation in excess of 10 percent for plantar fasciitis associated with flatfoot, effective from October 2, 2002 to August 16, 2010; (3) entitlement to an initial evaluation in excess of 10 percent for right plantar fasciitis associated with flatfoot, effective August 16, 2010; and (4) entitlement to an initial evaluation in excess of 10 percent for left plantar fasciitis associated with flatfoot, effective August 16, 2010 should be issued. The Veteran should be informed that he must file a timely and adequate substantive appeal in order to perfect an appeal of these issues to the Board. 38 C.F.R. §§ 20.200, 20.202, 20.302(b). Only if the Veteran perfects a timely appeal should these claims be certified to the Board. The Veteran has the right to submit additional evidence and argument on the 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 or by the Court for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ____________________________________________ S. HENEKS Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs