Citation Nr: 1601694 Decision Date: 01/14/16 Archive Date: 01/21/16 DOCKET NO. 10-04 104 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a back disability, claimed as a pinched nerve, to include neurologic symptoms of the lower extremities claimed as right foot neuropathy. 2. Entitlement to service connection for a right foot or ankle disability. 3. Entitlement to service connection for a left foot disability, to include plantar fasciitis. 4. Entitlement to an initial disability rating in excess of 70 percent for major depressive disorder with posttraumatic stress disorder (PTSD). 5. Entitlement to a total disability rating based on individual unemployability (TDIU). REPRESENTATION Appellant represented by: Kenneth LaVan, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Hager, Counsel INTRODUCTION The Veteran served on active duty from December 1978 to January 1986, with subsequent Reserve service. These matters initially came before the Board of Veterans' Appeals (Board) on appeal from multiple rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In a December 2007 rating decision, the RO granted entitlement to service connection for major depressive disorder and assigned a 10 percent rating, effective January 2007. The Veteran timely appealed the initial rating assigned, and in subsequent rating decisions the RO increased the initial rating to 70 percent, also effective January 2007, and recharacterized the issue to include PTSD. The issue has been characterized accordingly on the title page. In September 2010, the RO granted entitlement to service connection for hypertension and assigned a noncompensable (0%) disability rating. That rating decision also denied service connection for a pinched nerve in the back and a right foot condition which had been claimed as neuropathy as a symptom of the claimed back disability. Finally in this regard, a March 2012 rating decision denied service connection for a right ankle disability and left foot plantar fasciitis. These issues have been recharacterized more broadly in light of the additional diagnoses noted below. In August 2012, the Veteran testified during a videoconference hearing before the undersigned; a transcript of that hearing is of record. In May 2013, the Board granted an increased, 10 percent rating, but no higher, for hypertension and remanded the remaining claims to the agency of original jurisdiction (AOJ) for additional development. For the reasons indicated below, the AOJ complied with the Board's remand instructions. Stegall v. West, 11 Vet. App. 268, 271 (1998). The AOJ also implemented the Board's grant of a 10 percent rating for hypertension in an October 2013 rating decision. The Veteran's attorney purported to file a notice of disagreement (NOD) with the assigned 10 percent rating, but it is well established that an appellant cannot challenge the merits of a Board decision by expressing disagreement with an RO decision implementing the Board's decision. Harris v. Nicholson, 19 Vet. App. 345, 348 (2005); see also Smith v. Brown, 35 F.3d 1516, 1526 (Fed. Cir. 1994) (construction of regulation to permit review by RO of a Board decision to be avoided); Donovan v. Gober, 10 Vet. App. 404, 409 (1997) ("an RO must not be placed in the anomalous position of reviewing the decision of the [Board], a superior tribunal"). In any event, the Veteran filed a February 2015 document consenting to the withdrawal of this matter. In its May 2013 remand, the Board noted that the Veteran had filed a timely NOD with the RO's denial of her claims for entitlement to service connection for right ankle disability and left foot plantar fasciitis but no statement of the case (SOC) had been issued, and therefore remanded these claims for issuance of a SOC. See 38 C.F.R. § 19.9(c) (2015), codifying Manlincon v. West, 12 Vet. App. 238 (1999). The RO issued a SOC in April 2014 and the Veteran filed a timely substantive appeal (VA Form 9) in June 2014, in which she requested a Board videoconference hearing. She later withdrew this request in August 2014, and the Board will therefore address these issues in the decision below. The Board notes that additional evidence has been received since the April 2014 SOC continuing the denials of the claims for service connection for right and left foot disabilities and the April 2015 SSOC continuing the denial of the claim for service connection for a back disability. This evidence, however, is either duplicative of evidence already in the claims file or relates to the Veteran's psychiatric disorder and employability, and not to the claims being decided herein. A remand for initial AOJ review of this evidence is therefore unnecessary. The issues of entitlement to an initial disability rating higher than 70 percent for major depressive disorder with PTSD and entitlement to a TDIU are addressed in the REMAND portion of the decision below and are REMANDED to the AOJ. FINDINGS OF FACT 1. A back disorder did not manifest in service, arthritis did not manifest within the one year presumptive period, and current back disability is unrelated to service. 2. The preponderance of the evidence reflects that the Veteran's current right ankle and foot disabilities are unrelated to her in-service right ankle injury and are neither caused nor aggravated by a service connected disease or injury. 3. A left foot disorder did not manifest in service or for many years thereafter, and neither the Veteran's current left foot plantar fasciitis nor any other left foot disability are related to service or caused or aggravated service connected disease or injury. CONCLUSIONS OF LAW 1. A back disability was not incurred in or aggravated by service and arthritis may not be presumed to have been incurred therein. 38 U.S.C.A. §§ 1101, 1112, 1131, 1137, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2015). 2. A right foot or ankle disability was not incurred in or aggravated by service and is not proximately due to, the result of, or aggravated by a service connected disease or injury. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 3. A disability of the left foot was not incurred in or aggravated by service and is not proximately due to, the result of, or aggravated by a service connected disease or injury. 38 U.S.C.A. §§ 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VCAA The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159; Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93. The requirements of the statutes and regulation have been met in this case. VA notified the Veteran in January 2010 and November 2010 of the information and evidence needed to substantiate and complete his service connection claims, to include notice of what part of that evidence he was to provide, what part VA would attempt to obtain, and how disability ratings and effective dates are determined. These claims were subsequently readjudicated in April 2014 and April 2015. VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate the claims. In its May 2013 remand, the Board instructed that the AOJ inform the Veteran that the CD ROM submitted in September 2012 was damaged and request that the evidence contained therein be resubmitted. The AOJ sent such a letter in September 2013 and thus complied with the Board's remand instructions in this regard. The AOJ also afforded the Veteran VA examinations and obtained opinions as to the nature and etiology of her back and right ankle disabilities, including a May 2014 VA spine examination conducted and opinion obtained pursuant to the Board's May 2013 remand instructions. No opinion was obtained as to the etiology of the Veteran's left foot plantar fasciitis. However, for the reasons discussed below, VA's duty to assist did not require that such an opinion be obtained because the evidence does not indicate that a left foot disability may be associated with service or a service connected disability. 38 U.S.C.A. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i)(C) (VA examination warranted where the evidence indicates that a current disability may be associated with another service connected disability). There is thus no evidence that additional records have yet to be requested, or that additional examinations are in order. Moreover, during the August 2012 Board hearing, the undersigned explained the issues on appeal, asked questions to suggest the submission of evidence that may have been overlooked, and left the claims file open for 60 days in order to allow the Veteran time to submit additional evidence. These actions provided an opportunity for the Veteran and his representative to introduce material evidence and pertinent arguments, in compliance with 38 C.F.R. § 3.103(c)(2) and consistent with the duty to assist. See Bryant v. Shinseki, 23 Vet. App. 488, 492 (2010). The Board will therefore proceed to the merits of the claims being decided herein. Analysis Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury or event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Consistent with this framework, service connection is warranted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Back As discussed in more detail below, the Veteran has been diagnosed with degenerative changes, degenerative disc disease (DDD), and intervertebral disc syndrome (IVDS) of the lumbar spine. Although degenerative changes are not specifically referenced as a chronic disease in 38 U.S.C.A. § 1101(3) or 38 C.F.R. § 3.309(a), the Court has long recognized that degenerative joint disease and degenerative changes denote the presence of arthritis. See Giglio v. Derwinski, 2 Vet. App. 560, 561 (1992) ("Degenerative joint disease, or osteoarthritis is defined as 'arthritis of middle age characterized by degenerative and sometimes hypertrophic changes in the bone and cartilage of one or more joints and a progressive wearing down of apposing joint surfaces with consequent distortion of joint position usually without bony stiffening'"). Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C.A. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis is one of the listed chronic diseases. In addition, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C.A. §§ 1101(3), 1112(a)(1), 1113, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). As noted, the Veteran has been diagnosed with degenerative changes, DDD, and IVDS of the lumbar spine and has thus met the current disability requirement. She contends that this disability is related to a motorcycle accident that she had in service, which during the Board hearing she indicated occurred in late 1982 or early 1983. See Board Hearing Transcript, at 19. She stated that her back symptoms worsened several years after service. Id. There is no notation of a motorcycle accident in the service treatment or personnel records, and the September 1985 separation examination report indicated that the spine was normal. Moreover, in a February 1986 report of medical history, apparently prepared in connection with entry into Reserve service, the Veteran indicated that she did not have and had never had recurrent back pain, bone, joint, or other deformity, or arthritis, rheumatism, or bursitis. In addition, a July 1987 annual certificate of physical condition indicated that the Veteran did not have any injury illness or disease within the past 12 months that required hospitalization or caused her to be absent from school or work for more than three consecutive days and that she did not have any physical defect that she believed might restrict her performance on active duty. The Board finds that the Veteran's contemporaneous statements at and shortly after separation indicating that she did not have and had never had recurring back pain to be of greater probative weight than her later statements made during the course of an appeal from the denial of compensation benefits indicating that her back symptoms began after a motorcycle accident during service. Fed. R. Evid. 803(4) (recognizing that statements made for the purpose of medical treatment generally are reliable); Pond v. West, 12 Vet. App. 341, 345 (1999) (interest may affect the credibility of testimony). Thus, the Veteran's statements in this regard are not credible. In addition, an August 2005 VA lumbar spine X-ray report indicated that the Veteran was complaining of paresthesias of the lower extremities, and X-rays showed mild disc space reduction and was otherwise unremarkable. A January 2006 addendum indicated that the Veteran had a history of a car accident with lower back pain and radiating pain to the legs, and that more recently, the Veteran had noted mid-lower back pain centered at the sacral area with radiation to the thighs. The impression was lumbago/sciatica with no motor or sensory deficits by examination and possible peripheral neuropathy. A March 2006 MRI showed mild degenerative disease. A September 2010 Neuroscience Consultants motor conduction study showed evidence of a sensory greater than motor peripheral neuropathy and indicated that the studies were more suggestive of an axonal type of neuropathy. On the May 2014 VA examination, the Veteran was diagnosed with lumbar spine DDD. The examiner noted that the Veteran complained of back pain after prolonged sitting that began gradually in about 1990. The Veteran noted a 1982 or 1983 motorcycle accident but did not remember treatment other than in the emergency room. After examining the Veteran and reviewing the claims file, the VA examiner concluded that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. His rationale included the following four points. First, the service treatment records were silent for complaint of back pain and the Veteran checked the box on the July 1987 annual certificate of physical condition indicating that there was no injury requiring hospitalization or absence from the workforce for the previous 12 months. Second, treatment records were silent for complaints until 2006. Third, the Veteran indicated at that time that she had been in a motor vehicle accident two years previously and had experienced back pain for one and a half years. Fourth, the Veteran had sciatica symptoms but her decreased sensation to light tough on the bilateral forefeet did not follow the dermatome for nerve root distribution. Moreover, he noted that the private motor conduction study that did not show radiculopathy, as opposed to the diagnosed peripheral neuropathy. He also cited the lumbar spine MRI report that indicated mild central disc protrusion with no neural compression. As the May 2014 VA examiner explained the reasons for his conclusions, his opinion is entitled to significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Although the examiner inaccurately stated that the first complaint of pain in the treatment records was in 2006 rather than 2005, this did not affect the underlying rationale for his opinion. Moreover, while the VA examiner noted the absence of treatment until many years after service, this was not the sole basis for his opinion. Thus, while the absence of contemporaneous evidence is not a valid basis for determining a lack of nexus between the current disability and service, see Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2008), reading the opinion as a whole and in the context of the evidence of record, the underlying rationale that there was no evidence of symptoms in service and for many years thereafter, that the Veteran had a post-service back injury, and that the nature of the current lumbar spine disorder was such that it was more likely of recent onset, was sufficient to render the opinion adequate. Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). During the Board hearing, the Veteran expressed her opinion that her current back disability was due to an injury in the motorcycle accident during service, and noted that she asked her physicians if her current back disability could have been from her motorcycle accident, and "The doctor said could be." Board Hearing Transcript, at 20. Lay witnesses are competent to report contemporaneous medical diagnoses and to opine on some medical questions. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran's report of the opinion that the current disability "could be" related to an in-service injury from an in-service motorcycle accident reflects that the opinion was too speculative to be of significant probative weight. Hood v. Shinseki, 23 Vet. App. 295, 298-99 (2009) (a medical opinion is speculative when it uses equivocal language such as "could" or "might," without any other rationale or supporting data). Moreover, the Veteran's testimony as to the etiology of her current back disability is testimony as to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Jandreau, 492 F.3d at 1377, n. 4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). To the extent that the Veteran's testimony on this complex medical question is competent, the Board finds that the specific, reasoned opinion of the physician who performed the May 2014 VA examination is of greater probative weight than the Veteran's general lay assertions and report of a speculative medical opinion. The weight of the evidence is thus against a relationship between the current back disability and service. The above evidence also reflects that arthritis did not manifest in service or within the one year presumptive period. Right Foot and Ankle An October 2010 VA treatment note contains a diagnosis of right lateral ankle instability. An October 2010 treatment note from Dr. K.K. indicated that examination showed pes cavus and claw toes. December 2010 VA right foot MRI reports contain diagnoses of stress reaction fracture involving the fourth metatarsal base, inflammatory changes in the plantar soft tissues at the posterior aspect of the foot, and small focal fluid collection immediately adjacent to the talonavicular joint, likely a small synovial cyst. The January 2012 VA examination report contains a diagnosis of right ankle synovitis, and noted hammertoes, mild bunion and subjective ankle swelling. The Veteran has thus met the current disability requirement. The service treatment records reflect that the Veteran suffered a right ankle injury in January 1983 when she stepped in a hole causing her foot to turn under and inward. The initial diagnosis was rule out rupture of calcaneofibular ligament. Significant soft tissue swelling was noted. A March 1983 service treatment record indicated that the ankle was in a cast for 6 weeks and was being removed, range of motion was within normal limits with good strength in all planes, and the Veteran was able to walk on toes and heels without difficulty, with no pain and swelling at the time. The Veteran complained of pain across the ball of the foot from the cast. The Veteran has thus met the in-service injury requirement. The dispositive question with regard to this claim is thus whether a current right ankle disability is related to the in-service right ankle injury. For the following reasons, the evidence weighs against the claim. On the December 1985 separation examination, the lower extremities and feet were indicated as normal. On the February 1986 Reserve enlistment report of medical history, the Veteran indicated that she did not have and had never had foot trouble. A July 1987 annual certificate of physical condition indicated that the Veteran did not have any injury illness or disease within the past 12 months that required hospitalization or caused her to be absent from school or work for more than three consecutive days and that she did not have any physical defect that she believed might restrict her performance on active duty. An October 2009 Neurology Mobile System Associates ultrasound of the right plantar fascia showed heterogenous echogenic consistency, with no evidence of clearly defined cystic lesion or abnormal fluid collection. March and April 2010 soft tissue ultrasound of various parts of the right foot contained an impression of no discrete soft tissue mass or abnormal fluid collection within the region of interest. An October 2010 VA treatment note indicated that the Veteran had pain in her right ankle for the past month, having been carrying boxes when she fell and inverted her foot. She had been wearing an Aircast for the previous month along with compression stockings. The Veteran indicated that she believed the problem originated from an injury when she was in the Navy. The assessment was right lateral ankle instability. An October 2010 treatment note from Dr. K. K. indicated that the Veteran complained of pain in her right ankle, a history of frequent giving way and twisting of the ankle, progressive clawing of the toes with pain in the toes as well as the ball of the right foot, and periods of plantar fascial pain. A history of severe ankle sprain in 1983 was noted. Examination showed pes cavus, claw toes. X-rays showed evidence of claw toe formation and no other significant bone or joint abnormalities. Dr. K.K.'s December 2010 treatment notes reflect that he performed arthroscopic surgery on the right ankle, with pre and post-operative diagnoses of right ankle synovitis and chronic right ankle lateral instability. After reviewing the claims file and examining the Veteran, the July 2010 VA examiner found that it was less likely as not that the Veteran's current right ankle disability was related to what he termed the right foot condition in service. The examiner noted that the right foot condition in service was a post traumatic soft tissue swelling of the right ankle/foot due to a sprain in 1983, which was treated with a case for 6 weeks and resolved as of March 1983. He noted the 1985 and 1986 indications of no foot problems, and the current diagnoses of pes cavus, bilateral hallux valgus, and bilateral hammertoes, as well as the Veteran's complaints of swelling. He opined that the swelling was more likely than not due to peripheral venous insufficiency, as it affected both of the feet. On the July 2012 VA examination, the Veteran indicated that Dr. K.K. told her that her hammer toes and plantar fasciitis were due to her in-service right ankle injury. Diagnoses were pes cavus, hammertoes 2-5 bilaterally, mild bunion, and subjective bilateral ankle swelling after prolonged standing and walking, not currently noted. After reviewing the claims file and examining the Veteran, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury. In his rationale, the examiner noted that the Veteran had a significant injury to her right ankle in 1983 during service, but that there were no complaints of right ankle problems or examination findings at separation. He noted that there were no complaints of problems documented with the right ankle until December 2010, and that that note suggested she had been having pain for only one month. He also noted that the private treatment notes indicated that the pain in her right ankle was for an unknown period. He concluded, "In short, the Veteran has a condition that may have been caused by injury during military service but there is no documentation of long term symptoms despite frequent access to medical care." The July 2010 VA examiner cited multiple factors in support of his conclusion. He noted the nature of the in-service injury, the lack of foot problems at around the time of separation, the nature of the current disorders and complaints, and the fact that the swelling likely due to peripheral venous insufficiency because it was bilateral. As the July 2010 VA examiner explained the reasons for his conclusions based on an accurate characterization of the evidence of record, his opinion is entitled to significant probative weight. See Nieves-Rodriguez, 22 Vet. App. at 304. The July 2012 VA examiner's opinion is flawed in two respects. First, his statement that the disorder may have been caused by the in-service injury it too equivocal to be of any significant weight. See Winsett v. West, 11 Vet. App. 420, 424 (1998) (terminology equivalent to "may or may not" is an insufficient basis for an award of service connection). Moreover, his ultimate determination that there was no such relationship was improperly based on the absence of documentation in the post-service treatment records. See Buchanan, 451 F.3d at 1337 (noting that the lack of contemporaneous medical evidence should not be an absolute bar to the veteran's ability to prove his claim of entitlement to disability benefits based on that competent lay evidence). The Board thus finds that the July 2012 VA examiner's opinion is entitled to little, if any, probative weight. As indicated in the August 2012 DRO pre-conference brief and elsewhere, the Veteran has indicated that she experienced right ankle symptoms since the in-service injury. Moreover, she contends that her May 2010 on the job injury resulted in further aggravation of her right ankle disorder, and that the right ankle had been weak since the in-service injury, with the ligaments never healing properly, resulting in the on the job sprain. This was supported, according to her attorney in the DRO pre-conference brief, by her statement in October 2010 to Dr. K.K. of frequent giving way and twisting of the right ankle. As noted, the Veteran is competent to testify to her observable right ankle symptoms, but this testimony must be weighed against the other evidence of record. Jandreau, 492 F.3d at 1376-77; Buchanan, 451 F.3d at 1336. The Board finds that the normal separation examination finding as to the lower extremities and statement in 1986 as to a lack of foot problems are of greater probative weight than the later statements of continuity of right ankle symptomatology made during the course of an appeal from the denial of compensation benefits. Fed. R. Evid. 803(4); Pond, 12 Vet. App. at 345 (1999). The Veteran's statements in this regard are therefore not credible. In addition, the Veteran reported that Dr. K.K. told her that her current right ankle disorders were due to the in-service injury and is competent to do so. Jandreau, 492 F.3d at 1377. For the reasons indicated above, however, the Board finds that the specific, reasoned opinion of the physician who performed the July 2010 VA examination is of greater probative weight than the more general assertion of Dr. K.K. as relayed by the Veteran. Finally, it was noted at the hearing the entitlement to service connection for a right foot disability was being claimed secondary to a back disability. As the Veteran is not in receipt of service connection for a back of any other orthopedic disability, entitlement to this benefit must be denied as a matter of law. See 38 C.F.R. § 3.310 (requiring that a service connected disability be proximately due to, the result of, or aggravated by an already service connected disease or injury in order to warrant entitlement). For the foregoing reasons, the weight of the evidence is against a relationship between any current right foot disability and the Veteran's in-service right ankle injury. Left foot A December 2010 VA left ankle MRI indicated some degree of plantar fasciitis. Moreover, Dr. K.K.'s October 2010 treatment note indicated bilateral pes cavus and claw toes. The July 2012 VA examiner noted hammertoes, mild bunion, and subjective bilateral ankle swelling. The Veteran has thus met the current disability requirement. There is no reference in the service treatment records to complaints, treatment, or diagnoses relating to the left foot. As noted, the lower extremities and feet were normal on the December 1985 separation examination and the Veteran indicated she did not have foot problems on the February 1986 report of medical history. An October 2009 Neurology Mobile System Associates (NMSA) left foot ultrasound noted heterogenous echogenic consistency and no evidence of clearly defined cystic lesion or abnormal collection fluid. March and April 2010 NMSA ultrasounds of various parts of the left foot showed no discrete soft tissue mass or abnormal fluid collection within the region of interest. The July 2010 VA examiner indicated symptoms of pain, fatigability, and lack of endurance while standing and walking. Left foot examination showed no evidence of painful motion, swelling, tenderness, instability, weakness, or abnormal weight bearing, skin or vascular foot abnormality, malunion of the tarsal or metatarsal bones, muscle atrophy of the foot. The only other significant finding noted was bunion, palpable lump on the arch. July 2010 X-ray showed an unremarkable left foot. Diagnoses were pes cavus, hammertoes 2-5 bilaterally, mild bunion, and subjective bilateral ankle swelling after prolonged standing and walking, not currently noted. Findings on the July 2012 VA examination with regard to the left foot were essentially normal. The Veteran did not specifically indicate that she suffered a left foot injury during service or indicate a specific nexus between a current left foot disability and service. As there is no evidence indicating that the Veteran's left foot disability is related to service, the weight of the evidence is against this theory of entitlement. In addition, a remand for an examination or to obtain an opinion on this issue is not warranted. To the extent that the Veteran alleges a general nexus between a current left foot disability and service, such a conclusory generalized lay statement does not meet the statutory and regulatory standard of indicating that a disability may be associated with service, as this would, contrary to the intent of Congress, result in medical examinations or opinions being "routinely and virtually automatically" provided to all veterans claiming service connection. Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010). In addition, in the August 2012 DRO pre-conference brief, the Veteran's attorney contended with regard to the left foot only that the issue had not been adjudicated on a secondary basis. He noted that the Veteran's gait had been noted to be antalgic, and that it should be considered whether a current left foot disability was related to a service connected or non-service connected disability. Given, however, that the Veteran is in receipt of service connection only for major depressive disorder with PTSD and hypertension, there is no basis on which to find that a left foot disability is caused or aggravated by a service connected disease or injury. The claim for entitlement to service connection for left foot disability secondary to a service connected disease or injury must therefore be denied as a matter of law. See 38 C.F.R. § 3.310 (requiring that a service connected disability be proximately due to, the result of, or aggravated by an already service connected disease or injury in order to warrant entitlement). Conclusion For the foregoing reasons, the preponderance of the evidence is against the claims for entitlement to service connection for a back disability, right foot or ankle disability, and left foot disability. The benefit of the doubt doctrine is therefore not for application and the claims must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a back disability, claimed as a pinched nerve, to include neurologic symptoms of the lower extremities claimed as right foot neuropathy, is denied. Entitlement to service connection for a right foot or ankle disability is denied. Entitlement to service connection for a left foot disability, to include plantar fasciitis, is denied. REMAND The Veteran contends she is entitled to an initial disability rating higher than 70 percent for her major depressive disorder with PTSD and has submitted evidence indicating an inability to work in the general labor market, as opposed to her current employment. The issue of entitlement to a TDIU has thus been raised and is before the Board. Rice v. Shinseki, 22 Vet. App. 447 (2009). However, the RO denied a formal claim for a TDIU in an October 2015 rating decision and the Veteran filed a timely, November 2015 NOD. The evidence reflects that the AOJ is in the process of developing and adjudicating a formal claim for a TDIU and is continuing to seek relevant information from the Veteran's current employer, as recently as December 2015. Consequently, a decision on the issue of entitlement to a TDIU would be premature and a remand to the AOJ is warranted. A directive instructing the AOJ to issue a SOC is unnecessary as it appears that the AOJ is developing the claim in anticipation of doing so. Cf. 38 C.F.R. § 19.9(c) (2015), codifying Manlincon v. West, 12 Vet. App. 238 (1999). In addition, the evidence being developed by the AOJ is relevant to the issue of entitlement to a higher initial rating for major depressive disorder with PTSD, to include a December 2015 vocational evaluation by a vocational rehabilitation consultant that has not been reviewed by the AOJ in connection with the rating claim. A remand of the issue of entitlement to an initial rating higher than 70 percent for major depressive disorder with PTSD, to include consideration of this additional relevant evidence, is therefore warranted as well. Accordingly, the issues of entitlement to an initial disability rating higher than 70 percent for major depressive disorder with PTSD and entitlement to a TDIU are REMANDED for the following action: Review any additional relevant evidence and readjudicate the issues of entitlement to an initial disability rating higher than 70 percent for major depressive disorder with PTSD and entitlement to a TDIU. If any benefit sought on appeal remains denied, furnish the Veteran and his attorney a SSOC and return the case 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 of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Alexandra P. Simpson Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs