Citation Nr: 1751264 Decision Date: 11/08/17 Archive Date: 11/17/17 DOCKET NO. 10-35 579 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for headaches. 2. Entitlement to service connection for bilateral foot disability. 3. Entitlement to service connection for neck disability. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD G. Johnson, Associate Counsel INTRODUCTION The Veteran had honorable active service in the United States Army from February 2003 to May 2004. Prior to his active service, the Veteran had lengthy reserve component service of unverified types from 1988 to the time of his active service in 2003, including a period of full time active duty for training from November 1988 to March 1989. The Veteran had additional unverified reserve service following his release from active duty. The Veteran received multiple awards and medals including the Combat Action Badge. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Board notes that, during the pendency of this appeal, a June 2010 rating decision granted a claim for a total rating based on individual unemployability due to service-connected disabilities (TDIU), effective November 7, 2009. In November 2011, the Veteran testified at a videoconference hearing before a Veterans Law Judge (VLJ). A transcript of that hearing has been associated with the claims file. In July 2015, the Board notified the Veteran that the VLJ who conducted the Board hearing was no longer employed at the Board. The Veteran was provided the opportunity to request another hearing on the appeal issue and was advised that if the Veteran did not respond within 30 days, the Board would assume that he did not want another hearing and would proceed accordingly. In August 2015, the Veteran responded that he did not want another hearing and requested that his claims be decided based on the evidence of record. The case was previously before the Board in December 2012, September 2015, and November 2016. In December 2012, the Board remanded the issue of service connection for headaches, service connection for bilateral foot pain, and service connection for a neck injury to the Agency of Original Jurisdiction (AOJ) for additional development, including, a VA examination to determine the current severity and etiology of the Veteran's headaches, neck injury, and bilateral foot pain, and to obtain relevant service treatment records, VA treatment records, private treatment records, and Social Security Administration (SSA) records. In September 2015, and November 2016, the Board found that there had not been substantial compliance with the remand directives with regards to the issues on appeal and remanded the claims for additional development. With regards to the Veteran's claim for service connection for bilateral foot pain there has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The issues of service connection for a neck disability and headaches are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ). FINDINGS OF FACT 1. Pes planus was noted upon entry into active service. 2. Bilateral pes planus existed prior to active service, and the probative evidence does not show that this disability was permanently aggravated by active service. 3. The preponderance of the probative evidence reflects that the Veteran's current bilateral foot disability (other than pes planus) was not present in service or for many years following his discharge from service, and is not etiologically related to service. CONCLUSION OF LAW The criteria for entitlement to service connection for a bilateral foot disability, characterized as bilateral plantar fasciitis, are not met. 38 U.S.C.A. §§ 1110, 1111, 1131, 1153 (West 2016); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. VA's Duties to Notify and Assist As provided for by the Veterans Claims Assistance Act of 2000 (VCAA), VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A. VA has met the requirements of 38 U.S.C.A. §§ 5103 and 5103A. By correspondence dated in December 2009, VA notified the Veteran of the information and evidence needed to substantiate and complete the claim. The letter also notified the Veteran as to how VA assigns disability ratings and effective dates. VA has also satisfied the duty to assist. The claims folder contains service treatment records and VA treatment records. The Veteran underwent VA examinations in March 2013 and November 2015. VA also obtained a July 2017 opinion from the VA Appeals Resource Center (ARC). The examinations and opinion include objective findings necessary for rating purposes and discuss the functional effects due to the Veteran's bilateral foot disability. See 38 C.F.R. § 4.71a; Martinak v. Nicholson, 21 Vet. App. 447, 455 (2007). Additional examination is not needed. In November 2011, VA afforded the Veteran the opportunity to give testimony before the Board. The Board hearing focused on the elements necessary to substantiate the claim, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claim. As such, the Board finds that, consistent with Bryant v. Shinseki, 23 Vet. App. 488, 496-497 (2010), the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). As noted in the introduction, the claim has been remanded for further development. In reviewing the record, the Board finds substantial compliance with the remand directives as concerns the issues on appeal. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran would serve no useful purpose. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). VA has satisfied the duty to inform and assist the Veteran, and the Board finds that any errors were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board adjudicating the claim. II. Service Connection for Bilateral Foot Disability The Veteran seeks service connection for bilateral foot disability, which he asserts is related to service. In a November 2011 Board hearing, the Veteran testified that his bilateral foot condition came from walking in service while he was on guard duty during cold nights. He testified that his bilateral foot condition, which involved pain at the bottom of his feet was different from his service-connected cold weather injury. He testified that he complained about his foot pain to M.B., a fellow service member who was a medic. In 2009, he was given inserts to treat his bilateral foot condition. He was also given medication to treat his bilateral foot condition. He testified that a foot doctor told him that his bilateral foot condition was related to service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also 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). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1166-1167 (Fed. Cir. 2004). A Veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C.A. §§ 1111, 1132; 38 C.F.R. § 3.304(b). Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b); see also Quirin v. Shinseki, 22 Vet. App. 390, 396-397 (2009). The disorder need not be currently symptomatic, but only noted on entrance. Verdon v. Brown, 8 Vet. App. 529, 535 (1996). If a condition is not noted upon entrance into service, then to rebut the presumption of soundness at service entrance VA must show by clear and unmistakable evidence both that there was a preexisting condition and that it was not aggravated during or by the Veteran's service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); VAOPGCPREC 3-2003 (July 16, 2003). Congenital or developmental defects are not considered "diseases or injuries" within the meaning of applicable legislation and, hence, do not constitute disabilities for VA compensation purposes. See 38 C.F.R. §§ 3.303(c), 4.9. A superimposed disease or injury is eligible for service connection. See VAOPGCPREC 82-90 (observing that even congenital defects "can be subject to superimposed disease or injury" and that "if during an individual's military service, superimposed disease or injury does occur, service-connection may indeed be warranted for the resultant disability"); see also Carpenter v. Brown, 8 Vet. App. 240, 245 (1995). As previously discussed, the Veteran served on active duty in the United States Army from February 2003 to May 2004. Prior to his active service, the Veteran had lengthy reserve component service of unverified types from 1988 to the time of his active service in 2003, including a period of full time active duty for training from November 1988 to March 1989. A June 1988 Report of Medical Examination for enlistment reflects that the Veteran had moderate asymptomatic pes planus. A July 2000 Report of Medical Examination reflects that the Veteran had bilateral asymptomatic pes planus. An April 2004 Report of Medical History reflects that, the Veteran had mild asymptomatic pes planus. The Board finds that the evidence demonstrates that the Veteran had bilateral pes planus disability that was noted on pre-induction examination in June 1988. As pes planus was noted during the Veteran's entrance examination, the presumption of soundness does not attach. See 38 U.S.C.A. § 1111; 38 C.F.R. § 3.304. If a preexisting disorder is noted upon entry into service, as in this case, the Veteran cannot bring a claim for service connection for that disorder, only a claim for service-connected aggravation of that disorder. In that case, however, 38 U.S.C.A. § 1153 applies and the burden falls on the Veteran, not VA, to establish aggravation. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). A preexisting injury or disease will be considered to have been aggravated during service when there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306; Falzone v. Brown, 8 Vet. App. 398, 402 (1995). See also Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002) (holding that evidence of a temporary flare-up, without more, does not satisfy the level of proof required of a non-combat Veteran to establish an increase in disability). In a July 2009 statement, a medic (M.B.) stated that during their tour in Iraq, he treated the Veteran for chronic pain at the bottom of his foot and heel, and the Veteran had to seek further medical attention from hospital staff upon their arrival back on base due to the severity of his condition. In another July 2009 statement, a fellow service member reported that the Veteran was treated for a severe case of inflammation and chronic foot pain, due to excessive walking with weight on his back. In a September 2009 statement, a fellow service member reported that the Veteran complained of inflammation and chronic foot pain after excessive walking. Post service treatment records reflect a diagnosis of plantar fasciitis from August 2009. An April 2006 VA examination of the Veteran's right ankle noted that there were no foot deformities, no hammertoe, high arch, pes planus or claw foot. An August 2009 VA treatment record reflects a diagnosis of bilateral plantar fasciitis. The Veteran complained of heel pain bilateral arches, and reported that the symptoms had been present for over a year. The Veteran was afforded a December 2009 VA examination for cold injury to bilateral lower extremities. The Veteran complained of pain and numbness in the plantar surface of the foot. Physical examination of the Veteran revealed decreased sensation on the plantar surface of the foot, and plantar flexion with pain throughout. In March 2013, the Veteran was afforded a VA examination, which reflected a diagnosis of pes planus. The examiner opined that the Veteran's claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner did not discuss the Veteran's August 2009 diagnosis of bilateral plantar fasciitis. The Veteran was afforded a VA examination in November 2015, which reflected a diagnosis of pes planus and plantar fasciitis. The examiner opined that the Veteran's claimed condition, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner opined that if the Veteran had plantar fasciitis, it was not caused by any in-service injury because he was not treated for or diagnosed with plantar fasciitis while in service. The examiner opined that if the Veteran had developed plantar fasciitis after service, there is no known correlation since he was not seen or diagnosed while on active duty with plantar fasciitis. However, as previously stated, the Veteran testified at a November 2011 Board hearing that he injured his foot during combat service. In a July 2017 opinion, an VA examiner opined that it was less likely than not that the Veteran's bilateral plantar fasciitis with or without mild pes planus was caused by and/or aggravated by any in-service injury, including walking for long distances carrying heavy weight while stationed in Southwest Asia. The examiner noted that based upon active duty records, the Veteran enlisted with an asymptomatic pes planus foot construct. The Veteran's "04 April 2006" separation examination reflected that the Veteran's feet remained "mild asymptomatic pes planus". In addition, the medical history clearly and unmistakable included the notation, "no" with respect to "ever having or ever reporting" foot trouble. The examiner also noted that the active duty and presumptive period medical and orthopaedic records were negative for complaints, diagnosis, treatment, injury and/or events related to bilateral foot conditions, to include plantar fasciitis and/or pes planus foot construct. The July 2017 examiner noted that current podiatric and orthopaedic literature agreed that plantar fasciitis was localized inflammation at the periosteal insertion of the medial band of the plantar fascia to the medial process of the calcaneal tuberosity. The examiner also noted that podiatric and orthopaedic specialists agreed that in comparison, pes planus foot architecture (decreased longitudinal arch) was an acquired condition associated with excessive pronation throughout the gait cycle. Biomechanically, pes planus functioned with changes in pronation throughout the gait cycle secondary to an unlocking of the subtalar and midtarsal joints of the rearfoot and midfoot complex resulting in the lowering (dropping) of the longitudinal arch. The examiner noted that the active duty, presumptive period and the 2017 C&P pedal examinations were negative for complaints, treatment, injury and/or events related to right foot pes planus foot construct. Moreover, the August 2008 plain films were negative for any bone and/or soft tissue (periosteal) abnormalities, and the joint spaces were maintained. Similarly, the August 2009 radiographs were negative for any bone abnormalities, and the joint spaces were maintained. Later radiographs, March 2013 and June 2015, observed normal calcaneal pitch without fracture, malalignment, or aggressive osseous lesions, normal mineralization, and the joint spaces were preserved. Therefore, the examiner opined that it was less likely than not that progression of bone and soft tissue moieties were observed over time. The July 2017 examiner also opined that it was less likely than not that the Veteran's claimed foot disabilities, to include as mild pes planus and/or plantar fasciitis, were aggravated by his service connected conditions, to include posttraumatic stress disorder (PTSD) with depression, obstructive sleep apnea (OSA), degenerative disc disease (lumbar spine) (previously strain) with associated radiculopathy of sciatic and/or femoral nerve, bilateral lower extremity, cold injury, bilateral lower extremity, tendinosis, left shoulder, chronic strain, left knee, and left finger scar. Based on the evidence as outlined above, the Board finds that the preponderance of the evidence shows that the Veteran's preexisting bilateral pes planus was not permanently aggravated by service, as the weight of the evidence does not show that the disability increased in severity in service. The record shows that the Veteran's other current bilateral foot disability did not have its onset in service and was not proximately due to or the result of a service-connected disability. As discussed, the Board notes that the Veteran entered service with asymptomatic bilateral pes planus and separated from service with asymptomatic bilateral pes planus. The service treatment records are silent to any complaints, treatment or aggravation of the Veteran's asymptomatic bilateral pes planus. The service treatment records are also silent as to any complaints, treatment, or diagnosis of any other bilateral foot disability, to include plantar fasciitis. The Veteran has testified that his bilateral foot disability began while he was serving in combat. A fellow service member stated that the Veteran complained of chronic foot pain after excessive walking; and another fellow service member, a medic, stated that he treated the Veteran for chronic foot pain after excessive walking. VA treatment records in August 2009 reflect a diagnosis of bilateral plantar fasciitis. To the extent that the Veteran is a combat Veteran and the fact of injury is therefore established, the Veteran must still generally establish his claim by competent medical evidence tending to show a current disability and a nexus between that disability and those service events. The July 2017 VA examiner specifically acknowledged the Veteran's assertion that his bilateral foot pain began while he was serving in combat. The July 2017 medical opinion, however, establishes that the Veteran's bilateral foot disability is not related to service. The July 2017 opinion is competent, credible and probative, and coupled with the other medical evidence of record including the service records, VA treatment records, and lay evidence, supports a conclusion that service connection for bilateral foot disability, characterized as bilateral plantar fasciitis, is not warranted. The Board observes that the July 2017 examiner opined that it was less likely than not that the Veteran's bilateral plantar fasciitis with or without mild pes planus was caused by and/or aggravated by any in-service injury, including walking for long distances carrying heavy weight while stationed in Southwest Asia. The examiner stated that his opinion was based upon active duty records, which reflected the Veteran enlisted with asymptomatic pes planus foot construct, and the Veteran's "04 April 2006" separation examination, which reflected that the Veteran's feet remained "mild asymptomatic pes planus". The Board notes that the Veteran's separation examination report was actually dated in April 2004 and not in April 2006. The April 2004 date was apparently transposed to April 2006 due to a clerical error. The Board notes that despite the recording of an incorrect date, the examiner reviewed the Veteran's claims file and provided an opinion with an accompanying rationale that is consistent with the evidence of record, to include specifically the Veteran's medical history and service treatment records. The July 2017 examiner noted that the Veteran's medical history in service clearly and unmistakable noted "no" with respect to "ever having or ever reporting" foot trouble. Moreover, the active duty and presumptive period medical and orthopaedic records were negative for complaints, diagnosis, treatment, injury and/or events related to bilateral foot conditions, to include as plantar fasciitis and/or pes planus foot construct. The examiner opined that based upon the Veteran's medical history, as well as films and radiographs of the Veteran's feet it was less likely than not that the progression of bone and soft tissue moieties were observed over time. Based on current podiatric and orthopaedic literature and a review of the Veteran's medical history the examiner opined that it was less likely than not that the Veteran's bilateral plantar fasciitis with or without mild pes planus was caused by and/or aggravated by any in-service injury, including walking for long distances carrying heavy weight while stationed in Southwest Asia. The Board notes that service connection is possible for disabilities first identified after service. 38 C.F.R. § 3.303(d). Therefore, the July 2017 examiner's finding that there was no complaints, treatment or diagnosis of a bilateral foot disability in service, is not enough, on its own, to deny the Veteran's claim. However, the examiner also set forth the additional reasons for his conclusion as outlined herein. Thus, while the examiner acknowledged the Veteran's report of injury in service, the examiner was unable to conclude that the Veteran's current bilateral foot disability resulted from any in-service injury or was proximately due to or the result of a service-connected disability. There is no contrary medical opinion of record. The VA examiner's opinion that the Veteran's current bilateral foot disability does not relate to service, is probative, even with consideration of the Veteran's assertion that his current bilateral foot disability was caused by his injury in-service. The Board finds that the Veteran is not competent to relate his injury in service to his current bilateral foot disability, as it would require medical expertise to say that the current bilateral foot disability identified after service is the result of an in-service injury. The Veteran, as a layperson, is not qualified to render an opinion concerning the medical cause of his bilateral foot disability. 38 C.F.R. § 3.159(a)(1), (2). The Board acknowledges the Veteran's belief that his current bilateral foot disability is related to his military service. Although the Veteran is competent to say he currently has bilateral foot pain, the cause of foot pain can have multiple possible etiologies and, thus, falls outside the realm of common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Consequently, the Veteran's lay testimony is not competent to establish a medical diagnosis or show a medical etiology because such matter requires medical expertise. See 38 C.F.R. § 3.159(a)(1). Because the Veteran is not professionally qualified to offer a diagnosis or suggest a possible medical etiology, his statements are afforded little weight as to whether a nexus exists between his current bilateral foot disability and his military service. In summary, the evidence of record weighs against a finding of a nexus between the Veteran's current bilateral foot disability and his active military service. The Board notes that under the provisions of 38 U.S.C.A. § 5107(b), the benefit of the doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. The preponderance of the evidence, however, is against the Veteran's claim, and thus, that doctrine is not applicable. The Veteran's claim of entitlement to service connection for bilateral foot disability, characterized as bilateral plantar fasciitis, is not warranted. ORDER Service connection for bilateral foot disability, characterized as bilateral plantar fasciitis, is denied. REMAND I. Service Connection for Neck Disability The Veteran seeks service connection for a neck disability, which he asserts is related to service. During a November 2011 Board hearing, the Veteran testified that he injured his neck in service when he was struck in the face by a fellow service member when they were aboard a helicopter, which was engaged in a basic maneuver trying to dodge incoming enemy fire. He had his neck checked out at a hospital, and they told him it was tendinitis, and gave him medication to treat the pain. Post service treatment records reflect complaints of a neck pain from October 2006. VA examinations for posttraumatic stress disorder (PTSD) in October 2006 and January 2008 reflected that the Veteran had an Axis III diagnosis of neck pain. In January 2008 and December 2008, two fellow service members reported that the Veteran injured his neck in a helicopter, which was engaged in battle maneuvers, and received medical treatment when they landed. In a January 2009 letter, a medic stated that he treated the Veteran for a neck injury that he sustained when his helicopter went into battle maneuvers, and that the Veteran sought further medical treatment from hospital staff due to the severity of his neck condition. The Veteran was afforded a VA examination in March 2013, which reflected a diagnosis of degenerative disc disease of the cervical spine. The examiner opined that the Veteran's neck condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that there was no documentation that the Veteran continued to suffer from neck pain at the time of his military discharge. The examiner noted that the first documented report of neck pain was in November 2012 VA treatment records, which was over 8 years after the reported injury. The examiner noted that there was no corroborating evidence to demonstrate a nexus between the 2004 neck injury and the current condition, as there were no documented reports of neck pain until over 8 years after the military injury. The examiner failed to note the Veteran's Axis III diagnosis of neck pain in his October 2006 and January 2008 VA examinations. The Veteran was also afforded a VA examination in November 2015, an independent medical opinion in March 2016, and a VA opinion in July 2017. Each of the examiners relied on the inaccurate medical history from the March 2013 VA examination, and copied the March 2013 VA examiner's inaccurate rationale regarding the span of time between the Veteran's neck injury in-service and the documentation of complaints of neck pain. Therefore, the Board finds that a supplemental VA opinion is warranted to determine the etiology of the Veteran's neck disability. II. Service Connection for Headaches The Veteran seeks service connection for headaches, which he asserts are related to service. In a November 2011 Board hearing, the Veteran testified that he began having headaches after he injured his neck in-service. As previously discussed, the Veteran testified that he injured his neck in service when he was hit by a fellow service member, aboard a helicopter, which was engaged in a basic maneuver trying to dodge incoming enemy fire. The Veteran testified that his headaches came from tendinitis in his neck, because of the whiplash in his neck. He testified that the treatment providers ruled out traumatic brain injury, and told him it was possible that it came from his neck injury. In January 2008 and December 2008, two fellow service members reported that the Veteran injured his head in a helicopter, which was engaged in battle maneuvers, and received medical treatment when they landed. In a January 2009 letter, a medic stated that he treated the Veteran for a head injury that he sustained when his helicopter went into battle maneuvers, and that the Veteran sought further medical treatment from hospital staff because he was experiencing severe headaches. The Veteran was afforded a VA examination in March 2013, which reflected a diagnosis of tension headaches. The examiner opined that the Veteran's claimed condition was less likely than not (less than 50 percent probability) incurred or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran reported that his headaches began in the muscles of his neck and then radiated around his head area. The examiner noted that according to the preponderance of current medical tests, it was a classic example of a muscle tension headache. It was most likely that the Veteran's current muscle tension headaches were secondary to his neck condition. The examiner did not discuss whether the Veteran's headaches were related to his service-connected disabilities, including posttraumatic stress disorder. The Veteran was afforded a VA examination in November 2015. The examiner noted an October 2015 CT scan of the Veteran's head without contrast, which revealed mild to moderate sinus thickening. The October 2015 treatment provider noted that clinical correlation for sinusitis was recommended for possible etiology of the Veteran's chronic headaches. The examiner opined that the Veteran's claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner did not discuss whether the Veteran's headaches were related to his other service-connected disabilities, including PTSD. VA obtained an independent medical opinion in March 2016. The examiner opined that the Veteran's claimed headaches, currently diagnosed as tension headaches, was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness, and were less likely than not (less than 50 percent probability) caused by or aggravated by his service-connected disease or injury, to include PTSD with MDD. The examiner noted that "A limited review of the scientifically based medical literature with respect to headache and PTSD also found support for a strong association," and noted an article, which stated that "Posttraumatic stress disorder (PTSD) is often comorbid with chronic migraine (CM) and chronic tension-type headache (CTTH)." The examiner noted that medical literature supports a strong association between PTSD and headaches, in Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and Operation New Dawn (OND) Veterans, but falls short of proving causation. However, the examiner noted that Veteran's headaches were presently better, so there was no basis for permanent worsening (aggravation) beyond normal progression. The March 2016 VA examiner applied the incorrect standard for aggravation when providing the medical opinion as to whether the Veteran's headaches had been aggravated by his service-connected PTSD. The United States Court of Appeals for Veterans Claims (Court) has explained that, "any increase in disability" is the standard to be used. See Allen v. Brown, 7 Vet. App. 445, 448-449 (1995). In a May 2017 VA opinion, an examiner opined that it was less likely than not that the Veteran's claimed headaches related to and/or was aggravated by his service connected mental health disability. The examiner noted that current internal medicine, orthopaedic and mental health literature lacks sufficient objective, medically based, clinical evidence to support a nexus between headaches, consistent with a past history of muscle tension etiology and nature, and PTSD. Although, the examiner noted that she agreed with the March 2016 medical opinion, she failed to consider and discuss the medical literature the March 2016 examiner noted which noted an association between PTSD and headaches. The Board further notes that the issue of entitlement to service connection for headaches is inextricably intertwined with the claim for service connection for neck disability, as the outcome of the claim for service connection for a neck disability directly affects whether entitlement to service connection for headaches is warranted. Therefore, the Board finds that a supplemental VA opinion is warranted to determine the etiology of the Veteran's headaches. Accordingly, the case is REMANDED for the following action: 1. Obtain a VA addendum opinion to ascertain the etiology of the Veteran's claimed neck disability. The claims file should be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should address the following: a. whether it is at least as likely as not (50 percent or greater likelihood) that any current neck disability had its onset in service or is otherwise related to service; The examiner should consider and discuss the following: i. the Veteran's October 2006 VA examination which reflected an Axis III diagnosis of neck pain; ii. the Veteran's January 2008 VA examination, which reflected an Axis III diagnosis of neck pain. iii. the January 2008, December 2008, and January 2009 statements from fellow service members regarding his neck injury. b. The examiner should provide an opinion as to whether the Veteran's neck disability was proximately caused by the Veteran's service-connected disabilities. c. The examiner should provide an opinion as to whether the Veteran's neck disability was aggravated (increased in severity) by the Veteran's service-connected disabilities. The examiner should provide a detailed rationale for the opinion. If an opinion cannot be provided without resort to speculation, the examiner should explain why it is not possible to provide an opinion. 2. Obtain a VA addendum opinion to ascertain the etiology of the Veteran's claimed headaches. The claims file should be made available to and be reviewed by the examiner in conjunction with the examination. The examiner should address the following: a. whether it is at least as likely as not (50 percent or greater likelihood) that any current headache disability had its onset in service or is otherwise related to service. b. The examiner should provide an opinion as to whether the Veteran's headaches were proximately caused by the Veteran's service-connected disabilities, to include PTSD. c. The examiner should provide an opinion as to whether the Veteran's headaches were aggravated (increased in severity) by the Veteran's service-connected disabilities, to include PTSD. The examiner should consider and discuss the following: i. the January 2008, December 2008, and January 2009 statements from fellow service members regarding his head injury; ii. the medical literature referenced in the March 2016 medical opinion, which noted an association between PTSD and headaches. The examiner should provide a detailed rationale for the opinion. If an opinion cannot be provided without resort to speculation, the examiner should explain why it is not possible to provide an opinion. 3. Readjudicate the claims on appeal in light of all of the evidence of record. If the issues remain denied, the Veteran and his representative should be provided with a supplemental statement of the case as to the issue on appeal, and afforded a reasonable period within which to respond thereto. 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). This claim 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. S. L. Kennedy Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs