Citation Nr: 18145458 Decision Date: 10/29/18 Archive Date: 10/29/18 DOCKET NO. 14-18 339 DATE: October 29, 2018 ORDER A compensable rating for service connected migraine headaches is not met prior to March 2, 2016. On and after March 2, 2016, entitlement to a 30 percent disability rating, but no greater, for service-connected migraine headaches is granted. Entitlement to an initial disability rating in excess of 10 percent for bilateral pes planus and plantar fasciitis is denied. REMANDED Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left shin disorder is remanded. Entitlement to service connection for a right shin disorder is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for a right ankle disorder is remanded. FINDINGS OF FACT 1. Prior to March 2, 2016, the Veteran’s service-connected migraine headaches manifested with prostrating attacks that occurred less frequently than one in two months over the last several months. 2. On and after March 2, 2016, the Veteran’s service-connected migraine headaches were manifest with prostrating attacks occurring on an average of once a month over the last several months. 3. At all relevant times, the Veteran’s service-connected bilateral pes planus and plantar fasciitis were no more than moderate in degree and has been manifested by pain on manipulation; his condition has not been manifested of the signs and symptoms of severe or pronounced degree of pes planus. CONCLUSIONS OF LAW 1. Prior to March 2, 2016, the criteria are not met for a higher, compensable disability rating for the Veteran’s service-connected migraine headaches. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.120, 4.123, 4.124a, Diagnostic Code 8100 (2017). 2. On and after March 2, 2016, the criteria have been met for an increased rating of 30 percent, but no greater, for migraine headaches. 38 U.S.C. §§ 1155, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.6, 4.7, 4.10, 4.21, 4.120, 4.123, 4.124a, Diagnostic Code 8100 (2017). 3. The criteria for an initial disability rating of in excess of 10 percent for bilateral pes planus and plantar fasciitis have not been met. 38 U.S.C. §§ 1155, 5107 (West 2000 & Supp. 2016); 38 C.F.R. §§ 3.102, 4.71a, Diagnostic Code 5276 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served honorably in the United States Navy from June 2004 to March 2009. The Board has thoroughly reviewed all the evidence in the Veteran’s claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, all of the evidence submitted by the Veteran or on his behalf. See Gonzalez v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claims. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran). Increased Ratings, Generally Disability ratings are determined by applying the criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. 38 U.S.C. § 1155 (2012); 38 C.F.R. § 4.1 (2017). The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life including employment. 38 C.F.R. § 4.10. If there is a question as to which evaluation to apply to the Veteran’s disability, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. When reasonable doubt arises as to the degree of disability, such doubt will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. In considering the severity of a disability, it is essential to trace the medical history of the veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole-recorded history is necessary so that a rating may accurately reflect the elements of any disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the veteran’s medical history in determining the applicability of a higher rating for the entire period in which the appeal has been pending. Powell v. West, 13 Vet. App. 31, 34 (1999). The Board must also assess the competence and credibility of lay statements and testimony. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). In increased rating claims, a Veteran’s lay statements alone, absent a negative credibility determination, may constitute competent evidence of worsening, at least with respect to observable symptoms. See Vazquez-Flores v. Shinseki, 24 Vet. App. 94, 102 (2010), rev’d on other grounds by Vazquez-Flores v. Shinseki, 580 F.3d 1270, 1277 (Fed. Cir. 2009). The Veteran is uniquely suited to describe the severity, frequency, and the duration of the symptoms that accompany his service-connected migraine headaches and pes planus disabilities. See Falzone v. Brown, 8 Vet. App. 398 (1995); Heuer v. Brown, 7 Vet. App. 379 (1995). 1. A compensable rating prior to March 2, 2016, for service-connected migraine headaches is denied; on and after March 2, 2016, an increased disability rating of 30 percent for service-connected migraine headaches is granted. In April 2012, the Veteran submitted his VA Form 21-526b. Therein, the Veteran initiated his entitlement claim for service connection for migraine headaches. Service connection was awarded in a February 2016 with assignment of a noncompensable disability evaluation. In March 2016, the Veteran submitted his VA Form 21-0958. Therein, the Veteran disagreed with the noncompensable rating assigned by the agency of original jurisdiction (AOJ) for his now-service connected migraine headaches. The AOJ has evaluated the Veteran service connected headache disability under Diagnostic Code (D) 8100, for migraine headaches. Under the terms of DC 8100, a non-compensable evaluation is assigned for less frequent attacks. A 10 percent evaluation is assigned for migraines with characteristic prostrating attacks averaging one in two months over the last several months. A 30 percent evaluation is warranted for migraines with characteristic prostrating attacks occurring on an average once a month over the last several months. A 50 percent evaluation, the highest available under DC 8100, is assigned for migraines with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. 38 C.F.R. § 4.124a. The rating criteria do not define “prostrating” as used in DC 8100. By way of reference, the Board notes that according to WEBSTER’S NEW COLLEGE DICTIONARY 909 (3d Ed. 2008), “prostrate” is defined as “physically or emotionally exhausted.” “Incapacitated” is listed as a synonym. A very similar definition is found in DORLAND’S ILLUSTRATED MEDICAL DICTIONARY 1554 (31st Ed. 2007), in which “prostration” is defined as “extreme exhaustion or powerlessness.” Similarly, the regulations provide no clarification as to the meaning of the phrase “productive of severe economic inadaptability.” The Court, however, has interpreted the phrase to mean “producing” or “capable of producing” economic inadaptability. See Pierce v. Principi, 18 Vet. App. 440, 445 (2004). When the appeal is from the initial rating assigned with an award of service connection, the severity of the disability at issue during the entire period from the initial assignment of the disability rating to the present is to be considered, and “staged” ratings may be assigned, based on facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). The AOJ has assigned a non-compensable rating for migraine headaches, and the following analysis is undertaken with consideration of the possibility of staged ratings. The Board has reviewed all evidence of record pertaining to the history of the service-connected disability. The Board has found nothing in the record which would lead to the conclusion that the current evidence of record is not adequate for rating purposes. 38 C.F.R. §§ 4.1, 4.2, 4.41, 4.42; Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In October 2012, the Veteran underwent a VA examination that addressed his now-service connected migraine headache disability. In the resultant report, the VA provider noted an un-dated diagnosis for “headaches.” Within the medical history, the VA provider reported that, “(h)e hasn’t been formally diagnosed with any migraines. He isn’t treated now with any PCP for any headache condition. He hasn’t seen any PCP or neurologist for this condition. His headaches occur every 2-3 days, lasting hours to all day, right behind his eyes.” While the Veteran had headaches, the VA provider reported that the Veteran did not have characteristic prostrating attacks of migraine headache pain. In April 2013, the Veteran underwent a VA examination that addressed his now-service connected migraine headache disability. In the resultant report, Dr. IW noted that, “during review of svc records . . . headaches were tabbed 4 times in a military career spanning close to 5 years. This is not an excessive frequency of headaches, as compared to the general public.” In his report, Dr. IW did not address prostrating incidents of migraine headache pain. In February 2016, the Veteran underwent a VA examination that considered his now-service connected migraine headache disability. In the resultant report, Dr. JDM confirmed a current diagnosis for migraine headaches, which originated in 2011. At that time, Dr. JDM noted that the Veteran took Imitrex and Excedrin for his migraine headaches. During the examination, the Veteran reported migraine-type headaches 1-2 times each week. Importantly, Dr. JDM did not report that the Veteran demonstrated characteristic prostrating attacks of migraine headache pain. As shown above, while the Veteran had several headaches during the week, neither the October 2012 or February 2016 examination described symptoms consistent with prostrating attacks of migraine headache pain. As the evidence does not show characteristic prostrating attacks averaging one in 2 months, the criteria for a compensable evaluation prior to March 2, 2016 are not met. On March 2, 2016, the Veteran submitted his notice of disagreement (NOD). Therein, the Veteran posited that, “(w)ith regards to my migraine headache condition, I continue to have significant headaches averaging 2 a week. Approximately once a month I will have a headache that is so severe that I have to block out all of the windows and am unable to do anything because of the pain and discomfort as well as physical exhaustion. I end up staying in bed most of the day and do not get anything accomplished.” In April 2016, VA received a headache log that was generated by the Veteran. Therein, the Veteran addressed the period from March 13, 2016 to April 7, 2016. During that period, the Veteran recorded two migraine episodes and utilization of headache medication on a majority of the days recorded. Important to this analysis, the Veteran reported one prostrating migraine during the chronicled month, on March 12, 2016. The Board is aware the Veteran reported more frequent headaches during this period. Although the Veteran reported more than one headache per month, there is no indication all the Veteran’s headaches rose to the severity of a prostrating headache. As a lay person, the Veteran is competent to report symptoms such as the length, severity, and frequency of his headaches, as these symptoms require only personal knowledge as it comes to him through his senses. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Board has considered the Veteran’s lay statements regarding the length and severity of his headaches. However, the Board finds the Veteran’s lack of specificity regarding the number of prostrating headaches during this period to be suggestive that they were not so numerous that they occurred more than once per month, averaged over a several month period. Furthermore, after careful and deliberate consideration of the claims file, the Board finds that the evidence does not support the Veteran’s symptoms were productive or capable of producing severe economic inadaptability during this time period. In conclusion, and after resolving all doubt in the Veteran’s favor, the Board finds the credible objective and subjective evidence of record supports the award of an increased initial 30 percent disability rating, effective March 2, 2016. Finally, the Board observes that neither the Veteran nor his representative have raised any other extraschedular arguments for the migraine headache issue, nor have any other extra-schedular been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016). Therefore, the Board will not undertake an extra-schedular analysis or a referral of the question under the provisions of 38 C.F.R. § 3.321 herein. 2. Entitlement to an initial disability rating in excess of 10 percent for bilateral pes planus and plantar fasciitis is denied. In September 2012, the Veteran submitted his VA Form 21-4138. Therein, the Veteran initiated his entitlement claim for service connection for a “feet condition,” which arose from long periods of standing. Service connection was awarded in a February 2016 with assignment of a 10 percent noncompensable disability evaluation. In March 2016, the Veteran submitted his VA Form expressing disagreement with the rating assigned by the AOJ. The Veteran’s bilateral pes planus is rated under Diagnostic Code (DC) 5276. Under DC 5276, a noncompensable rating is warranted when there are mild symptoms, which are treated with built up shoes and/or arch support. Under DC 5276, the criteria for a 10 percent rating are moderate impairment with the weight-bearing line over or medial to the great toe, inward bowing of the Achilles tendon and pain on manipulation and use of the feet, bilateral or unilateral. The criteria for the next higher rating, 30 percent, are bilateral severe flatfoot with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities. A 50 percent evaluation is for application when there is pronounced bilateral disability evidenced by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the Achilles tendon on manipulation, which is not improved by orthopedic shoes or appliances. The rating schedule does not provide a rating higher than 50 percent rating for pes planus. Again, when the appeal is from the initial rating assigned with an award of service connection, the severity of the disability at issue during the entire period from the initial assignment of the disability rating to the present is to be considered, and “staged” ratings may be assigned, based on facts found. See Fenderson v. West, 12 Vet. App. 119 (1999). As discussed below, the AOJ has already increased the Veteran’s initial disability rating to 10 percent for bilateral pes planus and plantar fasciitis, and the following Board analysis is undertaken with consideration of the possibility of staged ratings. In March 2013, the Veteran underwent a VA examination that considered miscellaneous foot disorders. Important to this Board analysis, the VA provider reported the following history for the Veteran’s bilateral foot condition: “(the Veteran) states that if he stands for an extended period time, he can have bilateral foot pain. He wears no orthotics. He notes no swelling. He describes pain in the arch which is worse at the end of the day following prolonged standing.” The VA provider did not note deformity of the feet. In February 2016, the Veteran underwent a VA examination that considered his service-connected pes planus and plantar fasciitis disability. At that time, Dr. JDM noted that the Veteran’s weight-bearing line did not fall over or medial to the great toe, bilaterally. Dr. JDM did not observe any indication of swelling on use. Also, Dr. JDM noted that orthotics provided some relief to the Veteran’s symptoms, bilaterally. In March 2016, the Veteran submitted his VA Form 21-0958. Therein, the Veteran filed his notice of disagreement (NOD) with the then current noncompensable disability rating, which was assigned by the AOJ for bilateral pes planus and plantar fasciitis. The Veteran supported his NOD by positing that, “I continue to have daily foot pain in both feet. The pain is there on a daily basis. The orthotics I have received from VA are no benefit whatsoever. On most days my pain manifests midway through the day and is at its peak by the end of the day. My VA Examination was at 0800 in the morning and I had not been on my feet for any significant amount of time. As stated to the examiner, physical therapy was the only thing that seemed to relieve my pain.” In April 2016, the Veteran’s treatment records from the VA NWIHS, Lincoln Division, were associated with the electronic claims file. Therein, in September 2013, the VA provider noted that, “(h)e states his foot pain was worse from 2006 through 2009. His pain somewhat improved once he was here. However, he still continues to have persisting pain. He has a difficult time finding shoes that fit properly. He describes the pain mainly in the arch area, top and bottom of both feet.” In December 2013, the VA provider noted that, “(t)he patient RTC for his foot pain. He is currently wearing insoles, stretching, going to physical therapy for the foot and knee pain. He states he saw ortho for his knee and foot pain, had a night splint ordered, but has yet to receive it. He is still frustrated with his pain. He is having pain in the right arch, but is better.” In April 2016 rating decision, the AOJ increased the disability rating for the Veteran’s bilateral pes planus and plantar fasciitis to 10 percent. At that time, the AOJ based the 10 percent disability rating on pain during manipulation of feet, mild symptoms, and symptoms partially relieved by arch support. After careful and deliberate consideration of the Veteran’s claims file, the Board concludes that the currently assigned 10 percent disability rating is warranted by the evidence of record. The evidence, to include the Veteran’s competent and credible statements, does not fulfill the criteria for a greater, severe or pronounced disability rating for his service-connected pes planus and plantar fasciitis. See 38 C.F.R. § 4.71a, DC 5276. While the Veteran has pain associated with his pes planus and plantar fasciitis, the record does not show that he objective evidence of marked deformity, pain on manipulation and use accentuated, indication of swelling on use or characteristic callosities. On the contrary, the February 2016 examination report indicates that such symptoms were not present. The Board notes that the Veteran and his representative have not raised any other issues, nor have any other issues been reasonably raised by the record. See Yancy v. McDonald, 27 Vet. App. 484, 495 (2016); Doucette v. Shulkin, 38 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). REASONS FOR REMAND 1. Entitlement to service connection for left and right knee disorders is remanded. In April 2012, the Veteran submitted his VA Form 21-4138. Therein, the Veteran initiated his entitlement claims for a bilateral knee condition. At that time, the Veteran posited that, “I frequently would bang my knees on the metal ladder wells while trying to navigate through the ship.” Additionally, the Veteran revealed that, “(m)y knees, shins, and ankles were put under a tremendous amount of strain while I served in Naples Italy for 3 years.” The Veteran continued with, “(w)hen we were at increased force protection conditions we would wear all of the above mentioned gear and a heavy flak jacket and a bulky helmet and gas mask strapped to our thigh. After standing 12 hours of watch in the blazing sun loaded down with gear we were forced to participate in mandatory Physical Training for an hour after our shifts. We would normally have to run on concrete roads which took its toll on my knees, shins, and ankles. . . .” Specific to his bilateral knee claims, the Veteran indicated that, “I still experience pain and discomfort when I try to exercise. I am unable to run and at times walking can be extremely painful. Both of my knees crack and pop every time I bend down. My knees at times will pop out of place causing excruciating pain. I have been unable to maintain my physical fitness due to the pain caused when I try to run or walk long distances.” In October 2012, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured knee condition. In the resultant report, the VA provider noted un-dated diagnoses for bilateral patellar lateral tracking. During the history portion, the Veteran reported that he endured extensive shin pain while running in the service and standing for prolong periods on security in Italy. The Veteran also reported that, “his knees are like ‘popcorn’ with popping and cracking. He has pain when going upstairs or running.” Ultimately, the VA provider opined that, “bilateral knees . . . are less likely as not due to any events in the service. Reasoning is that he was either not diagnosed with any chronic condition, never seen in the service, or only seen ounce for these conditions without any continue care in the interim to show that conditions have continued to be chronic issues since 2009.” In August 2013, VA received the Veteran’s treatment notations from the Norfolk CBOC. Therein, Dr. Nutt reported that, “I reviewed the patients records and have examined him in clinic and I believe that his chronic knee pain and misalignment of the right patella as well as his knee crepitus, is more than likely as not due to his standing for long periods of time in full gear and then marching long distances on concrete while he was in the military despite the fact he never reported to sick bay.” Unfortunately, Dr. Nutt delivered a succinct, conclusory statement without support for his opinion. Consequently, the Board concludes that his opinion is inadequate for the analysis of the Veteran’s claim for entitlement to service connection for left and right knee disorders. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (an opinion without any rationale against which to evaluate the probative value of the determination is inadequate). In February 2016, the Veteran underwent a VA examination that considered his now-service connected pes planus disability. Importantly, the Veteran reported flare-ups that impacted the function of his feet; however, Dr. JDM did not record how flare-ups effected foot function. Instead, Dr. JDM noted when flare-ups occurred, during prolonged standing and/or walking. Ultimately, Dr. JDM opined that, “it is this examiner’s opinion despite the diagnosed foot disorder ‘it is less likely than not’ the bilateral knee, ankle and shin splints are relate to his feet. Rationale is there is no demonstrable functional deficit with his feet on exam today nor was there a gait alteration noted on exam today when walking the Veteran back to & from the waiting room to the exam room.” The VA’s duty to assist also includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159 (c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The VA examination and/or opinion must be adequate to decide the claim. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). In February 2016, the VA provider was supplied VA Form 21-2507a. Therein, the VA provider was directed, “if the Veteran has a diagnosed foot disorder . . .is it at least as likely as not that his claimed bilateral knee, bilateral ankle, and bilateral shin splints are proximately caused or aggravated by his bilateral foot disorder.” The VA provider failed appropriately address this query. Despite noting that the Veteran endured flare-ups, the VA provider did not address whether pes planus flare-ups impacted the Veteran’s bilateral knees. Instead, the VA provider supported his negative opinion with objective observations made during a non-flare-up period, which did not answer the query in the VA Form 21-2507a. Consequently, a remand is necessary to identify whether the Veteran’s service-connected pes planus aggravates his bilateral knees. 2. Entitlement to service connection for left and right shin disorders is remanded. In April 2012, the Veteran submitted his VA Form 21-4138. Therein, the Veteran initiated his entitlement claims for a bilateral shin condition. At that time, the Veteran revealed that, “(m)y knees, shins, and ankles were put under a tremendous amount of strain while I served in Naples Italy for 3 years.” The Veteran continued with, “(w)hen we were at increased force protection conditions we would wear all of the above mentioned gear and a heavy flak jacket and a bulky helmet and gas mask strapped to our thigh. After standing 12 hours of watch in the blazing sun loaded down with gear we were forced to participate in mandatory Physical Training for an hour after our shifts. We would normally have to run on concrete roads which took its toll on my knees, shins, and ankles. . . .” The Veteran also posited that, “I have been unable to maintain my physical fitness due to the pain caused when I try to run or walk long distances.” In October 2012, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured shin disorder. In the resultant report, the VA provider noted un-dated diagnoses for bilateral shin splints. During the history portion, the Veteran reported that he endured extensive shin pain while running in the service and standing for prolong periods on security in Italy. The Veteran reported that he was not seen for shin pain in service. The Veteran also reported that he currently endures “achiness” in his shins. Ultimately, the VA provider opined that, “bilateral shins . . . are less likely as not due to any events in the service. Reasoning is that he was either not diagnosed with any chronic condition, never seen in the service, or only seen once for these conditions without any continue care in the interim to show that conditions have continued to be chronic issues since 2009.” In February 2016, the Veteran underwent a VA examination that considered his now-service connected pes planus disability. Importantly, the Veteran reported flare-ups that impacted the function of his feet; however, Dr. JDM did not record how flare-ups effected foot function. Instead, Dr. JDM noted when flare-ups occurred, during prolonged standing and/or walking. Ultimately, Dr. JDM opined that, “it is this examiner’s opinion despite the diagnosed foot disorder ‘it is less likely than not’ the bilateral knee, ankle and shin splints are relate to his feet. Rationale is there is no demonstrable functional deficit with his feet on exam today nor was there a gait alteration noted on exam today when walking the Veteran back to & from the waiting room to the exam room.” In February 2016, the VA provider was supplied VA Form 21-2507a. Therein, the VA provider was directed, “if the Veteran has a diagnosed foot disorder . . .is it at least as likely as not that his claimed bilateral knee, bilateral ankle, and bilateral shin splints are proximately caused or aggravated by his bilateral foot disorder.” The VA provider failed appropriately address this query. Despite noting that the Veteran endured flare-ups, the VA provider did not address whether pes planus flare-ups impacted the Veteran’s bilateral shins. Instead, the VA provider supported his negative opinion with objective observations made during a non-flare-up period, which did not answer the query in the VA Form 21-2507a. Consequently, a remand is necessary to identify whether the Veteran’s service-connected pes planus aggravates his bilateral shins. 3. Entitlement to service connection for left and right ankle disorders is remanded. In April 2012, the Veteran submitted his VA Form 21-4138. Therein, the Veteran initiated his entitlement claims for a bilateral ankle condition. At that time, the Veteran revealed that, “(m)y knees, shins, and ankles were put under a tremendous amount of strain while I served in Naples Italy for 3 years.” The Veteran continued with, “(w)hen we were at increased force protection conditions we would wear all of the above mentioned gear and a heavy flak jacket and a bulky helmet and gas mask strapped to our thigh. After standing 12 hours of watch in the blazing sun loaded down with gear we were forced to participate in mandatory Physical Training for an hour after our shifts. We would normally have to run on concrete roads which took its toll on my knees, shins, and ankles . . ..” The Veteran also indicated that, “the one time that I remember going to sick call was because I injured, my ankle while playing soccer during mandatory physical training after watch standing and was unable to walk unassisted. I was placed on Light Limited Duty as a result of my injury.” The Veteran also posited that, “I have been unable to maintain my physical fitness due to the pain caused when I try to run or walk long distances.” In October 2012, the Veteran underwent a VA examination that considered the nature and etiology of any currently endured ankle disorder. In the resultant report, the VA provider noted un-dated diagnoses for bilateral ankle strains. During the history portion, the VA provider recorded that the Veteran sustained a left ankle injury in March 2008 while playing soccer. The VA provider did not note any in-service trauma to the Veteran’s right ankle. The VA provider noted that imaging studies had been performed, and they did not reflect abnormal findings for either of the Veteran’s ankles. Ultimately, the VA provider opined that, “(right) ankle and left ankle are less likely as not due to any events in the service. Reasoning is that he was either not diagnosed with any chronic condition, never seen in the service, or only seen once for these conditions without any continue care in the interim to show that conditions have continued to be chronic issues since 2009.” In February 2016, the Veteran underwent a VA examination that considered his now-service connected pes planus disability. Importantly, the Veteran reported flare-ups that impacted the function of his feet; however, Dr. JDM did not record how flare-ups effected foot function. Instead, Dr. JDM noted when flare-ups occurred, during prolonged standing and/or walking. Ultimately, Dr. JDM opined that, “it is this examiner’s opinion despite the diagnosed foot disorder ‘it is less likely than not’ the bilateral knee, ankle and shin splints are relate to his feet. Rationale is there is no demonstrable functional deficit with his feet on exam today nor was there a gait alteration noted on exam today when walking the Veteran back to & from the waiting room to the exam room.” In February 2016, the VA provider was supplied VA Form 21-2507a. Therein, the VA provider was directed, “if the Veteran has a diagnosed foot disorder . . .is it at least as likely as not that his claimed bilateral knee, bilateral ankle, and bilateral shin splints are proximately caused or aggravated by his bilateral foot disorder.” The VA provider failed appropriately address this query. Despite noting that the Veteran endured flare-ups, the VA provider did not address whether pes planus flare-ups impacted the Veteran’s left and right ankles. Instead, the VA provider supported his negative opinion with objective observations made during a non-flare-up period, which did not answer the query in the VA Form 21-2507a. Consequently, a remand is necessary to identify whether the Veteran’s service-connected pes planus aggravates his left and right ankles. Consequently, these matters are REMANDED to the agency of original jurisdiction (AOJ) for the following action: 1. The Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of his left and right knee disorders. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s left and right knee disorders had their clinical onset during military service, or is otherwise related to his active duty service? (b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s left and right knee disorders were either (i) caused by or (ii) aggravated by any of the Veteran’s service connected disabilities, to include his pes planus? Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as a chronic and permanent worsening of the underlying condition beyond its natural progression versus just a temporary or intermittent flare-up of symptoms. If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his left and right knee disorders. 2. The Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of his left and right shin disorders. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s left and right shin disorders had their clinical onset during military service, or is otherwise related to his active duty service? (b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s left and right shin disorders were either (i) caused by or (ii) aggravated by any of the Veteran’s service connected disabilities, to include his pes planus? Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as a chronic and permanent worsening of the underlying condition beyond its natural progression versus just a temporary or intermittent flare-up of symptoms. If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his left and right shin disorders. 3. The Veteran should be scheduled for a VA examination with the appropriate physician, to determine the nature and etiology of his left and right ankle disorders. Based upon a review of the entirety of the claims file, the history presented by the Veteran, and the examination results, the examiner is requested to provide an opinion as to the following questions: (a) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s left and right ankle disorders had their clinical onset during military service, or is otherwise related to his active duty service? (b) Is it at least as likely as not (i.e. a 50 percent probability or greater) that the Veteran’s left and right ankle disorders were either (i) caused by or (ii) aggravated by any of the Veteran’s service connected disabilities, to include his pes planus? Governing regulations provide that service connection is permissible on a secondary basis if a claimed disability is proximately due, the result of, or aggravated by a service-connected disability. See 38 C.F.R. § 3.310. The term aggravation is defined as a chronic and permanent worsening of the underlying condition beyond its natural progression versus just a temporary or intermittent flare-up of symptoms. If the examiner determines there has been aggravation, he or she should try and quantify the amount of additional disability the Veteran had, above and beyond that he had prior to the aggravation. It should be noted that the Veteran, is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a clinical basis to support or doubt the lay history provided by the Veteran, the examiner should provide a fully reasoned explanation. Explanations for all opinions must be provided. While providing the requested rationale, the examiner is asked to cite to the pertinent evidence of record, including clinical records and the Veteran’s statements regarding the onset of his left and right ankle disorders. DAVID L. WIGHT Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD RLBJ, Associate Counsel