Citation Nr: 18151784 Decision Date: 11/20/18 Archive Date: 11/20/18 DOCKET NO. 16-35 750 DATE: November 20, 2018 ORDER The petition to reopen the claim of service connection for bilateral plantar fasciitis, also claimed as bilateral foot problems, is granted. Entitlement to service connection for depressive disorder with anxious distress features is granted. Entitlement to service connection for obstructive sleep apnea (OSA) is granted. Entitlement to service connection for a lower back condition is denied. Entitlement to a disability rating of 50 percent for migraines is granted from August 1, 2011, subject to the regulations governing monetary awards. REMANDED Entitlement to service connection for a neck condition is remanded. Entitlement to service connection for bilateral plantar fasciitis, also claimed as bilateral foot problems is remanded. FINDINGS OF FACT 1. Service connection for bilateral plantar fasciitis was previously denied in an unappealed July 2009 rating decision; evidence that was not previously before decision makers at that time and that raises a reasonable possibility of substantiating the claim has subsequently been received. 2. The Veteran’s depressive disorder with anxious distress features is aggravated beyond its natural progression by his service-connected migraines. 3. The Veteran’s OSA is aggravated beyond its natural progression by his service-connected depressive disorder with anxious distress features. 4. The preponderance of the evidence is against finding that a low back disability began during active service, or is otherwise related to an in-service injury, event, or disease. 5. From August 1, 2011, the preponderance of the evidence shows that the Veteran’s service-connected migraines have manifested with very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability. CONCLUSIONS OF LAW 1. The criteria for the petition to reopen the claim of service connection for bilateral plantar fasciitis, also claimed as bilateral foot problems, have been met. 38 U.S.C. §§ 501, 5108, 7105; 38 C.F.R. §§ 3.104(a), 3.156(a), (c), 3.160(d), 20.200, 20.302, 20.1103. 2. The criteria for secondary service connection for depressive disorder with anxious distress features are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 3. The criteria for secondary service connection for OSA are met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). 4. The criteria for service connection for a lower back condition are not met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 5. From August 1, 2011, the criteria for entitlement to a disability rating of 50 percent for migraines have been met; this is the highest schedular rating for this condition. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.1, 4.3, 4.7, 4.21, 4.124a, Diagnostic Code 8100. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from December 1985 to June 1989, from November 1989 to February 1990, and from September 1990 to May 1991. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision. New and Material Evidence Previously denied claims may be reopened by the submission of new and material evidence. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(a). Evidence is new if it has not been previously submitted to agency decision makers. Id. Evidence is material if it, either by itself or considered in conjunction with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. Id. New and material evidence cannot be cumulative with or redundant of evidence already of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim. Id. When determining whether the claim should be reopened, the credibility of the newly submitted evidence is to be presumed. Fortuck v. Principi, 17 Vet. App. 173, 179-80 (2003); Justus v. Principi, 3 Vet. App. 510 (1992). Moreover, in Shade v. Shinseki, 24 Vet. App. 110, 117-18 (2010), the United States Court of Appeals for Veterans Claims (Court) clarified that the phrase “raises a reasonable possibility of substantiating the claim” is meant to create a low threshold that enables, rather than precludes, reopening. Specifically, the Court stated that reopening is required when the newly submitted evidence, combined with VA assistance and considered with the other evidence of record, raises a reasonable possibility of substantiating the claim. Id. After considering all information including the lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 1. The petition to reopen the claim of service connection for bilateral plantar fasciitis, also claimed as bilateral foot problems The Veteran’s previous claim for entitlement to service connection for bilateral plantar fasciitis was denied in a July 2009 rating decision. The Veteran neither submitted new and material evidence nor a notice of disagreement (NOD) within a year of that decision; therefore, the July 2009 rating decision is final and binding based on the evidence of record at that time. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104(a), (b), 3.156(a), (b), 3.160(d), 20.1103. In May 2013, the Veteran submitted a claim for foot problems. This was interpreted as a claim to reopen his previously denied claim for bilateral plantar fasciitis. However, as framed by the Veteran, it embraces a broader range of potential disabilities, including bilateral plantar fasciitis. VA treatment records document a variety of foot problems and symptoms including recurrent in-grown toenails, Haglund’s deformities, heel spur, pain in the achilles tendon, and swelling. While the Veteran’s service treatment records do not conclusively demonstrate that any of these conditions were present during his period of service, the Veteran appears to have at least reported a complaint about his toes on a May 1991 report of medical history and his demobilization examination report appears to contain a reference to a low arch. There is also a report that the Veteran suffered a foot injury in July 1989, which was not a period of active service, but did precede his final two periods of active service, and VA assistance should explore whether this injury was aggravated by those subsequent service periods. Consequently, the VA treatment records establishing the existence of other disabilities beyond simply plantar fasciitis, when combined with VA assistance, raise the reasonable possibility of substantiating the claim. As described above, the Veteran’s May 2013 claim appears to be broader than the claim that was denied in 2009. However, the Board finds that it remains appropriate to characterize this claim as a claim to reopen, so as not to define the plantar fasciitis out of the Veteran’s claim benefits. Subsequent development may yield information that links any of the Veteran’s foot conditions to each other and to the Veteran’s service. Additionally, the Board notes that the VA service treatment records that are currently associated with the claims file were added to the record in June 2013 and January 2016. Consequently, the Board has considered whether it was necessary to treat this claim as a claim to reopen, or whether it was more appropriate to apply VA’s duty to reconsider a claim when service records are added to the record subsequent to a prior adjudication. 38 U.S.C. § 501; 38 C.F.R. § 3.156(c). However, the July 2009 rating decision and VA examinations conducted prior to the Veteran’s claim that forms the basis of the present appeal all recite that service treatment records were reviewed, and make some reference to conditions in the Veteran’s service treatment records. Consequently, the Board finds that the evidence of record does not establish that these service treatment records were not of record in July 2009, and that the appropriate way to address this case is to reopen it on the basis of the evidence described previously. To this extent only, the claim is granted. Service Connection Service connection may be established for a disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To prevail on the issue of service connection, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247 (1999). Secondary service connection is warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) Evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. After considering all information including the lay and medical evidence of record in a case with respect to benefits under laws administered by the Secretary, when there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt will be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The benefit of the doubt rule is inapplicable when the evidence preponderates against the claim. Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). 2. Entitlement to service connection for depressive disorder with anxious distress features The Veteran submitted a Disability Benefits Questionnaire (DBQ) in January 2017 that shows the Veteran has a current diagnosis of depressive disorder with anxious distress features, and included the opinion that this condition is at least as likely as not proximately due to or the result of his service-connected migraines. The examiner supported his opinion with an explanation of the Veteran’s symptoms and the history of his condition and citations to literature. Furthermore, this conclusion finds at least some support in some of the Veteran’s reports about the nature of his depression, as when he reported that he perceived his migraines as causing him bouts of depression in December 2014 when seeking treatment at his local VA hospital. There is no contrary opinion in the record. Consequently, the Board finds that the preponderance of the evidence establishes that the Veteran’s depressive disorder with anxious distress features is at least as likely as not proximately due to or the result of his service-connected migraines. Therefore, service connection for this condition is appropriate. 3. Entitlement to service connection for OSA The Veteran submitted a DBQ in April 2017 confirming the Veteran’s longstanding diagnosis of OSA. VA treatment records show the Veteran was a diagnosed with OSA as early as 1998 and continues to be treated for it as a current disability, and April 2017 private examiner opined that it is at least as likely as not aggravated beyond its natural progress by his service-connected depressive disorder with anxious distress features. The examiner explained that the Veteran’s mental health condition aggravated his OSA by interfering with the Veteran’s treatment and therapy for the condition, exacerbating the symptoms. No contrary opinion appears in the record. Consequently, the Board finds that a preponderance of the evidence has established that it is at least as likely as not that the Veteran’s OSA is aggravated beyond its natural progression by his service-connected mental health condition, and service connection for OSA is appropriate. 4. Entitlement to service connection for a lower back condition The Veteran seeks service connection for a lower back condition. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board notes that VA radiographs from June 2014 document degenerative changes in his spine. Certain chronic diseases, including degenerative arthritis, will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). The Veteran’s service treatment records do not contain any complaints, treatments, or symptoms related to his back. The Veteran’s medical records do not contain any history or reports of chronic back pain until July 2011. VA treatment records since that time document intermittent complaints of lower back and sciatica pain. Beginning in January 2012, VA radiographs document some abnormalities in the Veteran’s spine, but do not indicate that these abnormalities are connected to the Veteran’s service. Finally, the provider who interpreted the June 2014 radiographs diagnosed the Veteran with degenerative changes in his spine, constituting the first specific evidence of a chronic disease, as that term is defined by VA regulation, related to the Veteran’s back in the record. Based on this evidence, the Board finds that the degenerative changes to the Veteran’s spine do not qualify for service connection under the presumption for chronic diseases. Even if the Board were to equate the July 2011 chronic back pain with degenerative changes to the Veteran’s spine, this condition would have manifested decades too late to qualify under this presumption. This presumption requires a condition to manifest either during service, during a presumptive period after service (in this case one year), or for there to be a continuity of symptomatology regarding this condition since service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a). However, there is a period of approximately 20 years between the Veteran’s last period of service and his first instance of back pain documented in the record. Additionally, there is no lay evidence indicating that his back pain began during or near the time of service. Under these circumstances, the Board finds that the presumption for chronic diseases cannot be applied to the Veteran’s condition. The Veteran’s lower back condition is not limited to the diagnosis of degenerative changes to his spine. VA treatment records reflect that, the Veteran has chronic lower back pain, degenerative changes in his spine, and developmental variation with a larger sacral ala on the left than the right and partial fusion of the upper right sacroiliac joint. However, the treatment records documenting these conditions do not contain any evidence or any indication that they are caused by or otherwise related to his service. As previously noted, the Veteran’s service treatment records do not contain any complaints, treatments, or symptoms related to his back. The Board notes that the Veteran’s service treatment records from November 1989 to February 1990 are not of record. The Veteran was notified that these records were missing, and offered the opportunity to supplement the record with additional information. However, neither the Veteran nor his representative have chosen to present any additional information to VA regarding the Veteran’s lower back condition. In any event, there are service treatment records that post-date the three-month period of missing records. The Board finds particularly persuasive the May 1991 report of medical history and demobilization examination. Neither the examiner nor the Veteran reported any back condition, and the Veteran specifically denied recurrent back pain. Further, there is no medical evidence of a nexus between any current back disability and the Veteran’s period of active service. Consideration has been given to the Veteran’s lay statements linking his back disability to his active service. The Veteran is competent to report symptoms observable through the senses, such as back pain. See Layno v. Brown, 6 Vet. App. 465 (1994). However, comment on the etiology of an orthopedic condition is a complex medical issue not subject to lay opinion. See Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The Veteran has not been shown to have the requisite medical knowledge to provide such medical opinions. Therefore, his statements are not afforded probative value. Consequently, the Board finds that a lower back condition was not present during service and that there is no competent evidence of a nexus between any current back disability and his period of active service. For these reasons, the Board finds the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and entitlement to service connection for a lower back condition must be denied. 38 U.S.C. §§ 1110, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Increased Rating 5. Entitlement to a disability rating in excess of 30 percent for migraines Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In view of the number of atypical instances, it is not expected, especially with the more fully described grades of disabilities, that all cases will show all the findings specified. Findings sufficiently characteristic to identify the disease and the disability therefrom and coordination of rating with impairment of function are expected in all instances. 38 C.F.R. § 4.21. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. In an increased rating claim, the Board must consider the evidence of disability during the period one year prior to the application. Hazan v. Gober, 10 Vet. App. 511 (1997). Reasonable doubt as to the degree of disability will be resolved in the Veteran’s favor. 38 C.F.R. § 4.3. The Board will consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of a matter. VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (noting VA must review the entire record, but does not have to discuss each piece of evidence). The Veteran’s headache disorder is rated 30 percent disabling under 38 C.F.R. § 4.124(a), Diagnostic Code 8100. Under Diagnostic Code 8100, VA assigns a 30 percent rating where headaches occur with characteristic prostrating attacks on an average once a month over last several months. Id. A headache condition characterized by very frequent completely prostrating and prolonged attacks productive of severe economic inadaptability is assigned a 50 percent disability rating, the highest schedular rating available for this condition. Id. The rating criteria do not define “prostrating.” Cf. Fenderson, 12 Vet. App. 119 (1999) (in which the Court quotes Diagnostic Code 8100 verbatim but does not specifically address the matter of what is a prostrating attack). By way of reference, the Board notes that according to Webster’s New World Dictionary of American English, Third College Edition (1986), p. 1080, “prostration” is defined as “utter physical exhaustion or helplessness.” A very similar definition is found in Dorland’s Illustrated Medical Dictionary 1367 (28th Ed. 1994), in which “prostration” is defined as “extreme exhaustion or powerlessness.” Similarly, the rating criteria do not define “productive of severe economic inadaptability.” However, this phrase encompasses both conditions that cause severe economic inadaptability as well as those that are merely capable of producing economic inadaptability. Pierce v. Principi, 18 Vet. App. 440, 445-46 (2004). “Severe economic inadaptability” does not require a showing of an inability to work. Id. at 446. The Veteran’s VA treatment records beginning one year prior to his claim, received in January 2012, include a January 2011 neurology note that documents that the Veteran was having 1-2 brief migraines each month lasting a few hours necessitating an emergency room visit. The Veteran made similar visits seeking treatment either at regular appointments or emergency room visits related to his migraines for several months. In July 2011, the Veteran sought treatment for his migraines and indicated that they appeared to be more severe in the summer months, that he was having these headaches 2-3 times per week, and included indications that the Veteran was experiencing sensitivity to light because he was continuing to wear his sunglasses indoors. On August 1, 2011, the Veteran reported for treatment, still indicating bad headaches 2-3 times per week, and advising that his headaches had necessitated him to miss 21 days of work the preceding month. In September 2011, the Veteran sought treatment for a 3-day migraine that was not relieved by his home medications, and described seeing an aura, being sensitive to light, sound, and smells, and experiencing intermittent nausea associated with his headache. In November 2011, the Veteran reported for additional treatment for his migraines, describing that he had a headache nearly every day, with particularly bad headaches occurring once a week. His home medications continued to be ineffective and he described photophobia associated with his headache pain. In January 2012, the Veteran’s payroll supervisor provided a statement documenting that the Veteran had missed 31 days of work in the year 2011. The Veteran underwent a VA examination in March 2012. The examiner recorded that the Veteran reported having a headache all day every day, with certain headaches worse in intensity, involving the top of the head and moving forward to the frontal portion of the head. His headaches ranged from dull throbbing headaches to sharp debilitating headaches. Debilitating headaches occurred 2-3 days per week and lasted the entire day. The Veteran reported that when those headaches occur that he had to be driven to the ER and given an injection. Medicines were not helping and he had developed other side effects on certain medications. The Veteran reported nausea, without vomiting; and light and sound sensitivity with the debilitating headaches. During these headaches, the Veteran reported that he could hardly move. The examiner indicated that the Veteran had prostrating attacks more frequently than once per month and very frequent prostrating and prolonged attacks of migraine headache pain. The examiner also noted that the Veteran had missed 31 days of work in the past 12 months due to his migraines, during debilitating attacks he needed to stop working and be driven home, and had been advised that he was facing termination if he continues to miss work. The Veteran continued to make similar visits and report similar headache symptoms sometimes reporting for treatment several times a month for his headache pain for the next several years. He continued to remain employed, but at least by January 2014 the Veteran was required to have his VA physicians fill out forms so that he could claim additional leave under the Family Medical Leave Act to avoid losing his job. Also during the January 2014 VA treatment visits, the Veteran reported more frequent headaches. The Veteran continued to seek treatment sometimes several times per month for his headache pain. In an August 2014 VA treatment visit, the Veteran reported that his migraine headaches with photosensitivity were occurring almost every day. In a September 2014 VA treatment note, the Veteran reported a migraine that had lasted for 3 days, associated with nausea, photophobia, and sensitivity to sound. In a December 2014 VA treatment note, the Veteran reported severe migraines that he believed were contributing to his depression. In a January 2015 VA treatment note, the Veteran reported a migraine that he described as a throbbing frontal headache, associated with nausea without vomiting, sensitivity to light, and vision changes. The physician noted an elevation in the Veteran’s blood pressure. In a March 2015 VA treatment record, the Veteran reported experiencing a headache lasting 2 days that he described as a 10/10 on a pain scale. In November 2015, the Veteran sought treatment for a headache that had lasted for 5 days, was resistant to medication, and had associated symptoms of nausea, smelling “transmission fluid,” and photophobia. The Veteran was treated for his headaches with a Botox injection. In December 2015, the Veteran underwent another VA examination. The examiner noted that the Veteran was treated with Botox shots and other medications. The examiner recorded that the Veteran reported constant headache pain, pulsating or throbbing, pain on both sides of head, pain in the occipital region. The Veteran experienced nausea, sensitivity to light, sensitivity to sound, and changes in vision. The Veteran’s prostrating headaches lasted from 2 days to 5 days 1 to 2 times per month, and the Veteran reported having mild headaches the rest of the time. The examiner indicated that the Veteran had prostrating attacks once every month but did not have very frequent prostrating and prolonged attacks productive of severe economic inadaptability. The examiner noted that the Veteran had to file family medical leave act papers because of absenteeism and had missed 68 days of work in 2015. In January 2016, his former supervisor provided a statement explaining that the Veteran had missed an excessive number of days of work over the 10 years that she had been his supervisor, that most of that missed time had been due to his headaches, and that he would sometimes have to leave work early during a shift due to a headache that had come on during his shift. She noted that while she supervised him, the Veteran used up nearly all of his leave and faced disciplinary action related to his absenteeism. Finally, in October 2016, the Veteran was examined privately and the examiner provided a DBQ regarding his headache condition. The examiner recorded that the Veteran complained of debilitating headaches 2-3 days per week, so bad that he could hardly move without triggering increases in the pain and nausea, resulting in the Veteran being required to lie down in a dark place. The Veteran described his pain as constant head pain, pulsating or throbbing head pain, pain on both sides of the head, and explained that the pain worsens with physical activity. In addition to pain, the Veteran reported symptoms of nausea, vomiting, sensitivity to light, sensitivity to sound, changes in vision, sensory changes, and loss of his sense of taste during migraines. His migraines lasted 12 hours to 2 days, occurred more frequently than once per month, and the examiner characterized them as very frequent prostrating prolonged attacks of migraine headache pain. The examiner summarized the Veteran’s condition as consisting of several migraine headaches each week lasting between 4-12 hours where he must lie down in a dark quiet room away from light and noise. The Veteran was completely incapacitated during these attacks, and although he was currently working, he reported missing 6-8 days per month due to these prostrating attacks. Based on the evidence of record, the Board finds that the Veteran meets the criteria for a 50 percent rating for his migraine condition from August 1, 2011. The frequency with which the Veteran reports debilitating headaches, seeks treatment for his headaches at a VA facility, sometimes in the emergency room, the statements from the Veteran and his supervisors documenting the significant amount of absences from work that he is required to take, and the fact that his VA physicians have been helping him to obtain additional leave in order to manage his migraine condition, meets the standard for economic inadaptability. 38 C.F.R. § 4.124(a), Diagnostic Code 8100. While the Board is mindful that the precise definition of this phrase is not set forth in the law, the evidence of record also indicates that the Veteran has been rendered incapable of working for between 1 and 3 months out of several of the years during the appeal period. Prior to August 1, 2011, the Board finds that the evidence does not show very frequent, prolonged, and prostrating attacks productive of severe economic inadaptability. Hazan, 10 Vet. App. 511. On August 1, 2011, the Veteran visited his local VA facility for treatment for his migraine condition and reported significant missed time from work, 21 days that month. The Veteran’s economic inadaptability was established based on this information. Prior to that time, the evidence shows characteristic prostrating attacks occurring on an average once a month. As such, a rating in excess of 30 percent for the Veteran’s service-connected migraine headaches prior to August 1, 2011 is not warranted. REASONS FOR REMAND 1. Entitlement to service connection for a neck condition is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a neck because no VA examiner has opined whether his neck condition was caused by or related to his active service. Specifically, the examiner should note a July 1986 injury to the back of the Veteran’s head that resulted in a loss of consciousness. 2. Entitlement to service connection for bilateral plantar fasciitis, also claimed as bilateral foot problems is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection because no VA examiner has opined as to whether the Veteran’s bilataral foot conditions, to include plantar fasciitis, were caused by or the result of his service, to include his May 1991 report of medical history that and demobilization examination that appears to make reference to complaints and recommendations related to his feet. Additionally, the Veteran’s records from July 1989, when he was with the National Guard, but not mobilized to Federal service, indicate that he suffered an injury to his right foot. The examiner should also indicate whether there is clear and unmistakable evidence that this resulted in any defect, infirmity, or disorder, and, if so, whether the Veteran’s subsequent period of service resulted in any aggravation of this condition. The matters are REMANDED for the following actions: 1. After obtaining any necessary releases, obtain any outstanding VA and private treatment records pertinent to the Veteran’s claims. 2. Thereafter, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any foot disabilities diagnosed during the appeal period. With regard to any diagnosed condition of the Veteran’s feet, the examiner should opine: (a.) Whether the July 1989 injury to the Veteran’s right foot resulted in any defect, infirmity, or disorder that clearly and unmistakably (undebatable) preexisted the Veteran’s last periods of active service. (b.) If the examiner finds this did clearly and unmistakably result in a disability that preexisted his final periods of active service, the examiner must opine whether the disability was clearly and unmistakably not aggravated by service. In this regard, aggravation means a non-temporary increase in severity due to service that is not clearly and unmistakably (undebatable) due to its natural progress of the disease or condition. (c.) If the examiner finds that a disability did not clearly and unmistakably preexist the Veteran’s last period of service, the examiner must opine whether it is at least as likely as not (50 percent or greater probability) that any current disability of the feet is related to an in-service injury, event, or disease, including the conditions complained about or for which recommendations were made on his 1991 demobilization examination report and report of medical history. A rationale should be provided for all opinions offered. 3. After completing directive (1), schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any neck disabilities diagnosed during the appeal period. With regard to any diagnosed condition of the Veteran’s neck, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) related to an in-service injury, event, or disease, including the July 1986 in-service injury he received to the back of his head. A rationale should be provided for all opinions offered. Lindsey M. Connor Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Steven H. Johnston, Associate Counsel