Citation Nr: 21061942 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 15-18 990 DATE: October 5, 2021 ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for an acquired psychiatric disorder is denied. REMANDED Entitlement to service connection for a right-hand disability, to include as due to service-connected shoulder conditions is remanded. Entitlement to service connection for a right knee disability, to include as due to service-connected bilateral plantar fasciitis is remanded. Entitlement to service connection for a left knee disability, to include as due to service-connected bilateral plantar fasciitis is remanded. REFERRED In October 2016 and March 2017, the Veteran submitted a timely notice of disagreement pertaining to the September 2016 rating decision, but a statement of the case has not yet been issued. This matter is referred to the agency of original jurisdiction (AOJ) to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). FINDINGS OF FACT 1. The Veteran's hypertension was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that the Veteran's diagnosed acquired psychiatric disorder began during active service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for hypertension have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.125. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the Marine Corps from July 1977 to July 1981. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran's claims were previously remanded by the Board for further development in August 2018 and October 2020. Most recently, the Veteran's claims were remanded by the Board in April 2021. The Board directed the AOJ to obtain addendum medical opinions for the Veteran's claims. The AOJ obtained addendum medical opinions in June 2021. As for the claims of service connection for hypertension and an acquired psychiatric disorder, the Board finds that the AOJ has substantially complied with the April 2021 Board remand directive. See Stegall v. West, 11 Vet. App. 268 (1998). However, as to the claims for service connection for a right-hand disability and left and right knee disabilities, the Board finds that additional development is needed to properly adjudicate the Veteran's claims. The Board notes that the Veteran has submitted documentation expressing his disagreement with previous AOJ rating decisions and his belief that the AOJ has committed clear and unmistakable error. However, the issues expressed by the Veteran in his correspondence are not presently before the Board. The Veteran may submit a VA Form 10182 for disagreement with rating decisions issued by the AOJ after February 19, 2019, if he wishes for the Board to review his claims. Service Connection Generally, service connection may be established if the evidence demonstrates that a current disability resulted from a disease or injury incurred in or aggravated by active duty service. 38 C.F.R. § 3.303. To that end, service connection may be established for any disease diagnosed after discharge, when all the evidence, including that pertinent to the period of service, establishes the disease was incurred during active duty service. 38 C.F.R. § 3.303 (d). In order to prove service connection, there must be competent and credible evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus or link between the current disability and the in service disease or injury. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Alternatively, when a disease at 38 C.F.R. § 3.309 (a) is not shown to be chronic during service or the one-year presumptive period, service connection may also be established by showing continuity of symptomatology after service. See 38 C.F.R. § 3.303 (b). The use of continuity of symptoms to establish service connection is limited only to those diseases listed at 38 C.F.R. § 3.309 (a) and does not apply to other disabilities which might be considered chronic from a medical standpoint. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for hypertension The Veteran contends that he was diagnosed with hypertension in service and has continued to take medication for hypertension since his separation. As hypertension is an enumerated condition under 38 C.F.R. § 3.309 (a); Walker, 708 F.3d 1331, the question before the Board is whether the Veteran's hypertension is shown as chronic in service, manifested to a compensable degree within a presumptive period, is noted in service with attributable continuity of symptomatology, or is directly related to an in-service injury, event, or illness. The Veteran's service treatments records do not include a diagnosis of hypertension nor do they indicate that the Veteran was prescribed medication for hypertension. His records do include blood pressure readings including: 122/78 at enlistment in January 1977; 130/64 in May 1979; 126/80 in May 1979; 130/78 in February 1980; 132/82 in May 1981; and 136/90 at separation. The Veteran's undated separation examination does not note a diagnosis of hypertension. In November 1984, the Veteran sought service connection for an eye condition. Upon examination, for the eye condition, the Veteran denied taking any medications at the time and there is no indication that he was diagnosed with hypertension. The Veteran's private medical records include the first notation regarding a diagnosis of hypertension in March 1994 after the Veteran was diagnosed with bell's palsy. The evaluation states that the Veteran has a history of hypertension, but it does not state when the Veteran was diagnosed with hypertension. In April 1994, the Veteran had an appointment to "follow-up" regarding his high blood pressure. In May 1994, an internal medicine summary indicates that the Veteran was prescribed medication for his hypertension. The Veteran's VA treatment records include an April 2002 physician note where the examining physician noted a diagnosis of hypertension in 1981. The Veteran was afforded a VA examination for his hypertension in January 2020. The examiner confirmed the Veteran's diagnosis of hypertension and his current prescriptions of hydrochlorothiazide and lisinopril to treat his hypertension. After review of the evidence, the examiner opined that the Veteran's hypertension is less likely than not incurred in or caused by the claimed in-service injury, event, illness. The rationale provided is that the available medical records are silent regarding treatment for hypertension or persistently elevated blood pressures while in service. The examiner further opined that the Veteran did not start treatment for hypertension until 2004 per available records, well beyond the Veteran's separation date. The Board notes that this examination was found to be inadequate in the previous October 2020 Board Remand based on a finding that the examiner did not consider the Veteran's statements regarding the onset of his hypertension and that the examiner's opinion was based on an inaccurate interpretation of the facts. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993). The Veteran was afforded an additional VA examination for hypertension in December 2020. The examiner again confirmed the Veteran's diagnosis of hypertension and indicated a diagnosis as early as April 1994 based on the available records. During the examination, the Veteran contended that he was diagnosed with hypertension during his separation physical in 1981. He stated that the doctor told him his blood pressure was elevated, gave him a pill, and told him to rest. The Veteran reported that he was told to follow up with a VA Medical Center; however, they would not help him. The examiner opined that the Veteran's hypertension is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The rationale provided is that a review of the service treatment records is silent for a diagnosis of or complaint of hypertension and/or elevated blood pressure. The examiner noted that while serving in the military, the Veteran demonstrated occasional slight elevations in his blood pressure while being evaluated for an unrelated condition. The Veteran was never evaluated with a 3-day, 5-day blood pressure check or 24 hours blood pressure monitoring test called ambulatory BL monitoring to confirm he had high blood pressure. Further, the examiner found that the Veteran was never prescribed medications or referred to a dietician for diet counseling. The examiner stated that a review of the Veteran's medical record documents a diagnosis for hypertension in April 1994, approximately 12 years, 8 months, and 30 days after separating from service. The Board notes that the April 2021 Board Remand found this examination to be inadequate citing that the opinion was based on inaccurate factual premises. Id. However, when citing to the December 2020 examination, the Board incorrectly stated the examiner found that the Veteran was diagnosed with hypertension in August 1994 rather than April 1994. Thus, in this decision, the Board finds that the December 2020 VA examination is adequate and correctly cites to the facts present in this case (emphasis added). Furthermore, the Board finds the opinion highly probative since it is based on an accurate medical history and provides an explanation that contains clear conclusions with supporting data. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008). An addendum medical opinion was completed in June 2021 pursuant to the April 2021 Board Remand directives. The June 2021 VA examiner opined that the Veteran's hypertension is less likely than not incurred in or caused by service. The rationale provided noted that while the Veteran did have elevated readings during active duty, his readings did not meet the diagnostic criteria for hypertension. The examiner indicated that the Veteran's lay statements were reviewed and contradict with evidence found in file. The examiner found that the Veteran separated from service in 1981, and was not diagnosed with hypertension until 2004. Per an emergency room visit, the Veteran was diagnosed with mild hypertension in May 2004. The Veteran had a span of greater than 20 years from separation until official diagnosis. The examiner concluded it is less likely than not that the Veteran had hypertension during active duty, but went unnoticed and without treatment for greater than 20 years. Similar to the January 2020 VA examination, the Board finds that the June 2021 VA opinion is inadequate as it fails to consider the 1994 medical records indicating that the Veteran was diagnosed with hypertension in 1994. See Reonal, 5 Vet. App. at 461. The Veteran has made several statements regarding the onset of his hypertension. In a December 1994 statement in support of claim, the Veteran asserted that he was treated for hypertension in 1981 at Camp Pendleton and he continued treatment until his discharge in 1981. In an August 1995 statement in support of claim, he stated that he was taking medication to control his high blood pressure while on active duty. In a November 1995 statement in support of claim, the Veteran stated that he was treated for hypertension one month prior to his separation and was prescribed medication at the time for hypertension. He also stated that after separating from service, he did not seek treatment for hypertension until 1994 after he was diagnosed with bell's palsy. In his November 2001 notice of disagreement, the Veteran stated that he had high blood pressure while in the military and he has been taking medication since that time. As previously noted, during the December 2020 VA examination, the Veteran stated that he was diagnosed with hypertension during his separation physical. The Board concludes that the Veteran's statements regarding the onset of his hypertension are not credible. The Veteran's reports are internally inconsistent with his reports in contemporaneous treatment records, lay statements, and are unsupported by the evidence of record. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). In weighing credibility, VA may consider interest, bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desire for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498 (1995). Although the Veteran has maintained that he was diagnosed with hypertension in 1981 while on active duty and given prescription medication, the Veteran's service treatment records do not support his contentions. The Veteran's separation physical only includes a single blood pressure reading, the examination does not mention a diagnosis of hypertension, a prescription for medication for hypertension, or recommendation for a follow-up appointment after separation. Furthermore, the Veteran's November 1984 examination for service connection for an eye condition does not indicate that the Veteran has a diagnosis of hypertension and states that the Veteran is not currently taking any medications. Also, the private medical records provided by the Veteran indicate that the Veteran was not prescribed medication for his hypertension until May 1994. Thus, as his post-service statements are inconsistent with the contemporaneous evidence of record, the Board finds that his statements regarding onset lack any probative value. After carefully considering the evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran's hypertension is shown as chronic in service, manifested to a compensable degree within a year of separation of service, is noted in service with attributable continuity of symptomatology, or is directly related to an in-service injury, event, or illness. The evidence does not show that the Veteran was diagnosed with hypertension in service, prescribed medication for hypertension in service, or suffered from consistent high blood pressure readings indicative of hypertension in service. Furthermore, the Veteran's hypertension was not diagnosed until 1994, over 12 years after separation from service. The Board acknowledges the April 2002 VA treatment record noting diagnosis of hypertension in 1981; however, this single notation is not supported by the credible evidence of record. Although the Veteran contends that he had high blood pressure in service, and continued to have high blood pressure thereafter, as previously noted, the Veteran's statements of continuity of symptomatology lack probative value as they are not credible. Finally, the December 2020 VA examiner opined that the Veteran's hypertension is less likely than not related to his service citing to the 1994 medical records as the earliest notations confirming a diagnosis of and treatment for hypertension. Accordingly, the Board finds that entitlement to service connection for hypertension is not warranted. In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine does not apply. Gilbert, 1 Vet. App. at 54; 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for an acquired psychiatric disorder The Veteran contends that he has an acquired psychiatric disorder that is related to his active service in the Marines. The question before the Board is whether the Veteran has a diagnosed psychiatric disorder that is at least as likely as not related to his service. In July 2011 correspondence, the Veteran reported several in-service stressors that he believes attributed to a diagnosis of an acquired psychiatric disorder. He recalled slipping off a hill during jungle training in Panama, cutting his left fingers while fishing, sleeping in a bunk bed and being attacked by other Veterans, being airlifted by a helicopter during combat training and landing on a beach, and being airlifted by a helicopter during desert training. The Veteran stated that he was traumatized by these events and can no longer fly because of these events. The VA provided an August 2011 memorandum of a formal finding of inability to corroborate the claimed stressors associated with the claim for service connection for posttraumatic stress disorder (PTSD). The Veteran's service treatment records are absent any complaints of or treatment for a psychiatric disorder. The Veteran's VA treatment records include a November 2006 attending note where the Veteran noted a history of depression. He stated that he has multiple stressors, including sick parents and his mother in the hospital. He also stated that there is a person at work who picks on him. The Veteran also stated that he is followed by a private psychiatrist. In May 2011, the Veteran underwent a PTSD consult. During the examination, the Veteran reported that since leaving the Marines in 1981 he has been easily startled, has nightmares about falling, and feels like his home is threatened. He attributed his symptoms to a series of non-combat incidents, including falling down a ravine while training in Panama and jumping out of aircraft that were having mechanical problems. The Veteran also described worsening depressive symptoms that started after his divorce in 1985. The examining psychology intern diagnosed the Veteran with major depressive disorder pursuant to Diagnostic-IV criteria. It was noted that although the Veteran has features of PTSD, his symptoms are most consistent with a diagnosis of major depressive disorder. In a September 2011 psychology note, Dr. K.M. reiterated that the Veteran does not meet the criteria for a PTSD diagnosis and continued Veteran's depressive disorder diagnosis. During the appointment, the examiner discussed his physical problems and was very distressed about his shoulder pain and not feeling well enough to perform his job. The Veteran's VA treatment records also include PTSD screens; however, his screens have been negative throughout the duration of the appeal. The Veteran was afforded a VA examination in December 2020. The examiner diagnosed the Veteran with unspecified depressive disorder. During the examination, the Veteran reported his stressors while serving in the Marines, including falling down a ravine while training in Panama and jumping from helicopters having mechanical problems. The examiner opined that although the identified stressors were undoubtedly stressful for the Veteran, these types of stressors are "subthreshold" for DSM-V PTSD criterion A traumatic stressor. The examiner further opined that the Veteran's diagnosed condition is less likely than not incurred in or caused by the claimed in service injury, event, or illness. The rationale provided is that there is no objective evidence that the Veteran's unspecified depressive disorder is due to his military service. The examiner noted that the Veteran first started mental care in 2011, 30 years after he left the military, although he alleges that he tried to get help in the 1980s, but was turned away from the VA. The examiner explained that the Veteran's VA records mostly cite current social stressors and there is no real evidence tying his current mental claims to his military time. In addition, there is no record of mental health complaints or treatment while on active duty. The examiner concluded that absent any evidence to support a nexus to military service, it is therefore, less likely than not that the Veteran's unspecified depressive disorder was incurred in or caused by the claimed in-service injury event or illness. The Board notes that in the April 2021 Board Remand, the Board found that the December 2020 VA examination is inadequate based on a finding that the examiner's opinion was based solely on the lack of treatment records until 2011. However, presently, the Board disagrees with this finding, as the examiner based her negative nexus opinion not only on the lack of in-service treatment records suggesting mental health issues, but also on the fact that the Veteran's VA records cite to current social stressors for his presently diagnosed depressive disorder. Accordingly, the Board finds that the December 2020 VA opinion is adequate and highly probative as it is based on an accurate medical history and provides an explanation that contains clear conclusions with supporting data. See Nieves-Rodriguez, 22 Vet. App. at 304. Moreover, in further support of the December VA medical opinion, is the opinion provided by the June 2021 VA provider who reached the same conclusion. The VA examiner opined that the Veteran's unspecified depressive disorder is less likely than not incurred in or caused by service. The rationale provided is that although the Veteran reported that he has experienced emotional distress since he left service, there is no evidence of mental health problems until 2011, 40 years after he left the military. There is no evidence that symptoms began during, or persisted since the military. Furthermore, the content of his mental health treatment sessions does not focus on his military stressors or emotional distress around events from military service. The mental health notes primarily focus on psychological stressors present at the time of the session, including familial stressors and frustration with the VA compensation process. The Board finds this opinion to be adequate and probative as it based on an accurate medical history and provides an explanation that contains clear conclusions with supporting evidence. Id. After careful consideration of the evidence of record, the Board finds that the preponderance of the evidence is against finding that the Veteran's diagnosed acquired psychiatric disorder started in service or is related to his military service. The Veteran's service treatment records do not include any complaints of or treatment for a mental health condition. The evidence shows that the Veteran was not diagnosed with major depressive disorder until May 2011. This diagnosis was confirmed and continued by both the December 2020 and June 2021 VA examiners. The examiner also opined that the Veteran's depressive disorder is less likely than not attributed to his military service. Significantly, both examiners opined that the Veteran's acquired psychiatric disorder was related to social stressors including familial stress and stress with the VA compensation process. The Board notes that the Veteran's initial claim filed in October 2012 was one for PTSD. However, the preponderance of the evidence is against finding that the Veteran has a diagnosis of PTSD that meets the requirements of 38 C.F.R. § 4.125. The May 2011 PTSD consult considered the Veteran's reported PTSD stressors and symptoms, but opined that the Veteran's symptoms were more reflective of a diagnosis of major depressive disorder. Moreover, the Veteran's VA treatment records include negative PTSD screens throughout the appeal period. The Board has considered the November 2006 VA treatment record noting a history of depression and treatment through a private psychiatrist; however, the Veteran was given an opportunity to submit additional information after the AOJ sent him a Subsequent Development Letter in November 2020, pursuant to instructions included in the October 2020 Board remand. However, the Veteran did not return a VA Form 21-4142 identifying a private psychiatrist. Furthermore, during the November 2006 appointment, the Veteran indicated that his depression was due to his sick parents and problems at his job, not his military service. The Board has also considered the Veteran's contentions that his depressive disorder started in service and is related to his service. Although the Veteran is competent to report his symptoms, as a lay person, however, the Veteran has not shown that he has specialized training sufficient to render an opinion or diagnosis as to the nature and etiology of his symptoms. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). Consequently, the Board affords more probative value to the December 2020 and June 2021 VA opinions that determined that the Veteran's unspecified depressive disorder is less likely than not related to his service. Also, the Board notes that the VA could not verify the Veteran's PTSD stressors reported in July 2011; however, even when considering the Veteran's stressors to be fact, the evidence of record is overwhelmingly against finding that these stressors contributed to the Veteran's diagnosis of unspecified depressive disorder. Accordingly, the Board finds that entitlement to service connection for an acquired psychiatric disorder is not warranted. In reaching the above decision, the Board considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim, the doctrine does not apply. Gilbert, 1 Vet. App. at 54; 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran's claim so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. VA's duty to assist includes a duty to provide a medical examination or obtain a medical opinion where it is deemed necessary to decide on the claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4); Duenas v. Principi, 18 Vet. App. 512 (2004); Robinette v. Brown, 8 Vet. App. 69 (1995); McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 1. Entitlement to service connection for a right-hand disability, to include as due to service-connected shoulder conditions is remanded. The Veteran contends that his right-hand disability is related to getting thorns stuck in his hand during training in Panama while on active service. Alternatively, the Veteran contends that his right-hand disability is due to his service-connected right shoulder disability. In his November 2001 notice of disagreement, the Vetearn stated that his fingers feel numb. His private medical records also include a November 2001 report of numbness in his fingers on his right hand. During an April 2012 orthopedic consultation, the examining orthopedic physician suggested that the Veteran's numbness in his hand is potentially related to his shoulders. The June 2021 VA addendum opinion found that the Veteran's right-hand disability is less likely than not proximately due to or the result of the Veteran's service-connected shoulder condition. The examiner stated that there was no evidence that the Veteran has radiating pain from the right shoulder to the right hand, discounting the Veteran's statements of numbness and the April 2012 VA treatment record noting that the Veteran's complaints are potentially related to his shoulder. Thus, the Board finds that a new VA examination is necessary to determine whether the Veteran's numbness is proximately due to or aggravated beyond natural progression by his service-connected shoulder condition. 2. Entitlement to service connection for a right knee disability, to include as due to service-connected bilateral plantar fasciitis is remanded. 3. Entitlement to service connection for a left knee disability, to include as due to service-connected bilateral plantar fasciitis is remanded. The Veteran contends that his bilateral knee disabilities are due to slipping on rocks while training during active service. Alternatively, the Veteran contends that his knee disabilities are due to his service-connected bilateral plantar fasciitis. The December 2020 VA examiner diagnosed the Veteran with degenerative arthritis of both knees as well as chondromalacia of both knees. The December 2020 VA examiner opined that the Veteran's bilateral knee disabilities are less likely than not related to his service. Part of the rationale for the opinion was based on a finding that flat feet may increase the likelihood of chondromalacia. The June 2021 VA examiner opined that the Veteran's bilateral knee disabilities are less likely than not proximately due to his service-connected bilateral feet disabilities, but failed to consider the December 2020 VA examiner's finding that the likelihood of chondromalacia is increased with flat feet. Accordingly, the Board finds that an addendum medical opinion is needed to offer an opinion as to whether there is a nexus between the Veteran's diagnosed chondromalacia of both knees and his service-connected bilateral feet disabilities. The matters are REMANDED for the following actions: 1. Schedule the Veteran for a VA examination for his claimed right-hand disability with an appropriate clinician. The examiner must review the claims file. The examiner is asked to determine the nature and etiology of his right-hand numbness complaints noted in November 2001 statement, November 2001 medical report, and April 2012 VA treatment note. The examiner is asked to opine whether the Veteran's right-hand numbness is at least as likely as not (1) proximately due to his service-connected right shoulder disability; or (2) aggravated, i.e., worsened beyond its natural progression, by his service-connected right shoulder disability. Any opinion expressed should be accompanied by a complete rationale. 2. Obtain an addendum medical opinion from an appropriate clinician as to whether the Veteran's bilateral knee chondromalacia is at least as likely as not (1) proximately due to his service-connected bilateral plantar fasciitis disability; or (2) aggravated, i.e., worsened beyond its natural progression, by his service-connected bilateral plantar fasciitis disability. The examiner is asked to consider the rationale provided by the December 2020 VA examiner noting that flat feet increases the likelihood of chondromalacia. Any opinion expressed should be accompanied by a complete rationale. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Hartford, Associate Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.