Citation Nr: 21065730 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 17-43 973 DATE: October 27, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD), is denied. Entitlement to service connection for a bilateral foot disability, to include pes planus, is granted. FINDINGS OF FACT 1. The preponderance of the probative evidence of record is against a finding that the Veteran has a current diagnosis of PTSD that meets the criteria under the DSM-5, nor a diagnosis of any other mental disorder for VA purposes. 2. Resolving all reasonable doubt in favor of the Veteran, the preponderance of the probative evidence of record reflects that the Veteran's bilateral foot disability, to include pes planus, had an onset during active duty service and/or is directly related to his active duty service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an acquired psychiatric disorder, to include PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303, 3.304. 2. The criteria for entitlement to service connection for a bilateral foot disability, to include pes planus, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § § 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from July 1973 to January 1985. This case comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. In March 2019, the Board remanded the Veteran's claims for additional development. The Board notes there was substantial compliance with its March 2019 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). SERVICE CONNECTION Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence showing (1) current disability; (2) in-service incurrence in or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). 1. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD. The Veteran contends that he currently has PTSD that is directly related to his active duty service; specifically, from engaging in combat during service and/or due to his fear of hostile military or terrorist activity. The Board notes that establishing service connection for PTSD requires medical evidence establishing a diagnosis of the condition in accordance with 38 C.F.R. § 4.125(a); credible supporting evidence that the claimed in-service stressor occurred; and a link, established by medical evidence, between current symptomatology and the claimed in-service stressor. See 38 C.F.R. §§ 3.304(f), 4.125. Service treatment records (STRs) are silent for any complaints, treatments, or diagnosis of any mental disorder, to include PTSD. Post-service VA treatment records are also silent for any diagnosis of a mental disorder, to include PTSD. However, a private treatment record reveals a diagnosis of PTSD in June 2016. In April 2015, the Veteran was afforded a VA PTSD examination, where the examiner found that the Veteran does not have a diagnosis of PTSD that conforms to the DSM-5 criteria, nor does he have any other diagnosis of a mental disorder. See C&P Exam, April 2015. In May 2016, the Veteran underwent a private psychiatric assessment, where the examiner diagnosed the Veteran with PTSD, and provided a favorable etiology opinion, noting that it is at least as likely as not that the Veteran's PTSD was incurred in or caused by his military service and results of a fear of hostile military or terrorist activities due to the course and type of symptoms. See Private treatment record, May 2016. The private examiner noted the PTSD diagnosis in a subsequent, June 2016 treatment record See Private treatment record, June 2016. In July 2017, the Veteran was afforded another VA PTSD examination, where the examiner found that the Veteran does not have a diagnosis of PTSD that conforms to the DSM-5 criteria, nor does he have any other diagnosis of a mental disorder. As a result, the examiner opined that it was less likely than not that the Veteran's claimed condition was related to his active service. The examiner rationalized that the Veteran does not meet the DSM-5 criteria for PTSD or any mental health clinical syndrome at this time, and thus, he does not have a diagnosis for which to provide an etiology opinion. The examiner noted that the Veteran met some criteria for PTSD, but not others, as defined by the DSM-5, and his mental health symptoms are not severe enough to interfere with social and occupational functioning. Additionally, the examiner further addressed the May 2016 private examiner's assessment, noting that the private assessment was somewhat disconnected from the Veteran's actual symptom presentation and functioning, including no reference to quantitative testing, and is based on relatively infrequent and brief sessions. See C&P Exam, July 2017. Subsequent medical records do not reflect a diagnosis of or treatment for any psychiatric disorders. While the Board acknowledges that the May 2016 private examiner and June 2016 private treatment record provided a diagnosis of PTSD, the Board notes that these diagnoses are inadequate for VA purposes, as the evidence does not appear to show that either diagnosis was based upon the criteria under the DSM-5, as required by 38 U.S.C. § 4.125(a). Additionally, the Board further notes that the May 2016 private opinion is also inadequate, as it does not provide a substantiated rationale, and is based entirely on the Veteran's statements, with no review of the Veteran's claims file and/or consideration or discussion of the relevant evidence of record, to include the Veteran's medical history. Therefore, based on the reasonings noted above, the Board accords the May 2016 private examination and June 2016 private treatment record little, if any, probative weight. Conversely, the Board assigns the April 2015 and July 2017 VA examinations great probative weight, as the examiners based their assessment of a lack of diagnosis for PTSD under the required DSM-5 criteria, with review of the Veteran's entire claims file; as well as the July 2017 VA examiner's medical opinion specifically addressed the May 2016 private examiner's assessment. Therefore, based on the above, the Board finds that the preponderance of the probative evidence of record is against a finding that the Veteran has a current disability for VA purposes. In the absence of a confirmed diagnosis of PTSD under the DSM-5 criteria, either during or post service, service connection for that disability cannot be established. As previously noted, there is no probative objective medical evidence of a current PTSD disability since the Veteran filed his claim. As such, the record is essentially void of competent and credible medical evidence of a current disability. Therefore, the Board concludes that the preponderance of the competent evidence of record is against the Veteran's claim, and service connection for an acquired psychiatric disorder, to include PTSD, is not warranted; and the claim is denied. While the Veteran believes he has PTSD, he has not shown to have the requisite medical knowledge and expertise to be deemed competent to provide any diagnoses in this case. The issue of providing a diagnosis is medically complex, as it requires specialized medical education. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). He has not provided, nor does the claims file include probative evidence of a current disability upon which to grant the claim. 2. Entitlement to service connection for a bilateral foot disability, to include pes planus. The Veteran contends that his bilateral foot disability, to include pes planus, is directly related to his active duty service. STRs in March 1981 reflect a complaint and treatment for hurting arches in the bilateral foot and dull pain in the left foot, with a diagnosis of pes planus given. Post-treatment VA and private treatment records reveal treatment and diagnoses for left hallux valgus with degenerative changes and left great toe degenerative changes. In March 1985, the Veteran was afforded a VA examination, where the examiner diagnosed the Veteran with congenital mild pes planus. See VA Examination, March 1985. As a result of the March 1985 diagnosis noting a congenital foot condition, the Board remanded the Veteran's claim in March 2019 to determine whether the Veteran's claimed bilateral pes planus, noted in service, was a congenital defect or disease, and if so, whether it clearly and unmistakably preexisted service and was aggravated by such service; and if not, whether the Veteran's claimed bilateral pes planus and any other currently diagnosed foot condition was directly related to his active duty service. See BVA Decision, March 2019. In January 2020, the Veteran was afforded a VA foot examination to assess the current nature and etiology of any claimed foot disability. Upon examination, the examiner diagnosed the Veteran with bilateral hallux valgus, left foot trauma, bilateral degenerative arthritis, and left foot degenerative joint disease. Additionally, the examiner provided several VA medical opinions regarding the etiology of his claimed bilateral foot disability, all of which opined that a review of the Veteran's claims file does not reflect a bilateral foot disability, to include bilateral pes planus, that clearly and unmistakably existed prior to service, nor were they clearly and unmistakably aggravated by such service by a superimposed disease and/or injury, to include as a result of cumulative impact of multiple parachute jumps in service that revealed additional disability of the feet during service. The examiner rationalized that the Veteran had no issues related to his bilateral foot disability, to include pes planus, prior to his military service, with no evidence of such condition noted on the July 1973 enlistment examination, and therefore, lacks clinical documentation of a preexisting condition. As such, the examiner further opined that the Veteran's currently diagnosed bilateral foot disabilities, to include bilateral pes planus, was at least as likely as not incurred in or caused by his active duty service, as bilateral pes planus had its onset and was incurred during active service as documented in the March 1981 STR; with further evidence of current, chronic care for his bilateral foot disabilities. See C&P Exams, January 2020. (Continued on the next page) Therefore, as the preponderance of the probative evidence of record is in favor of the Veteran's claim, with no additional probative evidence to the contrary, the Board finds that, resolving all reasonable doubt in favor of the Veteran, service connection for a bilateral foot disability, to include pes planus, is warranted; and the claim is granted. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Hodges, 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.