Citation Nr: 21066970 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 17-43 599 DATE: November 3, 2021 ORDER Entitlement to an initial disability rating greater than 30 percent from February 23, 2012, for posttraumatic stress disorder (PTSD) is denied. Entitlement to an increased rating of 70 percent from February 14, 2017, but no earlier or greater, for PTSD is granted. REMANDED Service connection for a low back disorder, to include degenerative disc disease, is remanded. Service connection for painful joints, to include as due to an undiagnosed illness or other qualifying, chronic disability, is remanded. Service connection for aching muscles, to include as due to an undiagnosed illness or other qualifying, chronic disability, is remanded. Service connection for pes planus is remanded. Service connection for gastroesophageal reflux disease (GERD), claimed as gastritis, to include as secondary to service-connected PTSD, is remanded. Service connection for headaches is remanded. FINDINGS OF FACT 1. From February 23, 2012, to February 13, 2017, the Veteran's PTSD manifested in symptoms suggesting occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks but has not resulted in flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships suggesting occupational and social impairment with reduced reliability and productivity. 2. From February 14, 2017, the Veteran's PTSD manifested in symptoms suggesting occupational and social impairment, with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood but has not resulted in in gross impairment of thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name suggesting total occupational and social impairment. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial disability rating greater than 30 percent from February 23, 2012, for PTSD have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, Diagnostic Code (DC) 9411. 2. The criteria for entitlement to an increased rating of 70 percent from February 14, 2017, but no earlier or greater, for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.7, 4.126, 4.130, DC 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1989 to September 1994 with an earlier period of active duty for training (ACDUTRA) from May 1989 to September 1989. These matters come to the Board of Veterans' Appeals (Board) on appeal from May 2013 and August 2013 rating decisions issued by the Department of Veterans' Affairs (VA) Regional Office (RO) in Decatur, Georgia. By way of background, the Board previously remanded all of these claims for additional development in an April 2019 decision. As will be discussed in more detail below, substantial compliance with the April 2019 remand directives has been met only regarding the Veteran's increased rating claim for PTSD. All of the remaining claims addressed herein must again be remanded. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board notes consideration has been given to whether the issue of entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) was reasonably raised by the record in this case. Rice v. Shinseki, 22 Vet. App. 447 (2009). While the Veteran's PTSD symptoms have been noted to interfere with his ability to work, there is no indication in the record that the Veteran is unable to obtain or maintain substantially gainful employment; indeed, the record indicates the Veteran is currently employed full-time and has been throughout the claim. Therefore, as the issue of a TDIU is not reasonably raised by the record, it is not part of the rating appeal and will not be further addressed herein. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 1. Entitlement to an initial disability rating greater than 30 percent from February 23, 2012, for PTSD is denied. 2. Entitlement to an increased rating of 70 percent from February 14, 2017, but no earlier or greater, for PTSD is granted At the outset, the Board notes, VA received the Veteran's claim for benefits on February 23, 2012. The Veteran timely appealed the initial May 2013 rating decision stemming from said claim. Thus, the Board will consider the period on appeal beginning February 23, 2012, the date of the receipt of the Veteran's claim for benefits. See 38 U.S.C. § 5110; 38 C.F.R. § 3.400. The Veteran contends his service-connected PTSD symptoms warrant a higher rating during the period on appeal. The RO awarded the Veteran an initial rating for his PTSD of 30 percent, effective February 23, 2012, which was increased to 70 percent, effective August 20, 2019. For reasons outlined below, the Board finds an increased initial rating greater than 30 percent is not warranted, but the 70 percent rating can be awarded from February 14, 2017, but no earlier and no higher, for his PTSD manifestations. The Veteran's PTSD is rated under DC 9411, which indicates that PTSD should be rated under the General Formula for Mental Disorders (General Formula). The Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned for total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name. Turning to the relevant evidence of record, the Veteran was afforded a VA examination in December 2012 during which the examiner opined the Veteran's PTSD symptoms were productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication. See December 2012 VA examination. Symptoms were noted to include depressed mood, anxiety, and chronic sleep impairment. The Veteran endorsed being married with a "strain" and having "good" relationships with his children. He conveyed being difficult to communicate with, temperamental, and emotionally disengaged. He conveyed doing well in his job but noted that he has been counseled about the "tone of his emails" which he described as being "too aggressive or straightforward." In 2013, the Veteran attended treatment for PTSD during which he was noted to be appropriately dressed and oriented. See February 2013 VA treatment records. His speech was clear and coherent. He denied suicidal or homicidal ideation. He complained of difficulty with temperament and ruminating over events. See January 2013 VA treatment records. He expressed being tired "all the time." The Veteran endorsed interacting with others. He conveyed feeling diminished and without ambition and easily agitated. He has avoidance of thoughts, people, and conversations about his military experience. He endorsed a lack of trust and did not "feel close to anyone." He reported difficulties at home and work due to irritability and that his daughter is afraid of him. On February 14, 2017, the Veteran complained of increased anger, rage, sadness, depression, paranoia, and anxiety including in large crowds, and hypervigilance over the past year. See February 2017 VA treatment records. He stated, "I feel like my ability to interact and sustain personal relationships is difficult. I'm trying not to use PTSD as an issue. It takes a lot for me to come out of my anger." He reported an altercation with his ex-girlfriend ending with a restraining order being issued to the Veteran. In March 2017, the Veteran continued to complain of worsened PTSD symptoms endorsing nightmares, avoidance, and constantly being on guard, watchful, or easily startled. See March 2017 VA treatment records. In August 2019, a private provider opined that the Veteran's PTSD caused occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, and thinking and / or mood. See December 2019 treatment records. Symptoms were noted to include depressed mood, anxiety, chronic sleep impairment, nightmares, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work-like setting, and impaired impulse control, such as unprovoked irritability with periods of violence. The Veteran was afforded another VA examination in December 2019 during which the examiner opined that the Veteran's PTSD symptoms were productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, and thinking and / or mood. See December 2019 VA examination. Symptoms were noted to include depressed mood; anxiety; suspiciousness; near-continuous panic or depression affecting the ability to function independently, appropriately, and effectively; chronic sleep impairment; mild memory loss, such as forgetting names, directions, or recent events; impairment of short- and long-term memory, for example, retention of only highly learned material, while forgetting to complete tasks; flattened affect; impaired judgment; impaired abstract thinking; gross impairment in thought processes or communication; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; difficulty in adapting to stressful circumstances, including work or a work-like setting; inability to establish and maintain effective relationships; and impaired impulse control. The Veteran endorsed having difficulty getting along with co-workers. He reported having great difficulty sustaining attention and concentration and is having difficulty meeting deadlines and completing work assignments. He reported difficulty retrieving information, sustaining attention and concentration, and remembering details of recent conversations and events, and forgetting to complete tasks. He was alert and oriented. He denied suicidal or homicidal ideation. As part of the 2019 VA examination, the examiner completed an individual unemployability statement opining that the Veteran has difficulty attending to or is easily distracted from the task at hand; has difficulty maintaining concentration and focus on work over a period of time, tends to skip from one task to another without completing the prior task; has intrusive thoughts which interfere with the ability to stay focused on the task at hand, has significant difficulty accepting supervision or receiving instructions without becoming angry; has significant difficulty remembering instructions and details of work assignments; has sleep so disrupted that he is usually fatigued at work, making concentration and focus on work assignments difficult; is so depressed that he has difficulty sustaining energy and motivation to complete assignments at work; and has other mental health problems or symptoms interfering significantly with the ability to work including intrusive thoughts, anxiety, social isolation, crowd avoidance, depression, suspiciousness, lack of motivation, hypervigilance, irritability, anger outbursts, and flashbacks. See December 2019 C&P Examination. February 23, 2012, to February 13, 2017 Based on the evidence of record, the Board finds a rating in excess of 30 percent from February 23, 2012, to February 13, 2017, is not warranted. During this period, the evidence shows that the Veteran's PTSD symptoms included depressed mood, anxiety, and chronic sleep impairment productive of occupational and social impairment due to mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of significant stress or symptoms controlled by medication. These symptoms were corroborated by the evidence of record including the Veteran's statements of being tired all of the time and difficulties at work and home due to irritability. Although, the Veteran endorsed doing well in his job with the only issue reported being counseling for the tone of emails. During this period, the Board finds that the Veteran's disability is fully capable of evaluation under the rating schedule. In so finding, the Board also concludes the Veteran's PTSD symptoms during this period do not warrant a 50 percent disability rating as the Veteran has never demonstrated occupational and social impairment with reduced reliability and productivity due to symptoms of similar severity, frequency, or duration as to those contemplated by the 50 percent criteria. Indeed, the evidence of record lacks any mention of flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short- and long-term memory; impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships. Indeed, the Veteran endorsed being married, albeit with strain, and having a "good" relationship with his children. He also endorsed doing well in his job with the only issue being counseled due to the tone of emails. While the Veteran's representative contended the Veteran's symptoms should be assigned a 50 percent disability rating or even a 70 percent disability rating from the date of claim, the Board finds this is not supported by the evidence of record during this period. Rather, the Veteran's symptoms during this period more nearly approximate that of a 30 percent disability rating as previously assigned. From February 14, 2017 Upon review of the evidence of record, the Board finds a 70 percent disability rating, is warranted from February 14, 2017, but no earlier or greater. Indeed, February 14, 2017, marks the date upon which the Veteran endorsed new and worsening PTSD symptoms. The Veteran complained of increased anger, rage, sadness, depression, paranoia, and anxiety including in large crowds, and hypervigilance. He stated, "I feel like my ability to interact and sustain personal relationships is difficult. I'm trying not to use PTSD as an issue. It takes a lot for me to come out of my anger." He conveyed an altercation with an ex-girlfriend prompting a restraining order and endorsed nightmares, avoidance, and being on guard. Based on these symptoms of worsening, the Veteran was afforded another VA examination, but said examination did not occur until 2019. The results of the examination corroborated the Veteran's complaints of symptom worsening productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, and thinking and / or mood. The December 2019 VA examiner noted multiple new PTSD symptoms including depressed mood, anxiety, chronic sleep impairment, nightmares, disturbances of motivation and mood, difficulty in establishing and maintaining effective work and social relationships, difficulty adapting to stressful circumstances, including work or a work-like setting, and impaired impulse control, such as unprovoked irritability with periods of violence. Further, the 2019 private provider also found symptoms of nightmares and disturbances of motivation and mood. While the RO awarded a 70 percent disability rating based on the date of the December 2019 VA examination, the Board finds the rating is warranted from February 14, 2017, the first date upon which the Veteran's complaints of worsening and additional symptoms were noted in his treatment records and later corroborated by the most recent VA examination of record. In so finding, the Board also decides a higher 100 percent rating is not warranted at any point during the appellate time period as the Veteran has never demonstrated total occupational and social impairment or symptoms of similar severity, frequency, or duration as to those contemplated by the 100 percent criteria. Indeed, treatment records lack any reference to gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others, intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene), disorientation to time or place, or memory loss for names of close relatives, own occupation, or own name. Throughout the entire period on appeal, the Veteran has consistently denied experiencing suicidal or homicidal ideation. He has always been alert and oriented. Resolving any doubt in favor of the Veteran, the Board finds a 70 percent disability rating from February 14, 2017, but no earlier or greater for PTSD is warranted. The Board finds that at all times on appeal the Veteran's disability has been fully capable of evaluation under the rating schedule. Based on the above, an initial rating in excess of 30 percent from February 23, 2012, to February 13, 2017, for PTSD is not warranted. From February 14, 2017, however, a 70 percent rating, but no greater, for PTSD is warranted. In denying any further increased ratings / staged ratings, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Service connection for a low back disorder, to include degenerative disc disease, is remanded. The Veteran contends his low back disorder was caused by or incurred during service. The Board finds the evidence of record is insufficient to resolve his claim and remand is necessary to ensure substantial compliance with the Board's prior remand directives. The Veteran was afforded another VA examination in December 2019 to determine the nature and etiology of any low back disorder. The examiner opined that the Veteran's low back disorder was less likely than not related to service because service treatment records (STRs) reflected an acute condition only in 1992 without evidence of chronicity of care. The Board, however, directed the examiner to consider the documented in-service incidents of back pain which included in 1992 and in 1994 at separation when the Veteran reported experiencing recurrent back pain. The examiner failed to address or reconcile the 1994 report of recurrent back pain when opining there was no chronicity of care. Thus, remand is necessary to obtain a VA opinion that considers all of the reports of back pain during service, including in 1992 and 1994, as previously directed. 2. Service connection for painful joints, to include as due to an undiagnosed illness or other qualifying, chronic disability, is remanded. 3. Service connection for aching muscles, to include as due to an undiagnosed illness or other qualifying, chronic disability, is remanded. The Veteran contends he has painful joints and aching muscles that were caused by or incurred during service, to include as due to an undiagnosed illness or other qualifying, chronic disability based on his Persian Gulf War service. The Board finds the evidence of record is insufficient to resolve his claim and finds remand is again necessary to ensure substantial compliance with the April 2019 Board remand directives. The Veteran was afforded a VA examination in December 2012 during which the examiner opined there was no pathology found with respect to the Veteran's complaints of aching muscles and painful joints. The Board referenced a separate disability benefits questionnaire (DBQ) for chronic fatigue syndrome wherein generalized muscle aches and weakness was noted. Additionally, in a back conditions DBQ a diagnosis of rheumatoid arthritis based on bloodwork was noted. Thus, the Board remanded the claim for a VA examination addressing these issues. Accordingly, the Veteran was afforded another VA examination in December 2019 during which the examiner opined the Veteran's condition was less likely than not incurred in or caused by service because the Veteran's symptoms were subjective only and there was no objective evidence of a chronic condition of achy muscles or joint pain. The examiner failed to address or reconcile the CFS DBQ noting aching muscles and painful joints. Additionally, the examiner only provided the Veteran with a fibromyalgia DBQ finding a diagnosis of such was not warranted. As such, remand is again necessary for an opinion addressing rheumatoid arthritis as well as whether the Veteran has painful joints and / or aching muscles caused by or incurred during service or as either an undiagnosed illness, or alternatively a diagnosed illness but the result of a medically unexplained chronic multi-symptom illness (MUCMI). Accordingly, this claim is remanded to obtain VA opinions based on the above. 4. Service connection for pes planus is remanded. The Veteran contends his pes planus was aggravated during service. The Board finds the evidence of record is insufficient to resolve his claim and remand is again necessary to ensure substantial compliance with the Board's remand directives. As indicated in the April 2019 remand, the Veteran was noted to have pes planus during a June 2013 VA examination, but the examiner opined there was no documentation of foot pain in the claims file. The Board referenced that the Veteran's entrance examination noted mild pes planus and later STRs in 1994 referenced foot trouble. Accordingly, because pes planus was noted upon entrance, the Veteran is not presumed to have been in sound condition with respect to this disability and benefits may only be awarded for service-connected aggravation of the disorder. See 38 U.S.C. § 1111. A pre-existing injury or disease will be considered to have been aggravated by active service where there is an increase in disability during service, unless there is a specific finding that the increase in disability is due to the natural progression of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. As such, the Board requested a VA opinion to determine whether the Veteran's pre-existing pes planus was aggravated during service. The December 2019 VA examiner, however, erroneously only rendered an opinion addressing whether the Veteran's pes planus was related to service. As such, remand is necessary for an addendum opinion addressing whether the Veteran's pre-existing pes planus was aggravated during service. 5. Service connection for GERD, claimed as gastritis, to include as secondary to service-connected PTSD, is remanded. The Veteran has recently, and for the first time, contended that his GERD is secondary to service-connected PTSD. While the Veteran was afforded a VA examination in December 2019, the VA examiner was only instructed to render an opinion addressing direct service connection. In light of the recently raised theory of entitlement, the Board finds remand is necessary to obtain a VA opinion addressing secondary service connection. See generally Schroeder v. West, 212 F.3d 1265 (2000); Buckley v. West, 12 Vet. App. 76, 83 (1998). Thus, this claim is remanded to obtain a VA opinion addressing whether the Veteran's GERD is secondary to service-connected PTSD. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). 6. Service connection for headaches is remanded. The Veteran contends his headache condition is related to service. The Board finds the evidence of record is insufficient to resolve his claim and remand is necessary to ensure substantial compliance with the Board's prior remand directives. The Veteran was previously afforded a VA examination in December 2012 and again in December 2019. The December 2019 VA examiner opined that the Veteran's symptoms are subjective only and there was no diagnosis warranted on the date of the examination. The examiner, however, failed to reconcile the Veteran's diagnosis of tension headaches during the December 2012 VA examination. Further, the December 2019 VA examiner was directed to address the Veteran's multiple STRs noting headaches during service. The examiner, however, opined the Veteran's symptoms were subjective only and there was no evidence of a chronic condition for headache or migraine. The examiner failed to address or reconcile the Veteran's STRs noting a headache in 1989, face trauma including a possible nasal fracture in 1992, a multiple-day migraine in 1993, a head injury and headaches reported in 1994, migraines reported in 1994, and headaches noted in the 1994 separation report of medical history. Accordingly, remand is necessary to obtain an addendum opinion. The matters are REMANDED for the following action: 1. Return the entire claims file and this remand to the December 2019 VA examiner, if available, or to another appropriate examiner for review to determine the nature and etiology of any low back disorder. The necessity of an in-person examination is left to the examiner's discretion. The examiner should render an addendum opinion, including rationale, addressing: - Whether it is at least as likely as not the Veteran's low back disorder was caused by or incurred during service? - For any diagnosed arthritis condition, whether it is at least as likely as not the condition (1) began during active service, (2) manifested within a year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? In so opining, the examiner is directed to address and consider the Veteran's 1992 report of back pain during service as well as the separation examination report of medical history noting recurrent back pain in 1994. 2. Return the entire claims file and this remand to the December 2019 VA examiner, if available, or to another appropriate examiner for review to determine the nature and etiology of any painful joints and / or aching muscles condition. The necessity of an in-person examination is left to the examiner's discretion. The examiner should render an addendum opinion, including rationale, addressing: - Addressing the opinions rendered in the prior December 2012 and December 2019 VA examinations and any other evidence deemed relevant, resolve whether the Veteran's painful joints and / or aching muscles is either an undiagnosed illness, or alternatively a diagnosed illness but the result of a medically unexplained chronic multi-symptom illness (MUCMI). The term "MUCMI" refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic MUCMIs of partially understood etiology and pathophysiology will not be considered "medically unexplained." - If the Veteran's painful joints and / or aching muscles is neither an undiagnosed illness nor a MUCMI, the examiner is asked to determine whether the Veteran has a painful joints and / or aching muscles disability, to include consideration of rheumatoid arthritis as noted in the back disabilities DBQ. In so opining, the examiner is directed to address and consider the Veteran's lay statements of symptoms and the previous VA examinations noting rheumatoid arthritis and generalized muscle aches and weakness. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. - For each diagnosed disability, is it at least as likely as not related to service? In so opining, the examiner is directed to address and consider the Veteran service treatment records noting cramps in the legs in 1994 and post-separation records noting chronic pain in the knees, lower back, and calves. 3. Return the entire claims file and this remand to the December 2019 VA examiner, if available, or to another appropriate examiner for review to determine whether the Veteran's pes planus was aggravated during service. The necessity of an in-person examination is left to the examiner's discretion. The examiner should render an opinion, including rationale, addressing whether the Veteran's pes planus noted upon entrance was clearly and unmistakably aggravated beyond natural progression during service (NOTE: "clearly and unmistakably" means "undebatable"). In so opining, the examiner is directed to address and consider the Veteran's entrance examination noting mild pes planus and the subsequent 1994 report of medical history noting foot trouble. 4. Return the entire claims file and this remand to the December 2019 VA examiner, if available, or to another appropriate examiner for review. The necessity of an in-person examination is left to the examiner's discretion. The examiner should render an opinion, including rationale, addressing whether it is at least as likely as not the Veteran's GERD was caused or aggravated by service-connected PTSD. In so opining, the examiner is directed to address and consider the Veteran's lay statements of symptom onset after diagnosis of PTSD. The VA examiner is cautioned that the term "aggravated," as used in 38 C.F.R. § 3.310(b), does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). 5. Return the entire claims file and this remand to the December 2019 VA examiner, if available, or to another appropriate examiner for review to determine the nature and etiology of any headache condition. The necessity of an in-person examination is left to the examiner's discretion. The examiner should render an addendum opinion, including rationale, addressing whether it is at least as likely as not the Veteran's headache condition was caused by or incurred during service, including consideration of the multiple reports of headaches / migraines during service. If a diagnosis is not rendered, the examiner is directed to address and reconcile the Veteran's previous 2012 VA examination noting a diagnosis of tension headaches. In so opining, the examiner is directed to address and consider the Veteran's service treatment records noting a headache in 1989, face trauma including a possible nasal fracture in 1992, a multiple-day migraine in 1993, a head injury and headaches reported in 1994, migraines reported in 1994, and headaches noted in the 1994 separation report of medical history. The examiners must provide a complete rationale for any opinion expressed, based on the examiner's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinions cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 6. After the above development, and any other development deemed necessary, readjudicate the claims. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.C. Allen, 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.