Citation Nr: 21068272 Decision Date: 11/09/21 Archive Date: 11/09/21 DOCKET NO. 18-36 028 DATE: November 9, 2021 ORDER Entitlement to service connection for vertigo is granted. Entitlement to service connection for benign prostatic hypertrophy (BPH) is denied. Entitlement to an initial disability rating of 30 percent, but no greater, for right ankle tendonitis is granted, subject to the rules and regulations governing the payment of monetary benefits. REMANDED Entitlement to service connection for bilateral pes planus is remanded. Entitlement to service connection for restless leg syndrome is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for a headache disorder is remanded. Entitlement to service connection for erectile dysfunction, to include as secondary to a service-connected disability is remanded. Entitlement to service connection for a neck disorder is remanded. Entitlement to service connection for right foot gout is remanded. Entitlement to service connection for a left foot bone spur is remanded. Entitlement to service connection for irritable bowel syndrome (IBS) is remanded. Entitlement to service connection for a right foot bone spur is remanded. FINDINGS OF FACT 1. With consideration of the benefit of the doubt, the preponderance of the evidence shows that the Veteran's vertigo was caused or aggravated by his service-connected bilateral hearing loss. 2. The Veteran's BPH was not incurred in and is not etiologically related to any incident of active duty service. 3. Since the initial grant of service connection, the Veteran's right ankle tendonitis has been manifested by no worse than absent range of motion of the ankle in dorsiflexion. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for entitlement to service connection for vertigo have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. The criteria for entitlement to service connection for BPH have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for an initial disability rating of 30 percent, but not higher, for right ankle tendonitis have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.10, 4.14, 4.71a, Diagnostic Codes 5024, 5270-5273. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from January 1986 to January 1990. Thereafter, he served in the United States Navy Reserves with various periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). In June 2020, the Board issued a decision which, in pertinent part, denied entitlement to service connection for BPH and bilateral pes planus. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In an April 2021 Order, the Court granted a Joint Motion for Partial Remand, vacating the Board's June 2020 decision with regard to the issues of entitlement to service connection for BPH and bilateral pes planus, and remanded the matters to the Board for additional consideration. Service Connection Service connection may be established for a disability resulting from disease or injury which was clearly present in service or for a disease diagnosed after discharge from service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may be established on a secondary basis for a disability which is shown to be proximately due to, the result of, or chronically aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id.; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc) (additional disability resulting from aggravation of a nonservice-connected disorder by a service-connected disorder is also compensable under 38 C.F.R. § 3.310). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). 1. Entitlement to service connection for vertigo After consideration of the evidence of record, the Board concludes that the weight of the evidence is at least in equipoise as to whether the Veteran's vertigo is etiologically related to his service-connected bilateral hearing loss. First, there is evidence of a current disability. An October 2020 VA examination reflects a diagnosis of vertigo. Degmetich v. Brown, 104 F.3d 1328, 1333 (Fed. Cir. 1997) (holding that the existence of a current disability is the cornerstone of a claim for VA disability compensation). Second, the weight of the probative medical evidence in the claims file addressing the etiology of the Veteran's vertigo shows that it was caused or aggravated by his service-connected bilateral hearing loss. In that regard, an October 2020 VA examiner opined that it was at least as likely as not that the Veteran's vertigo was proximately due to or the result of his service-connected bilateral hearing loss. The examiner explained that the Veteran had all the symptoms of Meniere's disease, "so it is likely that his vertigo is related to his hearing loss . . . ." While a May 2016 VA opinion determined that the Veteran's vertigo was not related to his active duty service and noted that "[t]here is no etiological correlation [sic] between tinnitus and hearing loss many years ago," the examiner did not provide any explanation or rationale for the conclusion. Accordingly, the Board does not afford the May 2016 VA opinion significant probative value. Pursuant to the "benefit-of-the-doubt" rule, where there is "an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter," the Veteran shall prevail upon the issue. 38 U.S.C. § 5107(b). Upon weighing the evidence of record, the Board finds that the evidence is at least in equipoise as to whether the Veteran's vertigo was caused or aggravated by his service-connected bilateral hearing loss. The Board therefore concludes that, with the benefit of the doubt resolved in the Veteran's favor, a grant of service connection for vertigo is warranted. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for BPH After thorough consideration of the evidence of record, the Board concludes that entitlement to service connection for BPH is not warranted. The record establishes a current diagnosis of BPH. VA treatment records beginning in June 2015 document diagnoses of and treatment for BPH. Thus, a current disability is demonstrated. However, the record does not establish in-service incurrence of BPH, as the Veteran's service treatment records are negative for any indication of BPH or enlarged prostate, bladder or urinary tract problems, or kidney problems. In that regard, the Veteran's November 1989 separation examination reflects that his G-U system was normal at that time. In an accompanying report of medical history, the Veteran denied frequent or painful urination. Similarly, a September 1991 Naval Reserve examination shows that the Veteran's G-U system was normal and that his prostate was within normal limits. In a report of medical history, completed at that time, the Veteran denied frequent or painful urination. Moreover, the Veteran has not provided any lay statements suggesting that he experienced symptoms of a prostate disorder during service or continuously since service. In fact, he has not provided any statements linking this disability to his active duty service. Additionally, there is no competent and credible evidence linking the Veteran's current BPH to any incident of service. Therefore, in-service incurrence is not established, and service connection for BPH is not warranted. In an April 2021 JMPR, the parties agreed that the Board failed to adequately address whether the Veteran was entitled to a VA examination relating to his claim for service connection for BPH. VA's duty to assist a veteran in obtaining evidence necessary to substantiate a claim includes providing an adequate medical examination or opinion when necessary. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. However, VA is not required to provide an examination in every case. See Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Rather, VA must provide a medical examination when the record contains (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence to make a decision on the claim. See 38 U.S.C. § 5103A(d)(2); McLendon v. Nicholson, 20 Vet. App. 79, 81-86 (2006). The Court has held that VA is not required to provide a medical examination when there is no credible evidence of an event, injury, or disease in service. See Bardwell v. Shinseki, 24 Vet. App. 36 (2010). The Board concludes that a VA examination addressing the etiology of the Veteran's BPH is not warranted in this case. As discussed above, the evidence does not show an injury or event during service and there is no competent evidence suggesting a nexus between the currently diagnosed BPH and the Veteran's active duty service. For these reasons, the Veteran was not entitled to a VA examination regarding his claim for service connection for BPH. The Board is grateful for the Veteran's honorable service. However, given the record before it, the Board finds that evidence in this case does not reach the level of equipoise. The claim is denied. Increased Rating Disability ratings are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), which is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; see also Mauerhan v. Principi, 16 Vet. App. 436 (2002). Where the Rating Schedule does not provide for a noncompensable evaluation for a diagnostic code, a noncompensable evaluation shall be assigned when the requirements for a compensable evaluation are not met. 38 C.F.R. § 4.31. The primary concern in a claim for an increased evaluation for service-connected disability is the present level of disability. Although the overall history of the disability is to be considered, the regulations do not give past medical reports precedence over current findings. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, when an appeal is based on the assignment of an initial rating for a disability, following an initial award of service connection for this disability, the rule articulated in Francisco does not apply. Fenderson v. West, 12 Vet. App. 119 (1999). Instead, the evaluation must be based on the overall recorded history of a disability, giving equal weight to past and present medical reports. Id. VA has a duty to consider the possibility of assigning staged ratings in all claims for increase. See Hart v. Mansfield, 21 Vet. App. 505 (2007). 3. Entitlement to an initial disability rating greater than 10 percent for right ankle tendonitis Service connection for right ankle tendonitis was granted in a May 2018 rating decision, and a 10 percent disability rating was assigned, effective June 15, 2014, under 38 C.F.R. § 4.71a, Diagnostic Codes 5024-5271. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned. The additional code is shown after the hyphen. 38 C.F.R. § 4.20 During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Pursuant to Diagnostic Code 5024, tenosynovitis is to be rated based upon limitation of motion of the affected part, as degenerative arthritis. 38 C.F.R. § 4.71a, Diagnostic Code 5024. Diagnostic Code 5024 was not materially changed in the February 2021 amendments to 38 C.F.R. § 4.71a. Under the version of Diagnostic Code 5271 in effect prior to February 7, 2021, a 10 percent rating is assigned for limitation of motion of the ankle that is moderate. A maximum 20 percent rating is warranted for limitation of motion of the ankle that is marked. 38 C.F.R. § 4.71a, Diagnostic Code 5271. As noted, the former rating criteria offered no guidance on the issue of the specific ranges of motion which were considered moderate and marked. Relying on Webster's definition, "marked" means noticeable. Webster's II New College Dictionary, 670 (1995)." Moderate means of average or medium quantity. Id. at 704. Normal ranges of motion of the ankle are dorsiflexion from 0 degrees to 20 degrees, and plantar flexion from 0 degrees to 45 degrees. 38 C.F.R. § 4.71, Plate II. As of February 7, 2021, under the amended criteria, a 10 percent rating is still assigned for limitation of motion of the ankle that is moderate, and a maximum 20 percent rating is still assigned for limitation of motion that is moderate. However, the terms "moderate" and "marked" are defined in the new criteria. Moderate limitation of motion and a 10 percent rating are appropriate when ankle dorsiflexion is less than 15 degrees and plantar flexion is less than 30 degrees. A 20 percent rating is warranted with marked limitation of ankle motion defined as dorsiflexion less than 5 degrees and plantar flexion less than 10 degrees. Under Diagnostic Code 5270, a 30 percent rating is warranted for ankylosis of the ankle in plantar flexion between 30 degrees and 40 degrees, or in dorsiflexion, between zero degrees and 10 degrees. A maximum 40 percent rating is warranted for ankylosis of the ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion, or eversion deformity. Diagnostic Code 5270 was not materially changed in the February 2021 amendments to 38 C.F.R. § 4.71a. For disabilities evaluated based on limitation of motion, VA is required to apply the provisions of 38 C.F.R. §§ 4.40, 4.45, pertaining to functional impairment. See also DeLuca v. Brown, 8 Vet. App. 202 (1995); Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. After thorough consideration of the evidence of record, the Board concludes that an initial disability rating of 30 percent, but no greater, is warranted for right ankle tendonitis. Private medical treatment records from 2016 report complaints of and treatment for right ankle pain due to tendonitis. The Veteran noted that the pain was worse after walking on concrete floors at work. He stated that he tried insoles and supportive shoes with little relief. Private medical treatment records from 2018 note the Veteran's complaints of pain in the feet. He reported that nothing relieved his symptoms, and that they were worse in the morning. On physical examination, there was absent dorsiflexion range of motion at the ankle and increased eversion range of motion of the subtalar joint. There was normal range of motion at the first metatarsophalangeal joints without any pain or crepitus. There was pain with palpation of the central posterior heel, bilaterally, and to a lesser degree across the dorsal midfoot. There was no evidence of gross deformities, instability, asymmetry, or atrophy. Muscle strength was normal and no antalgic gait was found. There was evidence of a bilateral pronation deformity. X-rays of the right and left feet showed degenerative changes to the tarsometatarsal joints and the naviculocuneiform joints. During an April 2021 VA ankle examination, the Veteran reported symptoms including pain and tightness in the right ankle and lower leg. He stated that treatment included resting his ankle by sitting down and prescription medication. He noted that the ankle disability caused difficulty walking at work, limping, and constant pain. He reported flare-ups of ankle symptoms on a daily basis which were moderate to severe, and precipitated by walking or running. The Veteran did not report functional impairment after repeated use over time or instability. On physical examination, active range of motion of the right ankle revealed plantar flexion to 40 degrees with pain and dorsiflexion to 15 degrees with pain. Passive range of motion of the right ankle was the same as active range of motion. There was evidence of pain with weight-bearing, active motion, and passive motion. There was no crepitus or objective evidence of localized tenderness or pain on palpation. The Veteran was able to perform repetitive use testing with three repetitions and no additional loss of range of motion. Repeated use over time and flare-ups elicited functional loss due to pain, and reduced range of motion with plantar flexion to 35 degrees and dorsiflexion to 10 degrees. No additional factors contributing to disability were identified. There was no evidence of muscle atrophy or ankylosis. Anterior Drawer and Talar Tilt Tests were normal, and there was no history of shin splints, stress fractures, Achilles tendon rupture, malunion of the calcaneus or talus, or history of talectomy. The diagnosis was right foot tendonitis. The examiner noted that the Veteran's right ankle disorder impacted his ability to work, as it limited his ability to walk more than two blocks during flare-ups. With consideration of the evidence of record, the Board finds that an initial disability rating of 30 percent is warranted for the Veteran's right ankle disability. Although the April 2021 VA examination showed right ankle range of motion with dorsiflexion to no less than 10 degrees and plantar flexion to no less than 35 degrees, private treatment records from 2018 document absent right ankle range of motion on dorsiflexion. Ankylosis is defined as "immobility and consolidation of a joint due to disease, injury, surgical procedure." Lewis v. Derwinski, 3 Vet. App. 259 (1992) (citing Saunders Encyclopedia and Dictionary of Medicine, Nursing, and Allied Health at 68 (4th ed. 1987). An ankylosed joint is more commonly referred to as "frozen." See, e.g., Dorland's Illustrated Medical Dictionary 286 (32d ed.2012). As the 2018 private treatment records show absent range of motion of the right ankle in dorsiflexion, which equates to immobility of the joint in dorsiflexion, a 30 percent disability rating is warranted under Diagnostic Code 5270 for ankylosis of the ankle. See also, Chavis v. McDonough, 34 Vet. App. 1 (2021) (the ankylosis requirement in 38 C.F.R. § 4.71a can be met with evidence of functional equivalent of ankylosis during a flare.) However, an initial disability rating greater than 30 percent is not warranted under Diagnostic Code 5270, as there is no evidence to suggest ankylosis of the right ankle in plantar flexion at more than 40 degrees, or in dorsiflexion at more than 10 degrees or with abduction, adduction, inversion or eversion deformity. The Board has also considered whether there is any other schedular basis for granting a higher rating, but has found none, as Diagnostic Code 5270 provides for the highest disability rating permissible based upon ankylosis or limited motion of the ankle. Thus, the other diagnostic codes pertaining to rating the ankle do not apply in this case. The Board has considered the doctrine of reasonable doubt but has determined that it is not applicable as the medical and lay evidence establish that a higher rating is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.7, 4.21. REASONS FOR REMAND 1. Entitlement to service connection for bilateral pes planus In an April 2021 Joint Motion for Partial Remand, the parties agreed that remand was warranted to permit the Board to determine whether an October 2018 VA examination was adequate. During the October 2018 VA examination, the Veteran reported that he began experiencing symptoms of pes planus in 1987, during active duty service. He reported symptoms including severe pain in his feet at that time, but that he was not told that he had flat feet until 2018. In an accompanying October 2018 VA opinion, the examiner opined that it was less likely than not that the Veteran's bilateral pes planus was related to his active duty service based upon "the absence of documented symptoms, evaluations, diagnosis, or treatment during military service." A medical opinion based solely on the absence of documentation in the service treatment records or that fails to take into account lay statements is inadequate. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006) (VA examiner's opinion inadequate that relied on the absence of contemporaneous medical evidence); see also Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). Because the October 2018 VA opinion was clearly based on a lack of evidence of pes planus in the service treatment records, and failed to adequately consider the Veteran's competent lay statements of in-service symptoms, remand is warranted for a new VA opinion which adequately addresses the Veteran's lay statements describing his in-service symptoms. 2. Entitlement to service connection for restless leg syndrome; entitlement to service connection for a low back disorder; entitlement to service connection for a headache disorder; and entitlement to service connection for a neck disorder; and entitlement to service connection for IBS The Veteran underwent VA examinations in April 2021 to determine the etiology of his restless leg syndrome, low back disorder, headache disorder, neck disorder, and IBS. With regard to his restless leg syndrome, in a February 2016 Notice of Disagreement, the Veteran reported that his restless leg symptoms began during service and have continued since that time. He also contends that his restless leg syndrome was caused by nerve damage resulting from an in-service right ankle sprain, which is documented in the service treatment records. In an August 2021 VA opinion, the examiner concluded that the Veteran's restless leg syndrome was not related to his active duty service because the "[r]ecords did not show any disability incurred during service that is known to cause [r]estless legs [sic] syndrome." The examiner did not address the Veteran's reported in-service symptoms or his contention that his restless leg syndrome was related to his in-service right ankle injury. In an April 2021 VA examination, the Veteran also reported that his low back disorder began during active duty service after lifting heavy objects. He reported symptoms during service including extreme pain in the lower back. He noted that his symptoms have continued since that time. An August 2021 VA examiner opined that it was less likely than not that the Veteran's low back disorder was related to his active duty service. The only rationale provided by the examiner was that "no records has [sic] been found that will confirm continuity of symptoms . . . ." The examiner did not address the Veteran's lay reports of in-service symptoms which have continued since active duty service. Further, the Board notes that continuity of treatment is not required to demonstrate continuity of symptoms. With regard to the Veteran's headache disorder, the Veteran has provided lay statements that he began experiencing headaches during active duty service after a head injury. He noted that he continues to experience headaches. In August 2021 opinions, a VA examiner concluded that the Veteran's headaches were not related to his active duty service. In one opinion, the examiner explained that the "[r]ecords did not confirm any condition that is related to headache." In another opinion, the same VA examiner explained, although the records showed a head trauma resulting in laceration in 1987 and reports of frequent severe headache in 1989, "no records are found to support continuity of the same symptomatology." Neither opinion considered the Veteran's lay statements of in-service symptoms which have continued since that time. During an April 2021 VA examination, the Veteran reported that his neck disorder started in 1987 after lifting heavy objects, and that he experienced extreme pain in his neck during that time. He noted that he still experiences daily pain. In an August 2021 opinion, the VA examiner opined that the Veteran's neck disorder was not related to his active duty service because the "[r]ecords did not show any consultation or treatment of any condition related to the neck." However, the VA examiner did not address or consider the Veteran's lay statements of in-service injury and symptoms since that time. During an April 2020 VA examination, the Veteran reported the onset of his IBS symptoms in 1987. He noted that he experienced constipation, diarrhea, and pain in his low gut. He noted that his symptoms have continued since then, and that he is still experiencing diarrhea, constipation, abdominal distension, bloating, pain in the gut, fatigue, excessive gas, and anxiety. In an August 2021 VA opinion, the examiner opined that it was less likely than not that the Veteran's IBS was related to his active duty service. The examiner explained that, although the service treatment records documented treatment for constipation and diarrhea during service, "no records are found that demonstrates [sic] continuity of the symptoms to establish [a] nexus to the present diagnosis of irritable bowel syndrome." The examiner did not address the Veteran's lay statements of in-service symptoms and continuing symptoms since that time. As noted above, a medical opinion based solely on the absence of documentation in the service treatment records or that fails to take into account lay statements is inadequate. See Buchanan, 451 F. 3d at 1336-37; see also Acevedo, 25 Vet. App. at 294; Dalton, 21 Vet. App. at 39. Additionally, the regulations do not require a continuity of treatment, but a continuity of symptomatology. See Savage v. Gober, 10 Vet. App. 488, 495-96 (1997); see Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991) ("regulations require a continuity of symptomatology, not continuity of treatment"). Because the VA opinions addressing the etiology of the Veteran's restless leg syndrome, back disorder, headaches, neck disorder, and IBS failed to consider the Veteran's competent lay statements of in-service and post-service symptomatology, new VA examinations are required. 3. Entitlement to service connection for obstructive sleep apnea The Veteran has provided lay statements that he began experiencing symptoms of sleep apnea during his active duty service. He noted that he had headaches, snoring, non-refreshing sleep, memory problems, fatigue, snoring, gasping for air, and dry mouth. Additionally, in a June 2017 statement, C.L. reported that, while serving with the Veteran, he observed the Veteran snore very loudly with periods of time when he would stop breathing and gasp for air. Two VA opinions were obtained in August 2021. In one VA opinion, the examiner stated that the Veteran's sleep apnea was not attributable to a known clinical diagnosis because the records did not show any consultation or treatment relative to sleep apnea during service, and then stated that the claimed disability is etiologically related to the Veteran's active duty service, to include exposure to Gulf War environmental hazards. In the second VA opinion, the examiner reported that the Veteran's sleep apnea was a disease with a clear and specific etiology, and that it is less likely than not that the Veteran's sleep apnea is related to a specific exposure event during service in Southwest Asia. The Board notes that both opinions were provided by the same VA examiner and do not attempt to explain, clarify, or reconcile the contradictory findings. Further, neither VA opinion addressed entitlement to service connection for sleep apnea on a direct basis or considered the lay evidence of in-service symptoms reported by the Veteran and C.L. The opinions are also conclusory in nature, and do not provide sufficient explanation or rationale. Accordingly, a new VA examination is warranted. 4. Entitlement to service connection for erectile dysfunction, to include as secondary to a service-connected disability As an August 2021 VA opinion links the Veteran's erectile dysfunction to his obstructive sleep apnea, the claim for entitlement to service connection for erectile dysfunction is inextricably intertwined with the claim for entitlement to service connection for sleep apnea. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 5. Entitlement to service connection for right foot gout The Veteran contends that his right foot gout is related to his active duty service. Although the Veteran was provided with a VA examination to determine the existence of right foot gout in April 2021, a VA opinion regarding the etiology of the right foot gout was not provided. Nevertheless, in an April 2021 VA feet examination, the examiner noted that the Veteran "had gout because of comorbidity of stress that occurred during his active duty . . . ." This suggests that the Veteran's gout may be related to his active duty service; however, it does not provide a clear etiological opinion. As the Veteran has not yet undergone a VA examination to assess the etiology of his right foot gout, a VA examination is warranted. 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i); see also McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). 6. Entitlement to service connection for a left foot bone spur and entitlement to service connection for a right foot bone spur The Veteran contends that service connection for right and left foot bone spurs is warranted on a direct basis, or as secondary to his service-connected right ankle tendonitis. In December 2018, the Veteran's representative cited medical treatise evidence to support the conclusion that heel spurs are caused by strain on the feet and ligaments, and that the right ankle sprain documented in the service treatment records constituted a strain on the ligaments. In compliance with the Board's June 2020 Remand, the Veteran underwent a VA examination in April 2021 to assess the etiology of his right and left foot bone spurs. In an August 2021 VA opinion, the examiner concluded that the Veteran's bone spurs were not proximately due to or the result of his service-connected right ankle disability. However, the rationale provided is conclusory, as the examiner merely provided some general information as to what a bone spur is and stated "therefore it is less likely than not that it is due to service-connected right ankle tendonitis." Furthermore, the examiner cited medical treatise evidence which states that heel spurs are often caused by strains on foot muscles and ligaments, but did not address the impact of the Veteran's in-service right ankle sprain on his later development of bone spurs. Last, the examiner did not address the medical treatise evidence cited by the Veteran's representative in his December 2018 statement. Accordingly, a new VA examination which provides a meaningful discussion of the impact of the Veteran's right ankle disability on his heel spurs and addresses the pertinent evidence of record is warranted. Additionally, in an April 2021 VA foot examination, the examiner reported that the Veteran's bone spurs "began because of cartilage damage due to injuries in 1987 while aboard [the] USS Saratoga." As the examiner did not provide a clear etiological opinion as to whether the Veteran's heel spurs are directly related to his active duty service but suggests a potential connection, a new VA examination is warranted to provide an opinion for entitlement to service connection for right and left foot heel spurs on a direct basis. The matters are REMANDED for the following action: 1. Provide the Veteran with a new VA examination by an appropriate physician to determine the etiology of his bilateral pes planus. To the extent possible, the examiner should be different from the October 2018 examiner. The Veteran's claims file, all electronic records, and a copy of this remand must be reviewed by the examiner, and the examiner must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, the VA examiner must state whether it is at least as likely as not (i.e., a 50 percent probability or more) that the Veteran's bilateral pes planus was caused or incurred as a result of his active duty service. A complete rationale for all opinions must be provided. The examiner must consider and discuss all pertinent evidence in the claims file, to include the Veteran's lay statements regarding in-service and post-service symptomatology. Specifically, the examiner is asked to address the Veteran's lay statements that he experienced symptoms of foot pain during active duty service and continuously since service discharge. Also, the examiner is advised that the Veteran is competent to report observable symptomatology. 2. Provide the Veteran with new VA examinations by an appropriate physician to determine the etiology of his restless leg syndrome, back disorder, headaches, neck disorder, and IBS. To the extent possible, the examiner should be different from the August 2021 VA examiner. The Veteran's claims file, all electronic records, and a copy of this remand must be reviewed by the examiner, and the examiner must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, the VA examiner must state whether it is at least as likely as not (i.e., a 50 percent probability or more) that the Veteran's restless leg syndrome, back disorder, headaches, neck disorder, and/or IBS was caused or incurred as a result of his active duty service. A complete rationale for all opinions must be provided. The examiner must consider and discuss all pertinent evidence in the claims file, to include the Veteran's lay statements regarding in-service and post-service symptomatology. Specifically, the examiner is asked to address the Veteran's lay statements that he experienced symptoms of restless leg syndrome, back disorder, headaches, neck disorder, and IBS during active duty service and continuously since service discharge. Also, the examiner is advised that the Veteran is competent to report observable symptomatology. 3. Provide the Veteran with a VA examination by an appropriate clinician to determine the etiology of his sleep apnea. To the extent possible, the examiner should be different from the April 2021 VA examiner. The Veteran's claims file, all electronic records, and a copy of this remand must be reviewed by the examiner, and the examiner must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, the VA examiner must state whether it is at least as likely as not (i.e., a 50 percent probability or more) that the Veteran's sleep apnea was caused or incurred as a result of the Veteran's active duty service. A complete rationale for all opinions must be provided. The examiner must consider and discuss all pertinent evidence in the claims file, to include the Veteran's lay statements and the lay statement of C.L. regarding in-service and post-service symptomatology. Also, the examiner is advised that the Veteran is competent to report observable symptomatology. 4. Provide the Veteran with a VA examination by an appropriate clinician to determine the etiology of his right foot gout. The Veteran's claims file, all electronic records, and a copy of this remand must be reviewed by the examiner, and the examiner must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, the VA examiner must state whether it is at least as likely as not (i.e., a 50 percent probability or more) that the Veteran's right foot gout was caused or incurred as a result of the Veteran's active duty service. A complete rationale for all opinions must be provided. The examiner must consider and discuss all pertinent evidence in the claims file, to include the Veteran's lay statements regarding in-service and post-service symptomatology. Additionally, the VA examiner should address the April 2021 VA examiner's statement that the right foot gout occurred due to a comorbidity of stress that occurred during the Veteran's active duty service. Also, the examiner is advised that the Veteran is competent to report observable symptomatology. 5. Provide the Veteran with a VA examination by appropriate physician to determine the etiology of his right and left foot heel spurs. To the extent possible, the examiner should be different from the August 2021 examiner. The Veteran's claims file and a copy of this remand must be reviewed by the examiner, and the examiners must state that this evidence was reviewed in the examination report. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be accomplished. Based upon a complete review of the evidence of record, to include the Veteran's lay statements, the VA examiner must opine as to whether it is at least as likely as not (i.e., a 50 percent probability or more) that the Veteran's right and/or left foot heel spurs were incurred in or caused by his active duty service. The examiner should also provide an opinion as to whether the Veteran's right and/or left foot heel spurs were proximately due to or aggravated by his service-connected right ankle tendonitis. Aggravation is defined as any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease. The examiner is advised that a finding that heel spurs were aggravated beyond the normal progression due to a service-connected disability does not require evidence of permanent worsening and may encompass any additional impairment in earning capacity resulting from an already service-connected condition. A complete rationale for all opinions must be provided. The examiner must consider and discuss the Veteran's lay statements and is advised that the Veteran is competent to report observable symptomatology. The examiner must also consider and discuss the medical treatise evidence cited by the Veteran's representative in his December 2018 statement as well as the April 2021 VA examination which noted that the Veteran's bone spurs began because of cartilage damage due to injuries in 1987 while aboard the USS Saratoga. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Katz, 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.