Citation Nr: 21071184 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 06-28 256 Date: November 30, 2021 ORDER Entitlement to service-connection for obstructive sleep apnea (OSA), as secondary to service-connected posttraumatic stress disorder (PTSD) and as caused by obesity caused by his service-connected disabilities, is granted. Entitlement to a rating in excess of 30 percent for bilateral plantar fasciitis is denied. Entitlement to an effective date earlier than May 25, 2004 for the award of service connection for asthma (also claimed as bronchitis) is denied. Entitlement to an effective date earlier than May 25, 2004 for the award of service connection for bilateral plantar fasciitis is denied. REMANDED Entitlement to a rating in excess of 30 percent for asthma (also claimed as bronchitis) is remanded. FINDINGS OF FACT 1. The Veteran's OSA is shown to be at least as likely as not (50 percent or greater) causally or etiologically related to his obesity which was caused by his service-connected disabilities. 2. The competent evidence of record does not show that the Veteran's bilateral plantar fasciitis included symptoms of bilateral involvement with pronounced symptoms; marked pronation, extreme tenderness of plantar surfaces of the feet, or marked inward displacement with severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 3. The Veteran filed his initial claim for VA disability benefits related to his asthma (also claimed as bronchitis) in May 2004, which is more than one year after he separated from active military service. 4. The Veteran filed his initial claim for VA disability benefits related to his bilateral plantar fasciitis in May 2004, which is more than one year after he separated from active military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for OSA have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to a disability rating in excess of 30 percent for bilateral plantar fasciitis have not been met. 38 U.S.C. § 1155; 38 C.F.R. § 4.71a, DC 5276. 3. The criteria for an earlier effective date for the award of entitlement to service connection for asthma have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. 4. The criteria for an earlier effective date for the award of entitlement to service connection for bilateral plantar fasciitis have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy (USN) from April 1980 to November 1986. He also served in the Army National Guard from 1987 until his retirement in September 2003, which included periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). His last period of ACDUTRA ended in July 2002. See Information Report dated April 3, 2020. The issue of entitlement to service connection for OSA returns to the Board of Veteran's Appeals (Board) after our June 2020 remand for additional development by the Department of Veterans Affairs (VA) Regional Office (RO) which is the agency of original jurisdiction (AOJ). The issues of entitlement to an increased rating for bilateral plantar fasciitis and asthma (also claimed as bronchitis), and an earlier effective date for both, come from the Veteran's appeal of a November 2016 rating decision which implemented the grant of entitlement to service connection for these disabilities by the Board's October 2016 decision. In the November 2016 rating decision, the Veteran's asthma disability was evaluated at a 30 percent disability rating, and his bilateral plantar fasciitis at a non-compensable evaluation of 0 percent disabling. Service connection for both disabilities was effective May 26, 2004, the date the Veteran filed his initial claim for compensation. The evaluation for his bilateral plantar fasciitis was subsequently increased to 10 percent disabling in a March 2019 rating decision, and again increased to 30 percent disabling in a January 2021 rating decision. Both of these increases were also effective for May 26, 2004. However, as these decisions did not constitute a full grant of the benefits sought on appeal, the claims for increased ratings remains before the Board. AB v. Brown, 6 Vet. App. 35 (1993). 1. Entitlement to service-connection for obstructive sleep apnea (OSA), The Veteran asserts that his OSA developed during or as a result of his military service, or that it developed as a secondary condition due to his service-connected posttraumatic stress disorder (PTSD) and/or bilateral plantar fasciitis which caused him to not be able to exercise regularly, thereby causing him to gain weight and become obese, which caused his OSA. VA concedes that the Veteran has a current diagnosis of OSA as of August 2002 and that he has gained weight since his separation from active service and is now considered obese. See Nocturnal Polysomnogram, August 1, 2002. He was granted service connection for his PTSD and bilateral plantar fasciitis disabilities, as well as neuralgia of his bilateral external popliteal nerves associated with his plantar fasciitis, all effective May 2004. Giving the Veteran the benefit of any reasonable doubt, the evidence supports a finding that his OSA was caused by his obesity which was caused or aggravated beyond its natural progression by his service-connected disabilities. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service-the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Active military service includes: (1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 C.F.R. § 3.6 (a). Service connection is available for injuries and diseases incurred during active duty or ACDUTRA but, except for the exceptions listed, only for injuries, and not diseases, sustained on INACDUTRA. Brooks v. Brown, 5 Vet. App. 484 (1994). If a claim relates to period of active duty for training, a disease or injury resulting in disability must have manifested itself during that period. Paulson v. Brown, 7 Vet. App. 466 (1995). ACDUTRA includes full-time duty performed for training purposes by members of the Reserves. 38 C.F.R. § 3.6(c). INACDUTRA is generally duty, other than full-time duty, prescribed for Reserves or duty performed by a member of the National Guard of any State, other than full-time duty. 38 U.S.C. § 101 (23); 38 C.F.R. § 3.6 (d). Annual training is an example of active duty for training, while weekend drills are examples of inactive duty training. With respect to members of the Army National Guard, ACDUTRA means full-time duty under section 316, 502, 503, 505 of title 32, or the prior corresponding provisions of law. 38 U.S.C. § 101 (22)(c). Service department records are binding on VA for purposes of establishing service in the U.S. Armed Forces. Duro v. Derwinski, 2 Vet. App. 530, 532 (1992). Establishing service connection on a secondary basis requires evidence sufficient to show that (1) a current disability exists and (2) the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 48 (1995) (en banc). As stated in the June 2020 Board Remand, we noted that obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38C.F.R. §3.310(a). See VAOPGCPREC 1-2017. However, in order to show secondary service connection is warranted under such a theory, a veteran must show (1) that his service-connected disability caused him to become obese; and, if so, (2) whether the obesity, as a result of the service-connected disability(ies), was a substantial factor in causing his claimed condition; and (3) whether the claimed condition would not have occurred but for obesity caused by the service-connected disability. Id. The Veteran's active-duty military service treatment records (STRs) do not contain complaints of, treatment for, or any diagnosis of OSA or related conditions. Nor are there any records which show that he developed OSA to a compensable level within one year of his separation from active military in November 1986. There were, however, several entries related to his allergies, hay fever, asthma, and respiratory issues. The Veteran was diagnosed with OSA in 2002, which was after his separation for active military service, but prior to his retirement from the Army National Guard in November 2003. OSA is not considered an injury sustained while on either ACDUTRA or INACDUTRA. Similarly, it is not a disease which would have been incurred during his ACDUTRA, even though it may have been present during his periods of ACDUTRA. VA received written lay witness "buddy" statements from the Veteran's wife, who is a registered nurse and at that time still on active duty, his father, and three service members with whom he served. All of these lay witnesses were consistent in their account of how the Veteran started to gain weight after he suffered service-related injuries, including his bilateral plantar fasciitis, and which began around or shortly after 1997. They were also consistent that the Veteran told him at that time he was not able to exercise like he used to because of the injuries and that he started to gain weight because of the limitations on his bility to exercise. VA received medical records dated August 2002 and May 2003 from the Veteran's private medical provider, Dr. W.B., through whom the Veteran's August 2002 nocturnal polysomnogram was requested and his diagnosis of OSA was first made. Dr. W.B. noted the Veteran's obesity, history of depression, bilateral plantar fasciitis, very loud snoring problems which began about 4 years prior (approximately 1998), and his "clear" diagnosis of OSA. In the May 2003 follow-up notes, Dr. W.B. references the Veteran's subsequent gastric bypass surgery after which he lost a significant amount of weight, with his weight recorded at that time to be 263 pounds, which caused an adjustment to his CPAP settings. The Veteran was provided a VA examination in December 2011 for his OSA, as well as his bilateral feet conditions and asthma/respiratory disability. During these examinations the Veteran stated he was not able to walk for an extended period of time due to his bilateral plantar fasciitis. On physical examination, the Veteran's weight was 229 pounds, and while his gait was normal, he was noted to use orthotic inserts for his bilateral plantar fasciitis. The VA examiner acknowledged the August 2002 diagnosis of OSA but opined that the Veteran's OSA was less likely caused by or aggravated by his military service, and that his OSA was more likely caused by his obesity, for which he was documented with Class II obesity in 1998 and Class III obesity in 2002 prompting his gastric bypass surgery in February 2003. In support of this opinion, the VA examiner listed his history of weight gain, starting with a December 1998 consultation which recorded weight of 276 pounds, and BMI of 35.43, Class II obesity, and his weight history thereafter, through his gastric bypass surgery from which he lost almost 50 pounds which resulted in adjustment to his CPAP settings. In an April 2012 Independent Medical Expert Medical Opinion prepared by Dr. C.B., he noted the Veteran's bilateral fasciitis, post-April 1999 bilateral plantar fasciotomy surgery, from which at the time of the April 2012 examination he continued to have bilateral pain on palpation with bilateral flat feet and bilateral limping and swelling in his feet which are regularly painful and numb, and he was unstable on his feet. Dr. C.B, stated it is at least a 90 percent level of probability that he gained weight due to his service-connected injuries and inability to exercise. Concerning his OSA, Dr. C.B. opined that it is at least 90 percent probably that his OSA is due to his military trauma and injuries which caused him to gain weight, up to 312 pounds since he separated form service, and that excess weight is a well-known cause of sleep apnea. Dr. C.B. further stated that the Veteran's records do not support another more plausible etiology for his current sleep apnea pathology or other risk factors (in or out of service). Dr. C.B. also referenced that the December 2011 VA examiner stated that his sleep apnea is less likely caused by service but caused by exogenous weight gain, but she did not discuss whether the Veteran's weight gain is likely due to his service time knee injury or bilateral foot problems. Dr. C.B. also referenced a published medical treatise in support of his opinion. September 2012 medical records for the Veteran's podiatrist, Dr. R.S., record that he complained of pain in both of his feet, and that after his feet injuries, his pain continued to get worse, especially with running and other physical training. An Independent Medical Evaluation was prepared by Dr. D.L. in October 2013, for which he provided the Veteran an in-person examination. Dr. D.L. recorded the Veteran's relevant history to include gain weight due to his PTSD/ mental health condition and that due to his feet injuries he was unable to exercise on a regular basis which caused him to continue to gain weight, reaching his maximum weight of 319 pounds with a BMI of 39. At that time, he was diagnosed with OSA, and then underwent gastric bypass surgery. At the time of this physical examination, the Veteran weighed 225 pounds with a BMI of 28. Dr. D.L. opined that the Veteran's OSA is greater than at least as likely as not (more than 50 percent probability) related to his military service and is a service-connected condition. He also opined that it is at least as likely as not that his obesity was exacerbated and increased due to his service-connected PTSD and mental health conditions and this obesity was the cause of his OSA. He further opined that his obesity was exacerbated and increased due to his inability to exercise because of his service-connected bilateral feet disabilities. He also stated that the December 2011 VA examiner did not address the possible causes of the Veteran's obesity when evaluating the claim and as part of her opinion that his OSA was not related to his military service. The record contains a January 2020 VA medical opinion on whether the Veteran's sleep apnea was at least as likely as not aggravated beyond its natural progression by his service-connected asthma (also claimed as bronchitis) bilateral plantar fasciitis, or PTSD. The VA examiner opined that the Veteran's obstructive sleep apnea was less likely than not aggravated beyond its natural progression by his service-connected asthma, bilateral plantar fasciitis, or PTSD. This was based on the stated facts that when he was diagnosed with OSA he was obese, and that after he lost weight due to gastric bypass surgery his CPAP pressure was adjusted suggesting that his OSA was improving though the Board notes he continued to use his CPAP for OSA. It was also note that in his December 2011 OSA disability benefits questionnaire (DBQ) there were no objective findings of signs and symptoms attributable to sleep apnea such as hypersomnolence, evidence of chronic respiratory failure with carbon dioxide retention and cor pulmonale to suggest a worsening of the veteran's condition beyond its natural progression. Finally, the VA examiner stated that common medical knowledge does not support OSA as being caused by or aggravated by inflammatory airway conditions, foot conditions, nor mental disorders, however, as it is medically known to be an anatomic problem resulting from obesity, its number one risk factor. This opinion appears to be related to a direct causal link. The Veteran was subsequently afforded a new OSA VA examination in December 2020, as directed in the June 2020 Board Remand. The VA examiner opined that the Veteran's OSA was less likely than not (less than 50 percent probability) incurred in or caused by his claimed in-service snoring and/or weight gain. The VA examiner based this on the general assertions that sleep apnea affects a large population in the United States, many people have sleep apnea that is not associated with any underlying medical conditions, and that anybody can have OSA, including those not over-weight. The VA examiner also stated that obesity and snoring have not always been shown to be linked with OSA and that it has not shown to be so in the Veteran's case, though the examiner did not provide specific facts to support that assertion. The Veteran's weight gain was not believed to have a correlation to his sleep apnea and that while he might have gained a few pounds, there is no correlation. The VA examiner also stated that he is not morbidly obese. The VA examiner did not address other medical opinions which stated that the Veteran's OSA was likely caused by his obesity, give specifics of why this Veteran's OSA was not caused by his obesity, comment on the numerous and consistent "Buddy" statements, or acknowledged his documented weight gain and Class II and III obesity findings. The VA examiner also opined that the Veteran's OSA was less likely than not (less than 50 percent likely) due to or the result of, or aggravated beyond its natural progression by, his service-connected PTSD with persistent depressive disorder. The VA examiner based this on the general statement that many people have sleep apnea that is not associated with any underlying medical conditions and there is no correlation or medical evidence to show that PTSD or depression is to be associated with OSA. Again, there was very limited analysis of this specific Veteran's medical history or medical issues. The VA examiner provided several other opinions which were also based primarily on general statements with very little analysis based on this Veteran's specific medical history and/or how his medical conditions relate to his other service-connected disabilities. In a subsequent VA medical opinion of February 2021, the same VA examiner provided ten additional opinions, all of which were negative as to a nexus between the Veteran's OSA and any of the claimed theories of etiological causation, including that obesity, snoring, asthma, mental health disorders such as PTSD, and bilateral plantar fasciitis or other foot conditions alone are not causes of OSA, snoring is not a cause of OSA. Again, these opinions were largely based on general medical assertions and did not analyze to any detail, or in many cases consider much of this Veteran's medical history, to include the medical opinions which did assert a causative connection between his obesity and his OSA, or the several lay statements which described the Veteran's weight gain which the Veteran at the time attributed to his reduced ability to exercise due to his service-connected disabilities. Other evidence of record, including those received from the Social Security Administration (SSA), do not add any additional relevant evidence contrary to the evidence described above. Analysis Based on the evidence of record, the Board finds that the competent medical evidence is at least in relative equipoise that the Veteran's OSA is the result of his obesity which was caused by or aggravated beyond its natural progression due to his service-connected disabilities which limited his ability to exercise on a regular basis. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the VA 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). The Board finds the opinions which relate the Veteran's OSA to his obesity to be the most probative. This was the consistent and prevailing opinion on the etiology of his OSA when the issue was related to whether it was caused or aggravated by his PTSD or foot disabilities directly. Changing the inquiry to whether his service-connected disabilities caused his obesity does not render those opinions incorrect or moot. The Board finds the opinions provided by the examiner in the December 2020 and 2021 medical opinions to be inadequate and of lesser probative value. These opinions were not based on an adequate or complete set of facts related to this specific Veteran. The examiner relied primarily on general medical assertions without explaining how or why they applied to this Veteran's OSA. The examiner also did not address the numerous other medical opinions which did indicate that obesity is a well-known and number one risk factor for and was the most likely cause for his OSA. This VA examiner also did not even mention the Veteran's or his "Buddy's" statements concerning how he gained weight after his in-service injuries and that he attributed his weight gain at that time to his inability to regularly exercise because of these service-connected disabilities. The Court has held that the Board is free to assess medical evidence and is not compelled to accept a physician's opinion. Wilson v. Derwinski, 2 Vet. App. 614 (1992). A bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The Court also has held that the value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion." Bloom v. West, 12 Vet. App. 185, 187 (1999). Thus, a medical opinion is inadequate when it is unsupported by accurate or the full range of clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). Lay witnesses, including the Veteran making the claim, are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed or experienced, and which are within the realm of his or her personal knowledge. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); 38 C.F.R. § 3.159 (a). However, without specialized medical training a lay witness is not competent to either diagnose or make a nexus opinion concerning most medical conditions. Layno v. Brown, 6 Vet. App. 465, 470 (1994). Overall, the Board finds these lay witnesses to be both competent and credible in their very consistent statements that the Veteran started to gain weight after his service-connected injuries many years ago, and the Veteran's explanation that it was these disabilities which caused him to not be able to exercise on a regular basis and thus gain weight. These statements are also consistent with the documented medical records which record his steady weight gian and statements to his providers of the pain and limitations from these disabilities. Here, the Veteran's wife is a trained registered nurse, and her observations related to his stated difficulties with his service-related disabilities and his weight gain are matters which are within her medical training and knowledge, and therefore her testimony is afforded a higher probative value. Given the strong and consistent competent evidence which indicates the Veteran's obesity is a major and likely primary cause of his OSA, and that his weight gain was caused by his inability to exercise due to difficulties from his service-connected disabilities, the Board finds that his obesity was caused by or aggravated by his service-connected disabilities, and that his obesity is an intermediate step towards his development of OSA. The claim for entitlement to service connection for OSA is granted. 2. Entitlement to a higher evaluation for bilateral plantar fasciitis The Veteran contends that his bilateral plantar fasciitis is more disabling than is compensated for in his current 30 percent disability rating. His entitlement to service connection and disability rating for this disability are effective and begin May 26, 2004. The Veteran's bilateral plantar fasciitis is rated under diagnostic code (DC) 5276 acquired flatfoot. 38 C.F.R. § 4.71a. Disability ratings are determined by applying the criteria set forth in the VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity resulting from disability. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. When assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for the higher evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. Separate ratings may be assigned for separate periods of time based on the facts found. This practice is known as "staged" ratings." Fenderson v. West, 12 Vet. App. 119, 126-127 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). The Board notes that the Schedule for Rating Disabilities: Musculoskeletal System and Muscle Injuries was amended in February 2021 to include Diagnostic Code 5269 for plantar fasciitis. See 85 Fed. Reg. 76453, 76464 (Nov. 30, 2020) and 86 Fed. Reg. 8142 (Feb. 4, 2021) (to be codified at 38 C.F.R. § 4.71a, Diagnostic Code 5269). However, the maximum rating permitted under this DC is 30 percent, and thus consideration under this DC would yield no increased benefit to the Veteran. The Veteran was assigned a non-compensable initial disability rating in a November 2016 rating decision. He was granted his first rating increase to 10 percent disabling in a March 2019 rating decision. Thereafter, his rating was increased to 30 percent disabling, effective May 26, 2004, in a January 2021 rating decision. This increase was based on accentuated pain on manipulation and use of his feet, bilaterally. Under DC 5276, a 50 percent rating is awarded on a showing of pronounced bilateral flatfoot with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. This is the highest rating permitted under this DC. 38 C.F.R. § 4.71a. In the Veteran's December 2020 VA examination, he was noted to only have a diagnosis of bilateral plantar fasciitis. He stated the history of his bilateral plantar fasciitis to have its onset in 1993 that started the process of painful feet which required fasciotomy in 1999, which then improved. He did not have tenderness at the base of the heel, he was able to walk on his toes and heels without any problems and there were no signs of acute inflammatory changes. He did claim flare-ups intermittently with the gaps between. His current symptoms were described as flare-ups every couple of weeks which resolve, though objectively none observed on this examination, and he complained of pain which the examiner did not notice any facial expressions (Chang's facial expression chart) and he was able to stand on his toes, take 5 steps, stand on his heels and take 5 more steps. Treatment history included bilateral fasciotomies by history alone with faint scars noticed on the heels, right more apparent than the left which was barely visible. These scars were not painful or unstable; and did not have a total area equal to or greater than 39 square cm (6 square inches). The Veteran did not have any arthritic or inflammatory conditions in either foot, and physical examination revealed accentuated pain on use and manipulation of both feet without swelling or characteristic calluses on either foot. He did not report use of orthotics. Examination also revealed no extreme tenderness of plantar surfaces, decreased longitudinal arch height of one or both feet on weight-bearing, objective evidence of marked deformity of one or both feet (pronation, abduction etc.), marked pronation of one foot, the weight-bearing line falling over or medial to the great toe on either foot, lower extremity deformity other than pes planus, causing alteration of the weight-bearing line, "inward" bowing of the Achilles' tendon (i.e., hindfoot valgus, with lateral deviation of the heel) of either foot, marked inward displacement with severe spasm of the Achilles' tendon (rigid hindfoot) on manipulation on either foot, or tenderness on palpation of the insertion of the plantar fascia on the heel and on the MTP joints of the feet. There were no residual signs or symptoms due to his foot surgeries. While the Veteran complained of pain, this was purely subjective, there was no objective evidence of such. The examiner found that the Veteran's bilateral plantar fasciitis disability did not cause any loss or limitation of motion. There was found to be no pain, weakness, fatigability, or incoordination that significantly limits his functional ability during flare-ups or when the foot is used repeatedly over a period of time, or evidence of other functional loss. There was found impact on his ability to perform any type of occupational task such as standing, walking, lifting, sitting, etc. Concerning the Correia criteria, no pain was noted bilaterally during either weight-bearing or non-weight bearing, or on ambulation, passive and active motion, and he was able to walk, stand on his toes and take 5 steps and stand on his heels and take 5 steps without demonstrable pain. The Veteran was not examined during a flare-up. The October 2, 2013 Independent Medical Evaluation prepared by Dr. D.L., submitted to support the Veteran's claim for service connection, indicated he had pain in the arches of both feet at the attachment of the plantar fascia on the right and left calcaneus bones. Physical examination showed bilateral tenderness to palpation along the plantar fascia at the insertion to the calcaneus and numbness to pinprick. Records from Dr. R. S., podiatrist, dated September 2012, indicate an initial and single consult for complaints of numbness in both of his feet which has been present for years. He indicated that he has used custom orthotics which he does use. Pain was described as 8 to 10 on a scale of 1 to 10, and as numbness, sharp, shooting, throbbing, aching, burning, and tingling. The pain was reported to get worse the longer he is on his feet. The pain was stated to be present with shoe wear, touch, walking, and weight-bearing. After his foot surgeries, he continued to report numbness in his forefeet, which was due to his diagnosed neuritis and neuropathy. Physical examination revealed deep tendon responses to be intact and symmetrical in both feet, proprioception was intact in both feet, vibratory sensation was very diminished in both feet, and he was unable to sense the Semmes-Weinstein 5.07 monofilament across all areas of his plantar surfaces for both feet. No Babinski response was noted in either the right or left foot. The assessment was pain in his feet with numbness and neuropathy, and diagnoses of pain in his limb and mononeuritis of an unspecified site. The Veteran was advised to consult with his local physicians at home. The December 2011 VA examination provided to the Veteran for the initial purpose of determining entitlement to service connection, recorded diagnoses only of bilateral plantar fasciitis in April 1999, currently described as begin of mild functional limitation, and right foot avulsion fracture in 1998. The Veteran reported that he was then currently not able to run and instead rides a bike or uses elliptical machines for exercise and he avoids long walks, and his feet condition is why he changed his career to teaching. Use of orthotic inserts on both feet on a constant basis was recorded. Physical examination indicated normal gait with the ability to walk heal to toe and perform heal walk, with normal plantar Babinski reflex, and dorsi and plantar flexion of feet and toes. No planus or cavus abnormalities, or painful motion, edema, weakness, instability or tenderness was seen. Functional limitations with standing and walking included difficulty walking without orthotics as both feet swell up. Calluses on both heels indicated abnormal weight bearing, however there was no achilles tendon misalignment or pain with foot manipulation (pes planus). Overall, there was stated to be no deformity, malalignment, drainage, tenderness, edema, redness, heat, spasms, painful motion, abnormal movement, guarding of movement, fatigue, lack of endurance, weakness, atrophy, incoordination, instability, or pertinent abnormal weight bearing, except as noted above. There was no loss of function with repetitive use, except as noted above. Loss of function, due to flare-ups was stated to be unable to be determined without resorting to mere speculation (DeLuca). The examiner described functional impact from his bilateral plantar fasciitis was described as not being able to walk for an extended period of time. The Veteran is currently awarded a 20 percent disability rating for both his left and right neuralgia of his external popliteal nerves associated with his plantar fasciitis, all effective May 2004. Thus, he is currently receiving compensation for his neurological disabilities related to his bilateral plantar fasciitis for the entire appeal period. While VA's rating schedule recognizes that a single disability may result from more than one distinct injury or disease, rating the same disability or its manifestation(s) under different DCs - a practice known as pyramiding - is prohibited. See 38 C.F.R. § 4.14. The critical element in permitting the assignment of several evaluations under various DCs is that none of the symptomatology for any one of the disorders is duplicative or overlapping with the symptomatology of the other disorder. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). Based on review of the relevant evidence, the Board finds that the Veteran's level of severity of his bilateral plantar fasciitis most closely correlates with a 30 percent rating for the entire appeal period. This is his currently assigned disability rating level. The preponderance of the evidence is against a higher schedular rating for any time during the appeal period as the evidence did not show bilateral involvement with pronounced symptoms; marked pronation, extreme tenderness of plantar surfaces of the feet, or marked inward displacement with severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances. 38 C.F.R. § 4.71a, DC 6276. The claim for an increased rating for bilateral plantar fasciitis is denied. Effective Date 3. Entitlement to an earlier effective date for asthma 4. Entitlement to an earlier effective date for bilateral plantar fasciitis For original claims for disability benefits the effective date of an award of disability compensation, in conjunction with a grant of entitlement to service connection, shall be the day following separation from active service or the date entitlement arose if the claim is received within one year of separation from service; otherwise, the effective date shall be the date of receipt of the claim, or the date entitlement arose, whichever is later. 38 U.S.C. § 5110; 38 C.F.R. § 3.400(b)(2)(i). Separation from service means separation under conditions other than dishonorable from continuous active service which extended from the date the disability was incurred or aggravated. 38 U.S.C. § 5110(b)(1); 38 C.F.R. § 3.400(b)(2)(i). The Veteran filed his initial claim for disability benefits related to his asthma and bilateral plantar fasciitis on May 26, 2004. The record does not indicate that he filed any earlier claims, notices of claims, or intent to file a claim prior to that date. The Veteran separated from active-duty military service in November 1986, which is more than one year prior to his filing his initial clam for benefits; therefore, that provision does not apply. Even assuming, arguendo, that this provision could apply to periods of ACDUTRA, his last period of ACDUTRA ended in July 2002, which is also more than one year prior to his filing the claim for benefits. See Information Report dated April 3, 2020. Therefore, even though the Veteran's asthma and/or plantar fasciitis may have manifested earlier, by law, the effective date of his award for entitlement to service connection is the date on which he filed his claim, May 26, 2004. The Veteran has no alleged that he filed a claim prior to May 26, 2004, and he has not provided any other argument or contention related to these appeals. Therefore, the facts are clear and not in dispute. As such, all evidence of record supports the currently assigned effective date for each appeal. The claims for an earlier effective date for asthma and bilateral plantar fasciitis are denied. REASONS FOR REMAND 1. Entitlement to a higher evaluation for asthma. The Veteran claims he is entitled to a higher disability rating for his service-connected asthma. This disability is currently rated as 30 percent disabling, effective the date he filed his initial claim for VA disability benefits for this condition. His last VA examination related to asthma was in December 2011. Since that time, the Veteran has submitted very few documents to support the claim for an increased rating, and private medical opinions submitted were related to the establishment of entitlement to service connection and they also are quite dated. See, e.g., Independent Medical Evaluation prepared by Dr. D.L., on October 2, 2013. The evidence of record indicates that Veteran has not been treating for this condition through VA medical facilities or with VA medical providers. While additional delay is unfortunate, an updated VA examination is needed as the December 2011 VA examination most likely no longer reflects the current level of severity of the Veteran's disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007); Snuffer v. Gober, 10 Vet. App. 400 (1997). The matters are REMANDED for the following action: 1. Take reasonable efforts to obtain any additional VA or military medical (e.g., Tri-Care) treatment records for the Veteran not already part of the record. Attach copies of this evidence to the Veteran's file. 2. Thereafter, provide the Veteran with a VA examination to determine the current level of severity for his asthma (also claimed as bronchitis) disability. R. FEINBERG Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Bannach 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.