Citation Nr: 21077515 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 17-55 158 DATE: December 30, 2021 ORDER New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for bilateral pes planus is granted. New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for bilateral plantar fasciitis is granted. New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for bilateral plantar tendonitis is granted. New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for heel spurs is granted. New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for a right knee disability is granted. New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for a left knee disability is granted. New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for a right ankle disability is granted. New and material evidence having been received, the application to reopen the previously denied claim of entitlement to service connection for a left ankle disability is granted. Entitlement to service connection for bilateral pes planus is granted. Entitlement to service connection for bilateral plantar fasciitis is granted. Entitlement to service connection for bilateral plantar tendonitis is granted. Entitlement to service connection for heel spurs is granted. Entitlement to service connection for a right knee disability is granted. Entitlement to service connection for a left knee disability is granted. Entitlement to service connection for a right ankle disability is granted. Entitlement to service connection for a left ankle disability is granted. FINDINGS OF FACT 1. In a February 2003 rating decision, the RO denied the Veteran's claims of service connection for bilateral pes planus, a bilateral knee disability, and a bilateral ankle disability. 2. In a January 2004 rating decision, the RO confirmed and continued the previous denial of service connection for bilateral pes planus, a bilateral knee disability, and a bilateral ankle disability, and denied service connection for bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs. The Veteran was duly notified of the decision and his appellate rights, but he did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of notification. 3. In a May 2006 rating decision, the RO confirmed and continued the previous denial of service connection for bilateral pes planus, a bilateral knee disability, a bilateral ankle disability, bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs. The Veteran was duly notified of the decision and his appellate rights, but he did not perfect an appeal within the applicable time period, nor was new and material evidence received within one year of notification. 4. Evidence received since the final May 2006 rating decision confirming the previous denial of service connection for bilateral pes planus, a bilateral knee disability, a bilateral ankle disability, bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs relates to an unestablished fact necessary to substantiate the claims and, presuming its credibility, raises a reasonable possibility of substantiating the claims for service connection for bilateral pes planus, a bilateral knee disability, a bilateral ankle disability, bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs. 5. Asymptomatic pes planus was noted at service enlistment; the Veteran has demonstrated an increase in disability during service and therefore has established the presumption of aggravation. 6. The evidence is in equipoise as to whether the Veteran's bilateral plantar fasciitis is causally related to active duty. 7. The evidence is in equipoise as to whether the Veteran's bilateral plantar tendonitis is causally related to active duty. 8. The evidence is in equipoise as to whether the Veteran's heel spurs are causally related to active duty. 9. The evidence is in equipoise as to whether the Veteran's right knee disability is causally related to active duty. 10. The evidence is in equipoise as to whether the Veteran's left knee disability is causally related to active duty. 11. The evidence is in equipoise as to whether the Veteran has a current right ankle disability which is causally related to active duty. 12. The evidence is in equipoise as to whether the Veteran has a current left ankle disability which is causally related to active duty. CONCLUSIONS OF LAW 1. The January 2004 rating decision confirming and continuing the previous denial of service connection for bilateral pes planus, a bilateral knee disability, and a bilateral ankle disability and denying the Veteran's claims of entitlement to service connection for bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. 2. The May 2006 rating decision determining that new and material evidence had not been received to reopen the Veteran's previously denied claims of entitlement to service connection for bilateral pes planus, a bilateral knee disability, a bilateral ankle disability, bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. 3. New and material evidence has been received to warrant reopening of the claims of service connection for bilateral pes planus, bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, right and left knee disabilities, and right and left ankle disabilities. 38 U.S.C. § 5107, 5108; 38 C.F.R. § 3.156. 4. The criteria for entitlement to service connection for bilateral pes planus have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.102, 3.303, 3.304, 3.306. 5. The criteria for entitlement to service connection for bilateral plantar fasciitis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. The criteria for entitlement to service connection for bilateral plantar tendonitis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 7. The criteria for entitlement to service connection for heel spurs have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 8. The criteria for entitlement to service connection for a right knee disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 9. The criteria for entitlement to service connection for a left knee disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 10. The criteria for entitlement to service connection for a right ankle disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 11. The criteria for entitlement to service connection for a left ankle disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 2000 to July 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO), which, inter alia, confirmed and continued the previous denial of service connection for bilateral pes planus, bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, right and left knee disabilities, and right and left ankle disabilities. In March 2021, the Veteran testified at a virtual hearing before the undersigned Acting Veterans Law Judge. A transcript of the hearing is of record. New and Material Evidence In general, decisions of the RO and the Board that are not appealed in the prescribed time period are final. See 38 U.S.C. §§ 7104, 7105; 38 C.F.R. §§ 3.104, 20.1100, 20.1103. Pursuant to 38 U.S.C. § 5108, a finally disallowed claim may be reopened when new and material evidence is presented or secured with respect to that claim. For claims to reopen such as this one, filed on or after August 29, 2001, new evidence means existing evidence not previously submitted to agency decision makers. Material evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156. To reopen a previously disallowed claim, new and material evidence must be presented or secured since the last final disallowance of the claim on any basis, including on the basis that there was no new and material evidence to reopen the claim since a prior final disallowance. See Evans v. Brown, 9 Vet. App. 273, 285 (1996). For purposes of reopening a claim, the credibility of newly submitted evidence is generally presumed. See Justus v. Principi, 3 Vet. App. 510, 513 (1992) (in determining whether evidence is new and material, the credibility of newly presented evidence is to be presumed unless evidence is inherently incredible or beyond competence of witness). The threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is low. See Shade v. Shinseki, 24 Vet. App. 110, 117 (2010). Furthermore, in determining whether this low threshold is met, VA should not limit its consideration to whether the newly submitted evidence relates specifically to the reason why the claim was last denied, but instead should ask whether the evidence could reasonably substantiate the claim were the claim to be reopened, to include by triggering the Secretary's duty to assist. Id. at 118; but see Villalobos v. Principi, 3 Vet. App. 450 (1992) (evidence that is unfavorable to a claimant is not new and material). New and material evidence having been received, the application to reopen the previously denied claims of entitlement to service connection for bilateral pes planus, bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, a right knee disability, a left knee disability, a right ankle disability, and a left ankle disability is granted. In October 2002, the Veteran, inter alia, submitted claims of service connection for bilateral pes planus and bilateral knee and ankle disabilities. In a February 2003 rating decision, the RO denied the claims, finding that the evidence did not show chronic knee or ankle disabilities or permanent residuals. With regard to the Veteran's bilateral pes planus, the RO found that there was no evidence that the condition, which existed prior to service, permanently worsened as a result of service. The RO considered the Veteran's service treatment records (STRs), as well as a VA examination which indicated that there was no evidence of residuals of traumatic or orthopedic pathology in the bilateral knees, ankles, or feet. The Veteran was duly notified of the RO's decision and his appellate rights in a February 2003 letter. In October 2003, the Veteran, inter alia, requested reconsideration of the service connection claims for bilateral pes planus and bilateral knee and ankle disabilities and submitted new claims for service connection for bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs. In a final January 2004 rating decision, the RO, inter alia, confirmed and continued the previous denial of service connection for bilateral pes planus and bilateral knee and ankle disabilities. The RO found that the evidence did not show that the Veteran's bilateral pes planus was caused or worsened by his active service or that he had current knee or ankle disabilities. Additionally, the RO denied service connection for bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs, finding that the evidence failed to show that the Veteran had a current disability. The record on appeal shows that the Veteran was duly notified of the RO's decision and his appellate rights. He did not, however, initiate an appeal within the applicable time period nor was new and material evidence received within one year of notification of the January 2004 rating decision. The Veteran does not contend otherwise. Thus, the January 2004 rating decision is final and not subject to revision on the same factual basis. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. In August 2005, the Veteran, inter alia, submitted a claim to reopen service connection for bilateral pes planus, a bilateral knee disability, a bilateral ankle disability, bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs. In a final May 2006 rating decision, the RO denied the claims, finding that the evidence submitted was not new and material. The RO found that the evidence failed to show that the Veteran's bilateral pes planus was aggravated by his military service. With regard to the other service connection claims, the RO denied service connection on the lack of a current disability. The record on appeal shows that the Veteran was duly notified of the RO's decision and his appellate rights. He did not, however, initiate an appeal within the applicable time period nor was new and material evidence received within one year of notification of the May 2006 rating decision. The Veteran does not contend otherwise. Thus, the May 2006 rating decision is final and not subject to revision on the same factual basis. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.104, 20.302, 20.1103. In this appeal, the Veteran seeks to reopen his claims of service connection for bilateral pes planus, right and left knee disabilities, right and left ankle disabilities, bilateral plantar fasciitis, bilateral plantar tendonitis, and heel spurs. As noted above, despite the finality of a prior adverse decision, a claim will be reopened and the former disposition reviewed if new and material evidence is presented or secured with respect to the claim which has been disallowed. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. In the July 2015 rating decision, the RO reopened the claims and denied them on the merits. Despite the RO's finding, the Board is obligated by statute (38 U.S.C. §§ 5108, 7104(b)) to address whether new and material evidence has been submitted prior to addressing the merits of the claims. Barnett v. Brown, 83 F.3d 1380 (Fed. Cir. 1996). Thus, despite the RO's findings, the Board must make a determination of whether new and material evidence has been presented to reopen the claims. Jackson v. Principi, 265 F.3d 1366 (Fed. Cir. 2001). In order to determine whether new and material evidence has been received, the Board has reviewed the entire record, with particular attention to the additional evidence received since the final May 2006 rating decision. After reviewing the record, the Board finds that the additional evidence received is new and material within the meaning of 38 C.F.R. § 3.156. The additional evidence received since the May 2006 rating decision includes a private nexus opinion from Dr. S.E.N. dated in February 2015 indicating that the Veteran's pre-existing pes planus was aggravated by active duty. In addition, Dr. S.E.N. opined that the Veteran's bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, bilateral knee disability, and bilateral ankle disability were causally related to the Veteran's active service. See February 2015 nexus opinion from Dr. S.E.N. received in March 2015. Also received since the final rating decision are VA examinations performed in July 2015 indicating diagnoses of bilateral pes planus, bilateral plantar fasciitis, bilateral patellofemoral pain syndrome, and bilateral ankle arthralgia. The additional evidence also includes the Veteran's March 2021 hearing testimony to the effect that the physical nature of his work on a rescue salvage ship during active duty aggravated his pre-existing pes planus and caused his other foot, knee, and ankle disabilities. See March 2021 Transcript of Hearing, pages 2-11. After reviewing the record, the Board finds that new and material evidence has been received sufficient to reopen the claims. Specifically, the February 2015 positive nexus opinion from Dr. S.E.N., indicating that the Veteran's pre-existing pes planus was aggravated by active duty and that his other feet, knee, and ankle disabilities were causally related to the Veteran's active duty, the July 2015 VA examinations noting diagnoses of bilateral plantar fasciitis, bilateral patellofemoral pain syndrome, and bilateral ankle arthralgia, and the Veteran's March 2021 hearing testimony, were not before agency decision-makers at the time of the May 2006 rating decision. These records are therefore new, and directly address unestablished facts necessary to substantiate the claims of service connection for bilateral pes planus, bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, a bilateral knee disability, and a bilateral ankle disability, particularly evidence of current disabilities, aggravation, and causation. When presumed credible, they raise a reasonable possibility of substantiating the claims and trigger the VA's duty to assist. Accordingly, the standards under 3.156(a) have been met and the claims are reopened. See Shade, 24 Vet. App. at 117. Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a pre-existing injury or disease in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.304, 3.306. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that which is pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Several statutory presumptions operate in connection with the laws providing for service connection, including the presumption of soundness. Under the presumption of soundness, a Veteran is presumed to have been in sound condition when entering service, except as to defects, infirmities, or disorders noted at the time of the examination or where clear and unmistakable evidence demonstrates that the injury or disease existed prior to service and was not aggravated by such service. 38 U.S.C. § 1111, 1137. The law provides that a pre-existing disease or injury will be considered to have been aggravated by military service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and after service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). Further, temporary or intermittent flare-ups of a pre-existing injury or disease are not sufficient to be considered "aggravation in service" unless the underlying condition, as contrasted with symptoms, has worsened. See Davis v. Principi, 276 F.3d. 1341, 1346-46 (Fed. Cir. 2002) ("[E]vidence of temporary flare-ups symptomatic of an underlying preexisting condition, alone, is not sufficient for a non-combat veteran to show increased disability under 38 U.S.C. § 1153 unless the underlying condition is worsened"); Maxson v. West, 12 Vet. App. 453, 458 (1999) (citing Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991)), aff'd 230 F.3d 1330 (Fed. Cir. 2000). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has distinguished between those cases in which the preexisting condition is noted upon entry into service, and those cases in which the preexistence of the condition must otherwise be established. See Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); Horn v. Shinseki, 25 Vet. App. 231, 234 (2012); see also 38 U.S.C. § 1111 (presumption of sound condition). "[I]f a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder." Wagner, 370 at 1096; see also 38 U.S.C. § 1153; 38 C.F.R. § 3.306. In such claims, the Veteran has the burden of showing that there was an increase in disability during service to establish the presumption of aggravation. See Wagner; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the claimant meets his or her burden of demonstrating an increase in service, the disability is presumed to have been aggravated in service, and the burden is on the Secretary to rebut that presumption. Horn, 25 Vet. App. at 234; 38 U.S.C. § 1153; 38 C.F.R. § 3.306. To rebut that presumption, the Secretary must show, by clear and unmistakable evidence, that the worsening of the condition was due to the natural progress of the disease. Horn, 25 Vet. App. at 235 n. 6; 38 U.S.C. § 1153. To be "noted" within the meaning of the presumption of soundness statute, the condition must be recorded in the entrance examination report. 38 C.F.R. § 3.304(b); see also 38 U.S.C. § 1111; Crowe v. Brown, 7 Vet. App. 238, 245 (1994). History of pre-service existence of a disease does not constitute a notation of such condition. See id. at 240 (holding that "asthma" was not noted where, although the Veteran checked a box indicating that he had a history of the disease, a clinical evaluation detected no abnormalities of the lungs). However, the disease need not be symptomatic at the time of the evaluation, so long as a diagnosis is provided. See Verdon v. Brown, 8 Vet. App. 529, 530 (1996) (holding that "bunions" were noted at induction examination where orthopedic examiner diagnosed "bunions," despite also stating "no problem [with] feet."). The standard of proof to be applied in decisions on claims for VA benefits is set forth in 38 U.S.C. § 5107(b). Under that provision, VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b); see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). "It is in recognition of our debt to our veterans that society has [determined that,] [b]y tradition and by statute, the benefit of the doubt belongs to the veteran." See Gilbert, 1 Vet. App. at 54. Entitlement to service connection for bilateral pes planus is granted. The Veteran contends that his pre-existing bilateral pes planus was aggravated by active service. At his April 2000 military entrance examination, the Veteran endorsed a history of foot trouble. The examiner noted a diagnosis of asymptomatic pes planus. An August 2001 entry in the Veteran's service treatment records (STRs) noted diagnoses of bilateral genu recurvatum, valgus, and pes planus. It was noted that the Veteran had been prescribed a navicular sling for his bilateral feet and an orthotic consult was recommended. See August 20, 2001 record. A November 2001 entry in the Veteran's STRs noted the Veteran's complaints of bilateral ankle and knee pain. The physician noted a diagnosis of bilateral pes planus and referred the Veteran to podiatry. See November 2001 treatment note. A December 2001 Report of Medical Board noted the following diagnoses: severe plantar fasciitis of both feet, heel spur syndrome secondary to flexible flatfoot deformity with subtalar joint hyperpronation of both feet, and history of bilateral knee pain. It was noted that X-rays showed loss of calcaneal inclination angle, subtalar joint hyperpronation, anterior deviation of the cyma line and that the Veteran had a severe flatfoot deformity for quite some time. It was also noted that the Veteran had been prescribed orthotics, placed on NSAIDs, and physical therapy would be incorporated in the near future. It was recommended that the Veteran be returned to a period of eight months of limited duty, ashore, during which time he should have the following limitations: no prolonged standing, no prolonged walking, no standing watch. He should be allowed to wear sneakers only, no physical readiness testing, and no running or jumping. A desk job would be preferred for the Veteran, and he should avoid steel decks and ladder climbing. See December 2001 Report of Medical Board. An April 2002 entry in the Veteran's STRs noted that he was fitted with custom orthotics for his feet. See April 2002 Podiatry note. The Veteran was afforded a VA examination in December 2002. The Veteran, inter alia, reported pain around his ankles and feet and that he tended to lose balance. On physical examination, the examiner found bilateral pes planus, left slightly more than the right. There was no tenderness. Calluses and other deformities were not found. X-rays revealed bilateral flat feet. The examiner did not find evidence of residual or traumatic pathology. VA treatment records noted a history of painful feet since the Veteran was in the military. See May 2004 Nursing Note. In a February 2015 private nexus opinion, Dr. S.E.N. opined that the Veteran's bilateral pes planus was aggravated by his active duty. See February 2015 nexus opinion from Dr. S.E.N. received in March 2015. The Veteran was afforded a VA examination in July 2015. The examiner noted diagnoses of bilateral pes planus and plantar fasciitis. The Veteran reported pain with prolonged standing and ambulating, as well as flare-ups with walking long distances and sitting. After examination of the Veteran and review of the claims file, the examiner rendered a negative etiological opinion. The examiner opined, This is a pre-existing condition and there is no evidence to support a worsening of veteran['s] condition as a result of his service and his current problems are a natural progression of the condition. At the March 2021 Board hearing, noted above, the Veteran testified that his bilateral pes planus was aggravated by his duties in the Navy. He testified that his work on a rescue salvage ship was very physical in nature. The Veteran testified that he walked on the steel deck and up steep stairs, which caused pain in his feet and required custom orthotics during service. See March 2021 Transcript of Hearing, pages 8-10. After a review of the evidence, the Board finds that service connection is warranted for bilateral pes planus. In the present case, the Veteran's service entrance examination report noted asymptomatic pes planus. The Veteran does not contend otherwise. Thus, the presumption of soundness at service entry does not attach, and the burden is on the Veteran to show that there was an increase in disability during service to establish the presumption of aggravation. The Board finds that the Veteran has met this burden. In that regard, the Veteran has testified that his pes planus worsened during active duty due to his physically demanding work on a rescue salvage ship. He testified that he experienced pain in his feet, for which he sought treatment during active duty, and was prescribed custom orthotics. Having had the opportunity to observe his demeanor at the hearing, the Board finds his statements to be credible. Additionally, his statements tend to be corroborated by his STRs indicating that he experienced foot symptoms due to his pes planus during active duty which required custom orthotics. Therefore, the Board assigns high probative value to the Veteran's statements. The Board also affords high probative value to the February 2015 positive nexus opinion from Dr. S.E.N., as the physician rendered his opinion after thorough review of the Veteran's medical records. Moreover, the physician provided a reasoned conclusion and detailed rationale. The Board affords less probative weight to the July 2015 VA examination, as the examiner's opinion did not address the correct aggravation standard by failing to make a determination as to whether there was clear and unmistakable evidence that the worsening of the Veteran's condition was due to the natural progress of the disease. The burden to show no aggravation of a pre-existing disease or disability during service is an onerous one that lies with the government. See Cotant v. Principi, 17 Vet. App. 116, 131 (2003); Kinnaman v. Principi, 4 Vet. App. 20, 27 (1993). In this case, there is not clear and unmistakable evidence that there was no increase in severity or that the increase in severity was due to the natural progression of the disease. Accordingly, the presumption of aggravation has not been rebutted and service connection based upon aggravation of a pre-existing disability is granted. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Entitlement to service connection for bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, a right knee disability, and a left knee disability is granted. The Veteran contends that his bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, and right and left knee disabilities are related to his active service. The Veteran's STRs contain multiple notations of bilateral knee pain and diagnoses of bilateral patellar tendonitis and patellofemoral pain syndrome (PFS). As noted above, a December 2001 Report of Medical Board noted the following diagnoses: severe plantar fasciitis of both feet, heel spur syndrome secondary to flexible flatfoot deformity with subtalar joint hyperpronation of both feet, and history of bilateral knee pain. It was noted that X-rays showed loss of calcaneal inclination angle, subtalar joint hyperpronation, anterior deviation of the cyma line and that the Veteran had a severe flatfoot deformity for quite some time. It was also noted that the Veteran had been prescribed orthotics, placed on NSAIDs, and physical therapy would be incorporated in the near future. It was recommended that the Veteran be returned to a period of eight months of limited duty, ashore, during which time he should have the following limitations: no prolonged standing, no prolonged walking, no standing watch. He should be allowed to wear sneakers only, no physical readiness testing, and no running or jumping. A desk job would be preferred for the Veteran, and he should avoid steel decks and ladder climbing. See December 2001 Report of Medical Board. The Veteran underwent a VA examination in November 2002. The examiner, inter alia, noted the Veteran's reports of shooting pain in both knees with some itching. The Veteran also reported pain around his ankles and feet and that he tended to lose balance. The Veteran reported that he had never had any joint trouble prior to joining the military. On physical examination, the Veteran complained of tenderness over the patellae of both knees. Patellar position was found to be normal and there was no effusion in the joints. McMurray and Drawer tests were negative. Range of motion was 0 to 140 degrees on both sides, both in active and passive tests. There was some hyperextension of the right and left knees. Examination of the feet revealed bilateral pes planus, left slightly more than the right. Tiptoeing was possible without any complaints. The Achilles tendon appeared to be on the medial side and went to neutral position on tiptoeing. The Achilles tendons were actively contracting well. There was no tenderness. Calluses and other deformities were not found. X-rays revealed bilateral flat feet and knees within normal limits. The examiner found no evidence of residual of any traumatic or orthopedic pathology. There was also no evidence of patellofemoral pain syndrome. A May 2004 VA treatment record noted the Veteran's reports of feet and knee pain since he was in the military. See May 2004 Nursing Note. In a February 2015 private nexus opinion, Dr. S.E.N. noted, inter alia, a history of bilateral plantar fasciitis, a heel spur with bilateral plantar tendonitis, and a bilateral knee disability, to include patellofemoral syndrome. The physician determined that the onset of the Veteran's bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, and bilateral knee disability were associated with active duty, with persistence of chronicity through the present. See February 2015 nexus opinion from Dr. S.E.N. received in March 2015. The Veteran was afforded VA examinations in July 2015. The examiner noted diagnoses of bilateral pes planus, plantar fasciitis, and patellofemoral pain syndrome. The Veteran reported pain with prolonged standing and ambulating, as well as flare-ups with walking long distances, stair climbing, and sitting. After examination of the Veteran and review of the claims file, the examiner rendered negative etiological opinions. Regarding the Veteran's heel spurs, the examiner opined, There is no evidence to support veteran['s] claim that the condition (heel spurs with tendonitis) worsened as a result of his military service. There is no evidence of heel spurring on current x-ray films. Veteran has had employment since the military which required veteran to be on his feet for long periods of time which could be equally contributory to veteran's complaint. With regard to the Veteran's bilateral knee disability, the examiner opined, There is no evidence to support the veteran's claim that his knee pain is the result of his duties while in the service or related to an incident while in the military. There is no evidence of definite associated trauma leading to functional loss. The examiner did not provide etiological opinions regarding the Veteran's bilateral plantar fasciitis or plantar tendonitis. At the March 2021 Board hearing, noted above, the Veteran testified that his bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, and bilateral knee disability developed during active duty. He testified that his work on a rescue salvage ship was very physical in nature. The Veteran testified that he walked on the steel deck and up steep stairs, which caused pain in his feet and knees and required custom orthotics during service. See March 2021 Transcript of Hearing, pages 4-10. After a review of the evidence, and affording the Veteran the benefit of the doubt, the Board finds that the evidence is in equipoise as to whether the Veteran's bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, and right and left knee disabilities are causally related to his active service. As a preliminary matter, no defects or diagnoses were noted with regard to the Veteran's bilateral feet or knees, with the exception of asymptomatic pes planus, as noted above. Therefore, the Veteran is presumed to have been in sound condition at the time he entered service. 38 U.S.C. § 1111, 1137. With regard to the first element of a service connection claim, the evidence shows that the Veteran currently has bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, and a bilateral knee disability. The February 2015 private nexus opinion from Dr. S.E.N. noted, inter alia, a history of bilateral plantar fasciitis, a heel spur with bilateral plantar tendonitis, and a bilateral knee disability, to include patellofemoral syndrome. While the Board notes that the VA examiner found that there was no evidence of heel spurs or plantar tendonitis, the Board affords more probative weight to the February 2015 private examination and opinion. In addressing the second element, the Board finds that the Veteran experienced foot and knee pain during active duty. The evidence shows that the Veteran came to sickbay with complaints of foot pain and was referred for custom orthotics. The evidence also shows that during active duty the Veteran was diagnosed with severe plantar fasciitis of both feet, heel spur syndrome secondary to flexible flatfoot deformity with subtalar joint hyperpronation of both feet, history of bilateral knee pain, bilateral patellar tendonitis, and PFS. With respect to the third element, the nexus requirement, the Board finds that the evidence is in relative equipoise as to whether the Veteran's current bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, and right and left knee disabilities are causally related to his in-service foot and knee symptoms. In this regard, the Board finds the February 2015 positive nexus opinion from Dr. S.E.N. of great probative weight, as the physician rendered his opinion after thorough review of the Veteran's medical records. Moreover, the physician provided a reasoned conclusion and detailed rationale. Additionally, the Board finds the Veteran's hearing testimony both competent and credible regarding his in-service foot and knee symptomatology, as his statements are consistent throughout the course of the claim and are supported by his STRs. Therefore, the Board also assigns great probative weight to the Veteran's statements. The Board assigns less probative weight to the November 2002 VA examination, as the examiner failed to provide nexus opinions. The Board also assigns less probative weight to the July 2015 VA examinations, as the examiner failed to consider notations in the Veteran's STRs regarding foot and knee pain, as well as diagnoses of severe plantar fasciitis of both feet, heel spur syndrome secondary to flexible flatfoot deformity with subtalar joint hyperpronation of both feet, bilateral patellar tendonitis, and PFS. In addition, the examiner failed to provide etiological opinions regarding the Veteran's bilateral plantar fasciitis or plantar tendonitis. The evidence is therefore at least evenly balanced as to whether the Veteran's bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, and right and left knee disabilities are causally related to his active service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for bilateral plantar fasciitis, bilateral plantar tendonitis, heel spurs, and right and left knee disabilities is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Entitlement to service connection for a right and left ankle disability is granted. The Veteran contends that his bilateral ankle disability is related to his active service. A November 2001 entry in the Veteran's STRs noted, inter alia, his complaints of bilateral ankle pain, which was getting worse. A December 2001 entry noted the Veteran's continued complaints of ankle pain. It was also noted that he was awaiting custom orthotics. As set forth above, the Veteran underwent a VA examination in November 2002. The examiner, inter alia, noted the Veteran's reports of pain around his ankles and feet and that he tended to lose balance. The Veteran reported that he had never had any joint trouble prior to joining the military. On physical examination, both ankles were noted to be normal looking without any swelling or deformity. It was noted that the Veteran complained of pain on palpation all around the joints. The Veteran had full range of motion and power was noted as satisfactory without any complaints. X-rays of the bilateral ankles were within normal limits. The examiner found no evidence of residual of any traumatic or orthopedic pathology. A May 2004 VA treatment record noted the Veteran's reports of ankle pain since he was in the military. See May 2004 Nursing Note. In a February 2015 private nexus opinion, Dr. S.E.N. determined that the onset of the Veteran's bilateral ankle disability was associated with active duty, with persistence of chronicity through the present. See February 2015 nexus opinion from Dr. S.E.N. received in March 2015. The Veteran was afforded a VA examination in July 2015. The examiner noted a 2001 diagnosis of bilateral ankle arthralgia. The Veteran reported that he experienced increased pain in the bilateral ankles due to climbing, marching, and job duties while in the military. After examination of the Veteran and review of the claims file, the examiner rendered a negative etiological opinion. The examiner opined, There is no medical evidence to support veteran's claim that his current ankle condition is the result of his military service/duties since he was able to pursuit [sic] employment as a Border Patrol Agent. At the March 2021 Board hearing, noted above, the Veteran, through his representative, testified that he experiences ankle pain, which was documented in service. He further testified that ankle pain, as well as his other musculoskeletal disabilities, kept him from pursuing a career in border patrol and law enforcement. See March 2021 Transcript of Hearing, pages 2-3. For the reasons that follow, the Board finds that the evidence is in relative equipoise as to whether entitlement to service connection is warranted for right and left ankle disabilities. With respect to the question of current right and left ankle disabilities, VA medical records reveal that the Veteran has experienced ankle pain. Additionally, the Veteran has competently reported pain and functional impairment, including during his March 2021 Board hearing. Moreover, having had the opportunity to observe his demeanor during the hearing, and absent anything contradictory in the record, the Board finds his reports of right and left ankle pain and functional impairment credible. In any event, regardless of whether the Veteran has diagnosed ankle pathology, the evidence is in relative equipoise as to whether the Veteran experienced a functional impairment in earning capacity with respect to his right and left ankles. Indeed, the Board notes that "disability" as defined in 38 U.S.C. §§ 1110 and 1131 refers to the functional impairment of earning capacity, not the underlying cause of said disability, and that pain alone can reach the level of a functional impairment of earning capacity. Saunders v. Wilkie, 866 F.3d 1356 (2018). With regard to the second element, the Board finds that the Veteran experienced bilateral ankle pain during active duty. The evidence shows that the Veteran came to sickbay with complaints of bilateral ankle pain and was referred for custom orthotics. In addressing the third element, the nexus requirement, the Board finds that the evidence is in relative equipoise as to whether the Veteran's right and left ankle disabilities are causally related to his in-service ankle pain. In this regard, the Board finds the February 2015 positive nexus opinion from Dr. S.E.N. of great probative weight, as the physician rendered his opinion after thorough review of the Veteran's medical records. Moreover, the physician provided a reasoned conclusion and detailed rationale. The Board assigns less probative weight to the November 2002 VA examination, as the examiner failed to provide a nexus opinion. The Board also assigns less probative weight to the July 2015 VA examination, as the examiner failed to consider notations in the Veteran's STRs regarding ankle pain. (Continued on next page) Accordingly, the Board has weighed the probative evidence of record, to include the positive and negative nexus opinions, and finds that the evidence is at least in relative equipoise as to the Veteran's current right and left ankle disabilities and the causal relation between the Veteran's disabilities and his in-service ankle pain. The benefit-of-the-doubt rule is therefore for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board will resolve the reasonable doubt in the Veteran's favor and find that the evidence supports the grant of service connection for right and left ankle disabilities. See 38 U.S.C. § 5107. Jenna Brant Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Ruddy, 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.