Citation Nr: A21019266 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 190403-11070 DATE: December 3, 2021 ORDER Service connection for strep throat is denied. Service connection for disability of the mouth is denied. Readjudication of the previously denied claim for service connection for problems walking is not warranted; the appeal of that issue is denied. Readjudication of the previously denied claim for service connection for amyotrophic lateral sclerosis (ALS) is not warranted; the appeal of that issue is denied. Readjudication of the previously denied claim for service connection for a low back disability is warranted; to this limited extent, the appeal of that issue is granted. Readjudication of the previously denied claim for service connection for a right knee disability is warranted; to this limited extent, the appeal of that issue is granted. Readjudication of the previously denied claim for service connection for a left knee disability is warranted; to this limited extent, the appeal of that issue is granted. Readjudication of the previously denied claim for service connection for a respiratory disability is warranted; to this limited extent, the appeal of that issue is granted. REMANDED Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a cervical spine disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for headaches, to include as secondary to posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for erectile dysfunction as secondary to PTSD is remanded. Entitlement to service connection for a respiratory disability is remanded. Entitlement to service connection for tendinitis is remanded. Entitlement to service connection for muscle pain is remanded. Entitlement to service connection for disability of the feet is remanded. FINDINGS OF FACT 1. The Veteran is not shown to have had a chronic strep throat disability at any time during the pendency or proximate to the filing of his claim. 1. The Veteran is not shown to have had a mouth disability at any time during the pendency or proximate to the filing of his claim. 2. Service connection was previously denied for problems walking and ALS by a September 2010 rating decision; the Veteran was informed of that decision and did not appeal. 3. The evidence received since the time of the September 2010 rating decision does not tend to prove or disprove a matter at issue in the Veteran's claims for service connection for problems walking and/or ALS and does not raise a theory of entitlement that was not previously addressed. 4. Service connection was previously denied for disabilities of the lumbar spine and both knees by an April 2012 rating decision, and service connection was previously denied for a respiratory disability by an April 2015 decision; the Veteran initiated appeals of those decisions, but did not perfect the appeals by filing a timely substantive appeal after statements of the case (SOCs) were issued in October 2017. 5. Evidence that was not part of the actual record before the RO at the time of the April 2012 and April 2015 decisions tends to prove or disprove a matter at issue in the Veteran's claims for service connection for disabilities of the lumbar spine, right knee, and left knee, and for a respiratory disability. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for strep throat have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. The criteria for an award of service connection for a mouth disability have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 3. New and relevant evidence has not been received as to the Veteran's claim for service connection for problems walking. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156, 3.2501. 4. New and relevant evidence has not been received as to the Veteran's claim for service connection for ALS. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156, 3.2501. 5. New and relevant evidence has been received as to the Veteran's claim for service connection for a lumbar spine disability. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156, 3.2501. 6. New and relevant evidence has been received as to the Veteran's claim for service connection for a right knee disability. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156, 3.2501. 7. New and relevant evidence has been received as to the Veteran's claim for service connection for a left knee disability. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156, 3.2501. 8. New and relevant evidence has been received as to the Veteran's claim for service connection for a respiratory disability. 38 U.S.C. § 5108; 38 C.F.R. §§ 3.156, 3.2501. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from July 1989 to January 1992, to included service in the Southwest Asia theater of operations during the Persian Gulf War, from June 1991 to September 1991. 38 C.F.R. § 3.317(e). His decorations include the Southwest Asia Service Medal. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2019 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran timely appealed to the Board, requesting the hearing review option pursuant to the Appeals Modernization Act (AMA). See April 2019 VA Form 10182; 38 C.F.R. §§ 20.201, 20.202(b)(2). In April 2021, the Veteran and his mother testified at a virtual Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. Under the AMA. the Board may only consider the evidence that was of record at the time of the February 2019 rating decision, together with any evidence submitted during the 90-day period that began on the date of the hearing. In that regard, the Board notes that evidence was added to the claims file subsequent to the February 2019 rating decision, and before the April 2021 hearing, during a time when the record on appeal was closed. That evidence may not be considered in connection with the present appeal. Service connection for a bilateral foot disability (previously identified as bilateral flatfoot) was previously denied in a January 2018 rating decision. In the February 2019 rating decision on appeal, the RO appears to have made an implicit finding the new and relevant evidence was presented or secured as to warrant readjudication of the claim, inasmuch as the RO addressed the claim on the merits. The Board is bound by that favorable finding. 38 C.F.R. § 3.104(c). Service Connection Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). The requirement of a current disability is satisfied when the claimant is shown to have the disability either at the time he files his claim for service connection, or during the pendency of that claim, even if the disability resolves prior to final adjudication. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When the record contains a recent diagnosis of disability prior to the filing of a claim for benefits based on that disability, the report of diagnosis is relevant evidence that must be addressed in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). The term "disability" as used for VA purposes generally contemplates functional impairment resulting in loss of earning capacity. See 38 C.F.R. § 4.1; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Service connection may also be established for a chronic disability manifested by certain signs or symptoms that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War or to a degree of 10 percent or more not later than December 31, 2026, and which, by history, physical examination, and laboratory tests, cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). The term "Persian Gulf Veteran" means a veteran who served on active military, naval, or air service in the Southwest Asia Theater of operations during the Persian Gulf War. The Southwest Asia Theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(d). A qualifying chronic disability means a chronic disability resulting from any of the following (or any combination of the following): an undiagnosed illness; a medically unexplained, chronic multi-symptom illness that is defined by a cluster of signs or symptoms; or any diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a). An undiagnosed illness is defined as a condition that by history, physical examination, and laboratory tests cannot be attributed to a known clinical diagnosis. A medically unexplained, chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases). The term medically unexplained, chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs, and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317(a). Objective indications of chronic disability include both "signs," in the medical sense of objective evidence perceptible to an examining physician, and other non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a). Signs or symptoms that may be manifestations of an undiagnosed illness or a medically unexplained, chronic multi-symptom illness include, but are not limited to: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs and symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Finally, compensation shall not be paid under section 3.317 if there is affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(a)(7). In reviewing the Veteran's claims, the Board observes that nothing of record shows that he has the requisite knowledge, skill, experience, training, or education to render medical opinions. Consequently, his contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). However, in making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of observable symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). 1. Entitlement to service connection for strep throat 2. Entitlement to service connection for a mouth disability The Veteran's service treatment records reflect that he was treated for complaints of a sore throat in November 1990. It was then indicated that it might be due to strep. At the April 2021 Board hearing, the Veteran clarified that his mouth claim pertained to an in-service root canal. In that regard, his service treatment records reflect that dental treatment was administered during service. Following review of the record, the Board finds that no current, chronic disability of the throat or mouth has been attributed to the aforementioned in-service findings. The Veteran's sore throat appears to have resolved with treatment, and no throat or mouth disability was noted at the time of the examination conducted in connection with his separation from service. Further, no such chronic disabilities are demonstrated in the post-service medical records. At the April 2021 Board hearing, the Veteran acknowledged that he did not have a current strep throat disability. In pertinent part, he indicated that he did not currently have strep throat or a chronic strep throat disability. He reported having incidents of strep throat following service which resolved with treatment. Although he reported receiving treatment for strep throat in 2019 or 2020 at VA, no chronic strep throat disorder is demonstrated in the medical evidence that is available for the Board's review as part of this appeal. In short, the record does not reflect that he has had a chronic strep throat disability at any time during the pendency or proximate to the filing of his claim. Regarding the mouth claim, the Veteran explained at the hearing that he believed he had developed conditions due to the in-service root canal, to include headaches (which is separately on appeal and addressed in the REMAND, below). In so doing, he did not identify or allege that he had a specific disability of the jaw or mouth per se as a residual of the root canal. Moreover, under the law, treatable carious teeth, replaceable missing teeth, dental or alveolar abscesses, and periodontal disease are considered non-disabling conditions and may be considered service connected only for the purpose of determining entitlement to VA dental examination or outpatient dental treatment. See 38 U.S.C. § 1712; 38 C.F.R. §§ 3.381, 17.161; see also Woodson v. Brown, 8 Vet. App. 352, 354 (1995). In order to establish service connection for loss of a tooth, the Veteran must have sustained a combat wound or other in-service trauma. 38 U.S.C. § 1712; 38 C.F.R. § 3.381(b). The Board notes that the term "service trauma" does not include the intended effects of therapy or restorative dental care and treatment provided during a veteran's service. See 38 C.F.R. § 3.306(b)(1); VAOGCPREC 5-97. In light of the foregoing, the Board must find that the evidence available for review does not support a finding that the Veteran has current, cognizable disabilities of strep throat and/or the mouth. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C. §§ 1110, 1131; see Degmetich v. Brown, 104 F.3d 1328, 1332 (1997). In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). For all these reasons, the Board finds the preponderance of the evidence is against the Veteran's claims for service connection for strep throat and a mouth disability. The appeal of those issues is denied. New and Relevant Evidence The Veteran's claims for service connection for problems walking, ALS, lumbar spine disability, right knee disability, left knee disability, and a respiratory disability were all the subject of prior rating decisions. Specifically, service connection was denied for problems walking and ALS by a September 2010 rating decision. The Veteran was informed of that decision, and did not appeal. Thereafter, the lumbar spine and knee claims were denied in an April 2012 rating decision, and the respiratory disability claim was denied in an April 2015 rating decision. The Veteran did initiate appeals with respect to those decisions, but did not perfect the appeals by filing a timely substantive appeal following the issuance of the relevant SOCs in October 2017. See 38 C.F.R. §§ 19.50-19.52 (previously 38 C.F.R. §§ 20.200, 20.302). In the February 2019 rating decision, the RO found that new and material evidence had not been received to reopen these claims. However, that is the old standard of review under the legacy system. Under the AMA, VA will readjudicate a previously denied claim if new and relevant evidence is presented or secured. 38 C.F.R. § 3.156(d). "Relevant" evidence is information that tends to prove or disprove a matter at issue in a claim and includes evidence that raises a theory of entitlement that was not previously addressed. 38 C.F.R. § 3.2501(a)(1). As the statutory definition of "relevant" does not require that the evidence relate to an unestablished fact necessary to substantiate the claim, or raise a reasonable possibility of substantiating the claim, "new and relevant" evidence is a lower standard than the former "new and material" evidence standard. 3. Whether new and relevant evidence has been presented or secured as to the claim for service connection for problems walking 4. Whether new and relevant evidence has been presented or secured as to the claim for service connection for ALS The evidence of record at the time of the September 2010 denial of service connection for problems walking and ALS included statements from the Veteran, his service treatment records, and various post-service medical records dated through 2010. The Board notes that the Veteran provided evidence that he had problems walking due to various conditions. However, service connection was denied because problems walking is not considered an actually disabling condition; the condition of problems walking was considered a description of symptoms and not a clinically diagnosed medical condition. Similarly, the evidence of record did not show the Veteran had actually been diagnosed with ALS. In fact, a May 2010 VA examination explicitly found that he did not have ALS. Therefore, service connection was denied, in essence, due to lack of a current disability. Evidence has been added to the record since the time of the September 2010 rating decision, to include statements by and on behalf of the Veteran, April 2021 hearing testimony, and additional post-service medical records. He has also submitted treatise evidence with regard to the nature of ALS. However, the Board finds that the evidence is not new and relevant as to the matter of whether he has ALS or a disability manifested by problems walking separate and distinct from the other claims he is pursuing (pertaining to, for example, tendinitis and disabilities of the low back, knees, and feet) that was incurred in or is otherwise the result active service. With respect to the problems walking, the Veteran has indicated that such problems are related his separate claims for service connection for the knees and feet, as well as his already service-connected shin splints. He confirmed that that was the case at the April 2021 hearing, and that his problems with walking were also related to his spine disabilities. No disability separate and distinct from those disabilities (which are separately on appeal and addressed in the REMAND, below) was identified. Similarly, the evidence of record available for review does not demonstrate that the Veteran has ALS. In fact, he acknowledged at the April 2021 hearing that he did not have such a diagnosis. He testified that his chiropractor had informed him that X-rays indicated he had "early manifestations" of ALS, but not ALS per se. In light of the foregoing, the Board must find that new and relevant evidence has not been presented or secured with respect to these two issues. Even assuming, for purposes of argument, that new and relevant evidence had been received, the claims would still have to be denied for lack of a current disability. See Holbrook v. Brown, 8 Vet. App. 91 (1995) (The Board has the fundamental authority to decide a claim in the alternative.). The appeal of these issues is denied. 5. Whether new and relevant evidence has been presented or secured as to the claim for service connection for a lumbar spine disability 6. Whether new and relevant evidence has been presented or secured as to the claim for service connection for a right knee disability 7. Whether new and relevant evidence has been presented or secured as to the claim for service connection for a left knee disability 8. Whether new and relevant evidence has been presented or secured as to the claim for service connection for respiratory disability The evidence of record at the time of the prior denials of these claims included statements from the Veteran, his service treatment records, and various post-service medical records. The Board observes that the Veteran's service treatment records do not document any specific treatment for the lumbar spine or knees. He was treated for an upper respiratory infection (URI) in March 1991. Nevertheless, his spine, lower extremities, and lungs were evaluated as normal at the time of his service separation examination. Further, no pertinent disability was noted on a concurrent Report of Medical History. Rather, the Veteran checked boxes to the effect that he and did not have, and had not had, recurrent back pain, "trick" or locked knee, asthma, or shortness of breath. The record also reflects that the Veteran did not report any back, knee, or respiratory problems until years after separation from service. The evidence added to the record since the prior denials includes additional statements by and on behalf of the Veteran, the April 2021 hearing testimony, and additional post-service medical records. In pertinent part, the Veteran submitted affidavits in 2018 attesting to developing recurrent respiratory problems, knee pain, and low back pain while on active duty. A fellow service member also submitted an affidavit attesting to the Veteran's knee and sinus (i.e., respiratory) problems while on active duty, and the Veteran's mother likewise submitted a supporting affidavit that such symptoms developed while on active duty. Moreover, the Veteran and his mother provided testimony to that effect at the April 2021 hearing. He also testified to his belief that his respiratory problems were related to environmental factors while on active duty in Southwest Asia theater of operations during the Persian Gulf War. The Board finds that the aforementioned affidavits and hearing testimony tend to prove that the Veteran developed recurrent lumbar spine, knee, and respiratory symptoms while on active duty. As such, new and relevant evidence has been received and readjudication of the claims is warranted. REASONS FOR REMAND 1. Entitlement to service connection for a lumbar spine disability is remanded. 2. Entitlement to service connection for a cervical spine disability is remanded. 3. Entitlement to service connection for a right knee disability is remanded. 4. Entitlement to service connection for a left knee disability is remanded. 5. Entitlement to service connection for headaches is remanded. 6. Entitlement to service connection for erectile dysfunction is remanded. 7. Entitlement to service connection for respiratory disability is remanded. 8. Entitlement to service connection for tendinitis is remanded. 9. Entitlement to service connection for muscle pain is remanded. The Board notes that none of the above-listed disabilities were noted at the time of the Veteran's examination for separation from service, and that the first documented evidence of such appears to be years after service. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for years after service, can be probative evidence against the claim). The foregoing facts notwithstanding, the Board finds that the nature and etiology of the claimed disabilities is not clear from the evidence of record, particularly with respect to the application of the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317. As noted previously, signs or symptoms that may be manifestations of an undiagnosed illness or a medically unexplained, chronic multi-symptom illness include headache, muscle pain, joint pain, and signs or symptoms involving the respiratory system (upper or lower). Here, it is not clear whether disabilities relating to Veteran's lumbar spine, knees, cervical spine, muscle pain, tendinitis, headaches, and/or respiratory system can be service connected consistent with these provisions. The AOJ should have sought clarifying medical opinions before adjudicating the claims. The failure to do so constitutes a pre-decisional duty to assist error that must be corrected. The Veteran has also contended that he has disabilities of the lumbar spine and knees that are secondary to his service-connected shin splints. Further, he has contended that he has headaches and erectile dysfunction that are secondary to his service-connected PTSD. Under applicable law, disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 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 or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Aggravation for purposes of 38 C.F.R. § 3.310(b) does not require that there be "permanent worsening" of a non-service-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability, any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). The Veteran was afforded a VA examination in October 2017 which resulted in an opinion against his lumbar spine being proximately due to or the result of his shin splints. A June 2018 VA examination resulted in a similar opinion regarding the knee, and an August 2018 report included a similar opinion as the cervical spine. However, none of those examinations clearly addressed the issue of aggravation. Absent that, the examinations were not adequate for purposes of adjudication. See El-Amin v. Shinseki, 26 Vet. App. 136, 138 (2013). This is another pre-decisional duty to assist error that must be corrected. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Regarding the headaches and erectile dysfunction, a November 2018 VA examination resulted in an opinion that the headaches were not related to service. However, the examiner did indicate that the headaches were related, at least in part, to stress, depression, or anxiety. A subsequent VA PTSD examination in January 2019 noted that medical diagnoses relevant to the understanding or management of the Veteran's mental health disorder were headaches, migraines, and erectile dysfunction. That is to say, there was evidence at time of the AOJ's decision which tended to indicate the Veteran's headaches and erectile dysfunction might be related to his service-connected acquired psychiatric disorder. It was a pre-decisional duty to assist error not to obtain a medical examination and/or opinion to clarify the matter prior to final adjudication. 10. Entitlement to service connection for disability of the feet is remanded. The AOJ denied the Veteran's claim for service connected for disability of the feet on the basis that he had bilateral pes planus that pre-existed service and was not aggravated thereby. The Board notes that bilateral pes planus, asymptomatic, was noted at the time of Veteran's November 1988 enlistment examination. Where a preexisting disease or injury is noted on an entrance examination, that disease or injury will be considered to have been aggravated by active military, naval, or air 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). Temporary flare-ups will not be considered to represent an increase in severity. Hunt v. Derwinski, 1 Vet. App. 292, 295 (1991). Here, the Board notes that the Veteran was prescribed arch supports for his feet in August 1989. Subsequent records from November 1989 note a mass on the sole of the foot and pain while walking. That said, his feet were evaluated as normal at the time of his service separation examination. He also checked a box on the concurrent Report of Medical History to the effect he did not have foot trouble. Nevertheless, he has since contended, to include at the April 2021 hearing, that he developed recurrent problems with both feet during active service. At the time of the rating decision on appeal, it was not clear from the evidence of record whether the Veteran's pre-existing bilateral pes planus was aggravated by his period of active service. The Board finds that it was a pre-decisional duty to assist error not to obtain an examination and opinion on the matter. See McLendon, supra. These matters are REMANDED for the following action: 1. Schedule the Veteran for medical examination(s) pertaining to his claimed lumbar spine disability, knee disabilities, respiratory disability, cervical spine disability, headaches, erectile dysfunction, tendinitis, and muscle pain by appropriately qualified examiner(s). The examiner(s) should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner(s) should offer an opinion as to whether the signs and symptoms associated with the Veteran's lumbar spine, knees, respiratory system, cervical spine, headaches, erectile dysfunction, tendinitis, and muscle pain are most consistent with: (1) a diagnosable but medically unexplained chronic multi-symptom illness of unknown etiology, (2) a diagnosable chronic multi-symptom illness with a partially explained etiology, or (3) a disease with a clear and specific etiology and diagnosis. If after examining the Veteran and reviewing the claims file, the examiner determines that the Veteran's disability pattern with respect to any of the signs or symptoms at issue is most consistent with a diagnosable chronic multi-symptom illness with a partially explained etiology, or a disease with a clear and specific etiology and diagnosis, the examiner(s) should offer a further opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that any such illness or disability is related to active service, to include environmental exposures experienced by the Veteran during service in Southwest Asia. For the headaches, the pertinent examiner should consider and discuss the Veteran's contention that the headaches are related to an in-service root canal. The pertinent examiner(s) should also express an opinion as to whether it is at least as likely as not that the Veteran has a disability of the lumbar spine, knees, and/or cervical spine that was (a) caused or (b) aggravated (i.e., permanently or temporarily worsened beyond natural progression) by his service-connected shin splints. In addition, the pertinent examiner(s) should express an opinion as to whether it is at least as likely as not that the Veteran's headaches and/or erectile dysfunction have been (a) caused or (b) aggravated by his service-connected PTSD with depressive disorder and alcohol use disorder. A complete rationale for all opinions expressed must be provided. 2. The Veteran should also be scheduled for an examination of his feet. The examiner(s) should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner(s) should offer an opinion as to whether it is clear and unmistakable (i.e., obvious, manifest, or undebatable) that the Veteran's pre-existing bilateral pes planus did NOT permanently or chronically increase in severity during service beyond the natural progress of the condition. A complete rationale for all opinions expressed must be provided. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board John Kitlas, 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.