Citation Nr: 21007432 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 13-25 574 DATE: February 9, 2021 ORDER Entitlement to service connection for a right foot disability is granted. Entitlement to service connection for a left foot 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. Entitlement to service connection for a right knee disability is granted. Entitlement to service connection for a left knee disability is granted. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran’s right foot disability manifested from service. 2. The evidence is at least evenly balanced as to whether the Veteran’s left foot disability manifested from service. 3. The evidence is at least evenly balanced as to whether the Veteran’s right ankle disability manifested from service. 4. The evidence is at least evenly balanced as to whether the Veteran’s left ankle disability manifested from service. 5. The evidence is at least evenly balanced as to whether the Veteran’s right knee disability manifested from service. 6. The evidence is at least evenly balanced as to whether the Veteran’s left knee disability manifested from service. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for a right foot disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for a left foot disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for a right ankle disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 4. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for a left ankle disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 5. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for a right knee disability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 6. Resolving reasonable doubt in the Veteran’s favor, the criteria for service connection for a left knee 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 January 1985 to December 1986. These matters initially came before the Board of Veterans’ Appeals (Board) on appeal from June 2011 and February 2013 rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO). In the June 2011 rating decision, the RO denied service connection for the Veteran’s claimed knee injuries; he was notified of the decision in July 2011. He submitted his Notice of Disagreement regarding his bilateral knee claim in August 2011. In the February 2013 rating decision, the RO denied service connection for bilateral foot and bilateral ankle disabilities. The Veteran submitted his Notice of Disagreement for the ankles and feet issues in April 2013. The RO issued a July 2013 Statement of the Case regarding the Veteran’s knees, which he appealed in a September 2013 Form 9. The RO issues an April 2014 Statement of the Case regarding the Veteran’s feet and ankles, which he appealed in an April 2014 Form 9. The case was certified to the Board in July 2017. In January 2018 Board remanded the case for new VA examinations. Following Supplemental Statements of the Case in May 2019 and August 2019, the case was returned to the Board. In January 2020, the Board remanded the case for adequate VA opinions which considered multiple theories of entitlement to service connection. Whether substantial compliance was met by the RO regarding the Board’s remands is moot, as the decisions herein constitute a full grant of benefits sought on appeal. As a final preliminary matter, the VLJ who conducted the August 2017 Board hearing is no longer employed by the Board. VLJs who conduct hearings must participate in making the final determination of the claim involved. 38 U.S.C. § 7107(c); 38 C.F.R. § 20.707. In a December 2020 letter, the Veteran was informed of his right to a hearing before a new VLJ and that if he did not respond to the letter within 30 days, it would be assumed he did not want another hearing and the Board would decide the claims. As the Veteran did not respond, the Board will adjudicate the claims. In any event, there is no prejudice in so proceeding, as the claims are being granted in full. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection also may be granted for a disability shown after service, when all of the evidence, including that pertinent to service, shows that it was traceable to a disease or injury incurred or aggravated in service. 38 C.F.R. § 3.303(d). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the current disability and an in-service precipitating disease, injury or event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection for a right and left foot disabilities The Veteran has attributed a current bilateral foot disability to service. He testified at the August 2017 Board hearing that the boots he was issued were not supportive, and that he was required to carry a heavy load over uneven terrain, including gravel roads uphill. He also testified that servicemembers did not usually utilize medical services. Regarding whether he developed his current foot problems on active duty, the Veteran said he does not remember having any problems or symptoms prior to active duty and that the issues have continued since active duty. In an October 2011 statement, the Veteran wrote that he was a combat infantryman and carried between 125 and 140 pounds on his back. He stated the boots issued did not have arch supports and his arches fell during boot camp. In his April 2014 appeal, the Veteran wrote that he wore foot pads, but was on his feet all day long and marched or ran 20 to 25 miles per week, and so he believes his issues began in the military and continue to the present day. Several supporting “buddy” statements are available for review in the claims file. In July 2011, R.W. wrote the Veteran also complained about his feet and ankles always being sore and the boots available lacked any real foot support but that being on their feet was part of the job. In a statement received June 2019, H.R.M. wrote that the Veteran had talked about foot pain. M.S. wrote a letter submitted in June 2019 regarding the Veteran’s in-service injuries which supports the Veteran’s accounts. He also explained that in service it was frowned on in their unit to go to the aid station, and that the Veteran was harassed for being on profile. Another statement, by J.M., reveals the Veteran was injured at least twice following basic training as well. J.M.’s detailed letter is another of the buddy statements which support the Veteran’s own assertions, including description of a prairie dog hole the Veteran was injured from. VA has confirmed J.M.’s assignment was the same as the Veteran’s. The Veteran has been diagnosed with disabilities of his feet, including pes cavus. See e.g. August 2013 VA examination (claw foot (pes cavus) with metatarsalgia and hammer toes); August 2013 Doctor O. examination (metatarsus adductus); February 2014 Doctor M.T. examination (pes cavus bilaterally)(examination dated August 2013 and received February 2014); March 2018 VA examination (bilateral pes planus, metatarsalgia, hammer toes, and left hallux valgus); August 2020 VA examination (bilateral metatarsalgia, hammer toes, pes cavus, plantar fasciitis, and degenerative arthritis, and hallux valgus of the left foot and left foot tendinopathy). Therefore, the requirement for a current disability has been met. The Veteran’s service treatment records do not show treatment or documentation of complaints during service. The Veteran’s December 1984 enlistment examination was negative for a prior foot problem. “Foot trouble” was also negative upon separation in November 1986. As noted above, the Veteran and his fellow servicemen have attested to the hesitation with seeking medical care in service. The Veteran did submit a photograph of himself in a river-crossing training exercise carrying an 80-pound ruck, 46-pound baseplate, 8-pound M16, and a radio. From the photograph it is apparent that the Veteran had to travel over rocky uneven terrain, and the Veteran included a note that in addition to rocks and the harsh landscape, other locations included prairie dog holes. Regarding a nexus to service, the Veteran testified that he had no symptoms or complaints prior to service, his feet began to hurt during service, and he experienced symptoms since service. Additionally, in regard to a separate psychiatric disability claim, the Veteran wrote in October 2011 that he remained in isolation after service and did not even see a doctor until ten years prior. The Veteran is competent to report when he experienced certain symptoms, and there is no reason to doubt the Veteran’s credibility. In a September 2011 private orthopedic record, Doctor J.T.S. wrote that the Veteran continued to display pes cavus. She did not believe it was related to military service but did not explain why. Without a rationale, the Board cannot rely on the opinion. In a February 2013 letter, a private foot and ankle clinic professional, Doctor J.L.O., diagnosed the Veteran with bilateral metatarsus adductus congenital malalignment of his bilateral feet. He wrote that malalignment is not necessarily symptomatic in all patients. However, Doctor J.L.O. felt that the physical demands placed on the Veteran’s extremities during military service did contribute to his development of chronic pain in his feet and ankles. In an August 2013 Disability Benefits Questionnaire (DBQ), Doctor J.L.O. wrote that pain in the Veteran’s bilateral lower extremities was exacerbated by prolonged physical activity and chronic tenonitis. The Veteran submitted records in February 2014 showing that another private physician, Doctor M.T., concurred with the opinion of Doctor J.L.O. In August 2013, Doctor M.T. diagnosed the Veteran’s feet with pes cavus bilaterally, and recorded a medical history of pain increasing during military service in carrying loads of 75 to 100 pounds. In August 2013, a VA examiner diagnosed the Veteran with claw foot/pes cavus, metatarsalgia, and hammertoes. The VA examiner wrote that the Veteran initially noted gradual onset of pain and stiffness to bilateral feet beginning in January 1985 with an abnormal gait. The Veteran told him he was not seen for the condition and did not mention his feet at separation. He told the VA examiner he was initially seen for his feet in 1986 in Georgia but could not remember the name of the physician. The August 2013 VA examiner found there was insufficient clinical evidence to support a diagnosis of pes planus and as the Veteran’s condition was diagnosed as congenital, it was not caused by or the result of repetitive injury from military service. The examiner furthered that the Veteran was not seen during service, did not complain at separation, and there is no documentation of continued care until 25 years after military service “which does not satisfy continuity of care.” Because there was no documentation during service, the examiner also found it was not aggravated by service. However, the examiner did not consider lay assertions supporting the contention that he was injured and had not experienced symptoms prior to service. In January 2018, the Board remanded for a new VA examination. A March 2018 VA examiner found the Veteran did have pes planus, as well as metatarsalgia, hammer toes, and left foot hallux valgus. However, she opined that the Veteran’s right and left foot disabilities were less likely than not due to service. She wrote this was because service treatment records are silent for documentation, but the opinion lacked analysis and rationale, and appears to not have been afforded careful consideration as she referenced “bilateral ankle condition.” The March 2018 VA examiner did acknowledge a buddy statement by R.W., but included that this “is not considered a medical record document.” The VA examiner’s explanation for rejecting a relevant lay statement is inadequate. Laypeople are competent to report symptoms and history that is experienced or observed with the five senses and the fact that a statement is given by a lay person as the sole basis for a negative opinion is inadequate. The March 2018 VA examiner’s opinions are therefore inadequate for decision making purposes. The Board determined another remand was needed. In the previous January 2018 Board remand order, the Board had instructed VA examiner(s) to consider the Veteran’s reports as to his symptoms and history. The order stated that if the examiner rejected the Veteran’s reports, the examiner must provide an explanation for such rejection. Instead, the March 2018 VA examiner relied on the absence of documented injuries in the service treatment records and did not consider all the lay and buddy statements of record, including Veteran’s testimony and lay statements, detailed statements describing firsthand observations of the Veteran’s in-service injuries provided by four fellow servicemen. The Board remanded the case for adequate medical opinion in January 2020. Following the Board remand, in August 2020, a VA examiner examined the Veteran’s feet and issued multiple opinions. The Veteran’s feet were provided with diagnoses of bilateral metatarsalgia, hammer toes, pes cavus, plantar fasciitis, and degenerative arthritis, hallux valgus of the left foot, and left foot fracture of the great toe. The August 2020 VA examiner provided near identical opinions on direct service connection regarding the right foot and the left foot, writing that during service, the foot was not documented in service treatment records to be a complain, symptomatic or have a diagnosis. The discharge examination is silent for any foot problems, concerns, or diagnoses. There is no evidence of chronicity of care from service, and “it is documented” that 25 years after service the Veteran had a congenital foot condition. The examiner also noted that the Veteran worked in boots for many years after service performing construction type physical labor and that this longer timespan is more likely to have contributed to the “worsening” of the congenital foot condition over time. Finally, she noted that only one of four buddy statements was available for review, but concluded that “other documentation does not support that any buddy statement would change this medical opinion.” Regarding secondary service connection, the August 2020 VA examiner actually wrote about how the Veteran’s disability was not caused from service and did not actually address whether he had a current foot disability caused by another disability. Regarding aggravation, the August 2020 VA examiner wrote that while temporary aggravation was “plausible,” there was not evidence of permanent aggravation, without explaining why the evidence in the file did not demonstrate permanent aggravation. She wrote “a thorough review of medical literature fails to support that the pre-existing condition was permanently aggravated by service.” However, she did not explain what that medical literature was or how it would have applied to the facts of this case. She also only opined regarding a “congenital” condition and did not address the numerous diagnoses of the Veteran’s feet. The examiner did not consider lay evidence and reiterated that no buddy statement would change her opinion. The August 2020 VA examiner also wrote that the problems did not start until 2011, with no explanation for why she discredited the Veteran’s report at the August 2013 VA examination that he was seen for his feet in Georgia around 1986 and why she would not consider any of the lay statements by the Veteran or other verified servicemembers detailing his injuries during service. Following review of the three additional buddy statements, in an October 2020 VA addendum, the August 2020 VA examiner provided updated opinions for the right foot and left foot, still finding that the condition was less likely than not from service in that the submitted buddy statements support an acute injury in service only, and do not support a chronic diagnosis, chronicity over time as records are silent for foot conditions between 1986 and 2011. A Veteran is presumed to have been sound upon entry into active duty service, except as to defects, infirmities, or disorders noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). In other words, "[w]hen no preexisting condition is noted upon entry into service, the veteran is presumed to have been sound upon entry." Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004). The Veteran's December 1984 medical examination report upon entry into service does not note any foot disability or symptoms of a foot-related problems. Private treatment records note that the Veteran’s metatarsus is congenital, but there is no clear and unmistakable evidence within the claims file which indicates all of the Veteran's foot disabilities existed prior to service and were not aggravated by service. The August 2020 VA examiner opined that the Veteran’s congenital foot disability was not aggravated by service, but based the opinion on the lack of medical evidence of foot treatment to support the opinion which is impermissible, thus the opinion is afforded no probative value. Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Additionally, the other diagnoses of pes planus, fasciitis, and others were not distinguished. As clear and unmistakable evidence has not been provided to establish whether the Veteran's bilateral foot disability preexisted service and was not aggravated by service, the presumption of soundness has not been rebutted and the Veteran is presumed to have been sound upon entry into active duty service. The Veteran has been provided diagnoses during the appeal period of pes cavus, pes planus, metatarsalgia, plantar fasciitis, and degenerative arthritis, among others. The evidence is at least evenly balanced as to whether the Veteran’s right and left feet were injured in service. Therefore, the first two requirements for service connection have been satisfied. Regarding a nexus, the VA opinions relied on a lack of relationship between a current foot disability and military service. However, the examiners largely based their opinions on a lack of medical treatment for the Veteran’s feet during service, and without presuming the Veteran was sound upon enlistment. The examiners also failed to consider the Veteran’s accounts of in-service events and continuity of symptoms since service, and the supporting buddy statements. Thus the opinions are inadequate. Buchanan, 451 F.3d at 1336. The February 2013 orthopedist provided a rationale to support his opinion that the physical demands place on the Veteran’s extremities during military service contributed to his development of chronic pain in his feet. It was based on an accurate review of the facts and correctly considered lay statements as evidence. Therefore, his opinion is afforded significant probative value. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). The August 2020 VA opinion on the other hand attributed the Veteran’s current foot disability to wearing boots for work following service and for having a congenital pes cavus diagnosis. However, in addition to not considering the Veteran’s non-congenital diagnoses, that opinion seems to focus on the amount of time the Veteran was working following service in physical labor, and not the nature of the work itself; as shown in his submitted photograph and described in many lay statements by himself and his fellow servicemen, the Veteran was required to run and march up to dozens of miles weekly, including uphill, through water, and on rocky and uneven paths in unsupportive shoes. Comparable facts were not shown as occurring during his time following service. Evidence shows he was injured multiple times during service due to these conditions but there is no evidence he was injured following service during his civilian work positions. The Veteran testified at the August 2017 Board hearing that he did not frequent “sick call” in the service because it was more common to avoid seeking medical care if he could push through the pain. As previously mentioned, in support of a separate claim for a psychiatric disability, in October 2011 the Veteran wrote that he remained in isolation after service and did not even see a doctor until ten years prior. The Veteran is competent to report continuous pain symptoms in the years since service. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a Veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service); Buchanan, 451 F.3d at 1337 (holding lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). There is nothing to explicitly contradict the Veteran’s testimony, and that testimony is consistent with the evidence of record. For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran’s right foot and left foot disabilities are related to 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 is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service connection for a right and left ankle disabilities The Veteran testified at the August 2017 Board hearing that he was required to march for training on 12 to 15-mile roads and he carried a great amount of weight considering his pack, barrels, baseplates, weaponry, and FDC plotting board. He told the Veterans Law Judge who conducted the hearing that because he walked more on the sides of his feet due to their condition, which caused his ankle to roll, twist, and sprain, but he carried on through lots of pain. In an October 2011 statement, the Veteran wrote to VA he was a combat infantryman and carried between 125 and 140 pounds on his back. In his April 2014 appeal, the Veteran wrote that he wore foot pads, but was on his feet all day long and marched or ran 20 to 25 miles per week, and so he believes his issues began in the military and continue to the present day. Several supporting “buddy” statements are available for review in the claims file. In July 2011, R.W. wrote that he remembers the Veteran having ankle and knee issues and can recall at least two occasions that he was either in knee or ankle braces, the first after a 21-mile speed march in basic training, and another incident was when the Veteran was held back from a field training exercise, and afterwards the Veteran wore a knee brace and used crutches. The Veteran also complained about his feet and ankles always being sore but that being on their feet was part of the job. In a statement received June 2019, H.R.M. wrote that he was in basic training and stationed with the Veteran, and remembered the run when the Veteran was injured from a fall and put on profile. H.R.M. witnessed the Veteran dislocating his knee during a field exercise, and the Veteran fell in pain and had swelling. M.S. wrote a letter submitted in June 2019 regarding the Veteran’s in-service injuries which supports the Veteran’s accounts. He also explained that in service it was frowned on in their unit to go to the aid station, and that the Veteran was harassed for being on profile. Another statement, by J.M., reveals the Veteran was injured at least twice after basic training as well. J.M.’s detailed letter is another of the buddy statements which support the Veteran’s own assertions, including description of a prairie dog hole the Veteran was injured from. VA confirmed J.M.’s assignment was the same as the Veteran’s. The Veteran has current diagnoses for his right ankle and his left ankle. See e.g. September 2011 private doctor impression (palsy to the left ankle); March 2018 VA examination (bilateral ankle strain (lateral collateral ligament of the ankle) with laxity); August 2020 VA examination (right ankle degenerative arthritis; bilateral ankle strain, lateral collateral ligament with laxity). Therefore, the requirement for a current disability has been met. As for an in-service disease or injury, the Veteran’s service treatment records do not show complaints, treatment, or diagnosis of ankle disorder or an injury occurring on active duty. Upon entry, the Veteran’s lower extremities were evaluated as normal. No foot trouble or ankle problems were reported at separation at his November 1986 examination. The Veteran’s service treatment records also do not show treatment or documentation of complaints during service. The Veteran did submit a photograph of him in a river-crossing training exercise carrying an 80-pound ruck, 46-pound baseplate, 8-pound M16, and a radio. From the photograph it is apparent that the Veteran had to travel over rocky uneven terrain, and the Veteran included a note that in addition to rocks and the harsh landscape, other locations included prairie dog holes. Additionally, the Veteran has testified and submitted signed written statements regarding his injuries in service, including those supported by the accounts of multiple persons he served alongside. Submitting in regard to a separate claim, the Veteran wrote in October 2011 that he remained in isolation after service and did not even see a doctor until ten years prior. The Veteran is competent to report when he experienced certain symptoms, and there is no reason to doubt the Veteran’s credibility. Jandreau, 492 F.3d at 1377 (a Veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service); Buchanan, 451 F.3d at 1337 (holding lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). This is sufficient to establish the second element of his service connection claim. The third element of the claim to establish service connection is whether there is a nexus between the Veteran’s current diagnosis, and his symptoms in service. In a February 2013 letter, a private foot and ankle clinic professional, Doctor J.L.O., noted the Veteran’s chronic pain in his ankles of more than 26 years duration. Doctor J.L.O. wrote he felt the physical demands placed on the Veteran’s extremities during military service did contribute to his development of chronic pain in his feet and ankles. In an August 2013 DBQ, Doctor J.L.O. wrote that pain in the Veteran’s bilateral lower extremities was exacerbated by prolonged physical activity and chronic tenonitis. The Veteran submitted records in February 2014 showing that another private physician, Doctor M.T., concurred with the opinion of Doctor J.L.O. In August 2013, and Doctor M.T. and Doctor J.L.O. had diagnosed the Veteran with ankle instability. In August 2013, a VA examiner diagnosed the Veteran with ankle instability and record a history of gradual onset of symptoms of pain, swelling, and stiffness to bilateral ankles beginning in bootcamp in January 1985. The Veteran denied being seen for ankles during service or mentioning at separation. The August 2013 VA examiner found the Veteran’s ankle condition was less likely than not caused by service because there was no documentation of evaluation or treatment during military service and the Veteran was not seen until 2011 which “does not satisfy continuity of care.” The VA examiner did find the Veteran’s ankle condition is at least as likely as not causally related to or the result of his bilateral pes cavus. However, the examiner did not consider lay assertions supporting the contention that he was injured and had not experienced symptoms prior to service. In January 2018, the Board remanded for a new VA examination. A March 2018 VA examiner diagnosed the Veteran with bilateral ankle strain, lateral collateral ligament of the ankle, with laxity. She noted the Veteran believed his bilateral ankle condition incurred due to in-service physical activities while service in indirect fire infantry, including long distances walking and hiking with gear and equipment. In a March 2018 opinion, the VA examiner noted service treatment records were silent for an ankle condition claimed to be incurred on active duty. She noted that she acknowledged the buddy statement by R.W., but did not consider it a “medical record.” The March 2018 VA examiner relied on the absence of documented injuries in the service treatment records and did not consider all the lay and buddy statements of record, including Veteran’s testimony and lay statements, detailed statements describing firsthand observations of the Veteran’s in-service injuries provided by four fellow servicemen. The VA examiner’s explanation for rejecting a relevant lay statement is inadequate. Laypeople are competent to report symptoms and history that is experienced or observed with the five senses and the fact that a statement is given by a lay person as the sole basis for a negative opinion is inadequate. The March 2018 VA examiner’s opinions are therefore inadequate for decision making purposes. The Board remanded the case for adequate medical opinions in January 2020. In August 2020, a VA examiner diagnosed the Veteran with right ankle degenerative arthritis and bilateral ankle strain with lateral collateral ligament with laxity. The Veteran reported when developing foot problems on active duty, his foot would curve inwards on incline while walking on his feet. Due to this, he twisted his ankles multiple times when running or walking during service on incline from paved roads and from dirt roads. Regarding the right ankle, the August 2020 VA examiner wrote a diagnosis or treatment was not identified in the claims file, including on the discharge examination, and there was no evidence of chronicity of care after service, with the first medical records discussing ankle problems in 2011. The opinion for the Veteran’s left ankle was almost identical, with the August 2020 VA examiner even mentioning “right” ankle in the opinion. Specifically related to direct service connection for the bilateral ankles, the August 2020 VA examiner reiterated there were no service records with “ankle diagnoses” and discharge examination documents normal findings and no concerns or previous problems with the right ankle or left ankle. However, the examiner did not provide a reason for favoring the lack of medical documentation over the supportive lay statements in the file. The VA examiner added that the Veteran worked other physically intense jobs over time, such as construction, which more likely contributed to development of ankle diagnoses. The examiner did not explain why the Veteran’s construction work would be more likely to contribute to an ankle disability over his military service for which there are multiple accounts of him injuring his ankles on active duty. The August 2020 VA examiner also found that regarding ankle disability as secondary to the Veteran’s feet “is not illustrated in service records.” However, that opinion is not supported by any rationale. As for aggravation, the August 2020 VA examiner wrote “no aggravation for the bilateral ankle cannot be stated.” She relied on lack of medical documentation before and during service for the negative finding, also noting there was only one of four buddy statements available for review, but added “other documentation does not support than any buddy statement would change this medical opinion,” implying no lay statement could change the finding. As with the March 2018 VA opinion, the August 2020 VA opinion is inadequate for not considering lay statements. Following review of the three additional buddy statements, in an October 2020 VA addendum, the August 2020 VA examiner provided updated opinions for the right foot and left foot, still finding that the condition was less likely than not from service in that the submitted buddy statements only support an acute injury in service and do not support a chronic diagnosis, chronicity over time is not established as records are silent for foot conditions between 1986 and 2011. The Veteran has current diagnoses of bilateral ankle strain, ankle instability, and right ankle degenerative arthritis. Additionally, the evidence is at least evenly balanced as to whether the Veteran’s right and left ankles were injured in service. Therefore, the first two requirements for service connection have been satisfied. Regarding a nexus, the VA opinions relied on a lack of relationship between a current ankle disability and military service. However, the examiners based their opinions on a lack of documented medical treatment for the Veteran’s ankles during service and following service, despite considering explanations for the lack of documentation. The examiners also failed to consider the Veteran’s accounts of in-service events and continuity of symptoms since service, and the supporting buddy statements. Thus, the opinions are inadequate. Buchanan, 451 F.3d at 1336. The February 2013 orthopedist provided a rationale to support his opinion that the physical demands place on the Veteran’s extremities during military service contributed to his development of chronic pain in his ankles. It was based on an accurate review of the facts and correctly considered lay statements as evidence. Therefore, his opinion is afforded significant probative value. See Nieves-Rodriguez, 22 Vet. App. at 304 (most of the probative value of a medical opinion comes from its reasoning). The August 2020 and October 2020 VA opinions on the other hand attributed the Veteran’s current ankle disabilities to wearing boots for work following service. However, in addition to not explaining why lay statements were not taken into account, the August 2020 VA examiner seemed to focus on the amount of time the Veteran was working following service in physical labor, and not the nature of the work itself; as shown in his submitted photograph and described in many lay statements by himself and his fellow servicemen, the Veteran was required to run and march up to dozens of miles weekly, including uphill, through water, and on rocky and uneven paths in unsupportive shoes. Comparable facts were not shown as occurring during his time following service. Evidence does show the Veteran was injured multiple times during service due to the running and marching over rough terrain, but there is no evidence he was injured following service during a civilian work position. The Veteran testified at the August 2017 Board hearing that he did not frequent “sick call” in the service because it was more common to avoid seeking medical care and he pushed through despite the pain. As previously mentioned, in support of a separate disability claim, in October 2011 the Veteran wrote that he remained in isolation after service and did not see a doctor until ten years earlier. The Veteran is competent to report continuous pain symptoms in the years since service. Jandreau, 492 F.3d at 1377 (a Veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service); Buchanan, 451 F.3d at 1337 (holding lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). There is nothing to explicitly contradict the Veteran’s testimony, and that testimony is consistent with the evidence of record. For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran’s right ankle and left ankle disabilities are related to 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 is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Service connection for a right and left knee disabilities The Veteran testified at the August 2017 Board hearing the first time he injured his knee was “coming in from a 12-mild speed march.” He explained that he was come up the back of a hill with a heavily-graveled hill, and as he was attempting to climb up alongside his fellow servicepersons, his knee “slipped out.” Another person grabbed the bottom of his ruck from behind and picked him up, pushing him up the hill and they kept going. On another occasion, the Veteran was on a run and twisted a run or dislocated it and went to medical when it “popped out.” He testified that he and another gentleman were held back for five days. In an October 2011 statement, the Veteran wrote to VA he was a combat infantryman and carried between 125 and 140 pounds on his back. In his April 2014 appeal, the Veteran wrote that he wore foot pads, but was on his feet all day long and marched or ran 20 to 25 miles per week, and so he believes his issues began in the military and continue to the present day. Several supporting “buddy” statements are available for review in the claims file. In July 2011, R.W. wrote that he remembers the Veteran having ankle and knee issues and can recall at least two occasions that he was either in knee or ankle braces, the first after a 21-mile speed march in basic training, and another incident was when the Veteran was held back from a field training exercise, and afterwards the Veteran wore a knee brace and used crutches. The Veteran also complained about his feet and ankles always being sore but that being on their feet was part of the job. In a statement received June 2019, H.R.M. wrote that he was in basic training and stationed with the Veteran, and remembered the run when the Veteran was injured from a fall and put on profile. H.R.M. witnessed the Veteran dislocating his knee during a field exercise, and the Veteran fell in pain and had swelling. M.S. wrote a letter submitted in June 2019 regarding the Veteran’s in-service injuries which supports the Veteran’s accounts. He also explained that in service it was frowned on in their unit to go to the aid station, and that the Veteran was harassed for being on profile. Another statement, by J.M., reveals the Veteran was injured at least twice after basic training as well. J.M.’s detailed letter is another of the buddy statements which support the Veteran’s own assertions, including description of a prairie dog hole the Veteran was injured from. VA confirmed J.M.’s assignment was the same as the Veteran’s. The Veteran has diagnoses which have been made during the appeal period for his right knee and his left knee. See e.g. June 2011 VA examination (left knee degenerative joint disease; right knee patellofemoral syndrome); September 2011 Doctor J.T.S. impression (bilateral knee degenerative joint disease); August 2013 examination by M.T. (chondromalacia patellae)(signed February 2014); March 2018 VA examination (bilateral knee strain; left meniscal tear; left instability; right patellofemoral pain syndrome; left degenerative joint disease; left Baker's Cyst); August 2020 VA examination (bilateral knee strain; left meniscal tear; bilateral degenerative arthritis; left Baker’s Cyst). Therefore, the requirement for a current disability has been met. As for an in-service disease or injury, the Veteran’s service treatment records do not show complaints, treatment, or diagnosis of knee disorder or an injury occurring on active duty. Upon entry, the Veteran’s lower extremities were evaluated as normal. At his November 1986 separation examination, the examiner wrote there was a history of locked knee for five years so it was not evaluated as it existed prior to service. However, a knee problem was not noted upon entry, and the Veteran testified that he had no problem with his knees prior to service. As clear and unmistakable evidence has not been provided to establish whether the Veteran’s bilateral knee disability preexisted service and was not aggravated by service, the presumption of soundness has not been rebutted and the Veteran is presumed to have been sound upon entry into active duty service. The Veteran’s service treatment records also do not show treatment or documentation of complaints during service. The Veteran did submit a photograph of him in a river-crossing training exercise carrying an 80-pound ruck, 46-pound baseplate, 8-pound M16, and a radio. From the photograph it is apparent that the Veteran had to travel over rocky uneven terrain, and the Veteran included a note that in addition to rocks and the harsh landscape, other locations included prairie dog holes. Additionally, the Veteran has testified and submitted signed written statements regarding his injuries in service, including those supported by the accounts of multiple persons he served alongside. Submitting in regard to a separate claim, the Veteran wrote in October 2011 that he remained in isolation after service and did not even see a doctor until ten years prior. The Veteran is competent to report when he experienced certain symptoms, and there is no reason to doubt the Veteran’s credibility. Jandreau, 492 F.3d at 1377 (a Veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service); Buchanan, 451 F.3d at1337 (holding lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). This is sufficient to establish the second element of his service connection claim. The third element of the claim to establish service connection is whether there is a nexus between the Veteran’s current diagnosis, and his symptoms in service. At a June 2011 VA examination, the Veteran stated his pulled his left knee out which started in basic training. During that time, he walked off the knee pain. He was jumping out of fox holes and both knee “went out” at various times and his knees “pop out” and are now “completely mess up.” His prior occupation was construction oriented, in business building architectural devices for birds and installed netting devices and some work was done on a ladder with some time up and down and on his knees. He was diagnosed with degenerative joint disease or the left knee and patellofemoral syndrome of the right knee. The June 2011 VA examiner pointed out the Veteran’s separation examination noted history of left knee problems prior to entering the service and no service treatment records documenting the Veteran sought medical attention or was injured in the service. There was also no documentation of treatment for a knee condition between 1986 and 2011. She concluded there are many other factors and issues which had time to occur between 1986 after separation from the service to 2011 which are more likely responsible for his current bilateral knee condition. In a September 2011 medical record by private physician, Doctor J.T.S. diagnosed the Veteran with bilateral degenerative joint disease, and wrote that it sounds as though the Veteran had injuries in the military with at least one patellar subluxation, and that repetitive subluxations can lead to degenerative joint disease. She also stated there is no way to ascertain what portion of his left knee problem is genetic verses related to patellar subluxations in the military. When an examiner is unable to distinguish the symptoms of a service-connected disability from non-service-connected manifestations, all the manifestations will be considered part of the service-connected disability. Mittleider v. West, 11 Vet. App. 181, 182 (1998). Similarly here, which precise portion of the knee problem is attributed to service is not necessary for service connection, only that the currently disability can be attributed to service. A May 2013 VA examiner noted the Veteran’s nine weeks of boot camp as supported by personnel records. However, while an opinion was rendered that the Veteran’s knee disabilities were less likely than not directly caused by service or aggravated by service, no rationale was given to connect the facts of the case to the finding. In an August 2013 DBQ, Doctor J.L.O. wrote that pain in the Veteran’s bilateral lower extremities was exacerbated by prolonged physical activity and chronic tenonitis. In August 2013, another private physician, Doctor M.T., diagnosed the Veteran with chondromalacia patellae and documented a history of pain increasing during military service in carrying loads of 75 to 100 pounds. He opined that the Veteran’s foot disability resulted in a gait which lead to transverse plane motion of the patellar femoral joint and exacerbated his underlying knee conditions with a history of meniscal damage in service. In January 2018, the Board remanded for a new VA examination. A March 2018 VA examiner diagnosed the Veteran with bilateral knee strain, left meniscal tear, left instability, right patellofemoral pain syndrome, left degenerative joint disease, and left Baker’s Cyst. She noted the Veteran believed his bilateral knee condition incurred due to in-service injuries and overuse of his knee in the service. He told her that his left knee was injured during long-distance hiking and it cause the knee to give out which led to him being put on light duties and crutches. She noted condition has progressed since its initial onset. In her opinion, the March 2018 VA examiner noted service treatment records were silent for “bilateral knee condition” claimed to be incurred on active duty. She noted that she acknowledged the buddy statement by R.W., but did not consider it a “medical record.” The March 2018 VA examiner relied on the absence of documented injuries in the service treatment records and did not consider all the lay and buddy statements of record, including Veteran’s testimony and lay statements, detailed statements describing firsthand observations of the Veteran’s in-service injuries provided by four fellow servicemen. As laypeople are competent to report symptoms and history that is experienced or observed with the five senses, and the VA examiner did not provide a rationale for rejecting relevant lay statements, the March 2018 VA examiner’s opinions are therefore inadequate for decision making purposes. The Board remanded the case for adequate medical opinions in January 2020. In August 2020, a VA examiner diagnosed the Veteran with bilateral knee strain, left meniscal tear, bilateral degenerative arthritis, and left Baker’s Cyst. The Veteran reported in basic training he was in full ruck for a speed march when his left knee “popped out,” he was picked up and his knee moved back into place, though he experienced left knee pain for days. Following that experience, the Veteran’s knee popped out regularly, with bilateral knee pain, the right the Veteran suspected was from compensation from the left. The Veteran said he was seen by medical, wrapped his knee, and used store-bought braces. Regarding the right knee, the August 2020 VA examiner wrote during service, right knee was acute only and there is a record of unspecified laterality knee injury in 1985 from a buddy statement. The examiner wrote there is no evidence of treatment records for this injury during service or for continued care for a right knee condition until 2011. The VA examiner furthered that the Veteran worked in physical labor and construction-type jobs “over time” which more likely than not contributed to the current right knee diagnosis. Regarding the left knee, the August 2020 VA examiner wrote during service, left knee was acute only and there is a record of unspecified laterality knee injury in 1985 from a buddy statement. The examiner noted that the Veteran’s discharge examination states there was a left knee injury prior to service with a five-year history and there is no evidence of chronicity of care over time, until 2011. As the Veteran also worked labor intensive jobs over time, the August 2020 VA examiner found it could not be excluded that post-service work contributed to his current knee diagnoses. In response to the examiner’s opinion, it is understandable that post-service labor having contributed to musculoskeletal disabilities could not be excluded; however, such contribution to the Veteran’s current disabilities from post-military jobs would not negate finding a nexus from service. Relying on lack of medical documentation during service and a gap in evidence for 25 years thereafter, the August 2020 VA examiner also opined the Veteran’s knee disabilities were not caused by another disability and were not aggravated by service. Following review of the three additional buddy statements, in an October 2020 VA addendum, the August 2020 VA examiner provided updated opinions for the right knee and left knee, finding that the condition was less likely than not from service in that the submitted buddy statements only support an acute injury in service and do not support a chronic diagnosis, chronicity over time is not established as records are silent for knee conditions between 1986 and 2011. The examiner also wrote records in 1986 also show that there were knee complaints present for years prior to entry into active duty service in 1985. The Veteran has current diagnoses of bilateral degenerative joint disease, right knee patellofemoral syndrome, bilateral chondromalacia patellae, knee strain, and left meniscal tear, among others. Additionally, the evidence is at least evenly balanced as to whether the Veteran’s right and left knees were injured in service. Therefore, the first two requirements for service connection have been satisfied. Regarding a nexus, the VA opinions relied on a lack of relationship between a current knee disability and military service. However, the examiners based their opinions on a lack of documented medical treatment for the Veteran’s knees during service and in close proximity to service, despite considering the numerous explanations for why there was a lack of documentation. The examiners also failed to consider the Veteran’s accounts of in-service events and continuity of symptoms since service, and the supporting buddy statements. Thus, the opinions are inadequate. Buchanan, 451 F.3d at 1336. The September 2011 record by J.T.S. noted that repetitive subluxations like the Veteran experienced during service can lead to degenerative joint disease. In combination with the Veteran’s written statements, the accounts of fellow service members, and the hearing testimony provided by the Veteran and his wife, the evidence is evenly balanced as to whether injuries in service caused his current knee disabilities. The August 2020 and October 2020 VA opinions on the other hand attributed the Veteran’s current knee disabilities to work following service. However, the August 2020 VA examiner seemed to focus on the amount of time the Veteran was working following service in physical labor, and not the nature of the work itself; as shown in his submitted photograph and described in many lay statements by himself and his fellow servicemen, the Veteran was required to run and march up to dozens of miles weekly, including uphill, through water, and on rocky and uneven paths. Comparable facts were not shown as occurring during his time following service. Evidence does show the Veteran was injured multiple times during service due to the running and marching over rough terrain, but there is no evidence he was injured following service during a civilian work position. The Veteran testified at the August 2017 Board hearing that he did not frequent “sick call” in the service because it was more common to avoid seeking medical care and he pushed through despite the pain. As previously mentioned, in support of a separate disability claim, in October 2011 the Veteran wrote that he remained in isolation after service and did not see a doctor until ten years earlier. The Veteran is competent to report continuous pain symptoms in the years since service. Jandreau, 492 F.3d at 1377 (a Veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service); Buchanan, 451 F.3d at 1337 (holding lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence). There is nothing to explicitly contradict the Veteran’s testimony, and that testimony is consistent with the evidence of record. For the foregoing reasons, the evidence is at least evenly balanced as to whether the Veteran’s right knee and left knee disabilities are related to 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 is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Kuczynski, 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.