Citation Nr: 21009791 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 17-14 170 DATE: February 23, 2021 ORDER Entitlement to service connection for bilateral plantar fasciitis is granted. Entitlement to a compensable initial disability evaluation for hypertension is denied. REMANDED Entitlement to service connection for a left shoulder disability is remanded. Entitlement to service connection for bilateral pes cavus is remanded. Entitlement to service connection for obstructive sleep apnea is remanded. Entitlement to service connection for a kidney condition, to include as secondary to hypertension, is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. FINDINGS OF FACT 1. Resolving all reasonable doubt in his favor, the Veteran’s bilateral plantar fasciitis is etiologically related to his service. 2. Although the Veteran takes continuous medication to control his blood pressure, the evidence of record does not show that his diastolic blood pressure measurements have been predominantly 100 or more during the period on appeal or historically, or that systolic blood pressure measurements have been 160 or more during the period on appeal. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for plantar fasciitis have been met. 38 U.S.C. §§ 1101, 1110; 38 C.F.R. §§ 3.303, 3.304. 2. The criteria for entitlement to a compensable initial disability evaluation for hypertension have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.104, Diagnostic Code 7101. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from November 2002 to July 2006. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. In October 2019, the Veteran testified before the undersigned at a hearing in St. Petersburg. A transcript of his testimony has been associated with the claims file. 1. Entitlement to service connection for plantar fasciitis At the outset, the Board notes that the Veteran has claimed entitlement to service connection for a “bilateral foot condition.” The record reflects diagnoses of various conditions affecting the bilateral feet and ankles, including plantar fasciitis and pes cavus. In this portion of the decision, the Board will adjudicate the claim to the extent that it encompasses a claim for service connection for plantar fasciitis. The remand portion of the decision will address his claim for bilateral foot conditions to the extent that it encompasses a claim for pes cavus. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303(a).  Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d).  Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury.  Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).   Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). VA shall consider all information and lay and medical evidence of record.  Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006).  Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. 38 C.F.R. § 3.159(a)(1).  Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience.  Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2).  This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007).   With respect to the first element of the test for service connection, a current disability, the Veteran’s VA treatment records indicate a current diagnosis of plantar fasciitis. As such, this aspect of his claim is not in question. The chief question for the Board is thus whether the Veteran’s plantar fasciitis is etiologically related to an in-service injury or illness. With respect to the second element of the test for service connection, in-service incurrence, the Board acknowledges that the Veteran’s service treatment records are absent for complaints of or treatment for plantar fasciitis. However, a lack of contemporaneous service treatment records is not fatal to a claim for service connection. To that end, the Veteran testified at his hearing that he did not seek medical treatment for his condition during service because he wanted to “tough it out” and avoid being discharged. Additionally, he testified that his ankles started hurting during boot camp and that his ankles would hurt due to wearing his military boots. The Board notes that the Veteran’s service treatment records reflect treatment for blisters on his feet in November 2002, shortly after beginning boot camp. The Veteran’s testimony regarding plantar fasciitis is bolstered by VA treatment records, which indicate that he had complained of discomfort in both heels when walking at an initial VA medical examination in August 2006. This was less than a month after he was discharged from service. At that time, he reported that he had been experiencing the bilateral heel pain occasionally for the past month. His treatment provider diagnosed bilateral plantar fasciitis and noted that the Veteran preferred conservative treatment options. As such, the Board finds that the second criterion of the service connection test has been satisfied. The remaining question for the Board is thus whether there is a nexus between the Veteran’s in-service foot and ankle pain and his currently diagnosed plantar fasciitis. In August 2015, the Veteran underwent a VA examination with respect to his claims for a bilateral foot condition. At that examination, the examiner diagnosed plantar fasciitis and noted that the Veteran was diagnosed with plantar fasciitis within two months of his discharge. He described the pain has pain on the bottom of his feet in the arch and lateral aspects. The examiner ultimately offered a negative nexus opinion with respect to the Veteran’s claim for a bilateral foot condition, but the nexus opinion focused on a condition that pre-existed his service, pes cavus, and whether it was aggravated in service. In other words, the examiner did not offer a nexus opinion as to plantar fasciitis. Overall, there are no probative medical opinions addressing the etiology of the Veteran’s plantar fasciitis. However, medical evidence is not categorically required to satisfy the nexus element of the service connection framework. See Davidson v. Shinseki, 581 F.3d 1212 (Fed. Cir. 2009). In this instance, the Board finds that the Veteran provided credible testimony regarding the onset and continuity of his plantar fasciitis. Tellingly, he sought treatment for the pain caused by his plantar fasciitis immediately after being discharged from service and reported that the pain had its onset a month ago, prior to his discharge. The Board notes that these statements regarding the onset of his symptoms are considered exceptionally trustworthy as they were made for the purpose of medical diagnosis and prior to the filing of a claim. See White v. Illinois, 502 U.S. 346, 356 (1992). Moreover, the short gap between his first treatment for plantar fasciitis and his service is highly probative. Resolving any reasonable doubt in the Veteran’s favor, the Board thus finds that entitlement to service connection for plantar fasciitis is warranted. 2. Entitlement to a compensable initial disability evaluation for hypertension Additionally, the Veteran is currently entitled to service connection for hypertension. In the September 2015 rating decision on appeal, the RO granted service connection for hypertension and assigned a noncompensable disability evaluation from June 18, 2015, the date his claim was received. The Veteran has asserted that he is entitled to a higher disability rating. For instance, he testified at his hearing that his home blood pressure readings showed that his average diastolic reading was somewhere between 100 and 110mm. Disability evaluations are determined by the application of the facts presented to VA’s Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4.  The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations.  See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1.  In evaluating the severity of a particular disability, it is essential to consider its history.  See 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991).  Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation.  Otherwise, the lower rating will be assigned.  See 38 C.F.R. § 4.7.  In every instance where the rating schedule does not provide a non-compensable evaluation for a diagnostic code, a non-compensable evaluation shall be assigned when the criteria for a compensable rating are not met. 38 C.F.R. § 4.31. Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern.  See Francisco v. Brown, 7 Vet. App. 55, 58 (1994).  However, where the evidence of record indicates fluctuations in the severity of symptoms during the rating period on appeal, an assignment of staged ratings is permissible. See Fenderson v. West, 12 Vet. App. 119, 126-28 (1999).  Where 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. See 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3.  Hypertension is evaluated under diagnostic code 7101, which provides that a 10 percent rating is assigned for diastolic pressure predominantly 100mm or more, systolic pressure predominantly 160mm or more, or for an individual with a history of diastolic pressure predominantly 100mm or more who requires continuous medication for control. A 20 percent rating is assigned for diastolic pressure predominantly 110mm or more or systolic pressure predominantly 200mm or more. A 40 percent rating is assigned for diastolic pressure predominantly 120mm or more, while a 60 percent rating is assigned for diastolic pressure predominantly 130mm or more. 38 C.F.R. § 4.104, Diagnostic Code 7101. The Veteran contends that he should be afforded a compensable disability rating for his hypertension because he takes hypertension medications to control his hypertension disability and because he has observed diastolic blood pressure readings above 100mm. Having carefully reviewed the evidence of record, however, the Board finds that the evidence during the period on appeal does not support a compensable evaluation for hypertension. The Veteran was afforded a VA examination for his hypertension in September 2015. At that examination, the VA examiner confirmed a diagnostic of hypertension that had its onset during service. The examiner noted that the Veteran was prescribed Lisinopril for hypertension in 2006, but that he stopped receiving treatment for hypertension until reestablishing treatment in March 2013. In April 2013 his dosage of Lisinopril was increased, and amlodipine was added to his regimen. In April 2015, Lisinopril was discontinued, and he was prescribed hydrochlorothiazide instead. The examiner indicated that the Veteran had a history of diastolic blood pressure elevation above 100 or more, but only cited to his blood pressure readings from September 2006 to describe the frequency and severity of his diastolic blood pressure elevation. On examination, the Veteran’s blood pressure readings were 144/90, 138/88, and 134/86. The average blood pressure reading was 138/88. The examiner noted that the Veteran did not have any other pertinent physical findings, complications, signs, or symptoms related to his condition. The Veteran’s VA treatment records also contain various blood pressure measurements. However, a review of the blood pressure measurements recorded since filing his claim does not support entitlement to a compensable disability rating. To that end, his blood pressure readings were measured as the following: 122/88 and 127/91 on July 2, 2015; 141/94 on July 21, 2015; 135/94 on July 27, 2015; 112/74 on July 28, 2015; 137/96 on October 28, 2015; 133/93 on February 22, 2016; 170/113 and 157/98 on March 3, 2016; 117/116 and 164/115 on April 8, 2016; 152/103 and 149/99 on April 25, 2016; 159/99 on April 29, 2016; 166/97, 162/104, and 137/86 on June 24, 2016; 150/89 on July 22, 2016; 136/88 on September 20, 2016; 153/93 on November 18, 2016; 148/99 on March 31, 2017; 153/85 on April 6, 2017; 126/80 on June 20, 2017; 135/82 on August 7, 2017; 110/73 on August 9, 2017; 131/73 on September 7, 2017; 138/87 on October 5, 2017; 115/67, 115/67, 119/71, 104/55, 106/58, and 115/58 on October 24, 2017; 119/82 on November 16, 2017; 136/87 on March 6, 2018; 137/81 on April 20, 2018; 128/91 on December 19, 2018; 184/102 and 154/87 on January 30, 2019; 154/91, 135/79, 137/85, and 136/82 on January 31, 2019; 162/102 and 159/101 on February 4, 2019; 158/95 on February 15, 2019; 138/84 on August 13, 2019; and 138/94 and 150/88 on August 26, 2019. In October 2019, the Veteran also submitted a weekly blood pressure log from August to October 2019. Those measurements were as follows: 150/102, 147/95, and 140/99 on August 1, 2019; 159/100, 158/100, and 158/96 on August 8, 2019; 164/102, 160/103, and 159/100 on August 15, 2019; 145/97, 143/98, and 144/95 on August 22, 2019; 154/91, 154/87, and 155/90 on August 29, 2019; 170/112, 166/111, and 162/104 on September 5, 2019; 149/99, 152/103, and 150/89 on September 12, 2019; 152/102, 150/101, and 151/101 on September 19, 2019; 180/122, 176/120, and 181/123 on September 26, 2019; 153/99, 153/93, and 150/89 on October 3, 2019; and 146/102, 154/116, and 140/104 on October 10, 2019. Although the Veteran did not submit weekly blood pressure logs from other points in the appeal period, his VA treatment records reflect that he reported home blood pressure readings in the 120-125/80 range in June 2015, the 125-130/70 range in August 2017, the 130/80 range in September 2017, and the 110-140/70-85 range in October 2017. Although the Veteran’s systolic and diastolic blood pressure were more frequently elevated above 160mm and 100mm, respectively, in the weekly blood pressure log he submitted, the Board has considered these measurements alongside the measurements obtained from his VA examination and other VA treatment providers. Ultimately, although his diastolic and systolic blood pressure measurements were sporadically at or above 100 and 160mm, respectively, they were not predominantly at or above these levels. Indeed, less than half of the Veteran’s blood pressure measurements were at or above the levels required for a 10 percent rating throughout the period on appeal. As such, a 10 percent rating is not warranted for systolic blood pressure predominantly at 160mm or greater or diastolic blood pressure predominantly at 100mm or greater. The Board recognizes that the Veteran has been on continuous medication to control his blood pressure, and that the September 2015 VA examiner noted that he had a history of diastolic pressure predominantly at 100mm or greater. This “history,” however, was based on blood pressure measurements recorded on a single day over 10 years prior, as opposed to more recent blood pressure measurements during the period on appeal. Moreover, the lay and medical evidence from the period on appeal (i.e., the period after his claim was filed) do not suggest a history of diastolic pressure that is predominantly 100mm or more. Indeed, the Board has reviewed the Veteran’s available blood pressure readings from September 2006 until his claim was filed in June 2015. However, these blood pressure readings are predominantly below the levels necessary for a compensable rating. As such, the Board concludes that the Veteran does not have a history of diastolic blood pressure at 100mm or greater. In sum, the benefit-of-the-doubt doctrine is not for application, and a compensable disability rating is not warranted from June 18, 2015. REASONS FOR REMAND 1. Sleep apnea, left shoulder disability, kidney condition, and acquired psychiatric disorder The Veteran has also claimed entitlement to service connection for sleep apnea, a left shoulder disability, kidney stones, and attention deficit disorder (ADD). At the outset, the Board notes that the Veteran’s post-service treatment records reflect current diagnoses of chronic kidney disease as well as attention deficit hyperactivity disorder (ADHD) and anxiety. As such, the Board has recharacterized the claims for kidney stones and ADD as claims for a kidney condition and an acquired psychiatric disability, however diagnosed, to recognize this fact. Clemons v. Shinseki, 23 Vet. App. 1 (2009). VA’s duties to assist claimants in the development of claims may include scheduling a medical examination. Such development is necessary if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim, but (1) contains competent evidence of diagnosed disability or recurrent symptoms of disability, (2) establishes that the Veteran suffered an event, injury or disease in service, or has a presumptive disease during the pertinent presumptive period, and (3) indicates that the claimed disability may be associated with the in-service event, injury, or disease, or with another service-connected disability. 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79, 83-86 (2006) (noting that the third element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and active service, including equivocal or non-specific medical evidence or credible lay evidence of continuity of symptomatology). Here, the record indicates that the Veteran has current diagnoses of sleep apnea, a left rotator cuff tear, chronic kidney disease, and ADHD and anxiety. Additionally, the evidence of record indicates that these conditions could have had their onset during service. For instance, the Veteran has submitted various buddy statements from shipmates describing his frequent snoring and daytime somnolence during service in support of his claim for sleep apnea, while he has provided testimony describing nightmares, anxiety, and difficulty §sleeping while aboard the U.S.S. Boxer. Additionally, the Veteran has testified that he has experienced pain in his left shoulder since boot camp, when he damaged the rotator cuff. Last, the Veteran’s service treatment records reflect that he was treated for hematuria during service and has asserted that his kidney condition is secondary to his service-connected hypertension. Given the above evidence, there is an indication that the Veteran’s claimed disabilities may be etiologically related to his service or service-connected conditions. To date, however, the Veteran has had not been afforded VA examinations in connection with these conditions. With respect to his claim for sleep apnea, Board notes that the Veteran has undergone VA examinations for respiratory conditions other than sleep apnea, but not sleep apnea itself. As such, the Board finds that remand is warranted to obtain medical examinations and opinions on the nature and etiology of his sleep apnea, left shoulder disability, kidney condition, and acquired psychiatric disorder. See McLendon, 20 Vet. App. at 83-86. 2. Pes cavus As set forth above in more detail, the Veteran originally filed a claim for entitlement to service connection for a bilateral foot condition. It appears that that he is being treated for various conditions affecting the feet and ankles, including plantar fasciitis and pes cavus. Although the Board has granted a claim for plantar fasciitis herein, the Board also finds that remand is warranted for additional development with respect to service connection for pes cavus. To that end, the Board acknowledges that mild bilateral pes cavus was noted on his enlistment examination. At his August 2015 VA examination, the VA examiner opined that the Veteran’s pes cavus was not aggravated beyond its natural progression by an in-service event, injury, or illness, because his service treatment records were silent for any foot pain. He also reasoned that although the Veteran was diagnosed with plantar fasciitis shortly after his discharge in 2006, his records were silent for any treatment since then. Although the examiner is correct that the Veteran’s service treatment records do not reflect complaints of or treatment for pes cavus, the absence of contemporaneous treatment records does not preclude granting service connection for a claimed disability. See Buchanan, 451 F.3d at 1337. Significantly, the VA examiner’s opinion does not consider the Veteran’s hearing testimony, which described the onset of foot pain during boot camp, or any VA treatment records from after August 2015. Moreover, the VA examiner does not explain whether the fact that the Veteran developed plantar fasciitis was evidence that his pes cavus had been aggravated beyond its natural progression. As such, remand is necessary to obtain an addendum opinion that contains a sufficiently detailed rationale. Accordingly, the matters are REMANDED for the following action: 1. After obtaining appropriate authorization, obtain and associate with the claims file all outstanding VA treatment records and all outstanding, relevant private treatment records. 2. Thereafter, obtain a VA examination with an appropriate VA examiner with respect to the nature and etiology of the Veteran’s sleep apnea. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. After compiling a detailed history and reviewing the claims file in its entirety, the examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s sleep apnea had its onset during or is otherwise etiologically related to his military service. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner must consider all relevant lay and medical evidence of record, including the buddy statements submitted by the Veteran’s shipmates from the U.S.S. Boxer, as well as his hearing testimony and post-service treatment records. The examiner is reminded that the absence of contemporaneous service treatment records, alone, is an insufficient basis for a negative medical nexus opinion. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. 3. After the development in the first instruction is completed, obtain a VA examination with an appropriate examiner with respect to the Veteran’s left shoulder disability. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. After compiling a detailed history and reviewing the claims file in its entirety, the examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s left shoulder disability had its onset during or is otherwise etiologically related to his military service. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner must consider all relevant lay and medical evidence of record, including the Veteran’s hearing testimony and post-service treatment records. The examiner is reminded that the absence of contemporaneous service treatment records, alone, is an insufficient basis for a negative medical nexus opinion. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. 4. After the development in the first instruction is completed, obtain a VA examination with an appropriate examiner with respect to the Veteran’s claimed kidney condition. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. The examiner is asked to compile a detailed history and review the claims file in its entirety before doing the following: (a.) Identify all relevant kidney conditions that have been present at any time during the pendency of this appeal, even if such conditions have since resolved. In doing so, the examiner is asked to consider the diagnoses reflected in the Veteran’s post-service treatment records, such as chronic kidney disease. All indicated tests and studies should be performed. (b.) For each identified condition, opine as to whether it is at least as likely as not (50 percent or greater probability) that it had its onset during or is otherwise etiologically related to his military service. (c.) For each identified condition, opine as to whether it is at least as likely as not (50 percent or greater probability) that it was (1) caused, or (2) aggravated by the Veteran’s service-connected hypertension, including its treatment. The examiner is reminded that causation and aggravation are distinct legal concepts that must be addressed separately. “Aggravation” is defined as worsening beyond the natural progression of the disability. (d.) For any identified condition aggravated by the Veteran’s hypertension, the examiner is asked to provide, to the extent possible, an opinion as to the approximate baseline level of severity of the condition before the onset of aggravation. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner must consider all relevant lay and medical evidence of record, including the Veteran’s hearing testimony and post-service treatment records. The examiner is reminded that the absence of contemporaneous service treatment records, alone, is an insufficient basis for a negative medical nexus opinion. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. 5. After the development in the first instruction is completed, obtain a VA examination with an appropriate examiner with respect to the Veteran’s acquired psychiatric disorder. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. The examiner is asked to compile a detailed history and review the claims file in its entirety before doing the following: (a.) Identify all relevant psychiatric conditions that have been present at any time during the pendency of this appeal, even if such conditions have since resolved. In doing so, the examiner is asked to consider the diagnoses reflected in the Veteran’s post-service treatment records, such as ADHD and anxiety. All indicated tests and studies should be performed. (b.) For each identified condition, opine as to whether it is at least as likely as not (50 percent or greater probability) that it had its onset during or is otherwise etiologically related to his military service. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner must consider all relevant lay and medical evidence of record, including the Veteran’s hearing testimony and post-service treatment records. The examiner is reminded that the absence of contemporaneous service treatment records, alone, is an insufficient basis for a negative medical nexus opinion. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. After the development in the first instruction is completed, obtain an addendum medical opinion from an appropriate examiner with respect to the Veteran’s acquired pes cavus. The Veteran’s claims file and a copy of this remand should be furnished to the examiner, who should indicate in the examination report that he or she has reviewed the claims file in its entirety. After compiling a detailed history and reviewing the claims file in its entirety, the examiner is asked to do the following: (a.) Opine as to whether it is clear and unmistakable (i.e., obvious, manifest, and undebatable) that the Veteran’s pre-existing pes cavus was not aggravated (i.e., permanently worsened) by or during his service. In this regard, the examiner is asked to consider whether his development of plantar fasciitis is indicative of aggravation of his pre-existing pes cavus. (b.) Opine as to whether it is clear and unmistakable (i.e., obvious, manifest, and undebatable) that any increase in severity of the Veteran’s pes planus was due to the natural progress of the disorder. (c.) If the answer to the foregoing questions is “no,” opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s pes planus was related to or caused by his service. A complete rationale is required for any opinion rendered by the examiner. All opinions should be based on examination findings, historical records, and medical principles. The examiner should fully articulate a sound reasoning for all conclusions made. In doing so, the examiner must consider all relevant lay and medical evidence of record, including the Veteran’s hearing testimony and post-service treatment records. The examiner is reminded that the absence of contemporaneous service treatment records, alone, is an insufficient basis for a negative medical nexus opinion. If the requested opinions cannot be provided without resorting to mere speculation, the examiner should so state but, more importantly, explain why an opinion cannot be provided without resorting to speculation, as merely stating this will not suffice. If the examiner is unable to provide an addendum opinion without performing a physical examination of the Veteran, a new examination should be scheduled to assess nature and etiology of his pes cavus. M. Tenner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rademacher, 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.