Citation Nr: 21012621 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 16-13 855 DATE: March 4, 2021 ORDER Entitlement to an initial rating in excess of 10 percent for genital herpes is denied. REMANDED Entitlement to service connection for residuals from an in-service softball injury, to include a left tibial stress fracture and left foot stress fracture with loss of strength and pain with orthotics, is remanded. Entitlement to service connection for bilateral pes planus (flat feet) with orthotics is remanded. Entitlement to service connection for degenerative disc disease (DDD) of the lumbar spine (claimed as lumbar back strain with pain) is remanded. FINDING OF FACT During the entire period on appeal, the Veteran’s genital herpes manifested by intermittent oral medication for a total duration of less than six weeks during a 12-month period and did not manifest by 20 to 40 percent of the entire body or 20 to 40 percent of exposed area affected or systemic therapy required for a total duration of six weeks or more, but not constantly, during the past 12 months. CONCLUSION OF LAW The criteria for entitlement to an initial rating in excess of 10 percent for genital herpes have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.118, Diagnostic Code (DC) 7820. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 2005 to July 2010. These matters come to the Board of Veterans’ Appeals (Board) on appeal from February 2011 and July 2019 rating decisions issued by the Department of Veterans’ Affairs (VA) Regional Office (RO). By way of background, in the February 2011 rating decision, the RO initially granted service connection for genital herpes with a noncompensable rating effective July 25, 2010 and denied service connection for the other issues addressed in this decision. The Veteran timely appealed. Of relevance to this decision, in the July 2019 rating decision an initial 10 percent disability rating was assigned for the Veteran’s service-connected genital herpes. In December 2020, the Board held a hearing on these issues, a transcript of which has been associated with the claims file and reviewed. During the hearing, the Veteran indicated her last name is different than that of record. While her current last name is so noted in the header of this decision, the Board advises the Veteran to contact the VA to officially update the system to reflect her current last name. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). 1. Entitlement to an initial rating in excess of 10 percent for genital herpes is denied. The Veteran contends her genital herpes symptoms support a higher initial disability rating. The Board finds an initial rating in excess of 10 percent is not warranted. Disability evaluations are determined by the application of a schedule of ratings that is based on the average impairment of earning capacity. Separate diagnostic codes identify the various disabilities. 38 U.S.C. § 1155; 38 C.F.R., Part 4. Where there is a question as to which of two disability evaluations shall be applied, the higher evaluation is to be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating is to be assigned. 38 C.F.R. § 4.7. The veteran’s entire history is reviewed when making disability evaluations. See Schafrath v. Derwinski, 1 Vet. App. 589 (1995). After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. The evaluation of the same disability under several diagnostic codes, known as pyramiding, must be avoided; separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See 38 C.F.R. § 4.14; see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 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 his symptoms. 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). Where the question for consideration is the propriety of the initial evaluation assigned, evaluation of the medical evidence since the grant of service connection is required. See Fenderson v. West, 12 Vet. App. 119, 126 (1999). Where the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibits symptoms that would warrant different evaluations during the course of the appeal, the assignment of staged ratings is appropriate. See Id.; Hart v. Mansfield, 21 Vet. App. 505 (2007); Francisco v. Brown, 7 Vet. App. 55, 58 (1994). The Veteran was granted service connection for genital herpes at 10 percent disabling under DC 7820 for infections of the skin not listed elsewhere (including bacterial, fungal, viral, treponemal, and parasitic disease) effective July 25, 2010. VA amended the criteria for rating skin disabilities effective from August 13, 2018. These new regulations apply to all applications for benefits received by VA or that are pending before the Agency of Original Jurisdiction (AOJ) on or after August 13, 2018. Claims, as in here, pending prior to the effective date will be considered under both old and new rating criteria, and whatever criteria is more favorable to the Veteran will be applied. The Board may not apply a current regulation prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). However, the Board is not precluded from applying prior versions of the applicable regulation to the period on or after the effective dates of the new regulation if the prior version was in effect during the pendency of the appeal. Prior to August 13, 2018, DC 7820 provides that infections of the skin not listed elsewhere in the rating schedule are to be rated as disfigurement of the head, face, or neck (DC 7800), scars (DC 7801-7805), or dermatitis (DC 7806), depending upon the predominant disability. 38 C.F.R. § 4.118, DC 7820. Under both the amended and pre-amended criteria of DC 7800, which contemplates scars or disfigurement of the head, face, or neck, a 10 percent rating is warranted for one characteristic of disfigurement. A 30 percent rating is warranted for visible or palpable tissue loss and either gross distortion or asymmetry of one feature or paired set of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with two or three characteristics of disfigurement. A scar with visible or palpable tissue loss and either gross distortion or asymmetry of two features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with four or five characteristics of disfigurement warrants a 50 percent rating. A scar with visible or palpable tissue loss and either gross distortion of three or more features or paired sets of features (nose, chin, forehead, eyes (including eyelids), ears (auricles), cheeks, lips), or; with six or more characteristics of disfigurement warrants an 80 percent rating. Note (1) following DC 7800 identifies 8 characteristics of disfigurement, for the purposes of evaluation under § 4.118: (1) scar 5 or more inches (13 or more cm.) in length; (2) scar at least one-quarter inch (0.6 cm.) wide at widest part; (3) surface contour of scar elevated or depressed on palpation; (4) scar adherent to underlying tissue; (5) skin hypo-or hyper-pigmented in an area exceeding six square inches (39 sq. cm.); (6) skin texture abnormal (irregular, atrophic, shiny, scaly, etc.) in an area exceeding six square inches (39 sq. cm.); (7) underlying soft tissue missing in an area exceeding six square inches (39 sq. cm.); and (8) skin indurated and inflexible in an area exceeding six square inches (39 sq. cm.). Under both the amended and pre-amended criteria of DC 7804, which contemplates unstable or painful scars, a 10 percent rating is provided for one or two scars that are unstable or painful, a 20 percent rating is provided for three or four scars that are unstable or painful, and a 30 percent rating is provided for five or more scars that are unstable or painful. Note (1) provides that an unstable scar is one where, for any reason, there is frequent loss of covering of skin over the scar. Note (2) provides that if one or more scars are both unstable and painful, add 10 percent to the evaluation that is based on the total number of unstable or painful scars. Note (3) provides that scars evaluated under Codes 7800, 7801, 7802, or 7805 may also receive an evaluation under DC 7804, when applicable. Prior to August 13, 2018, under DC 7806, a noncompensable rating is assigned for less than 5 percent of the entire body or less than 5 percent of exposed areas affected, and; no more than topical therapy required during the past 12 months. A 10 percent rating is assigned for at least 5 percent, but less than 20 percent, of the entire body, or at least 5 percent, but less than 20 percent, of exposed areas affected, or; intermittent systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of less than six weeks during the past 12-month period. A 30 percent rating is assigned for 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. A 60 percent rating is assigned for more than 40 percent of the entire body or more than 40 percent of exposed areas affected, or; constant or near- constant systemic therapy such as corticosteroids or other immunosuppressive drugs required during the past 12- month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability.  “Corticosteroids or other immunosuppressive drugs” refers to any oral or parenteral medication(s) prescribed by a medical professional to treat the underlying skin disorder. For claims filed prior to August 13, 2018, the Court held that compensation is available for all systemic therapies that are “like or similar to corticosteroids or other immunosuppressive drugs.” Warren v. McDonald, 28 Vet. App. 194, 197-99 (2016). A topical corticosteroid could be administered on a large enough scale to affect the body as a whole, thus meeting the definition of “systemic therapy.” Johnson v. Shulkin, 862 F.3d 1351, 1354-56 (Fed. Cir. 2017). A systemic therapy is one that that affects the entire body in its treatment of the condition at issue, and that the Board must determine (1) whether a topical treatment affects the body as a whole in treating a veteran’s skin condition; and (2) whether the given treatment is “like” a corticosteroid or other immunosuppressive drug.” Burton v. Wilkie, 30 Vet. App. 286 (2018). Only the second question need be addressed if the treatment is clearly systemic.  Id.  Effective August 13, 2018, a new General Rating Formula for the Skin applies to DCs 7806, 7809, 7813 to 7816, 7820 to 7822, and 7824. Under this formula, a noncompensable rating is assigned for no more than topical therapy required over the past 12-month period and at least one of the following: characteristic lesions involving less than 5 percent of the entire body affected; or characteristic lesions involving less than 5 percent of exposed areas affected. A 10 percent rating is assigned for at least one of the following: characteristic lesions involving at least 5 percent, but less than 20 percent, of the entire body affected; or at least 5 percent, but less than 20 percent, of exposed areas affected; or intermittent systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of less than 6 weeks over the past 12-month period. A 30 percent rating is assigned for at least one of the following: characteristic lesions involving more than 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected; or systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, PUVA, or other immunosuppressive drugs required for a total duration of 6 weeks or more, but not constantly, over the past 12-month period. A 60 percent rating is assigned for at least one of the following: characteristic lesions involving more than 40 percent of the entire body or more than 40 percent of exposed areas affected; or constant or near-constant systemic therapy including, but not limited to, corticosteroids, phototherapy, retinoids, biologics, photochemotherapy, psoralen with long-wave ultraviolet-A light (PUVA), or other immunosuppressive drugs required over the past 12-month period. Or rate as disfigurement of the head, face, or neck (DC 7800) or scars (DC’s 7801, 7802, 7803, 7804, or 7805), depending on the predominant disability.  Additionally, effective August 31, 2018, VA regulations explicitly state that systemic therapy is treatment that is administered through any route other than the skin, and topical therapy is treatment that is administered through the skin. 38 C.F.R. § 4.118(a). Turning to the relevant evidence of record, as previously mentioned the Veteran was granted service connection effective July 25, 2010 thus the Board will consider evidence beginning that date. In August 2011, the Veteran indicated that she experiences genital herpes flare-ups 1-2 times per year. See August 2011 VA treatment records. She stated that she is mostly bothered with cold sores. See December 2011 VA treatment records. In 2012, the Veteran stated that her herpes presents as cold sores and vaginal sores. See April 2012 VA treatment records. She reported experiencing a genital flare-up in April 2012. Id. In December 2013, the Veteran’s genital herpes was noted to be stable. See December 2013 VA treatment records. In April 2017, the Veteran’s treatment records note an oral outbreak about one time every 3-6 months. See April 2017 VA treatment records. In 2019, the Veteran’s treatment records note the Veteran has genital herpes with cold sores. See May 2019 VA treatment records. The Veteran testified that she experiences an “occasional outbreak” one to three times per year. See December 2020 hearing transcript, p. 3. She stated that she had no current symptoms other than discomfort during outbreaks. Id. When she has lesions or symptoms other than that, she takes prescribed oral medication. Id. Typically, her medication course lasts for 14 days during an outbreak. Id. She stated that her outbreaks fluctuate in frequency with there being three months between outbreaks at times or six months or even nine months but could also happen for three months in a row. Id. Outbreaks produce genital lesions that can become open sores causing pain. Id. She denied having scars. Id. The Veteran confirmed that she experiences one to three outbreaks per year and each outbreak requires a two-week course of medication. Id. The Veteran was afforded a VA examination in June 2019 to determine the severity of her genital herpes. She reported experiencing burning, itching, and blisters on the genitals when the condition began. See June 2019 VA examination. She was treated with medication. Id. At the time of the examination, she reported symptoms including genital outbreaks every six months, the most recent of which was four months ago. Id. She is treated with Acyclovir as needed during outbreaks. Id. She does not take prophylactic anti-viral medications. Id. Physical limitations were not indicated. Id. The examiner reported that the Veteran treated her condition with oral medication for less than 6 weeks in the past 12 months. Id. At the time of the examination, the Veteran’s skin condition was without any visible characteristic lesions. Id. The Veteran did not have benign or malignant neoplasm or metastases related to her diagnosis. Id. The examiner found that the Veteran’s genital herpes does not cause scarring or disfigurement of the head, face, or neck. Id. There were no other pertinent physical findings, complications, signs or symptoms related to the Veteran’s diagnosis. Id. The Veteran’s skin condition does not impact her ability to work. Id. The Board finds the June 2019 VA examination includes consideration of the Veteran’s medical history and set forth all pertinent findings, such that the Board is able to make a fully informed decision regarding severity. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Based on the above, the Board finds the Veteran’s genital herpes symptoms more nearly approximate the criteria for a 10 percent disability rating under the pre-August 13, 2018 regulations. The VA examination of record indicates based upon the Veteran’s examination and the evidence of record that she experiences flare-ups every six months with medication prescribed as needed during flare-ups. The examiner found that the Veteran had medication for less than six weeks in the past 12 months. This is corroborated by the medical evidence of record. Specifically, in 2011, the Veteran reported flare-ups 1-2 times per year. While the Veteran estimated during the hearing that she has outbreaks anywhere from 1 to 3 times per year, the medical evidence of record does not show any 12-month period during the appellate time frame where she had 3 outbreaks. Indeed, the Veteran conceded during her hearing that the outbreaks change frequency and sometimes there was even nine months in-between outbreaks. In light of the variance, the Board assigns more probative value to the confirmed outbreaks as reflected in the treatment records, which shows no more than 2 outbreaks per year, treated with medication. Even if the medication includes 14-day courses of antibiotics, this would amount to less than 6 weeks per year. Thus, the probative medical evidence and lay evidence of record establishes that the Veteran has medication for a total duration of less than six weeks during the past 12-month period. The Board also finds that the preponderance of the evidence is against the assignment of a rating in excess of 10 percent under the pre-August 13, 2018, regulations and the post-August 13, 2018, regulations because the Veteran’s genital herpes does not more nearly approximate 20 to 40 percent of the entire body or 20 to 40 percent of exposed areas affected, or; systemic therapy such as corticosteroids or other immunosuppressive drugs required for a total duration of six weeks or more, but not constantly during the past 12-month period. As mentioned above, the Board finds the evidence shows the Veteran has approximately 1 to 2 outbreaks every year with medication lasting two weeks per outbreak (or a total of four weeks per year). Further, the VA examiner indicated at the time of the examination visible characteristic lesions were not present. The record lacks any evidence of outbreaks amounting to 20 to 40 percent of the entire body being impacted or 20 to 40 percent of exposed areas. Thus, the Veteran’s genital herpes symptoms are appropriately rated as 10 percent disabling under the pre-August 13, 2018 regulations. The Board acknowledges that the Veteran believes that the disability on appeal has been more severe than the assigned disability rating reflects. Moreover, the Veteran is competent to report observable symptoms, to include her symptoms during outbreaks, and her reports are credible. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, the most probative and credible medical evidence of record does not show that the Veteran’s disability more nearly approximates the criteria in the next higher rating. To the extent the Veteran’s outbreaks do become more frequent, the Veteran is not without remedy as she can file an increased rating for her disability at that time. At this time, however, the evidence does not show outbreaks of such frequency during the appellate time frame to warrant a higher rating. The Board has also considered whether any other Diagnostic Codes related to disabilities of the skin would provide for a higher disability evaluation. The evidence, however, does not reflect that she would warrant a higher rating under a different diagnostic code. See 38 C.F.R. § 4.118. Indeed, the Veteran does not experience scarring; therefore; DCs 7800-7805 are not for application. In conclusion, the Board finds that the preponderance of the evidence is against the Veteran’s claim of an initial rating in excess of 10 percent for genital herpes. In denying such a rating, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. REASONS FOR REMAND 1. Entitlement to service connection for residuals from an in-service softball injury, to include a left tibial stress fracture and left foot stress fracture with loss of strength and pain with orthotics, is remanded. The Veteran contends she experiences left ankle and tibia residuals from an in-service softball injury. The Board finds the evidence is insufficient to resolve her claim. At the outset, the Board concedes the Veteran has a documented in-service injury in 2006 when she was hit in the left ankle with a softball. The Veteran competently and credibly testified that she suffered a left ankle injury during service when she was hit with a softball. Her STRs corroborate this injury and subsequent treatment. Thus, the Board has recharacterized the Veteran’s service connection claim for residuals stemming from this injury in-service. The Board notes the Veteran clearly had an in-service injury and subsequent treatment. The remaining question is whether the Veteran’s current left ankle and tibia conditions are causally related to the in-service injury. The Veteran was afforded a VA examination in June 2019 to determine the nature and etiology of a left tibial condition status post stress fracture. The examiner found that the Veteran had bilateral knee strain. Of note, as part of the Veteran’s pes planus examination, she was found to have bilateral ankle degenerative arthritis. The June 2019 examiner stated that the Veteran’s bone scan from 2006 did not show conclusive evidence of a stress fracture of the left tibia and imaging from the 2019 examination was normal. The examiner, however, failed to address the multiple documented injuries during service as well as the Veteran’s lay statements regarding injuries. As discussed above, the Veteran’s STRs document an in-service softball injury resulting in stress related changes and closed fractures to the left second, third, fourth and fifth metatarsals. Subsequent STRs reference continued pain and other injuries to the left foot, ankle, and tibia. All of which remain unaddressed. At separation, the Veteran reported foot trouble, chronic ankle sprain, and stress related injury in left tibia. Post-separation records reference left peroneal tendonitis, left ankle arthroscopy and repair of anterior talofibular ligament, repeated left ankle sprains, and multiple reports of pain before and after the arthroscopic procedure. Remand is necessary to address these incidents and statements. Cf. Polovick v. Shinseki, 23 Vet. App. 48 (2009) (finding an examiner’s opinion inadequate if not based on a veteran’s specific medical history, risk factors, and military history); see also Miller v. Wilkie, 32 Vet. App. 249 (2020) (holding when an examiner fails to address the Veteran’s lay evidence, and the Board does not find the Veteran not credible or not competent to offer that lay evidence, a new exam is needed). Accordingly, this matter is remanded in order to obtain clarity regarding the Veteran’s in-service incidents and the relation, if any, to her current left foot and tibia injuries. 2. Entitlement to service connection for bilateral pes planus (flat feet) with orthotics is remanded. The Veteran contends she was diagnosed with bilateral pes planus during service. The Board finds the evidence is insufficient to resolve her claim. The Veteran was afforded a VA examination to determine the nature and etiology of her contended bilateral pes planus and its relation, if any, to service. Upon examination, the June 2019 examiner found no physical evidence that the Veteran has bilateral pes planus. Thus, the examiner offered a negative nexus opinion reasoning that the Veteran has no physical evidence of any fallen arches. Upon review of the Veteran’s service treatment records, however, the Board finds a noted diagnosis of flat feet with use of orthotics. See April 2009 and May 2009 service treatment records (STRs). The VA examiner failed to address the Veteran’s in-service diagnosis of bilateral flat feet when offering the nexus opinion of record. Thus, remand is necessary for consideration of the Veteran’s STRs. Cf. Polovick, 23 Vet. App. 48. The Board notes the VA examiner indicated the Veteran has degenerative arthritis of both feet. An opinion, however, was not rendered as to whether this condition was caused by or incurred during service including the Veteran’s multiple documented ankle sprains and foot injuries. As such, remand is necessary for clarification regarding the Veteran’s current foot disabilities and their relation, if any, to service. Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board’s duty to return an inadequate examination report “if further evidence or clarification of the evidence... is essential for a proper appellate decision”). Thus, this claim is remanded for another VA examination and opinion. 3. Entitlement to service connection for DDD of the lumbar spine (claimed as lumbar back strain with pain) is remanded. The Veteran contends her DDD began during service with continuity of symptoms since separation. The Board finds the evidence is insufficient to resolve her claim. The Veteran was afforded a VA examination in relation to this claim in June 2019. The examiner found the Veteran has DDD of the lumbar spine with radiculopathy to the left leg and thoracic spine strain. As an aside, the Veteran has already been granted service connection for thoracic spine strain. The examiner offered a negative nexus opinion for DDD based on the reasoning that the Veteran’s in-service injuries involved muscle whereas DDD is a bony condition of the spine that cannot be caused by muscle injuries. The examiner, however, failed to address the Veteran’s lay statements regarding continuity of symptomatology since service including documented complaints of recurrent back pain at separation. See Miller, 32 Vet. App. 249. Additionally, the VA examiner only discussed the Veteran’s documented back injury following running down hill in formation in 2008. STRs, however, reference multiple complaints of back pain and injuries including back pain in 2006 and low back strain with pain reported multiple times in 2007. See Cf. Polovick, 23 Vet. App. 48. Consequently, remand is necessary for another VA examination addressing this claim. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination before an appropriate examiner to determine the nature and etiology of any residuals from an in-service softball injury, to include a left tibial stress fracture and left foot stress fracture with loss of strength and pain with orthotics. The entire claims file and this remand should be made available for review prior to the examination. The examiner shall render an opinion, including rationale, addressing whether the Veteran has any residuals from an in-service softball injury, to include a left tibial stress fracture and left foot stress fracture with loss of strength and pain with orthotics, and whether each residual found is at least as likely as not (50 percent or greater probability) related to service, to include the conceded in-service softball injury. The examiner must provide a complete rationale for any opinion expressed, based on the examiner’s clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. The examiner is specifically directed to address the Veteran’s lay statements regarding symptoms related to the left tibia, ankle, and foot since the in-service softball injury and following separation. The examiner is directed to consider the Veteran’s STRs and post-separation treatment records referencing repeated injuries and treatment related to the left foot, ankle, and tibia. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 2. Schedule the Veteran for a VA examination before an appropriate examiner to determine the nature and etiology of any feet conditions, to include bilateral pes planus and bilateral degenerative arthritis of the feet. The entire claims file and this remand should be made available for review prior to the examination. The examiner shall render an opinion, including rationale, addressing whether the Veteran has a foot disability at any point during the pendency of the Veteran’s claim, to include bilateral pes planus and bilateral degenerative arthritis of the feet. If the Veteran has a foot disability, the examiner is directed to render an opinion as to whether each foot disability is at least as likely as not (50 percent or greater probability) related to service. The examiner must provide a complete rationale for any opinion expressed, based on the examiner’s clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. The examiner is specifically directed to address the noted diagnosis of pes planus and use of orthotics during service in April 2009 and May 2009. The examiner is also directed to address the Veteran’s lay statements regarding pes planus including her symptoms, onset, and treatment as well as the documented ankle sprains and injuries during service. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 3. Schedule the Veteran for a VA examination before an appropriate examiner to determine the nature and etiology of any back condition, to include degenerative disc disease of the lumbar spine. The entire claims file and this remand should be made available for review prior to the examination. The examiner shall render an opinion, including rationale, addressing whether the Veteran has a back disability, and whether the disability is at least as likely as not (50 percent or greater probability) related to service. The examiner must provide a complete rationale for any opinion expressed, based on the examiner’s clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. The examiner is specifically directed to address the Veteran’s lay statements regarding continuity of symptomatology since service including the reported recurrent back pain at separation. The examiner is also directed to address the multiple documented back injuries during service as well as the multiple complaints of lower back pain and/or strain in 2006 and 2007. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. After the above development, and any other development deemed necessary, readjudicate the claims. Shereen M. Marcus Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A.C. Allen, 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.