Citation Nr: 21028051 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 17-00 013A DATE: May 10, 2021 ORDER Entitlement to service connection for bilateral pes planus is denied. Entitlement to service connection for patellofemoral syndrome, left knee, is denied. Entitlement to service connection for erectile dysfunction is denied. FINDINGS OF FACT 1. The Veteran's bilateral pes planus, which was noted on entry into active duty, was not aggravated by or during active duty. 1. Patellofemoral syndrome of the left knee was not present during active duty and the current patellofemoral syndrome of the left knee is not otherwise causally related to an in-service disease or injury, nor is it caused or aggravated by a service-connected disability, to include the service-connected right knee disability. 2. Erectile dysfunction was not present during active duty or manifest in the first post-service year; the current erectile dysfunction is not otherwise causally related to an in-service disease or injury, nor is it caused or aggravated to a service-connected disability, to include service-connected hypertension or medications to treat service-connected hypertension. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for bilateral pes planus have not been met. 38 U.S.C. §§ 1110; 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. 2. The criteria for entitlement to service connection for patellofemoral syndrome, left knee, have not been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. 3. The criteria for entitlement to service connection for erectile dysfunction have not been met. 38 U.S.C. §§ 1110; 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1992 to November 1998. This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2014, March 2015, and August 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. In December 2018 and December 2020, the Board remanded the claims for further evidentiary development. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. The three-element test for service connection requires 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). Secondary service connection may be granted for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). A veteran is presumed to have been in sound condition when entering service, except as to defects, infirmities, or disorders noted at the time of the examination or where clear and unmistakable evidence demonstrates that the injury or disease existed prior to service and was not aggravated by such service. 38 U.S.C. §§ 1111, 1137. In this case, as set forth in more detail below, pes planus was noted at the time of the Veteran's entry on active duty. As the condition was noted on entry, the presumption of soundness is not applicable with respect to that condition. Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff'd 749 F.3d 1370 (Fed. Cir. 2014). If a preexisting disorder is noted upon entry into service, a veteran cannot bring a claim for service connection for that disorder, but may bring a claim for service-connected aggravation of that disorder. In that case, 38 U.S.C. § 1153 applies and the burden falls on the veteran to establish an increase in disability during service. If the presumption of aggravation attaches, the burden shifts to the government to show by clear and unmistakable evidence that there has been no increase in the severity of the preexisting condition or that any increase was the result of natural progression. Id; see also 38 C.F.R. § 3.306(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). 1. Entitlement to service connection for bilateral pes planus is denied. The Veteran contends that his preexisting bilateral pes planus was aggravated by active service, resulting in his current disability. During his July 2017 Board hearing, the Veteran testified that his military occupational specialty (MOS) was supply, but he performed physical training, participated in road marches and athletic activities such as basketball and football, and ran in combat boots. He carried heavy packs, and even had to carry two 90-pound packs at once on occasion. He recalled that following separation from service, he had to change his physical activities due to foot pain, so he began swimming and biking rather than play basketball and football. He reported that, following physical activity in service, he noted pain and swelling of the feet. In pertinent part, the Veteran's January 1992 enlistment examination report indicates that mild pes planus was observed on entry. At that time, he denied foot trouble. In-service treatment records are negative for complaints or findings of pes planus. The Veteran was treated for a first degree left ankle sprain in October 1993 and a mild first degree right ankle sprain in July 1995. At a March 1998 final examination, the Veteran's feet were normal and he denied foot trouble. In October 1999, the Veteran submitted an original application for VA compensation benefits on which he sought service connection for multiple disabilities. His application, however, is silent for any mention of pes planus, as is clinical evidence assembled in support of the claims. That clinical evidence includes a March 2000 VA orthopedic examination which identified a left ankle disability but no symptoms referrable to pes planus. In November 2012, the Veteran submitted multiple additional claims, including a claim of service connection for pes planus. The Veteran was afforded a VA examination in December 2013. The examiner noted diagnoses of mild bilateral flat foot and mild bilateral hallux valgus with first MTP joint degenerative joint disease (DJD). The VA examiner opined in an August 2014 addendum opinion that it was less likely than not that flat foot and hallux valgus with first MTP DJD were related to the Veteran's active service because, while pes planus can sometimes contribute to hallux valgus, there was documentation of mild pes planus upon entry, but no documentation of any worsening, or any other foot complaints in service. The VA examiner opined in a February 2017 addendum opinion that it was at least as likely as not that the Veteran's bilateral first MTP DJD and hallux valgus were caused by the Veteran's in-service playing of basketball and football. It was noted that playing basketball and football, particularly at aggressive professional levels, can cause multiple types of foot injuries such as turf toe. The Veteran had multiple documented ankle injuries, the forces of which are often transmitted into the foot. The Veteran also had multiple degenerative changes in his feet documented on X-ray at a relatively young age. The Board notes that, based in part on this medical opinion, in a March 2017 rating decision, the RO granted service connection for right and left hallux valgus with first MTP joint degenerative joint disease. In a July 2017 statement, S.P., a nurse practitioner, noted that the Veteran recalled developing foot pain in April 1992 which was aggravated by running, jumping/landing, and marching with heavy gear, and wearing military boots. It was noted that the Veteran had separated from the Marine Corps in November 1998 and that his foot pain had been increasing. April 2017 imaging studies revealed dorsal prominence of the left medial cuneiform, which was probably the result of injury. The Veteran was afforded a VA examination in October 2019. The examiner noted diagnoses of bilateral pes planus, bilateral plantar fasciitis, bilateral hallux valgus with first MTP DJD, bilateral foot instability, and bilateral foot swelling. During the examination, the Veteran reported that he began experiencing problems with his feet in the mid-1990s. He reported that physical therapy and running with boots injured his feet during service and that his symptoms had progressively worsened since that time. After examination of the Veteran and review of the claims file, the examiner rendered a positive etiological opinion regarding the Veteran's pes planus. In a June 2020 VA addendum opinion, the examiner determined that the Veteran's preexisting pes planus was clearly and unmistakably not aggravated by service. In the December 2020 remand, the Board found the October 2019 examination and subsequent June 2020 medical opinion inadequate Pursuant to the December 2020 remand instructions, the RO obtained a supplemental opinion. After a review of the claims file, the examiner determined that the Veteran's pes planus clearly and unmistakably existed prior to active service, and such was clearly and unmistakably not aggravated by service. The examiner opined in pertinent part, As found in the Report of Medical Exam for Enlistment 01/24/1992 the veteran entered the service with pes planus, a condition which is usually chronic and progressive in nature. Due to effects of gravity, weight, activities etc. the longitudinal arch is expected to collapse/sag further causing worsening flattening. There is no documented measurement or radiologic evidence to show that the arches collapsed any further than or more aggressively than expected. More specific evidence, namely objective measurement, is needed to show abnormal progression beyond the [Veteran's] expected worsening. The [V]eteran's exam on 10/15/2019 shows similar findings of pes planus without signs of unnatural aggravation. Reports of foot pain during the service would represent flare ups of a pre-existing condition. As a result of this lack of evidence, no findings suggest unnatural aggravation or progression. The [V]eteran's plantar fasciitis, noted in the C&P exam is due to the pre-existing pes planus condition. As a result of chronic decrease longitudinal arch the plantar fascia was pulled/stretched and accentuated force of weight bearing on this fascia led to the development of plantar fasciitis. The plantar fasciitis which occurs in most people with chronic pes planus, would likely have occurred in this case with or without the service activity and represents a NATURAL progression of the pre-existing condition and not unnatural aggravation. The examiner discussed the etiologies, symptoms, and functional limitations of the Veteran's diagnosed bilateral plantar fasciitis, and bilateral hallux valgus with first MTP DJD. The examiner also "found no evidence in the e-file objectively linking the [Veteran's service-connected hallux valgus] to the [pes planus] or [plantar fasciitis] or ankle problems." Applying the facts in this case to the applicable legal criteria, the Board finds that the preponderance of the evidence is against the claim of service connection for pes planus. The Veteran's service treatment records reflect that his current claimed disability, pes planus, was noted upon his entry into active duty service. There is no dispute from the Veteran that the disability was noted upon entry. As such, the Board finds that the condition is noted on entry and that the presumption of soundness is not applicable in this case. Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff'd 749 F.3d 1370 (Fed. Cir. 2014). In Wagner v. Principi, 370 F.3d 1089, 1096 (2004), the United States Court of Appeals for the Federal Circuit held if a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case, 38 U.S.C. § 1153 applies and the burden falls on the veteran to establish an increase in disability during service. If the presumption of aggravation attaches, the burden shifts to the government to show by clear and unmistakable evidence that there has been no increase in the severity of the preexisting condition or that any increase was the result of natural progression. Id; see also 38 C.F.R. § 3.306(b). In this case, the Board finds that the probative evidence of record shows that the Veteran's underlying pes planus did not increase in severity during his period of active duty. His service treatment records document no complaints referrable to the feet or pes planus. Although since filing his claim, the Veteran has reported that he developed symptoms of foot pain during active duty, the Board finds that the preponderance of the evidence establishes that the Veteran's claimed symptoms represented a temporary flare-up of the condition that was present on entry. Temporary or intermittent flare-ups during service of a pre-existing injury or disease are not sufficient to be considered aggravation in service unless the underlying condition, as contrasted to symptoms, is worsened. Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). The occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002). Evidence of the Veteran being asymptomatic on entry into service, with an exacerbation of symptoms during service, does not constitute evidence of aggravation. Green v. Derwinski, 1 Vet. App. 320, 323 (1991). The preponderance of the evidence of record is against a finding that the Veteran's reported symptoms in service represented an increase in the severity of his underlying condition. Instead, the most probative medical evidence of record, and the preponderance of the evidence, indicates that this was a routine and expected flare-up of the condition. See Hunt, 1 Vet. App. at 297. This includes the determination made by the January 2021 VA examiner which was based on a review of the Veteran's service and post-service records, his reported history, a clinical examination, and the examiner's knowledge of the pathology. The VA medical opinion was provided by a medical professional, qualified to provide an opinion due to training and experience. The opinion is also well-reasoned, consistent with the evidence of record, and supported by a rationale. As such, the Board affords this opinion significant probative weight. The Board has considered the private medical opinion offered by the Veteran's nurse practitioner who noted that the Veteran's foot pain began in April 1992 and was "aggravated by running, jumping/landing, ruck marching with the added weight of gear, and wearing military boots." The Board affords this opinion low probative value, as these conclusions were offered with no additional supporting rationale. Moreover, the nurse practitioner only described symptoms and did not indicate that the underlying condition increased in severity. See Davis, 276 F.3d at 1345; see also Green v. Derwinski, 1 Vet. App. at 323. The Board has also considered the appellant's lay assertions that his development of symptoms during active duty service represented an increase in the underlying severity of his disability. However, the record does not establish that the appellant has knowledge, training, or experience to provide a competent opinion on aggravation of the underlying condition, as opposed to describing his symptoms. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Such an opinion involves pathological processes not observable to the average person that require specialized knowledge, training, or experience to diagnose and interpret. As such, the Board affords this opinion no probative weight, especially when weighed against the rest of the evidence of record. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). As the most probative evidence of record shows no increase in the severity of the Veteran's pes planus during service, the presumption of aggravation does not attach. As such, a discussion of clear and unmistakable evidence to rebut the presumption of aggravation is not required. Wagner, 370 F.3d at 1096. Because the Veteran's pre-existing pes planus was not aggravated by military service entitlement to service connection must be denied. 38 C.F.R. §§ 3.304, 3.306. 2. Entitlement to service connection for patellofemoral syndrome, left knee, is denied. The Veteran contends that his left knee disability is secondary to his service-connected right knee disability. Although a December 2014 Report of General Information indicated that the Veteran informed the RO that his left knee disability was secondary to his service-connected hypertension, the Veteran subsequently clarified that he does not believe that his left knee disability is secondary to his hypertension, but rather is due to overcompensating for his right knee. See April 2015 Notice of Disagreement (NOD). The Veteran's service treatment records show that in August 1992, he reported left knee pain for the past two to three days with normal activities. He denied recent trauma although he reported a prior history of trauma in 1988 while playing basketball. The impression was left knee strain. X-ray studies of the left knee showed that no abnormalities were present. See August 1992 Chronological Report of Medical Care and August 1992 X-ray Impression Report. The Veteran's March 1998 separation examination shows that the Veteran's lower extremities were examined and determined to be normal and he denied having a trick or locked knee. Post-service clinical records obtained in connection with the Veteran's claim noted a history of bilateral knee pain beginning in 2013. On examination in March 2013, the Veteran exhibited full range of left knee motion and the ligaments were stable. Gait was normal. X-ray studies of the left knee in March 2013 were unremarkable. The Veteran was afforded a VA examination in February 2015. The examiner noted, in pertinent part, a diagnosis of left knee patellofemoral syndrome. The Veteran reported gradual onset of symptoms between 1992 and 1998 which had increased. He reported that he played basketball and football during active duty and began to experience swelling in the front and back of the knee. After examination of the Veteran and review of the claims file, the examiner opined that it is less likely than not that the Veteran's left knee disability is a result of the Veteran's service-connected hypertension. However, the examiner failed to address the issue of direct service connection, as well as the Veteran's contentions that his left knee condition is secondary to his service-connected right knee disability. Pursuant to the December 2020 remand instructions, the RO obtained an addendum opinion in January 2021. After a review of the claims file, the examiner determined that the Veteran's current left knee disability, patellofemoral syndrome, was less likely than not incurred in or caused by service. The examiner acknowledged the August 1992 service treatment record showing a left knee sprain but explained that such injury did not result in a chronic disability or permanent residuals. The examiner also determined that the Veteran's current left knee disability was less likely than not proximately due to, the result of, or aggravated by the service-connected right knee disability. The examiner cited medical literature establishing that available studies had shown that an injury in one extremity rarely causes a major problem in the opposite or uninjured extremity except when damage to the leg results in a major displacement of the center of gravity of the body while walking, significant shortening of the injured limb and the abnormal gait pattern has been present for an extended period of time. The examiner noted that the Veteran's clinical records repeatedly reflected a normal gait and further contained no indication of major displacement of the center of gravity of his body while walking, a history of significant shortening of the injured limb, or abnormal gait pattern to attribute the left knee condition to the right knee. After reviewing the record on appeal in light of the applicable legal criteria, the Board finds that the preponderance of the evidence is against the claim of service connection for left knee patellofemoral syndrome. First, there is no probative evidence that the currently-diagnosed left knee disability had its inception during active service. As reflected above, the Veteran's service treatment records contain no findings of left knee patellofemoral syndrome. Although the Veteran sustained a left knee sprain in August 1992, that an injury occurred during active service is not enough to establish service connection. Rather, there must be chronic disability resulting from that injury. In this case, the most probative evidence reflects that such injury resolved without residuals. The subsequent service treatment records are negative for complaints or findings of a left knee disability, including left patellofemoral syndrome, and his separation examination in March 1998 reflected that his lower extremities were normal at that time; he also denied a trick or locked knee. The Board also finds that the most probative evidence reflects that the current left knee disability is not otherwise casually related to service, nor is it caused or aggravated by a service-connected disability. As reflected above, in January 2021, a VA examiner rendered a negative nexus opinion on these medical questions. The Board finds the January 2021 VA medical opinion is entitled to great probative weight. The opinion was based a review of the claims file and consideration of the relevant medical history, and the opinion was accompanied by a detailed rationale and is consistent with the medical evidence of record. Indeed, there is no competent opinion to the contrary. Although the Veteran in this case is competent to report observable symptomatology regarding his left knee disability, the Board finds he does have the experience, education, training, and expertise to provide an opinion regarding its etiology. See Jandreau, supra. His statements do not rise to a level of competency to offer an opinion as to the etiology of his left knee disability. As the evidence preponderates against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. 3. Entitlement to service connection for erectile dysfunction is denied. The Veteran contends that his erectile dysfunction is secondary to his service-connected hypertension, including prescribed anti-hypertensive medications. See April 2015 VA Form 21-526EZ Application for Disability Compensation and Related Compensation Benefits. The Board notes that service connection has been effect for hypertension from November 29, 2012. As an initial matter, the Board finds that the record contains no indication, nor does the Veteran contend, that his current erectile dysfunction had its inception during active duty, was manifest to a compensable degree within one year of separation, or is otherwise related to an in-service disease or injury. Service treatment records are negative for treatment for or a diagnosis of erectile dysfunction during active service. Notably, at the time of the March 1998 separation examination, the Veteran underwent normal clinical evaluations of his testicles and genitourinary system. The post-service record on appeal reflects that the Veteran first complained of erectile dysfunction in 2005, approximately seven years after service separation. Further, there is also no indication that the Veteran's post-service erectile dysfunction is causally related to an in-service disease or injury. Although post-service medical records demonstrate a diagnosis of erectile dysfunction, the clinical and lay evidence contains no indication that the condition is due to an in-service disease or injury. With regard to the Veteran's contention that his erectile dysfunction is secondary to or aggravated by a service-connected disability, particularly his service-connected hypertension and/or medications taken for such, the Board finds that the preponderance of the evidence is against the claim. The Veteran underwent a VA examination in May 2015. He reported that in 2012, he noticed a decreased ability to sustain and maintain an erection. The condition had been progressively worsening. The Veteran denied a history of trauma and diabetes. He reported that he had been on anti-hypertensive medications since 1998. After review of the claims file and examination of the Veteran, the examiner diagnosed him with erectile dysfunction and opined that it was less likely than not proximately due to or the result of service-connected hypertension. The examiner noted that the Veteran had a long history of hypertension dating back to 1998 but no evaluation in the clinical records provided a diagnosis or evaluation for erectile dysfunction. The examiner indicated that the etiology of the Veteran's erectile dysfunction was unknown. An Acceptable Clinical Evidence (ACE) opinion was obtained in February 2018. After review of the Veteran's claims file, the examiner concluded that it was less likely than not that the Veteran's erectile dysfunction was proximately due to or the result of the Veteran's service-connected condition. The examiner noted the Veteran's history of treatment for hypertension with medication beginning in 2009. She noted that the first clinical notation of complaints of possible erectile dysfunction were in September 2005. The examiner explained that hypertension, in and of itself, is not a primary cause of erectile dysfunction. She noted that reviewing available records, it appeared there were concerns about erectile dysfunction in the early/mid 2000s, prior to being prescribed medications for hypertension. She further noted that in 2014, the Veteran's primary care provider diagnosed erectile dysfunction and prescribed Viagra. At that time, however, he was noted to be on Amlodipine, which is not known to cause erectile dysfunction. Further, other medications he had been on at the time of the diagnosis, including lisinopril and hydrochlorothiazide, were also not known to be a factor in erectile dysfunction. Although blood pressure pills of the class "beta blockers" are known to be a factor in erectile dysfunction, it did not appear that the Veteran was on a medication of that classification at the time of any documentation of early ED concerns in mid 2000s and in 2014. In its December 2020 remand, the Board found the February 2018 opinion inadequate to the extent the examiner addressed only a causal relationship and did not address the question of aggravation. Pursuant to the December 2020 remand instructions, the RO obtained an additional medical opinion. After review of the claims file, the examiner determined that the Veteran's erectile dysfunction was less likely than not proximately due to, the result of, or aggravated by the service-connected hypertension or medication taken for hypertension. The examiner opined, Firstly, hypertension has not been positively linked as a direct cause of Erectile Dysfunction. Review of this Veteran's VBMS-file shows no objective evidence supporting the premise that his hypertension condition caused his erectile dysfunction. I found no medical evidence in the e-file to suggest the medication has caused it either since the [Veteran] has been on multiple different medications over the years and yet still had ED. The ED could be due to hormonal issues, advanced age, psychologic issues, interpersonal issues etc. There is no way to isolate the problem to the hypertension or hypertension meds without speculating. The veteran's alcohol use, his morbid obesity, other medications, age, hormones, inter-personal relationships etc. can all be causing ED. I cannot correlate any aggravation of his subjectively reported erectile dysfunction to any issue in particular without merely speculating. Based on the record on appeal, the Board finds that the preponderance of the evidence is against a finding that the Veteran's hypertension is causally related to or aggravated by a service-connected disability, to include hypertension or medications used to treat that condition. The Board finds the February 2018 and January 2021 VA medical opinions collectively highly probative as to the question of nexus, including aggravation. The opinions were based a review of the claims file and consideration of the relevant medical history, and the opinions were accompanied by a detailed rationale which is consistent with the medical and lay evidence of record. Moreover, there is no competent opinion to the contrary. Although the Veteran in this case is competent to report observable symptomatology regarding his erectile dysfunction, the Board finds he does have the experience, education, training, and expertise to provide an opinion regarding its etiology. His statements do not rise to a level of competency to offer an opinion as to the etiology of his erectile dysfunction. Based on the evidence of record, the most probative evidence reflects that the Veteran's current erectile dysfunction was not caused or aggravated by a service-connected disability, to include hypertension and/or medications taken for such. For the foregoing reasons and bases, the preponderance of the evidence is against the claim. 38 U.S.C. § 5107(b); Gilbert, supra. K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.N., 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.