Citation Nr: 21028334 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 17-43 612 DATE: May 11, 2021 ORDER Entitlement to service connection for tinea pedis (athlete's foot) is denied. Entitlement to an initial 50 percent rating, but no higher, prior to March 20, 2017, for service-connected posttraumatic stress disorder (PTSD) is granted, subject to the law and regulations governing the payment of monetary benefits. Entitlement to an initial rating in excess of 50 percent for service-connected PTSD from March 20, 2017, is denied. REMANDED Entitlement to service connection for left foot pes planus (flat foot) is remanded. Entitlement to service connection for hypertension is remanded. Entitlement to service connection for a stomach/gastroesophageal disability, to include duodenal ulcer and gastroesophageal reflux disease (GERD) is remanded. Entitlement to service connection for obstructive sleep apnea (OSA) is remanded. FINDINGS OF FACT 1. The most probative evidence does not reflect a diagnosis of tinea pedis (athlete's foot) at any time during or approximate to the pendency of the claim, and the Veteran does not have an unexplained rash on his feet which is a manifestation of an undiagnosed illness. 2. Prior to March 20, 2017, the Veteran's PTSD symptoms have been productive of, at most, occupational and social impairment with reduced reliability and productivity and not by symptoms productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. 3. Since March 20, 2017, the Veteran's PTSD symptoms have been productive of, at most, occupational and social impairment with reduced reliability and productivity and not by symptoms productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood. CONCLUSIONS OF LAW 1. The criteria for service connection for tinea pedis (athlete's foot) have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. Prior to March 20, 2017, the criteria for a disability rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. 3. Since March 20, 2017, the criteria for a disability rating in excess of 50 percent for PTSD have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.126, 4.130, Diagnostic Code 9411. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1987 to July 1990, and from December 2002 to June 2003, with additional service in the Reserves. This matter is before the Board of Veterans' Appeals (Board) following a Board Remand in May 2019. Service Connection 1. Entitlement to service connection for tinea pedis (athlete's foot) The Veteran contends that he has athlete's foot that is related to his active duty service. In a statement received by VA in April 2016, the Veteran indicated that his athlete's foot has been intermittent since wearing web boots in boot camp. In a statement received by VA in February 2017, the Veteran reported that he developed athlete's foot in boot camp and that he had been using Naftin foot cream for years to get rid of it. 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, 5107; 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). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. As noted above, the Veteran served on active duty from July 1987 to July 1990, and from December 2002 to June 2003. He also had additional periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA) with the Navy Reserves. Service connection may be granted for disability resulting from disease or injury incurred during ACDUTRA, or injuries suffered during INACDUTRA to include when a cardiac arrest or a cerebrovascular accident occurs during such training. See 38 U.S.C. §§ 101(24), 106. Reserve service generally means ACDUTRA and INACDUTRA. ACDUTRA is full time duty for training purposes performed by Reservists. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). Basically, this refers to the two weeks of annual training that each Reservist must perform each year. It can also refer to the Reservist's initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d). Basically, this refers to the twelve four-hour weekend drills that each Reservist must perform each year. These drills are deemed to be part-time training. Service treatment records for both active duty and Reserves are absent complaints, findings or diagnoses of athlete's foot or any skin disorder of the feet during service. On the clinical examinations in June 1990, August 1990, November 1991, November 1996, and November 2001, the Veteran's feet and skin were evaluated as normal; and on the Reports of Medical History completed by the Veteran in conjunction with his physicals, as well as one he completed in December 2002, he consistently denied ever having skin disease. On the Report of Medical Assessment completed by the Veteran in June 2003, the Veteran indicated that compared to his last medical assessment/physical exam, his overall health was the same. He also indicated that since his last medical assessment/physical examination he had not had any illness or injuries that caused him to miss duty for longer than 3 days; had not been seen by or been treated by a health care provider, admitted to a hospital, or had surgery; had not suffered from any injury or illness while on active duty for which he did not seek medical care; was not taking any medications; did not have any conditions which limited his ability to work in your primary military specialty or require geographic or assignment limitations; and did not have any other questions or concerns about his health. A May 2010 letter from Dr. Zennato notes that the Veteran's chief concern was itching of both feet and that he reported excessive perspiration of both feet and being treated for Athlete's foot infection in the past. Dr. Zennato noted that the Veteran stated that he had been dealing with his foot problem for many years dating back to his days in the military. A diagnosis of tinea pedis was noted. Pharmacy records indicate that the Veteran has been prescribed Naftin since 2010. In a statement received by VA in September 2018, the Veteran noted that during boot camp, he marched in the rain and placed the same boots back on his feet the next morning, and that he soaked his feet in peroxide to kill all the germs. The Veteran underwent VA examination in February 2020 at which time he reported that his skin symptoms started during service. He reported that during boot camp, he developed broken, cracked skin in between and the bottom of his toes and feet. The Veteran reported that during service he was given a topical cream to treat his skin condition. The examiner noted there was no objective evidence of a chronic tinea pedis condition, that the Veteran's symptoms were subjective only, and that there was no diagnosis on the basis of that day's examination. Nevertheless, the examiner opined that tinea pedis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also opined that tinea pedis was less likely than not proximately due to or the result of service-connected disability. The examiner noted that a nexus or plausible secondary relationship could not be established. The Board concludes that the Veteran does not have a current diagnosis of tinea pedis and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The February 2020 VA examiner evaluated the Veteran and determined that he did not have a diagnosis of tinea pedis. Further, VA and private treatment records are absent complaints, findings or diagnoses of athlete's foot or any skin disorder of the feet after 2010. The Veteran initially filed his claim for service connection for athlete's foot in 2015 and his most recent claim in April 2016. Although the Veteran believes he has a current diagnosis of athlete's foot/tinea pedis, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence. The Board notes that service connection may be established for a Persian Gulf Veteran who exhibits objective indications of chronic disability which cannot be attributed to any known clinical diagnosis, but which instead results from an undiagnosed illness that became manifest either during active duty in the Southwest Asia theater of operations, or to a degree of 10 percent or more not later than December 31, 2021. 38 C.F.R. § 3.317 (a)(1)(i). Signs or symptoms that may be a manifestation of an undiagnosed illness or a chronic multi-symptom illness include unexplained rashes. The record, however, is absent evidence of unexplained rashes on the Veteran's feet since he filed his original claim for service connection for athlete's foot in 2015 and his most recent claim in April 2016. As such, service connection is not established under 38 C.F.R. § 3.317 (a)(1)(i). Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection, and the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107(b) is not for application. Increased Ratings 2. Entitlement to an initial rating in excess of 30 percent prior to March 20, 2017, for PTSD 3. Entitlement to a rating in excess of 50 percent since March 20, 2017, for PTSD The Veteran contends that the symptoms associated with his service-connected PTSD are more severely disabling than reflected by the currently assigned disability ratings and warrant higher ratings. In a July 2020 statement, the Veteran's attorney argued that the record shows indications that the Veteran suffers from impaired impulse control such as unprovoked irritability with periods of violence. Under the General Formula for Mental Disorders (General Formula), the Board must conduct a "holistic analysis" that considers all associated symptoms, regardless of whether they are listed as criteria. Bankhead v. Shulkin, 29 Vet. App. 10, 22 (2017); 38 C.F.R. § 4.130. The Board must determine whether unlisted symptoms are similar in severity, frequency, and duration to the listed symptoms associated with specific disability percentages. Then, the Board must determine whether the associated symptoms, both listed and unlisted, caused the level of impairment required for a higher disability rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112, 114-118 (Fed. Cir. 2013). The issue in this appeal is whether the Veteran's associated symptoms caused the level of impairment required for a disability rating of 50 percent or higher prior to March 20, 2017 and 70 percent or higher since March 20, 2017. A noncompensable rating is assigned when a mental condition has been formally diagnosed, but symptoms are not severe enough to either require continuous medication, or to interfere with occupational and social functioning. A 10 percent rating is assigned when mild or transient symptoms which decrease work efficiency and ability to perform occupational tasks only during periods of occasional stress, or symptoms controlled by medication cause occupational and social impairment. A 30 percent rating is assigned when symptoms such as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, or mild memory loss (such as forgetting names, directions, or recent events), cause occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and normal conversation). A 50 percent rating is assigned when symptoms such as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; or difficulty in establishing and maintaining effective work and social relationships cause occupational and social impairment with reduced reliability and productivity. A 70 percent rating is assigned when symptoms such as suicidal ideation; obsessional rituals which interfere with routine activities; intermittently illogical, obscure, or irrelevant speech; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a worklike setting); or inability to establish and maintain effective relationships cause occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. A 100 percent rating is assigned when symptoms such as gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. The Board finds that the evidence of record reflects psychiatric symptoms and resulting functional impairment which more nearly approximate the criteria for a 50 percent evaluation during the entire appeal period. On his application for service connection for PTSD in July 2016, the Veteran reported that he was still having sleeping problems and nightmares of the stressful event in service since his return home. In addition, the Veteran noted symptoms of depression, anxiety, flashbacks, increased anger, as well as suicide issues. The Veteran reported weight changes, increased alcohol use, and problems in his marriage. In April 2016, the Veteran was seen in the emergency department complaints of having nightmares, flashbacks and night sweats related to his military experience. The Veteran reported that he had been feeling depressed for many years with insomnia, anxiety, isolation, decreased motivation, and anger management problems but denied any thoughts of hurting self/others and psychotic symptoms. On mental status examination, the Veteran's mood was depressed. His speech was clear and goal directed; he denied suicidal/homicidal ideations, or hallucinations; there were no delusions elicited; and his insight and judgment were fair. Three days later, he was seen at the PTSD clinic for an initial assessment. At that time, he reported depressive and anxiety symptoms, feelings of sadness and irritability, low energy level, poor concentration, and anhedonia. The Veteran reported that he felt numb at times, that he got upset easily, had low frustration tolerance, got into frequent arguments with his wife, and yelled at his children. He also reported high levels of anxiety and tension, flashbacks, sleep disturbances, and nightmares with frequency of about seven to eight times per month. The Veteran denied previous psychiatric admissions, medication trials, and suicide attempts; he also denied current suicidal or homicidal thoughts, plan, or intent. There was no evidence of extreme anxiety, despondency, hopelessness, and there were no reports of manic/psychotic symptoms. In May 2016, the Veteran reported feeling hopeless about the present and future as well as recent thoughts of taking his life. When asked when he had such thoughts, he replied three weeks prior when he was seen in the emergency department. At a May 2016 psychosocial assessment, however, he denied suicidal ideations at that time, in the prior 12-month period, and history of suicidality. In June 2016, the Veteran reported feeling better since taking the medications and stated that he noticed improvement in his mood, that he was more relaxed and focused at work, and that he slept for two to three hours with medication. The Veteran noted that when he needed a full night sleep and took another medication prescribed by his private doctor for last 8 years. The Veteran underwent initial VA PTSD examination in August 2016 at which time he was diagnosed as having PTSD with occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks although generally functioning satisfactorily with normal routine behavior, self-care, and conversation. The examiner noted that the Veteran experienced avoidance of distressing memories, thoughts, or feelings about traumatic event; avoidance of external reminders that arouse distressing memories, thoughts, or feelings about traumatic event; inability to remember an important aspect of the traumatic event; persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; persistent, distorted cognitions about the cause or consequences of the traumatic event; persistent negative emotion state; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; persistent inability to experience positive emotions; irritable behavior and angry outbursts; hypervigilance; exaggerated startle response; depressed mood; and anxiety. The next week, the Veteran reported doing better overall; he noted that he still experienced episodic depression, irritability, and mood swings, but that they were less intense and frequent than before. He also noted that he was learning how to cope with difficult situations after getting angry. In December 2016, the Veteran noted that his mood was more stable with medications. He noted that he was more calm and able to manage stressful situations better than before. The Veteran noted that if he got upset at work or at home, he started playing a video game on his phone which helped him calm down and prevented him from escalating the situation. He noted that he was sleeping better with medication and that he was sleeping for four to five hours per night. In March 2017, the Veteran reported that he had started working the night shift and had noticed changes in his sleep pattern, difficulty falling asleep despite taking medication and feeling tired the next day. He reported feeling "the same" and still having some irritability and anger outbursts but less frequent than before. The Veteran denied suicidal or homicidal thoughts, plan, or intent; there was no evidence of extreme anxiety, despondency, or hopelessness; and there were no reports of manic/psychotic symptoms. The Veteran underwent VA PTSD examination in April 2017 at which time he reported increased sleep disturbance although he denied nightmares; he reported increased irritability but denied physical aggression. He also denied suicidal and homicidal ideation. The Veteran was diagnosed as having PTSD with occupational and social impairment with reduced reliability and productivity. The examiner noted that the Veteran experienced recurrent, involuntary, and intrusive distressing memories of the stressful event; avoidance of distressing memories, thoughts, or feelings about traumatic event; avoidance of external reminders that arouse distressing memories, thoughts, or feelings about traumatic event; inability to remember an important aspect of the traumatic event; persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; markedly diminished interest or participation in significant activities; feelings of detachment or estrangement from others; irritable behavior and angry outbursts; hypervigilance; anxiety; panic attacks occurring weekly or less often; chronic sleep impairment; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances. In statements received by VA in September 2018, the Veteran indicated that since leaving service, he found life difficult and tiring, that many times over the past eight years, and even more often recently, he felt that ending his life would be the best solution. The Veteran stated that depression had taken its toll and that he had a difficult time being open with his feelings. He also noted that he had family problems due to his PTSD symptoms including anger. The Veteran also noted having vivid dreams, flashbacks, and anxiety after bouts of anger. The Veteran stated that he was always screaming and yelling at his wife, at his kids, and also at work. In another statement, the Veteran's wife noted that changes in her husband such as no longer communicating, no longer expressing emotion, inability to control anger, and difficulty sleeping. The Veteran underwent VA examination in February 2020 at which time he reported depressed mood, fatigue, irritability, and about four hours of sleep per night. He denied nightmares, suicidal ideation, and homicidal ideation. The Veteran was diagnosed as having PTSD with occupational and social impairment with reduced reliability and productivity. The examiner noted that the Veteran experienced avoidance of distressing memories, thoughts, or feelings about traumatic event; avoidance of external reminders that arouse distressing memories, thoughts, or feelings about traumatic event; persistent and exaggerated negative beliefs or expectations about oneself, others, or the world; markedly diminished interest or participation in significant activities; irritable behavior and angry outbursts; hypervigilance; problems with concentration; depressed mood; anxiety; panic attacks occurring weekly or less often; chronic sleep impairment; mild memory loss; disturbances of motivation and mood; difficulty in establishing and maintaining effective work and social relationships; and difficulty in adapting to stressful circumstances. The Board notes that prior to March 20, 2017, the Veteran's PTSD symptom severity has fluctuated during the appeal period which included symptoms of depression, anxiety, flashbacks, chronic sleep impairment, isolation, poor concentration, and decreased motivation. In addition, it appears that the most troubling symptoms to the Veteran including low frustration tolerance, increased anger, anger management problems, irritable behavior, and angry outbursts. He reported frequent arguments with his wife and yelling at his children; he also reported problems with anger at work. In fact, the Veteran's problems with anger management, including irritable behavior and angry outbursts, have caused major problems with his family and coworkers. Such consistent problems with anger management are analogous to impaired impulse control such as unprovoked irritability with periods of violence, although verbal and not physical. Acknowledging PTSD symptoms have been more than mild but less than severe and resolving reasonable doubt in the Veteran's favor, the Board finds that the Veteran's PTSD has been productive of occupational and social impairment with reduced reliability and productivity. The Board, therefore, finds that the severity, frequency, and duration of the Veteran's PTSD symptoms more closely approximate the symptoms contemplated by a 50 percent rating, which are less severe, less frequent, and shorter in duration than those contemplated by a 70 percent rating. In addition, at no time has the Veteran's PTSD been productive of symptoms such as obsessional rituals; abnormal speech; near-continuous panic or depression; periods of violence; spatial disorientation; neglect of personal appearance and hygiene; inability to establish and maintain effective relationships; gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living; disorientation to time or place; or memory loss for names of close relatives, own occupation or own name cause total occupational and social impairment. Although the Veteran reported irritability, periods of frustration, and outbursts of anger, and periodic verbal abuse, there is no indication that the Veteran becomes violent. In December 2017, the Veteran reported irritable behavior, angry outburst, or acting aggressively; however, in February 2018, he denied any history of domestic violence. In January 2018, May 2019, September 2019, and May 2020, the Veteran was not considered a danger to himself or others. Although the Veteran reported suicidal ideation in May 2016, July 2016, and December 2017, September 2018, most psychiatric records show that the Veteran specifically denied suicidal ideation and any previous suicide attempts. The Board notes that in a December 2017 nursing primary care note, the provider noted that the Veteran reported suicidal gesture in the prior 12-month period; however, that same day, the clinical psychologist noted that a review of Veteran's chart revealed a past suicide attempt 10 years prior by overdose and that the Veteran reported he had thoughts of harming himself "before the medication", but had not experienced suicidal ideation, plans, preparations, or intent for almost two years. As noted above, in January 2018, May 2019, September 2019, and May 2020, the Veteran was not considered a danger to himself or others. As such, the Board finds that the overall evidence does not demonstrate a level of impairment associated with a 70 percent rating. The Veteran's PTSD symptoms are either contemplated by or more consistent with a 50 percent rating. The above represents a partial allowance of the benefits sought on appeal. REASONS FOR REMAND 4. Entitlement to service connection for left foot pes planus (flat foot) The Veteran contends that he has pes planus of the left foot which pre-existed service worsened during his active duty service. In a statement received by VA in April 2016, the Veteran indicated that his left foot arch fell from wearing boots all the time. In a September 2018 statement, the Veteran stated that his left foot arch fell because he was in military boots all the time and, perhaps, from marching his whole military career. In a July 2020 statement, the Veteran's attorney noted that studies have shown that PTSD can cause weight gain; and weight gain can both cause and aggravate flat feet. The Veteran's April 1987 enlistment examination shows that he had bilateral pes planus upon entry to service. As such, the Veteran's preexisting pes planus was noted upon entry into service. The balance of the Veteran's service treatment records for both active duty and Reserves are absent complaints, findings, or diagnoses of pes planus during service. On the clinical examinations in June 1990, August 1990, November 1991, November 1996, and November 2001, the Veteran's feet were evaluated as normal. On the Report of Medical Assessment completed by the Veteran in June 2003, the Veteran indicated that compared to his last medical assessment/physical exam, his overall health was the same. He also indicated that since his last medical assessment/physical examination he had not had any illness or injuries that caused him to miss duty for longer than 3 days; had not been seen by or been treated by a health care provider, admitted to a hospital, or had surgery; had not suffered from any injury or illness while on active duty for which he did not seek medical care; was not taking any medications; did not have any conditions which limited his ability to work in your primary military specialty or require geographic or assignment limitations; and did not have any other questions or concerns about his health. In June 2016, the Veteran was seen for follow up after initial VA visit. It was noted that he had occasional bilateral foot pain. X-rays were ordered as well as Lynco arch supports. A private treatment record dated November 2019 provided by the Veteran noted active problems of pes planus and plantar fasciitis. The Veteran underwent VA examination in February 2020 at which time he reported that his foot symptoms started after service. On physical examination, there was no evidence of left flat foot, and the examiner indicated that the left foot was normal. Nevertheless, the examiner opined that the Veteran's pes planus clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner stated that although temporary aggravation was plausible, there was no evidence of permanent aggravation of the pre-existing left flat foot and that there was no current medical literature to support this contention. In July 2020, the Veteran submitted a medical article, "Does Obesity Cause Flat Foot?" showing a strong correlation between obesity and flat foot presence. The Board notes that on separation from service in June 1990, the Veteran's weight was 137 pounds. During the appeal period, the Veteran's weight has fluctuated from 166.8 to 195. In January 2017, the Veteran was determined to be overweight as evidenced by BMI of 28.9. In January 2017, VA's Office of General Counsel issued a precedential opinion that concluded that obesity per se is not a disease or injury for purposes of 38 U.S.C. §§ 1110 and 1131 and therefore may not be service connected on a direct basis. Similarly, obesity is not a "disability" for the purposes of secondary service connection under 38 C.F.R. § 3.310. However, VAOPGCPREC 1-2017 recognized that obesity may act as an "intermediate step" between a service-connected disability and a current disability that may be service-connected on a secondary basis under 38 C.F.R. § 3.310 (a). Given the evidence presented since the February 2020 VA examination, the Board finds that addendum opinions should be obtained which takes into account the medical article submitted by the Veteran. 5. Entitlement to service connection for hypertension The Veteran contends that his hypertension had its onset during active duty. In the alternative, the Veteran contends that his hypertension is secondary to service-connected PTSD. In a statement received by VA in April 2016, the Veteran indicated that was angry and yelled often since being home. In a statement received by VA in September 2018, the Veteran stated that he took blood pressure pills because he screamed, had a bad temper, and yelled at his family and workers at work. In a July 2020 statement, the Veteran's attorney noted that studies have shown that PTSD can cause weight gain; and weight gain can both cause and aggravate hypertension. As noted above, in May 2019, the Board remanded the case for additional development. Specifically, the Board directed that the Veteran should be provided with a VA examination and that the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran's hypertension was incurred in or due to his active duty or was caused or aggravated by a service-connected disability. Although a VA examination was provided and the examiner opined that hypertension was less likely than not incurred in or caused by the claimed in-service injury, event, or illness and not proximately due to or the result of PTSD, the examiner failed to provide an opinion as to whether the Veteran's PTSD aggravated his hypertension. Specifically, the VA examiner stated, Risk factors include being overweight or obese. The more you weigh the more blood you need to supply oxygen and nutrients to your tissues. As the volume of blood circulated through your blood vessels increases, so does the pressure on your artery walls. Age. The risk of high blood pressure increases as you age. Until about age 64, high blood pressure is more common in men. Veteran is 57 [years old], BMI 28.3 this is more likely than not the cause of his elevated blood pressure. In addition, the Veteran's attorney noted that although the examiner specifically found that hypertension was related to obesity, he did not give an opinion about the cause of the obesity. In July 2020, the Veteran submitted a medical article entitled, "Hypertension and Obesity: How Weight-loss Affects Hypertension. As noted above, the Veteran has been determined to be overweight as evidenced by BMI of 28.9. As there has not been substantial compliance with the Board's previous remand directives, and given the evidence presented since the February 2020 VA examination, the Board finds that an addendum opinion should be obtained which takes into account the medical articles submitted by the Veteran. 6. Entitlement to service connection for a gastrointestinal disability, to include duodenal ulcer, GERD The Veteran contends that he has a stomach/gastrointestinal disability that had its onset during active duty service. In September 2020, the Veteran submitted an application in which he indicated that his gastroesophageal reflux disease was caused by exposure to some kind of chemical. Service treatment records for both active duty and Reserves indicate that he was diagnosed as having mild gastritis in September 1987, a duodenal ulcer by upper GI as well as peptic ulcer disease in April 1988. In November 1993, the Veteran reported having nervous stomach or ulcer. On the clinical examination in November 1996, the Veteran's abdomen and viscera were abnormal; and an umbilical hernia was noted. In April 2017 the Veteran underwent an upper GI endoscopy which demonstrated normal esophagus, non-erosive gastritis, gastric polyp, and acute duodenal ulcer without hemorrhage or perforation. The Veteran underwent VA examination in June 2017 at which time an upper GI was unremarkable with no evidence of discrete ulcer, hiatal hernia, or reflux. The examiner noted that the Veteran had symptoms due to GERD which was not a stomach condition; and as such, the examiner found that there was no stomach diagnosis. The examiner also noted that the duodenal ulcer in service had healed. In July 2017, the Veteran submitted a medical article entitled, "Anxiety and depression in patients with gastroesophageal reflux disease and their effect on quality of life." The Veteran underwent VA examination in February 2020 at which time he reported that his intestinal symptoms started after service. The examiner noted there was no objective evidence of a chronic stomach/gastrointestinal condition, that the Veteran's symptoms were subjective only, and that there was no diagnosis on the basis of that day's examination. Nevertheless, the examiner opined that a stomach/gastrointestinal disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner also opined that a stomach/gastrointestinal disability was less likely than not proximately due to or the result of service-connected disability. The Veteran underwent VA examination in October 2020 at which time the examiner noted that GERD was a recent diagnosis starting in 2020 and was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The Veteran underwent an esophagogastroduodenoscopy (EGD) procedure in November 2020 at which time he was diagnosed as having reflux esophagitis, hiatal hernia, and gastritis with hemorrhage. The February 2020 opinion is inadequate as the VA examiner found that the Veteran did not have a diagnosed disability; however, because the Veteran had a diagnosis during the appeal period, the VA examiner needed to address that diagnosis and whether it was accurate or in error. In addition, EGD in November 2020 diagnosed three GI conditions. The October 2020 opinion is also inadequate as it provides no rationale. Given the evidence presented since the February and October 2020 VA opinions, the Board finds that an addendum opinion should be obtained. 7. Entitlement to service connection for OSA The Veteran contends that he has a sleep disorder that is related to his active duty service. In a statement received by VA in September 2018, he noted that since he got home, he has not been able to sleep and that he has been taking sleeping pills for over eight years. The Veteran stated that he found himself "jumping out of [his] sleep" because he could not breathe. In a July 2020 statement, the Veteran's attorney noted that studies have shown that PTSD can cause weight gain; and weight gain can both cause and aggravate OSA. In July 2020, the Veteran submitted a medical article entitled, "Interactions Between Obesity and Obstructive Sleep Apnea" which notes that obesity is considered a major risk factor for the development and progression of OSA. As noted above, the Veteran has been determined to be overweight as evidenced by BMI of 28.9. The Veteran also submitted the medical article entitled, "Obstructive Sleep Apnea and Psychiatric Disorders: A systematic review," which concludes that OSA prevalence may be increased in PTSD. A February 2021 sleep study revealed mild OSA with worse respiratory events on the left side and mid hypoxemia. As noted above, in May 2019, the Board remanded the case for additional development. Specifically, the Board directed the AOJ to schedule the Veteran for a VA examination with a sleep specialist to provide an etiology opinion with respect to the Veteran's sleep disorder. Although a VA examination was provided in February 2020, it was provided by a nurse practitioner and not a sleep specialist. As there has not been substantial compliance with the Board's previous remand directives, and given the evidence presented since the February 2020 VA examination, the Board finds that an addendum opinion should be obtained which takes into account the medical articles submitted by the Veteran. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician, preferably a psychiatrist or a psychologist, regarding whether the Veteran's weight status (overweight as evidenced by BMI of 28.9) is at least as likely as not (i) proximately due to service-connected PTSD or (ii) aggravated beyond its natural progression by service-connected PTSD. The clinician is asked to address the following medical articles submitted by the Veteran: "Post-Traumatic Stress Disorder Predicts Future Weight Change in the Millennium Cohort Study." 2. Obtain an addendum opinion from an appropriate clinician, preferably a podiatrist, regarding whether the Veteran's left foot pes planus is at least as likely as not (i) aggravated beyond its natural progression by service-connected PTSD; (ii) aggravated beyond its natural progression by the Veteran's weight status (overweight as evidenced by BMI of 28.9). The clinician should address the following medical article submitted by the Veteran: "Does Obesity Cause Flat Foot?" 3. Obtain an addendum opinion from an appropriate clinician as to whether hypertension it is at least as likely as not (i) related to an in-service injury, event, or disease, including elevated blood pressure readings during service; (ii) proximately due to service-connected PTSD, (iii) aggravated beyond its natural progression by service-connected PTSD; (iv) aggravated beyond its natural progression by the Veteran's weight status (overweight as evidenced by BMI of 28.9). The clinician is asked to address the following medical articles submitted by the Veteran: "Post-traumatic Stress Disorder and Cardiovascular Disease" and "Hypertension and Obesity: How Weight-Loss Affects Hypertension." 4. Obtain an addendum opinion from an appropriate clinician, preferably a gastroenterologist, to determine the nature and etiology of any stomach/gastroesophageal disability. The examiner must identify all chronic stomach/gastroesophageal disorders since 2015 and for each such disorder opine (1) whether it is at least as likely as not related to an in-service injury, event, or disease, including symptoms and disorders noted in service; (2) whether it is at least as likely as not (i) proximately due to service-connected PTSD, or (ii) aggravated beyond its natural progression by service-connected PTSD. The clinician is asked to address the following medical article submitted by the Veteran: "Anxiety and depression in patients with gastroesophageal reflux disease and their effect on quality of life." 5. Schedule the Veteran for an examination with a sleep specialist to determine the nature and etiology of his OSA. The examiner must opine (1) whether it is at least as likely as not related to an in-service injury, event, or disease; (2) whether it is at least as likely as not (i) proximately due to service-connected PTSD, or (ii) aggravated beyond its natural progression by service-connected PTSD. The clinician is asked to address the following medical articles submitted by the Veteran: "Post-Traumatic Stress Disorder Predicts Future Weight Change in the Millennium Cohort Study;" "Interactions Between Obesity and Obstructive Sleep Apnea;" and "Obstructive Sleep Apnea and Psychiatric Disorders: A Systematic Review." SCOTT W. DALE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Olson, Patricia 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.