Citation Nr: 21028852 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 10-11 636 DATE: May 12, 2021 ORDER Entitlement to service connection for pes planus and plantar fasciitis is denied. FINDING OF FACT 1. The appellant's pes planus was noted on induction and is not shown to have increased in severity beyond normal progression during his ACDUTRA service from June 20, 1984 to August 22, 1984. 2. Plantar fasciitis was first manifested after, and is not shown to be etiologically related to, the appellant's ACDUTRA service from June 20, 1984 to August 22, 1984. CONCLUSION OF LAW Service connection for bilateral pes planus and plantar fasciitis is not warranted. 38 U.S.C. §§ 1111, 1131, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant served on ACDUTRA from June 20, 1984 to August 22, 1984 and had additional service in the U.S. Army Reserve. This matter is before the Board on appeal from a July 2008 rating decision. In April 2015, a Travel Board hearing was held before the undersigned; a transcript is in the record. In August 2015, December 2016, and April 2019 the case was remanded for development. Entitlement to service connection for pes planus and plantar fasciitis is denied. The appellant contends that his bilateral pes planus was aggravated in service, and argues that his plantar fasciitis developed from his duties in service. His theory of entitlement is based on the cumulative effect of being on his feet for several years of Reserve service, in addition to claimed service in 1999/2000. The medical record shows that pes planus (flat feet) was diagnosed prior to the appellant's service entrance. On May 1983 service enlistment examination, it was noted that he had flat feet that were occasionally painful. In June 1984, he was seen for a complaint of bilateral arch pain due to pes planus, and was issued arch supports for his boots. On September 1990 Reserve service examination, bilateral flat feet were noted. On September 1995 Reserve service examination, he reported intermittent foot pain for which he had not had any work-up, noting that it "never interfered with performance of duties"; it was noted that his civilian occupation was mail carrier. In July 1999, he was evaluated for profile for bilateral plantar fasciitis; it was noted that he worked as a postal worker, delivering letters for 10 years, and needed a profile for his annual training. On January 2000 treatment, the appellant reported painful plantar fascia bilaterally and pain in the arches of both feet; it was noted that he was seen in May 1999 for podiatric care as well; the diagnosis was chronic plantar fasciitis. In March 2000, he was placed on physical profile for bilateral plantar fasciitis. In February 2002 he sought treatment for foot pain, left greater than right. It was noted that he had a history of plantar fasciitis with acute exacerbations. On August 2002 treatment, he reported that he was injured "two years ago" [in 2000]; it was that he had flat feet, and the assessment was bilateral plantar fasciitis, stable. In December 2003, he was placed on physical profile for plantar fasciitis. On July 2006 electrodiagnostic evaluation, the appellant was noted to have been suspect for tarsal tunnel syndrome and plantar fasciitis; it was noted that he did not have a particular instance with a work injury but rather described difficulty beginning with both feet while doing his walking as a letter carrier, with onset of symptoms about 6 years prior [in 2000]. On May 2008 VA examination, it was noted that the appellant was on ACDUTRA from June to August 1984 and had subsequent Reserve service. The examiner noted that the appellant has evidence of treatment for bilateral plantar fasciitis, with examinations on multiple occasions, and in July 1999 had evidence of bilateral plantar fasciitis. Following physical examination, the diagnoses included bilateral moderate flat feet, residuals of plantar fasciitis, and bilateral calcaneal spurs. The examiner opined that the claimed condition of pes planus, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner noted pes planus (flat feet occasionally painful) was noted on the appellant's May 1983 Reserve service enlistment exam; bilateral flat feet was noted on September 1990 report of medical examination; chronic bilateral plantar fasciitis was diagnosed and treated in January 2000, with subsequent treatment as well; and the appellant was placed on physical profile for bilateral plantar fasciitis in April 2000, and moderate pes planus was noted in November 2003. The examiner opined that it is at least as likely as not the appellant's bilateral feet condition was aggravated beyond natural progression by his Reserve service. The examiner explained that, as noted in the evidence, the appellant had flat feet that was occasionally painful on enlistment examination, and since he began Reserve service, bilateral pes planus had become chronic and symptomatic, with treatment by a podiatrist when he was seen for worker's compensation in January 2000. The examiner opined that the evidence on examination of moderate symptomatic bilateral pes planus is as likely as not aggravation beyond natural progression, noting that during Army Reservist service weight bearing with activities involving carrying heavy weights increases the stress on plantar arches and plantar fascia, aggravating the flat feet condition. On November 2010 evaluation, the appellant was noted to have extreme pes planus bilaterally, in addition to chronic bilateral plantar fasciitis. In September 2014, the appellant was examined to measure permanent impairment sustained subsequent to his work-related accident on approximately May 17, 1999. Regarding the history of the injury, it was noted that the appellant had been employed as a city letter carrier for approximately 6 years when he began to notice throbbing pain in both feet; he had no significant past medical history. The assessment was bilateral plantar fibromatosis. At the April 2015 Board hearing, the appellant testified that he enlisted in the Reserves in June 1983 and served on ACDUTRA status during boot camp for approximately two months in 1983, and he did his MOS training in 1984. He testified that he began working for the U.S. Postal Service as a letter carrier in 1987, and that he filed a worker's compensation claim while working for the postal service. In a May 2015 letter, a private reviewing provider stated that he had reviewed the appellant's records from Carle Clinic Division of Occupational Medicine, and talked to the appellant regarding his pes planus and plantar fasciitis. He opined that the appellant's military duties required prolonged standing and walking. He noted the appellant's report of developing foot pain which led to a PT profile, excusing him from running part of the annual military physical fitness test. The provider opined that the appellant's military duties led to plantar fasciitis, which will not resolve except by avoidance of activities which cause foot pain. In the August 2015 remand, the Board noted that development at that time had included securing STRs pertaining to the appellant's Reserve service and a report indicating the total service points accrued. However, development to ascertain the alleged period(s) of service when the aggravation of pes planus occurred and/or when plantar fasciitis was incurred, to verify whether the appellant was indeed in the line of duty at such times, and to determine whether or not any of his claimed disability may be attributed to the alleged periods, was lacking. (There was a medical opinion in the record indicating that the current foot disability is related to military service in 1999 and 2000, but there was nothing in the record showing he was serving on active duty in the line of duty at that time.) The Board also noted that pertinent postservice treatment records were outstanding, including records associated with the appellant's postservice employment with the Postal Service and records pertaining to his worker's compensation claim. On April 2016 VA examination, the appellant reported that he had a diagnosis of flat feet on entry in service in 1983. He reported that he was first evaluated for his feet in about 1999 and was put on profile in about 2001 or 2003 for running due to plantar fasciitis. He reported that he was put on work restrictions due to plantar fasciitis in about 1999. The examiner noted that in response to the appellant's worker's compensation claim, he was given 12% for the right foot and 8% for the left foot and received payment for the condition since 1999. Following physical examination, the diagnoses were bilateral pes planus (diagnosed in 1983), bilateral plantar fasciitis (diagnosed in about 1999 for the right foot and about 2000 for the left foot), and right foot gout diagnosed in 2015. The examiner opined that the pes planus was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted the appellant's report that the diagnosis of flat feet was made at the time of his service entry exam and opined that this corresponds to his diagnosis of congenital flat feet. The examiner further opined that the claimed condition, clearly and unmistakably existed prior to service, and was not aggravated beyond its natural progression by an in-service event, injury, or illness. The examiner noted that neither the appellant nor his records indicate a foot injury occurred during his performance of inactive duty for training (IDT). The examiner noted that studies of military personnel have shown that pes planus does not cause problems in asymptomatic feet and pes planus is not a cause for exclusion from military duty as it once was. The examiner opined that the current status of the appellant's pes planus with pronation more likely represents the natural progression of the condition and would be the same whether or not he was in service. Regarding plantar fasciitis, the examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that the appellant's records clearly document a diagnosis of plantar fasciitis by April 2000 when a physical profile noted bilateral plantar fasciitis. The examiner noted that a chronological statement of retirement points dated July 2003 "indicates ENL class from 1983 from 2003", and a detailed post listing for previous retirement year indicates inactive points from dates that are generally in threes and separated by a month, whereas active points are from one date. The examiner opined that no evidence for a foot injury during service activities was identified. The examiner noted that a November 2010 worker's compensation document alludes to previous visits in the 1990s for foot problems and opined that a diagnosis from that time is not given, but the note indicates a diagnosis at that time (in 2010) of chronic plantar fasciitis. The examiner noted that a November 2001 treatment record gives a diagnosis of bilateral flat feet with indicated restrictions and opined that this is consistent with the note indicating foot problems in the 1990s that required work restrictions. The examiner noted a November 2001 Department of Labor report indicating plantar fasciitis as a diagnosis due to injury. The examiner noted the appellant's reports that he filed a worker's compensation claim that his foot problems were caused by his post office work, and that the claim was paid covering the period back to 1999/2000, when the diagnosis was made, but did not cover when he was having foot problems prior to the diagnosis. The examiner opined that this established that the appellant's work at the post office was the cause of his plantar fasciitis, a conclusion that is consistent with the duration, frequency, and character of his occupational activities. The examiner opined that the nature of the appellant's occupational and service activities appear to have been similar during the time period prior to the diagnosis. The examiner noted that the activities of the appellant as a food service specialist during INACDUTRA and ACDUTRA (described by him as shopping, setting up facilities, and standing) were performed over a period of days separated by periods of weeks, whereas the activities for the postal service (as letter carrier, described and documented in the Duty Status Report) were performed 8 hours a day, 5 days a week. The examiner noted that added to this would be time spent standing and walking during non-occupational daily activities. The examiner opined that, thus, while standing and walking during periods of ACDUTRA or INACDUTRA may have provoked symptoms, it is more likely than not that they would have been too small to aggravate the plantar fasciitis beyond its natural progression. Regarding gout, the examiner opined that the appellant's gouty arthritis was less likely than not incurred in or caused by the claimed in-service injury, event or illness, noting that gout is a metabolic condition, and the appellant and the record do not indicate he had gout before the diagnosis of acute gouty arthritis in March 2015. In a May 2016 medical opinion, a private podiatrist who saw the appellant in April 2016 for treatment of bilateral foot pain noted that the appellant's diagnoses included plantar fasciitis, pes planus, and equinus, bilaterally. The provider noted that, according to the appellant, he had served in the military since 1983, and had the pes planus deformity when he joined the service in 1983. The provider opined, based on his examination of the appellant, that it is more likely than not that his military service, based on his description of his duties, aggravated his foot conditions, and made his painful symptoms worse. The appellant submitted a September 2017 foot conditions disability benefits questionnaire (DBQ), which notes diagnoses of bilateral plantar fasciitis, bilateral equinus deformity, and bilateral tarsal tunnel syndrome, with a date of diagnosis cited as June 2006 for each diagnosis. The podiatrist who completed the DBQ noted that the appellant reported the onset of heel pain in 1999, which was gradually worsening and aggravated by standing on hard surfaces, walking, and running. In a February 2019 addendum, the April 2016 VA examiner noted the February 2018 AOJ memorandum regarding misdirected development, as well as a July 2018 VA Form 21-2507 which states that the AOJ has provided the dates of the appellant's active duty and of the nature of his duties during such periods. The examiner noted that these records are comprised of forms containing coded information that neither he nor the other clinic staff were able to decipher and, for these reasons, he did not now have interpretable additional evidence to supplement that which formed the basis for his April 2016 opinions. The VA examiner noted the May 2016 opinion as well as the Board's remand instructions that the opinion consider the cumulative result of the appellant's prolonged standing, walking, or otherwise being on his feet during periods of ACDUTRA or INACDUTRA. The examiner therefore sought and found additional evidence from the medical literature to further elucidate the role of cumulative activity on the appellant's conditions. The examiner noted that, since the previous opinion in 2016, advances in medical science had improved and changed the understanding of cumulative trauma to the plantar fascia. The examiner noted that researchers have found that the human plantar fascia contains stem cells, and that these stem cells produce protein molecules that give the plantar fascia its structural properties, meaning that the plantar fascia possesses a repair capability. The examiner noted that the researchers discovered that the stem cells are activated by mechanical forces that stretch the tissue; specifically, moderate forces, such as those that mimic walking, stimulate reparative cellular functions; in contrast, high mechanical forces, such as those produced by fast running, activate damaging behavior by the cells. The examiner opined that these new data indicate that forces such as those produced by walking are not injurious to the fascia. The examiner opined that these findings are of particular significance when coupled with prior clinical data showing that regular stretching of the plantar fascia is an effective treatment for plantar fasciitis, and such stretching exercises are a standard treatment for chronic plantar fasciitis. The examiner opined that these data, taken together, indicate that it is less likely as not that the appellant's current plantar fasciitis was caused or aggravated by his standing and walking during periods of ACDUTRA or INACDUTRA. The examiner opined that, while the existence of a connection remains within the realm of medical possibility, it does not achieve the level of at least as likely as not. Regarding aggravation, the examiner noted that the appellant's condition of bilateral flexible pes planus arises in childhood and is a physiological, rather than the pathological, form of pes planus. The examiner noted that there is no history of injury or specific aggravating event [during active service), though there is a long history of walking long distances as a letter carrier. The examiner reviewed the literature to obtain data on the effect of prolonged standing and walking on the natural history of flexible pes planus. The examiner cited studies of over 5,000 military personnel from several countries, which found that pes planus did not cause foot disability and/or predispose to injury; indeed, one study found that pes planus was protective against injury. The examiner cited a study of adult civilians which found that there was no relationship between flat feet and pain, and that flat feet were not a source of disability. Based on the published literature, one researcher concluded that there is no data to conclusively prove that flexible flat foot early in life leads to long term morbidity in adults. The examiner opined that this lack of connection between the appellant's type of pes planus and future foot problems indicates that it is less likely as not that whatever added standing and walking occurred during periods of ACDUTRA/INACDUTRA would have significantly altered the natural history of the condition; while the existence of a connection remains within the realm of medical possibility, this does not achieve the level of at least as likely as not. Regarding the May 2016 private opinion, the VA examiner noted multiple limitations of [the probative weight] of that opinion: it was requested by the appellant, creating a conflict of interest for the provider that prevents him from being fully objective; the provider did not review any records from the appellant's file; the opinion did not consider the appellant's history of worker's compensation disability from his work as a letter carrier; and no rationale was provided. The examiner opined that, given these limitations, the evidence provided in that opinion was considered to be less strong than the other evidence cited by the examiner. In a February 2021 VA advisory medical opinion based on review of the record, the consulting provider noted that the appellant's pes planus and plantar fasciitis existed prior to service. The provider opined that the appellant's pes planus and plantar fasciitis were not proximately due to, secondary to, the result of, or aggravated by any in-service event, condition, or exposure, including periods of active duty and inactive duty. The provider noted that the appellant's own statements shown in the non-military medical records and Social Security records reflect that he had attributed the foot condition to his civilian employment as a letter carrier and postal worker. The provider opined that while a contemporaneous daily accounting of the appellant's activities on active duty or inactive duty status is not available, it is apparent from the extant records that he was not engaged in running, jumping, or marching for prolonged periods from 1999 forward; profiles were sought and provided in anticipation of military training periods to protect the appellant from aggravation. The provider noted that STRs reveal the appellant had pes planus that was intermittently painful when he entered service in 1983; there is no evidence of chronic foot troubles during his initial enlistment for training in 1984; in 1995 he acknowledged intermittent foot pain that never interfered with (military) duties; and in July 1999 he presented with a request for a profile for annual training. The reviewing provider opined that this corresponds to when he began having foot pain that he, himself, then related to his civilian employment. The provider opined that the accommodations described by his commander's buddy statement, and supported by the limitation listed on the permanent profiles, would not have aggravated his foot condition. The provider opined that the claimed condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an event, injury, or illness in service. Service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military service in the line of duty. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To substantiate a claim of service connection, there must be evidence of (1) a current disability (for which service connection is sought); (2) incurrence or aggravation of a disease or an injury in service; and (3) a causal connection, between the disease or injury in service and the current disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). A disability first diagnosed after discharge may be service connected if the evidence, including that pertinent to service, establishes the disability was incurred in service. 38 C.F.R. § 3.303(d); Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). Lay evidence may be competent evidence to establish incurrence. See Davidson v. Shinseki, 581 F. 3d 1313 (Fed. Cir. 2009). Competent medical evidence is necessary where the determinative question is one requiring medical knowledge. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The appellant is presumed to have been in sound condition when examined, accepted, and enrolled for service except as to defects, infirmities, or disorders noted at the time of examination, acceptance, enrollment (such as pes planus), or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. A preexisting disease will be considered to have been aggravated by military, naval, or air service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability was due to natural progression of the disease. Aggravation may not be conceded where the disability underwent no increase in severity during service based on all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. Inasmuch as only active duty Reserve service (to include ACDUTRA and inactive duty training (INACDUTRA)) is qualifying service to establish line of duty and entitlement to compensation, development in a claim of service connection based on such duty must include identification of the period/periods when the claimed disability is alleged to have been incurred or aggravated; verification of whether the claimed period was a recognized period of active duty service; and development of evidence to establish whether the claimed disability is indeed related to disease, injury, or event shown during the verified period of active duty service. As an initial matter, the Board notes that numerous unsuccessful attempts were made to verify whether the appellant's claimed period of 1999/2000 was indeed a recognized period of active duty service in the Reserves. The claims file includes Leave and Earnings Statements for the appellant from January 1983 through December 2016; however, no further efforts were conducted to verify the appellant's claimed service during 1999/2000, including whether or not he was serving in the line of duty, on active duty, or ACDUTRA or INACDUTRA. A February 2018 AOJ memorandum of misdirected development noted the Board's instruction that a memorandum be prepared regarding the appellant's ACDUTRA and/or INACDUTRA periods of service, yet stated, "We cannot take a formal document of ACDUTRA and INACDUTRA and turn it into an informal document." A November 2020 AOJ memorandum of misdirected development again noted the Board's instruction that a memorandum be prepared regarding the appellant's ACDUTRA and/or INACDUTRA periods of service, and stated, "We cannot take formal documents that provide ACDUTRA/INACDUTRA information and turn it into an informal document and assess it as valid evidence." The Board finds that additional remands to obtain this information would be futile and only cause further delays in this longstanding appeal. Therefore, the Board will proceed with a decision on the merits (with the understanding that the only verified period active duty in line of study is the period of ACDUTRA from June 20, 1984 to August 22, 1984, and that whether he had any additional periods of INACDUTRA when he was in line of duty is not relevant or material because he has not indicated he suffered a foot injury during any specific period of INACDUTRA (instead his reports suggest that there was no such injury). See 38 C.F.R. § 3.6(a). Pes planus that was occasionally painful was noted on the appellant's May 1983 service enlistment examination; consequently, the presumption on soundness on entry in service does not apply as to that disability entity. See 38 U.S.C. § 1111. Consequently, the analysis with respect to pes planus turns to whether the pre-existing pes planus was aggravated by his ACDUTRA service. Aggravation is established by showing an increase in disability during active service (considering the status of the disability prior to, during, and subsequent to the period of service). The Federal Circuit has held that lack of aggravation could be shown by establishing there was no increase in disability or that any increase in disability was due to the natural progress of the pre-existing condition. See Wagner v. Principi, 370 F.3d 1089, 1096-1097 (Fed. Cir. 2004). The pertinent evidence in the record does not show a chronic worsening of the appellant's pes planus during, or as a result of, service. The evidence of record shows that during his period of ACDUTRA the appellant was seen on one occasion for a complaint of arch pain and was provided arch supports, that single occasion is similar to the characterization of the disability on service entrance. It does not reflect a chronic worsening of pes planus in service. There is also no evidence during the immediate post-ACDUTRA period that the appellant's pes planus had worsened in severity. Service connection for pes planus based on aggravation of pre-existing pes planus during or as a result of the ACDUTRA is not warranted. Plantar fasciitis was not noted on service entrance examination, and the appellant is presumed sound as to such disability on entrance in service. However, there is no evidence that it was manifested during the ACDUTRA period of service in question (or soon thereafter). Consequently, because the evidence shows clearly that the appellant now has developed plantar fasciitis (and further foot pathology), substantiation of the claim must be under 38 C.F.R. §3.303(d) when all the evidence shows that a disability first diagnosed after service was incurred in service. Whether a current foot disability (such as fasciitis) which was first diagnosed years after service was incurred in remote service (to include as due to activities therein) is a medical question that is beyond the scope of common knowledge or capability of resolution by lay observation. It requires medical expertise. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007). There is medical evidence both supporting and against this claim. In support of the claim is a May 2008 VA examiner's opinion that points to the entire period of the appellant's Reserve service, notes that by the end of that service his foot complaints had been chronic (vs. occasional), and indicates essentially that the current foot disability was incurred in service. That opinion lacks probative value because it is based on an inaccurate factual premise (apparently assuming that the entire period of Reserve service was "in line of duty" and qualifying service for VA compensation benefit, rather than that the only service that is for consideration is the verified period of ACDUTRA (and any periods of INACDUTRA when a related injury occurred; here none are shown or have been identified). The provider also did not acknowledge that for a large part of the period the appellant was employed in a civilian occupation (mail-carrier) that required extensive walking (carrying significant weight) and apparently sustained an on-the job injury resulting in pathology for which he received workers' compensation. Also supporting the claim are private podiatrist's statements/opinions describing the current state of the foot disabilities (noting various diagnoses), and indicating in essence that the appellant's foot disability progressed beyond natural progression during his Reserve service. That opinion is also based on the inaccurate factual premise that the entire period of Reserve service is for consideration as in line of duty (rather than only the verified period of ACDUTRA. And that provider also did not discuss the significance of the appellant's civilian occupation of mail carrier or his work-related foot injury. There that opinion also lacks probative value. Against the claim is the report of a 2010 evaluation for workers' compensation purposes when it was noted that the appellant's foot complaints began about 6 years after he started his amil carrier occupation, and also that he suffered a foot injury on the job in approximately May 1999 (nearly 15 years after the ACDUTRA). The Board finds most probative in this matter the opinions offered on May 2016 VA examination and in February 2021 (based on review of the record). The providers opined based on a review of the complete record that it is not at least as likely as not that the appellant's pes planus was not permanently aggravated by service beyond its normal progression. The VA providers are medical professionals competent to offer the opinions provided; the opinions include rationale that cites to supporting clinical data. The Board finds them to be persuasive. There is no competent (medical) evidence supporting that the pre-existing pes planus chronically worsened in severity during active service in line of duty (on ACDUTRA or INACDUTRA). Regarding plantar fasciitis, it is not shown to have been manifested in service and is not noted in postservice clinical records in the record prior to 1999, approximately 15 years after service. It is not shown by the record that the appellant's plantar fasciitis is somehow etiologically related directly to his ACDUTRA service. As noted above, VA examiners have opined that it is less likely than not that the disability was incurred during, or caused by, his active service. They cited to factual data and medical principles and identified more likely, non-service-related, alternate etiological factors for the appellant's plantar fasciitis, including his civilian occupation (and the record also shows there was a work-related injury). The opinions are probative evidence in the matter, and the Board finds them persuasive. The Veteran is a layperson; consequently, his own opinion is not competent evidence in this matter. See Jandreau, supra. Significantly, he has not submitted a competent medical opinion that is based on an accurate underlying factual premise (regarding the period of service that was "in line of duty" and is for consideration. The preponderance of the evidence is against these claims; therefore, the appeal in these matters must be denied. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Schechner, 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.