Citation Nr: 21031406 Decision Date: 05/21/21 Archive Date: 05/21/21 DOCKET NO. 19-02 973A DATE: May 21, 2021 ORDER Service connection for posttraumatic stress disorder (PTSD) with major depressive disorder (MDD) is granted. Service connection for headaches is denied. Service connection for a gastrointestinal disability is denied. Service connection for a cervical spine disability is denied. Service connection for a lumbar spine disability is denied. Service connection for a left foot disability is denied. Service connection for a right knee disability is denied. Service connection for a left knee disability is denied. Service connection for a left lower extremity disability is denied. Service connection for right a right lower disability is denied. Service connection for right shin splints is denied. Service connection for left shin splints is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) as a result of service-connected disabilities is remanded. Entitlement to Dependents' Educational Assistance (DEA) benefits is remanded. FINDINGS OF FACT 1. The Veteran's PTSD and MDD, which clearly and unmistakably preexisted service, was aggravated beyond its natural progression by her military service. 2. The preponderance of the evidence is against finding that a headache disability began during active service or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that a gastrointestinal disability began during active service or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that a cervical spine disability began during active service or is otherwise related to an in-service injury or disease. 5. The preponderance of the evidence is against finding that a lumbar spine disability began during active service or is otherwise related to an in-service injury or disease. 6. The preponderance of the evidence is against finding that a left foot disability began during active service or is otherwise related to an in-service injury or disease. 7. The preponderance of the evidence is against finding that a right knee disability began during active service or is otherwise related to an in-service injury or disease. 8. The preponderance of the evidence is against finding that a left knee disability began during active service or is otherwise related to an in-service injury or disease. 9. The preponderance of the evidence is against finding that a disability of the left lower extremity began during active service or is otherwise related to an in-service injury or disease. 10. The preponderance of the evidence is against finding that a disability of the right lower extremity began during active service or is otherwise related to an in-service injury or disease. 11. The preponderance of the evidence is against finding that right shin splints began during active service or are otherwise related to an in-service injury or disease. 12. The preponderance of the evidence is against finding that left shin splints began during active service or are otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD with MDD on the basis of service aggravation are met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.306. 2. The criteria for service connection for headaches are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 3. The criteria for service connection for a gastrointestinal disability are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 4. The criteria for service connection for a cervical spine disability are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 5. The criteria for service connection for a lumbar spine disability are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 6. The criteria for service connection for a left foot disability are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 7. The criteria for service connection for a right knee disability are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 8. The criteria for service connection for a left knee disability are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 9. The criteria for service connection for a left lower extremity disability are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 10. The criteria for service connection for right lower extremity disability are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 11. The criteria for service connection for right shin splints are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. 12. The criteria for service connection for left shin splints are not met. 38 U.S.C. §§ 101, 1131, 5107; 38 C.F.R. §§ 3.6, 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1982 to September 1982. In a February 2017 rating decision, the issues on appeal were denied by a Department of Veterans Affairs (VA) Regional Office (RO). In October 2019, the Board of Veterans' Appeals (Board) remanded the issues for additional development. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. § 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In general, a Veteran is presumed to have been sound upon entry into active service, except as to conditions noted at the time of the acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b); Wagner v. Principi, 370 F.3d 1089 (Fed. Cir. 2004). A preexisting injury or disease will be considered to have been aggravated by active 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 is due to the natural progress of the disease. See 38 U.S.C. § 1153; 38 C.F.R. § 3.306. When there is approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Service connection for PTSD with MDD. The Veteran contends that service connection for her psychiatric disabilities is warranted as it is directly related to her military service. However, recent development conducted in connection with this claim and in compliance with the March 2019 remand, raises an alternate theory of service connection on the basis of service aggravation. Thus, the question also turns as to whether the Veteran's psychiatric disorder preexisted her military service and, if so, whether such psychiatric disorder was aggravated by her military service. Here, service treatment records (STRs) reflects that the Veteran was afforded an entrance medical examination in May 1982. At that time, she did not report a preexisting psychiatric disorder and the examination did not note any psychiatric symptoms. STRs are silent as to any treatment sought or received for a psychiatric disorder. Because a psychiatric disorder is not noted at service entrance, the Veteran is presumed sound. 38 U.S.C. § 1111; 38 C.F.R. § 3.304 (b); McKinney v. McDonald, 28 Vet. App. 15, 22-23 (2016); Wagner, 370 F.3d at 1096. Once the presumption of soundness applies, the burden of proof shifts to and remains with VA to prove both preexistence and aggravation by clear and unmistakable evidence. A "claimant need not produce any evidence of aggravation in order to prevail under the aggravation prong," even if clear and unmistakable evidence establishes that a disease preexisted service. In other words, the burden is not on the claimant to show that his/her disability increased in severity. To the contrary, the burden is on VA to "establish by clear and unmistakable evidence that [a preexisting disease] did not [increase in severity during service] or that any increase was due to the natural progress of the disease." This burden must be met by "affirmative evidence" demonstrating that there was no aggravation. The burden is not met by finding "that the record contains insufficient evidence of aggravation." Horn v. Shinseki, 25 Vet. App. 231 (2012). To that effect, in a private psychiatric disorder examination report received in February 2017, Dr. W.A.J., a clinical psychologist, diagnosed the Veteran with PTSD, Other Specified Depressive Disorder, and Generalized Anxiety Disorder. The Veteran reported that she was sexually abused as a young child by a close relative. The Veteran also explained that she had intrusive recollections and nightmares associated with that abuse prior to, during, and after her military service but that she never discussed those abuse episodes. She described preservice symptoms such as distrust on others, isolation, physical altercations, concentration problems and difficulties with sleep. The private examiner described these as "consistent with PTSD." The private examiner also noted that the Veteran's symptoms prior to service resulted from her history of sexual trauma exposure during her childhood. Thereafter, during a February 2020 VA psychiatric examination, the Veteran reported in detail how prior to her military service she was sexually abused as a young child without ever telling anyone, out of fear, until later in her adulthood. The VA examiner, a clinical psychologist, noted that although there was no record of mental health concerns and/or diagnoses and she was deemed to be of sound mind and fit for duty with no restrictions, based upon the evaluation, the Veteran's statements and the in-person examination conducted, it is likely that her PTSD and associated symptoms began as a child. In a subsequent September 2020 addendum opinion requested by the RO, the VA psychologist reiterated and reaffirmed that based on the examination and in-person interview conducted, the Veteran's PTSD and associated symptoms began as a child as a result of the sexual abuse experienced by a close relative during her childhood despite the fact that her May 1982 entrance medical examination did not show a diagnosis or a note to that extent. While the February 2020 VA examiner did not provide an aggravation opinion per se, the contents of the opinion and conclusion that a preexisting disorder was exacerbated by service in light of the Veteran's history and the in-person interview, clearly render her opinion as one of service aggravation. This is supported by the February 2017 private examiner who indicated that the symptoms the Veteran experienced during her childhood and prior to her military service are consistent with those of PTSD. Based on the medical judgment of the February 2017 private psychologist and the February 2020 VA examiner, both licensed clinical psychologists and competent mental health professionals, who not only provided an opinion in favor of a preexisting psychiatric disorder in their respective reports, but which conclusions were reiterated and reaffirmed by the September 2020 VA examiner's addendum opinion, the Board finds that it is clear and unmistakable that the Veteran's PTSD and associated symptoms preexisted service. Accordingly, the first prong of the presumption of soundness is rebutted. Accordingly, the next question for the Board is whether there is affirmative evidence to establish that the Veteran's preexisting psychiatric disorder clearly and unmistakably increased in severity, but not due to the natural progress of the disorder. In a February 2017 statement in support of claim, the Veteran indicated that her basic training experience was one of horror, harassment and sexual advances by the men in authority and by fellow basic trainees. The Veteran also indicated that she witnessed how her fellow bunk mate intended to commit suicide by slashing her wrists in the barracks' bathroom during basic training as a result of harassment and mistreatment. The Veteran indicated that she was ordered, along with other basic trainees, to clean the blood on the floor. In addition, the Veteran stated that in May 1982, she was sexually advanced by her Drill Sergeant when he "fondled" her breasts while apparently inspecting her uniform during formation. The Veteran noted that the incident left her frozen and that the Drill Sergeant used his position of authority to render her helpless since after the incident she was called individually to consent that "nothing had happened." Thereafter, the Veteran indicated that she was forced to wear a duffle bag over her head while standing in formation and that the incident was a humiliating one in front of her peers. Lastly, the Veteran asserts that in July 1982, while on Advanced Individual Training (AIT), while using the back stairs to go down to the barracks' recreation room she was blocked by two soldiers who had been apparently drinking; one of them jumping behind her, when a fellow female trainee opened the door, realized what was happening, and yelled them to the leave her alone. The Veteran submitted a February 2017 psychiatric evaluation from Dr. W.J.A. As previously noted, the psychologist noted that the Veteran's PTSD symptoms were present prior to, during, and after her military service. In addition, the private provider noted that while in basic training, the Veteran described that she was treated terribly by men with whom she served, that she was harassed and told all kind of sexual things which in turn made her feel helpless. The Veteran described how she experienced fellow soldiers trying to commit suicide. She further noted she did not feel safe going out at night and how she was "touched" during formation by her Drill Sergeant without her being able to do anything. The Veteran also reported an incident in which she was forced to wear a duffle bag on her head in front of others and how humiliating and degrading the incident was. The Veteran further noted additional difficulties during AIT. In conclusion, the private psychologist stated that the Veteran, as likely as not, met the criteria for PTSD secondary to the sexual abuse experienced during her childhood. That symptomatology, more likely than not, intensified in reaction after her exposure to sexual harassment while she was in the Army Reserve. The Veteran was afforded a VA examination in February 2020. The examination report contains diagnoses of PTSD and major depressive disorder (MDD). The Veteran reported that she struggled through basic training as there were men who did not want her to be there, that she was called derogatory names and was rubbed up against. She stated that this triggered early childhood trauma given the inability to tell anyone about the inappropriate behavior. The Veteran indicated that she opted to get through with it in order to get out of the situation. With respect to the Veteran's PTSD, the VA examiner opined that the claimed condition was at least as likely as not incurred in or caused by the claimed in-service event by noting that the Veteran was a victim of sexual abuse as a young child and that the continued sexual harassments in the military would have exacerbated these symptoms beyond their typical progression as she was victimized again on several occasions. The examination report reflects that although the Veteran never drank alcohol before basic training, she began doing so after the sexual harassments/assaults and as a result, got in trouble for coming late to formation. In sum, the examiner opined that her preexisting PTSD was at least as likely as not affected beyond its normal progression as a result of the in-service assaults. With respect to her MDD, the examiner noted that the Veteran has a diagnosis of depression that has led to increased suicidal ideations, anhedonia, and social isolation. She further made reference to the February 2017 Personality Testing conducted by Dr. W.J.A., which noted that individuals with a similar profile are experiencing significant emotional distress and are prone to feeling negative emotions more intensely than other people. They are quite anxious, fearful, and uneasy, and endorse being tense and restless and having sleep disturbances. They also have many symptoms of depression, including a loss of interest in daily activities, anhedonia, and feelings of sadness, hopelessness, and guilt. Such individuals are overwhelmed, and they lack the energy and coping skills necessary to help them deal effectively with their concerns and life demands. Their somatic complaints are likely to increase as their stress level rises. In sum, the examiner concluded that in addition, it is at least as likely as not that the depression is the result of the in-service events and assaults. In a September 2020 addendum opinion, the VA examiner reiterated that the Veteran's PTSD is at least as likely as not affected beyond its normal progression not only as a result of the in-service sexual advances experienced, but also due to the report that she had to assist in cleaning up the blood after a fellow soldier attempted suicide during basic training, which qualifies as a traumatic event as well. The examiner again reaffirmed that the continued sexual assaults in the military would have exacerbated the symptoms beyond their typical progression as she was victimized again on several occasions. As to the second prong of the presumption of soundness, the February 2017 private psychologist opinion and both opinions issued by the same VA psychologist in February and September 2020, show that the Veteran's psychiatric disorder was aggravated, not only by the Veteran's predisposition given her childhood sexual trauma and the exacerbation caused by the sexual advances experienced during basic training, but also for the incident in which the Veteran experienced the suicide attempt of a fellow soldier. Moreover, there is no medical evidence to the contrary. The Board finds the Veteran's statements credible supporting evidence as to the in-service events that exacerbated her preexisting psychiatric disorders, particularly after two separate mental health professionals have indicated that in fact, these events occurred. See 38 C.F.R. § 3.304(5). Therefore, VA's burden has not been met and the second prong of the presumption of soundness is not rebutted as there is not clear and unmistakable evidence that the preexisting psychiatric disorder was not aggravated by service. See Wagner, 370 F.3d at 1089; Horn, 25 Vet. App. at 231. As the presumption of soundness is not rebutted, the provisions set forth in 38 C.F.R. § 3.306 have the effect of the preexisting psychiatric disorder being considered as aggravated by active service. This is particularly so when, as noted by the February 2020 VA examiner, the in-service events reported by the Veteran not only triggered and exacerbated her preexisting PTSD symptoms but also appear to have established the onset of her depression. Accordingly, service connection for PTSD with MDD is warranted. 2. Service connection for headaches. The Veteran contends that service connection for headaches, also claimed as cephalgia, is warranted as it is related to her military service. A May 1982 entrance medical examination does not contain any notations for headaches. STRs do not account for treatment, reports or complaints of neck, cervical injuries, or headaches during the Veteran's short period of ACDUTRA. The Veteran has not asserted that she sought treatment for headaches during service. Post-service private treatment records from Dr. A.P.K., gastroenterologist, dated from November 2004 to August 2012; from Dr. N.M.B., podiatrist, dated from April 2016 to January 2020; from Arthritis & Rheumatology Associates of Treasure Coast dated from February 2016 to October 2017; and from Dr. D.C., neurologist, dated from December 2014 to February 2020, do not account for treatment sought or received, complaints or reports of headaches. However, private treatment records from Dr. G.G., the Veteran's private endocrinologist, which are dated from July 2016 to February 2020, reflect three recent and isolated episodes in which the Veteran reported headaches (i.e. see March 2017; June 2017; and November 2017 progress notes). Nevertheless, these appear to be related to nonservice-connected goiter and diabetes mellitus and associated uncontrolled glucose levels without any mention or association to the Veteran's military service. Thereafter, the Veteran has expressly denied headaches. See March 2018; April 2019; and October 2019 progress notes. In a statement received in September 2016, the Veteran's chiropractor, Dr. P.J.Y, indicated that per the Veteran's report, she fell in a fox hole during basic training at Fort Jackson causing injury to her lower extremities, neck and low back. The provider noted that ever since the injury to the cervical and cervicothoracic regions the Veteran has suffered from progressive cephalgia. The private provider determined that the Veteran's headaches/cephalgia are secondary to her cervical spondylosis and opined that it is more likely than not that the aforementioned is directly and causally related to the cervical injury. In light of the foregoing, in March 2019 the Board remanded the present claim to afford the Veteran a VA examination and opinion pursuant to McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). A February 2020 VA examination report in connection with this claim reflects that there is no diagnosis of neither headaches nor cephalgia. The examiner noted that not only the Veteran does not complain of cephalgia, but that the medical evidence of record is negative for such diagnosis. In addition, the VA examiner determined that the Veteran does not suffer headaches that are attributable to any conditions affecting cranial nerves. While there is some evidence suggesting the presence of sporadic headaches (i.e. see March 2017; June 2017; and November 2017 progress notes from Dr. G.G.), the additional evidence of record fails to establish the occurrence of an in-service event, disease, or injury, and it follows that the nexus element of the claim is not established. Although the September 2016 private provider indicated that the Veteran's headaches are directly and causally related to her in-service cervical spine injury, STRs do not account for an event or injury involving the neck or the cervical spine. Moreover, there is no indication that the September 2016 chiropractor reviewed the Veteran's STRs or any prior medical evidence to provide his opinion. A bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). The probative medical evidence of record shows that the Veteran's headaches were first noted in 2017 by her private endocrinologist. That is approximately 35 years after her release from active duty service. Furthermore, the Veteran's isolated episodes of headaches appear to be associated to other nonservice-connected disabilities such as goiter and/or diabetes mellitus and associated uncontrolled glucose levels. Merely making a claim is insufficient to indicate a nexus to service. See Waters v. Shinseki, 601 F.3d 1274, 1278 (Fed. Cir. 2010). The Board accords more probative value to the February 2020 VA examiner's opinion who, after reviewing the Veteran's STRs, medical record, history, and the Veteran's own statements, determined that there is no evidence of an in-service event and that the Veteran does not have the claimed disability. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and service connection for headaches is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. Service connection for a gastrointestinal disability. The Veteran contends that service connection for a gastrointestinal disability is warranted, as it is the result of her military service. The Board notes that the Veteran has a current diagnosis of gastroesophageal reflux disease (GERD) that was established in January 2019. See February 2020 VA examination report. As such, the current disability element of the claim has been established. In a September 2016 medical statement, the Veteran's private chiropractor indicated that the Veteran has a military medical history of treatment for GERD and was prescribed medications for this during service. The private provider further noted that there is documented evidence of the onset of this condition during service, and that the condition persists to this day. A review of the Veteran's STRs, however, do not account for treatment, complaints, or reports of gastrointestinal disorders, to include the prescription of medicine for GERD during service. Private treatment records dated from November 2004 to August 2012 from the Veteran's private gastroenterologist, Dr. A.P.K., reflect that the Veteran began to receive treatment for gastrointestinal disorders in November 2004. To that effect, Dr. A.P.K. indicated that the Veteran has been under his treatment for some lose bowel movement and that a "recent colonoscopy" revealed some evidence of distal colitis. The provider further noted that he had a discussion with the Veteran about the natural history of ulcerative colitis and its risks. See December 9, 2004 progress notes. Thereafter, additional diagnoses such as antral ulcers, gastric ulcers and epigastric pain were provided. See August 2005; December 2005; and August 2012 progress notes. The Veteran was afforded a VA examination in February 2020. The VA examiner noted that upon review of the Veteran's STRs, there is no evidence for stomach complaints or conditions at entrance nor during her period of active duty. The examiner opined that based on the in-person interview conducted and review of the Veteran's claims file, the claimed condition is less likely than not incurred in or caused by the Veteran's military service as the Veteran's STRs are silent for any gastrointestinal conditions or symptoms. With respect to this claim, the evidence of record again fails to establish the occurrence of an in-service event or disease during the Veteran's period of active duty. Therefore, it follows that the nexus element of the claim is not established. Although the September 2016 private provider indicated that the Veteran's GERD is related to her military service and that there is documented evidence of the onset of the condition, STRs do not account for complaints, treatment sought or received for a gastrointestinal disorder. Moreover, there is no indication that the September 2016 chiropractor reviewed the Veteran's STRs or any prior medical evidence to provide his opinion. As previously noted, a bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller, 11 Vet. App. at 345, 348. The probative medical evidence of record shows that the Veteran's gastrointestinal disorders were first documented in 2004 by her private gastroenterologist. That is approximately 22 years after her release from active duty service. Merely making a claim is insufficient to indicate a nexus to service. See Waters, 601 F.3d 1274, 1278. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and service connection for a gastrointestinal disability is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 4. Service connection for cervical spine disability. 5. Service connection for a lumbar spine disability. The Veteran asserts that her cervical and lumbar spine disabilities are related to her military service. In support of her claim, the Veteran submitted a private medical opinion from her chiropractor, Dr. P.J.Y., indicating that "she fell in a fox hole during basic training at Fort Jackson and suffered injuries to her neck and low back." Initially, the Board notes that the Veteran has current diagnoses of degenerative arthritis of the cervical and the lumbar spine with intervertebral disc syndrome (IVDS). See February 2020 VA examinations. As such, the current disability element of both claims has been established. The next question for the Board is whether there is an in-service event involving the cervical, thoracic or lumbar spine and, if so, whether there is a nexus between the current disabilities and the alleged in-service event. As to the in-service element of the claims, STRs do not account for a fall during basic training and/or AIT, or for any treatment, complaints, or reports of cervical, neck, or lumbar spine pain or injury during service. Post-service treatment records reflect that during a September 2016 follow up appointment to review a recent Lumbar Spine MRI study, the Veteran denied any history of an injury, to include work-related. See September 26, 2016 progress notes from Dr. D.A.C. The Veteran neither attributed any of her spine disabilities to her military service. Social Security Administration (SSA) records associated with the claims file reflect that it was during a July 2016 MRI that the Veteran was diagnosed with bulging discs at the L5-S1 level traversing the S1 nerve root. Thereafter, April 2017 x-rays revealed her chronic cervical and lumbar spine chronic degenerative changes. As to the lumbar spine disability, in the private opinion received in September 2016, the Veteran's chiropractor indicated that her current degenerative joint disease and osteoarthritis of the lumbar and cervical spine is the residual of her traumatic in-service event and therefore, it is more likely than not that her lumbar and cervical spine disabilities are directly and casually related to her military service, specifically to the in-service injury described above. The Veteran was afforded a VA examination for her lumbar spine disability in February 2020. Contrary to the etiology indicated by her chiropractor, she reported that she injured her back while in the military "due to carrying heavy gear." She indicated that she continued to experience back pain ever since. The examiner noted that an MRI conducted in 2015 revealed bulging discs of the lumbar spine. Upon review of the Veteran's medical history, her claims file and the Veteran's lay statements, the VA examiner opined that the claimed lumbar spine disability was less likely than not incurred in or caused by the Veteran's military service. The examiner noted that STRs are silent for any back conditions or diagnoses related to the back. It was further noted that although there is objective evidence from the Veteran's chiropractor received in 2016 indicating that the Veteran's back pain is related to a fall in fox hole while on active duty, there is no objective evidence to support such statement. In conclusion, the VA examiner reiterated that the Veteran's lumbar spine disability is less likely than not incurred in or caused by her military service. With respect to the cervical spine disability, a VA examination was afforded in February 2020 as well. The Veteran reported that she began experiencing neck pain in 2012-2013, which has worsened over time. Upon review of the Veteran's medical history, her claims file and the Veteran's lay statements, the VA examiner opined that the claimed disability was less likely than not incurred in or caused by her military service. The examiner indicated that STRs are silent for any neck conditions or diagnoses related to the neck. She noted that while there is objective evidence from the Veteran's chiropractor received in 2016, indicating that the Veteran's neck pain is related to a fall in a fox hole while on active duty, there is no objective evidence to support such statements. In sum, the examiner reaffirmed that the claimed neck disability is less likely than not incurred in or caused by the Veteran's military service. The Board has considered the evidence of record and finds that two fundamental elements for entitlement to service connection for a lumbar and cervical spine disabilities are not met. As to the lumbar spine disability, the 2016 private chiropractor's opinion attributes her disability to a fall in a fox hole during active duty. However, during her February 2020 VA examination, the Veteran attributed it to "carrying heavy gear" during basic training. Regardless of both theories, STRs do not account for an injury, fall, or any treatment for the back or neck during service. Moreover, the probative medical evidence of record shows that the Veteran was not diagnosed with a lumbar spine disability until 2016, and for her cervical spine until 2017, which for both conditions is well over 34 years following separation from service. Furthermore, the Veteran herself not only denied an injury during her 2016 lumbar spine MRI review, but also indicated that the onset of her neck pain began in 2012 and progressively worsened thereafter. As such, the evidence is against an in-service event and accordingly, a nexus cannot be established. The Board accords more probative value to the February 2020 VA examiner's nexus opinions as they were issued by considering the particular circumstances of the case and based on a thorough review of the record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-03 (2008). As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not applicable, and service connection for a lumbar spine disability and a cervical spine disability are not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 6. Service connection for a left foot disability. The Veteran contends that service connection for a left foot disability is warranted as it is directly related to her military service. In support of her claim, in September 2016 the Veteran submitted a private opinion from her chiropractor indicating that while training at Fort Dix during her AIT, she sustained an injury to the plantar surface of the left foot for which she was treated with medications. The Veteran has current diagnoses of left foot plantar fasciitis, achilles tendinopathy, arthritis, and plantar calcaneal enthesotypes. See February 2020 VA examination; August 2018 and July 2019 progress notes from Dr. N.B. As such, the current disability element of the claim has been established. As to the in-service element of the claim, STRs do not account for an in-service injury of the left foot. STRs are also silent for complaints, reports, or treatment sought or received for a left foot disability. Post-service treatment records from Dr. N.B., podiatrist, dated from April 2016 to February 2020 reflect that the Veteran was initially assessed for bilateral foot disabilities in 2016. The Veteran was referred by her neurologist, to include as part of her preventive care for documented neurological symptoms associated to her diabetes mellitus type II. Treatment records from Arthritis & Rheumatology Associates of Treasure Coast reflect that in February 2016, the Veteran reported seeing her private podiatrist for follow up of a tear of the achilles tendon of the left foot and for which the Veteran was wearing a boot. Thereafter, the Veteran continued to receive treatment for left foot pain. See August 2018 progress notes from Dr. N.B. (pain in left ankle and joints of left foot). The Veteran was afforded a VA examination in connection with the present claim in February 2020. She reported that the onset of her left foot disability began during active service and that it has worsened over time. The Veteran did not specify a particular in-service event or injury. She further noted that she is under care by a podiatrist and is seen every three months. Upon review of the Veteran's claims file, the in-person interview and consideration of the Veteran's lay statements, the VA examiner opined that the claimed disability was less likely than not incurred in or caused by the Veteran's military service. In support of her opinion, the examiner indicated that first, while STRs show some evidence of right foot pain during service, there is no evidence for symptoms or diagnoses of the left foot. In addition, the examiner stated that the Veteran's x-ray of the left foot dated January 2020 shows degenerative arthritis of the foot and calcaneal spurs, which is a diagnosis made 37 years post-separation. In support of the foregoing, the examiner cited to the American Academy of Orthopedic Surgeons which states that "osteoarthritis, also known as degenerative or "wear-and-tear" arthritis, is a common problem for many people after they reach middle age. In osteoarthritis, the cartilage in the joint gradually wears away. As the cartilage wears away, it becomes frayed and rough, and the protective space between the bones decreases. This can result in bone rubbing on bone and produce painful bone spurs. In addition to age, the examiner noted that other risk factors for osteoarthritis include obesity and that in the present case, the Veteran is both middle aged and obese. In sum, the examiner concluded that the Veteran's left foot plantar fasciitis, left foot degenerative arthritis with calcaneal spurs is less likely than not incurred in or caused by or related to the Veteran's period of service. A separate VA opinion was obtained in January 2021. Upon review of the Veteran's medical record and claims file, a separate VA examiner also opined that the claimed condition was less likely than not incurred in or caused by the Veteran's military service as STRs show no evidence of a diagnosis, treatment or symptoms suggestive of left foot condition while on active duty or within one year of separation from military service. Here, the evidence of record fails to establish the occurrence of an in-service event to which attribute the Veteran's left foot disability. It follows that the nexus element of the claim is not established. Although the September 2016 private chiropractor indicated that the Veteran's left foot plantar surface condition is related to her military service and that there is documented evidence of the treatment and medication prescribed for the injury, such opinion appears to have been based on inaccurate information. STRs reflect otherwise as they do not account for complaints, reports, or treatment sought or received for a left foot disability at any time during service. Moreover, there is no indication that the September 2016 chiropractor reviewed the Veteran's STRs to provide his opinion. As previously noted, a bare conclusion, even one reached by a medical professional, is not probative without a factual predicate in the record. Miller, 11 Vet. App. 345, 348. The probative medical evidence of record shows that the Veteran's left foot condition was first documented in 2016 by her private podiatrist following an injury to the Achilles Tendon. That is 34 years after her release from active duty service. Merely making a claim is insufficient to indicate a nexus to service. See Waters, 601 F.3d 1274, 1278. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and service connection for a left foot condition is not warranted. See 38 U.S.C. § § 5107(b); 38 C.F.R. § § 3.102. 7. Service connection for a right knee disability. 8. Service connection for a left knee disability. 9. Service connection for a left lower extremity disability. 10. Service connection for a right lower extremity disability. 11. Service connection for right shin splints. 12. Service connection for left shin splints. The Veteran claims service connection for bilateral knee disabilities, bilateral lower extremity disabilities, and bilateral shin splints. The Board notes that the Veteran has current diagnoses of bilateral knee osteoarthritis, bilateral shin splints, and bilateral radiculopathy and peripheral neuropathy of the lower extremities. See February 2020 VA examinations. Thus, the current disability element of all claims is established. In support of her claim, in September 2016 the veteran submitted a private opinion from her chiropractor attributing all of the claimed lower extremities' disabilities to an alleged in-service fall in a fox hole during basic training. Nevertheless, and as previously noted, STRs do not account for such in-service event. In fact, STRs do not reflect treatment sought or received for knee injuries, bilateral lower extremity injuries (other than right foot pain), or shin splints injuries during service. Post-service treatment records show that the Veteran was diagnosed with fibromyalgia in February 2016. See February 21, 2016 Arthritis and Rheumatology Associates progress notes. The record also shows that the Veteran began to recently experience left thigh pain. Id. Thereafter, she began to present neurological symptoms associated to her diabetes mellitus. See April 11, 2016 progress notes from Dr. N.H. (significant history of diabetes, high cholesterol and neuropathy of both legs and feet with numbness); see also June 21, 2016 progress notes from Dr. D.C. (diabetes mellitus type II with diabetic neuropathy); and October 21, 2019 progress notes from Dr. G.G. (type II diabetes mellitus with diabetic polyneuropathy). In August 2018, her private provider documented multiple joint pain and that the Veteran denied any trauma. See August 30, 2018 Arthritis and Rheumatology Associates progress notes. With respect to the Veteran's knees, private treatment records are limited to indicate that the Veteran underwent an arthroscopy of the left knee in 2012, and that there is a diagnosis of bilateral knee osteoarthritis. The foregoing private medical evidence does not indicate nor suggest an in-service injury or event. The Veteran was afforded multiple VA examinations in connection with these claims. With respect to the bilateral knee disability claims, during her February 2020 VA examination the Veteran reported she began to experience right knee pain during service and that her left knee pain gradually worsened over time as a result of her right knee. Again, she did not specify a particular in-service event or injury. She noted that her condition continued to worsen over time until a left knee arthroscopy was performed in 2012. The VA examiner indicated that a review of the Veteran's STRs show no evidence for any symptoms of any knee conditions or complaints during active duty. The examiner opined that the claimed bilateral knee condition was less likely than not incurred on or caused by her military service. In support of her opinion, the VA examiner stated that upon review of the entire record, not only are STRs silent for any complaints of right knee symptoms or diagnoses during service, but that the National Institute of Health (NIH) states that osteoarthritis is the most common form of arthritis among older people, and it is one of the most frequent causes of physical disability among older adults. The disease affects both men and women and that after age 45, osteoarthritis is more common in women. In sum, the examiner concluded that the Veteran's degenerative arthritis of both knees shown by the x-rays performed in January 2020, is a diagnosis established 37 years post service, age being one of the contributing factors. Accordingly, she concluded that the Veteran's degenerative arthritis of the knees is less likely than not incurred in or caused by the Veteran's period of active service. A second VA opinion with respect to the knee claims was obtained in January 2021. Upon review of the Veteran's medical record and claims file, the VA examiner also opined that the claimed condition was less likely than not incurred in or caused by the Veteran's military service as STRs show no evidence of a diagnosis, treatment or symptoms suggestive of left or right knee condition while on active duty or within one year of separation from military service. With respect to the bilateral lower extremities' disabilities and bilateral shin splints condition, the Veteran was also afforded a VA examination February 2020. As to these claims, the VA examiner opined that the Veteran's STRs are silent for any complaints of the right or left lower extremities. She noted that while the VA exam revealed a positive diagnosis for bilateral peripheral neuropathy and radiculopathy of the lower extremities and bilateral shin splints, the private treatment records "brought in" by the Veteran to the examination reflects treatment for diabetes mellitus, which is a cause for peripheral neuropathy. The VA examiner made reference to the September 2016 evaluation from her private chiropractor which reports a post traumatic peripheral neuropathy secondary to a fall in a fox hole while on active duty and that this fall caused injury to bilateral extremities for which she received medical attention and was placed on light duty. However, the examiner stated that this "reported information was not found in the Veteran's e-folder" and, therefore, it is her opinion that the Veteran's conditions of bilateral lower extremities is less likely than not incurred in or caused by or related to the Veteran's period of service. Specifically with respect to the bilateral shin splints, in a separate February 2020 VA opinion the examiner clearly stated that STRs are also silent for any complaints of shin splints or any diagnosis of shin splints and while the Veteran's evaluation by her private chiropractor in September 2016 states that the shin splints condition started and was treated while on active duty, there is no objective evidence to support this report. The examiner noted that indeed, the Veteran's exam is positive for shin splints, however, this diagnosis is 37 years post service and not related to any condition or diagnosis rendered while on active duty. In conclusion, the examiner opined that the Veteran's left shin splints is less likely than not incurred in or caused by her military service. The Board has considered the evidence of record and finds that such evidence, again, fails to establish the occurrence of an in-service event or disease. Accordingly, the nexus element of the claims is neither established. With respect to the Veteran's bilateral lower extremities, the more probative evidence before the Board suggests that the Veteran's peripheral neuropathy and radiculopathy is associated to her nonservice-connected diabetes mellitus without any association to her military service. This is supported by private treatment records indicating that while her diabetes mellitus appears to be controlled, there is documented neurological symptoms associated to that disability, to include neuropathy of both legs and feet with numbness and diabetic polyneuropathy. As for the bilateral lower extremities' radiculopathy, the February 2020 VA examination determined that it is associated to the Veteran's lumbar spine disability, which the Board has previously determined that is not linked to service. As for the bilateral knee disability, not only STRs are silent for any treatment or complaint during service, but the medical evidence of record documents that treatment for such disability began in 2012, which is 30 years following service. Ultimately, with respect to the claimed bilateral shin splints, the more probative evidence of record shows that the disability was first documented by the Veteran's private chiropractor in 2016. That is 34 years following service. Moreover, the private medical evidence received in support of this claim do not account for any treatment received for such disability. Moreover, while the Veteran has indicated that the onset of her lower extremities, knees, and shin splints disabilities began during active service, she has denied to her private medical providers any trauma to which attribute the lower extremities disabilities for which care has been sought. As previously stated, merely making a claim is insufficient to indicate a nexus to service. See Waters, 601 F.3d 1274. The Board accords more probative value to the February 2020 VA examiner's nexus opinions as they were issued by considering the particular circumstances of the case and based on the Veteran's statements and a thorough review of the record. See Nieves-Rodriguez, 22 Vet. App. 295, 302-03. As the preponderance of the evidence is against the claims, the benefit of the doubt doctrine is not applicable, and service connection for bilateral lower extremities disability, a bilateral knee disability, and a bilateral shin splints disability are not warranted. See 38 U.S.C. § § 5107(b); 38 C.F.R. § § 3.102. REASONS FOR REMAND Entitlement to a TDIU. Entitlement to DEA benefits. In her September 2016 VA 21-526EZ, Fully Developed Claim, the Veteran claimed "individual unemployability." Per this Board decision, service connection has been granted for PTSD with MDD which will be rated by the Agency of Original Jurisdiction. In light of the grant of service connection for PTSD with MDD, the Veteran's claim for a TDIU and DEA benefits should be developed and readjudicated. The matters are REMANDED for the following action: Develop and readjudicate the claim for a TDIU and DEA benefits in light of the grant of service connection for PTSD with MDD. M.W. Kreindler Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board William Pagan 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.