Citation Nr: 22001237 Decision Date: 01/10/22 Archive Date: 01/10/22 DOCKET NO. 16-01 318 DATE: January 10, 2022 ORDER Entitlement to service connection for a lumbar spine disability, to include as due to a service-connected disability, is denied. Entitlement to service connection for chronic headaches, to include as due to a service-connected disability, is granted. Entitlement to an increased rating in excess of 50 percent for bilateral pes planus, with degenerative disease and callouses, is denied. REMANDED Entitlement to service connection for a heart disability, to include as due to a service-connected disability, is remanded. Entitlement to service connection for neuropathy, to include as due to a service-connected disability is remanded. FINDINGS OF FACT 1. A lumbar spine disability was not manifested during active service or for many years thereafter. The Veteran's intervertebral disc syndrome (IVDS), spinal stenosis and lumbar herniated discs has not been shown to have originated during active service or to be caused by an incident of service or a service-connected disability. 2. The Veteran's tension headaches are related to his service-connected posttraumatic stress disorder (PTSD). 3. The Veteran's bilateral pes planus is manifested by marked pronation of the feet, that is not improved by orthopedic shoes or appliances. CONCLUSIONS OF LAW 1. The criteria for service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310(a). 2. The criteria for service connection for headaches have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310(a). 3. The criteria for an increased rating in excess of 50 percent for bilateral pes planus have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.40, 4.59, 4.71a, Diagnostic Code (DC) 5276. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from February 1972 to December 1973. SERVICE CONNECTION CLAIMS Service connection may be granted for chronic disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disability has aggravated a nonservice connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Entitlement to service connection for a lumbar spine disability The Veteran contends that service connection is warranted for a lumbar spine disability, to include as due to his service-connected bilateral foot disability. The Veteran contends that his current low back disability is related to service. The Veteran reports ongoing low back pain in-service and that his back pain has worsened over the years. The Veteran reports undergoing steroid injections in 2010 after his low back pain worsened. The Veteran reports flare ups of his low back with stabbing and shooting pain and tingling and numbness to his bilateral lower extremities. The question for the Board is whether the Veteran has a current lumbar spine disability that began during service or is at least as likely as not caused by an in-service injury or disease; or is caused or aggravated by a service-connected disability. The Veteran has a diagnosis of IVDS, spinal stenosis and lumbar herniated discs. The Veteran's service treatment records (STRs) have been associated with the claims file. STRs do not refer to any low back disability. At separation in November 1973 on the report of medical examination clinical evaluation of the spine, musculoskeletal system and lower extremities was normal. Private treatment records note in September 1996 a normal evaluation of the musculoskeletal system with no dysfunction or problems of the back or sacral spine area. February 2011 VA treatment records note chronic low back pain due to the rupture of three lumbar discs. July 2013 private treatment records note the Veteran received lumbar spine injections which improved his low back pain. VA treatment records note pain, numbness and tingling in the Veteran's back and legs. The Veteran was afforded a VA back examination in September 2020. The VA examiner noted IVDS, spinal stenosis and lumbar herniated discs. Functional loss or functional impairment of the low back was noted with prolonged walking/standing, and no lifting/carrying greater than 25 pounds. Range of motion testing noted forward flexion to 25 degrees, extension to 10 degrees, right and left lateral flexion to 20 degrees, and right and left lateral rotation to 20 degrees, with pain. Evidence of pain on weight bearing was noted. Pain, weakness, fatigue and lack of endurance limited functional ability with repeated use over time. No muscle spasms or guarding were noted. Muscle strength testing was 5/5, with no muscle atrophy. A June 2018 magnetic resonance imaging (MRI) noted bilateral compressive neural foraminal, central canal and bilateral lateral recess stenosis at L4-5 due to broad based disc protrusion and superimposed tiny subligamentous herniated nucleus pulposus that could account for asymmetric and or symmetric radiculopathy. Bilateral neural foraminal stenosis at L5-S1 was noted which should also contribute to the Veteran's low back pain or radicular pain. The Veteran's back condition impacts his ability to work in that he has functional loss with no prolonged, walking, standing, sitting and carrying greater than 25 pounds, and needs to change positions every 20 minutes. The VA examiner found that it is less likely than not that the Veteran's low back disability was incurred in or caused by the claim in-service injury, event or illness. The examiner noted no evidence in the Veteran's STRs of any symptomology pertaining to a lumbar spine condition. The VA examiner found that as to secondary service connection, it is less likely than not that the Veteran's current lumbar spine disability is proximately due to or the result of his service-connected right/left foot pes planus. The examiner noted that the Veteran's low back pain started in 2010, and that pes planus does not cause lumbar disc herniation with stenosis, lumbar IVDS, and lumbar radiculopathy. A review of the medical literature found no connection between lumbar disc herniation with stenosis, lumbar IVDS, and lumbar radiculopathy secondary to a mild pes planus condition. Rather the examiner found that the Veteran's chronic low back pain and condition can be attributed to him being overweight. Treatment records from 2010 to 2019 note a body mass index (BMI) of over 40. In addition, the examiner found that the Veteran's lumbar spine disability was less likely than not aggravated, beyond its natural progression, by the Veteran's service-connected right and left foot pes planus. The examiner noted a worsening of the Veteran's low back symptomology, and that it was the Veteran's obesity since 2010, which is a strong contributory factor to and aggravation of his lumbar spine condition with a BMI over 40. VA and private treatment records have been associated with the claims file. These treatment records do not contradict the VA examination and are absent indications between the Veteran's current lumbar spine disability and in-service disease or injury or caused or aggravation by a service-connected disability. After consideration of all the evidence of record the Board finds that the weight of the evidence is against finding that service connection for a lumbar spine disability is warranted. The Board concludes that service connection for a lumbar spine disability on a direct basis is not warranted as the Veteran's current lumbar spine disability was not caused by service. The Veteran's lay statements regarding his current symptoms, in-service events, and ongoing symptomology are credible. However, while the Veteran reports that his current low back disability is related to service, and a service-connected disability, the record does not reflect that he has the requisite training or expertise to offer a medical opinion linking a current disability to service and as such the Veteran is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the medical evidence is more probative and credible than the lay opinions of record. The competent medical evidence including the September 2020 VA examination is entitled to significant probative weight. The September 2020 VA examiner noted that the Veteran's low back has been caused and aggravated by his obesity and BMI over 40 as noted in VA treatment records from 2010 to 2019. The examiner found that it is less likely than not that the Veteran's lumbar spine disability was incurred in or was caused by service. However, even in consideration of the Veteran's and associated lay statements, the examiner found that it is less likely than not that the Veteran's lumbar spine disability was incurred in or was caused by service. The Board finds that direct service connection is not warranted as the Veteran's lumbar spine disability was not onset in or caused by service. The Board has considered the Veteran's and associated lay statements however, the Board gives more probative weight to the competent medical evidence especially the September 2020 VA examination. As such the Board finds the Veteran's current lumbar spine disability is less likely than not related to active service. As to secondary service connection, the Veteran is currently service-connected for bilateral pes planus with degenerative disease and callouses rated as 50 percent disabling. The Veteran contends that his current lumbar spine disability is due to his service-connected bilateral pes planus. As noted above, the Board finds the September 2020 VA examination is entitled to significant probative weight. As to secondary service connection the September 2020 VA examiner found it is less likely than not that his current lumbar spine disability is proximately due to or the result of his service-connected right/left foot pes planus. The examiner noted that the Veteran's low back pain started in 2010, and mild pes planus does not cause lumbar disc herniation with stenosis and lumbar IVDS. Rather the examiner found that the Veteran's chronic low back pain and condition can be attributed to him being overweight. In addition, the examiner found that the Veteran's lumbar spine disability was less likely than not aggravated, beyond its natural progression, by the Veteran's service-connected right and left foot pes planus. Rather, it was the Veteran's obesity since 2010, which is a strong contributory factor to aggravation of his lumbar spine condition with a BMI over 40. As such secondary service connection is not warranted for the Veteran's lumbar spine disability. In conclusion, the Board finds that the Veteran's lumbar spine disability was not manifested during active service or for many years thereafter. Further, the Board finds his low back disability is not related to either active service or the Veteran's service-connected bilateral pes planus. The Board has considered the applicability of the benefit of the doubt doctrine. Because the evidence is not in approximate balance or nearly equal, the benefit of the doubt doctrine does not apply. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57(1990). Accordingly, the Board finds that service connection for a lumbar spine disability is not warranted. Therefore, the claim is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Entitlement to service connection for chronic headaches The Veteran contends that service connection is warranted for headaches, to include as due to his service-connected PTSD and/or his service-connected traumatic brain injury (TBI). The Veteran's STRs do not refer to a headache disability. At separation in November 1973 on the report of medical examination clinical evaluation of the head and neurologic system was normal. A January 2015 private opinion from M.M., M.D., has been associated with the claims file. The physician noted that the Veteran experiences near constant headaches which is attributed to his in-service TBI. The opinion found that the Veteran's chronic headaches are more likely than not caused by his TBI. April 2012 private treatment records from K.P., M.D., note that the Veteran's headaches are related to his diagnosis of obstructive sleep apnea and hypertension that is not well controlled. The Veteran was afforded a VA headaches examination in September 2020. The Veteran reported recurrent tension headaches daily, with no photophobia or phonophobia, pulsating or throbbing head pain, and pain on both sides of his head. The Veteran reports these began in 2000, and he takes Tylenol as needed. The examiner noted that the Veteran's headache condition does not impact his ability to work. The VA examiner found that it is less likely than not that the Veteran's tension headaches are proximately due to or the result of his service-connected TBI. The VA examiner noted that he "cannot ascertain that the Veteran's PTSD is the sole condition contributing to the Veteran's tension type headaches." The examiner noted that the Veteran also has hypertension and obstructive sleep apnea which could very well be a contributing cause of his tension headaches. The Veteran reports often developing headaches when his blood pressure is elevated. The VA examiner noted a review of the medical literature relating to hypertension and headaches, obstructive sleep apnea and headaches, and PTSD and headaches. Noting that literature from January 2020, The Link Between PTSD and Headaches suggests that a connection between PTSD and headaches makes sense, and while it is not entirely clear why people with PTSD may be more likely to experience increased problems with headaches and stress such has been linked to the occurrence of headaches. The literature suggests that symptoms of PTSD can contribute to very high levels of stress and emotional strain, and the impact PTSD has on a person's life including work and relationships likely causes more stress increasing the likelihood of headaches. Further, traumatic events may also increase the likelihood of headaches including following a TBI. Further, as to aggravation, the examiner noted that the Veteran's tension headaches were less likely than not aggravated beyond its natural progression by the Veteran's TBI. The examiner did not directly address aggravation relating to the Veteran's PTSD. A March 2021 VA supplemental opinion found that the Veteran's claimed chronic headaches are less likely than not proximately due to or the result of the Veteran's TBI. The examiner noted that the Veteran's hypertension and obstructive sleep apnea could very well be the cause of his chronic type tension headaches. The Veteran has been diagnosed with tension headaches. The September 2020 VA examiner noted that he "cannot ascertain that the Veteran's PTSD is the sole condition contributing to the Veteran's tension type headaches." The VA examiner concluded that the Veteran's current PTSD is in part contributing to his headaches and that his PTSD and headaches are related. The VA examiner noted a review of the medical literature suggesting that PTSD can contribute to very high levels of stress and emotional strain, and the impact PTSD has on a person's life including work and relationships which causes more stress increasing the likelihood of headaches. The evidence is in at least equipoise as to whether the Veteran's tension headaches are related to his service-connected PTSD. Resolving reasonable doubt in the Veteran's favor, the Board of Veterans' Appeals (Board) finds that service connection for tension headaches is warranted. INCREASED RATING CLAIM Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321 (a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings. Hart v. Mansfield, 21 Vet. App. 505 (2007). Here, staged ratings will be considered and discussed, as warranted. VA regulations set forth at 38 C.F.R. §§ 4.40, 4.45, and 4.59 provide for consideration of functional impairment due to pain on motion when evaluating the severity of a musculoskeletal disability. If feasible, these determinations are to be expressed in terms of the degree of additional range-of-motion loss due to any weakened movement, excess fatigability, incoordination, or pain. DeLuca v. Brown, 8 Vet. App. 202 (1995); Johnston v. Brown, 10 Vet. App. 80, 84-5 (1997); 38 C.F.R. § 4.59. Moreover, joint testing is to be conducted on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 170 (2016). The Veteran contends that an increased rating is warranted for his service-connected bilateral pes planus. During the course of the appeal, an increased 50 percent rating for bilateral pes planus and degenerative disease with callouses was granted effective December 22, 2014 in an October 2021 rating decision. The Veteran's current bilateral foot disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5276. Diagnostic Code 5276 provides ratings for acquired flatfoot. Pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, that is not improved by orthopedic shoes or appliances, is rated 30 percent disabling for unilateral disability, and is rated 50 percent disabling for bilateral disability. 38 C.F.R. § 4.71a. During the course of the appeal, effective February 7, 2021, 38 C.F.R. § 4.71a Schedule of Ratings-Musculoskeletal System was amended. However, no changes were made to Diagnostic Code 5276. As a result, the Board has considered the updated Diagnostic Code, but finds that the application of such is not warranted. The Veteran was afforded a VA foot conditions examination in July 2015. The examiner noted right foot mild pes planus, mild hammertoes, mild valgus, mild callouses and degenerative disease. As to the left foot the examiner noted mild pes planus, mild hammer toes, mild hallux valgus, mild callouses, degenerative disease and residuals of left foot trauma. The Veteran reported daily pain, burning of his feet, and increased pain and symptomology with activity. The Veteran did not currently wear inserts, arch supports or use any orthopedic assistive devices. Flare ups were noted with increased pain in the toe balls, arches and heels of the feet bilaterally. Functional loss was noted with impaired walking and standing. Pain on use of the feet bilaterally was noted, as was pain on manipulation. Bilateral callouses were noted. Bilateral decreased longitudinal arch height on weight bearing was noted, as was bilateral marked pronation. The weight-bearing line did not fall over or was not medial to the great toe. Bilateral posterior pronation of 5 degrees was noted. Bilateral inward bowing of the Achilles tendon was noted. No marked inward displacement and severe spasm of the Achilles tendon on manipulation of the feet was noted. Physical examination noted mild bilateral hammertoes, and mild to moderate bilateral hallux valgus without surgery. Left foot trauma in-service in 1973 resulted in mild compromises to the left foot weight bearing. Examination noted bilateral excess fatigability, pain on movement, pain on weight-bearing, pain on non-weight bearing, interference with standing and a lack of endurance. X-ray imaging noted bilateral mild tarsometatarsal degenerative changes. The examiner noted that the Veteran's current foot condition impacts his ability to perform occupational tasks in that his foot condition moderately impacts sedentary work and severely impairs physical work. VA and private treatment records have been associated with the claims file. Treatment records note reports of foot pain and swelling at times with increased standing and completing tasks around the house. VA treatment records note ongoing foot and nail care with symptoms of burning, numbness, tingling, prickling and itching of his feet. The Board has considered the Veteran's representative contentions in November 2021 correspondence. Specifically, the representative contends that an increased rating is warranted for the Veteran's bilateral foot disability relating to his left foot hammertoes and hallux valgus. The Board has considered the Veteran's and his representative contentions however, VA benefits may not be granted based on speculative opinions. Rather, opinions must be made by competent professionals and be based on a rationale that is clear to the Board. The Veteran's representative is not competent to provide a medical opinion. Lastly, the benefit of the doubt rule is for application when the evidence is in equipoise, which occurs only when there is an approximate balance between the positive and negative evidence. 38 C.F.R. § 3.102. That evidence must be both competent and credible. Here, there is no such balance of evidence. During the entire period on appeal the Veteran has been in receipt of a 50 percent rating, which is the maximum rating permitted under Diagnostic Code 5276. The Board notes that the medical evidence also includes a diagnosis of right and left foot hallux valgus and right and left foot hammertoes for which the Veteran is currently service-connected rated as noncompensable during the appeal. Further, treatment records note ongoing reports of bilateral foot pain, numbness and tingling which has been attributed to the Veteran's bilateral lower extremity radiculopathy, and this claim is discussed in greater detail below. The primary symptoms associated with the Veteran's service-connected bilateral pes planus is pain, tenderness and swelling of his feet, which is specifically what is contemplated by and compensated for in the current 50 percent rating under Diagnostic Code 5276. The Board concludes that additional separate compensable ratings would constitute impermissible pyramiding. The Board also finds that the Veteran's overall foot symptomology is best represented by and compensated under Diagnostic Code 5276. As the Veteran currently is receiving the maximum rating contemplated for the feet based on symptomatology that includes pain resulting in limitation of motion, as well as during flare ups, and absent loss of use of the feet, the DeLuca provisions and those of 38 C.F.R. §§ 4.40, 4.45 are not for application. Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997). The Board has considered all potentially applicable provisions of the Diagnostic Code regardless of whether they have been raised by the Veteran. In this case, the Board finds no provision upon which to assign a rating greater than 50 percent for the Veteran's bilateral pes planus. Therefore, a rating in excess of 50 percent for bilateral pes planus with callouses and degenerative changes is denied. REASONS FOR REMAND 1. Entitlement to service connection for a heart disability, to include as due to a service-connected disability, is remanded. The Veteran contends that service connection is warranted for his current heart disability, to include as due to his service-connected PTSD. The Veteran contends his service-connected PTSD has caused or aggravated his current heart disability. A June 2019 opinion from the Veteran's VA treating physician has been associated with the claims file. The VA physician noted that based on a review of the medical literature previous studies have shown a relationship between PTSD and coronary artery disease, noting it is possible that the Veteran's coronary artery disease is in part related to his PTSD. As a result of the Board Remand in July 2020, a September 2020 VA heart examination has been associated with the claims file. The VA examiner noted myocardial infarction, coronary artery disease, percutaneous coronary intervention with stent placement and valvular heart disease. The examiner noted that that the Veteran currently experiences intermittent shortness of breath and chest discomfort especially with strenuous activities. The VA examiner found that it is less likely than not that the Veteran's current heart disability was incurred in or caused by the claimed in-service injury event or illness. As to secondary service connection, the VA examiner found that it is less likely than not that the Veteran's current heart disability is proximately due to ot the result of his service-connected PTSD or any other psychiatric disability. The examiner found that the Veteran's heart condition is due to his obesity, hypertension, dyslipidemia and is not secondary to his PTSD. However, the VA examiner failed to fully address secondary service connection and specifically aggravation. In light of such deficiencies, the Board finds the September 2020 VA evaluation is of limited probative value. When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board of Veterans' Appeals (Board) finds that further VA heart examination is needed. Clinical documentation dated after October 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to service connection for neuropathy, to include as due to a service-connected disability is remanded. The Veteran contends that service connection for neuropathy, to include as due to his service-connected bilateral foot disability is warranted. The Veteran reports tingling, numbness and pain radiating down his legs as well as numbness in his arms at times. Previously, in its July 2020, Remand instructions, the Board requested that the Veteran be scheduled for a Department of Veterans Affairs (VA) peripheral nerves examination. In September 2020 the Veteran was afforded a VA back examination and opinion related to his neuropathy, and a Parkinson's examination. However, the Veteran has not been afforded a VA peripheral nerves examination. The Board directed that the VA examiner was to address any currently diagnosed neuropathy disability and opine as to direct and secondary service connection. Further, the possibility of Parkinson's disease or other systemic disorder was also to be addressed. The September 2020 VA examiner noted that the Veteran has not now or ever been diagnosed with Parkinson's disease and a diagnosis of bilateral lower extremity radiculopathy was noted. The examiner found that the Veteran's lumbar radiculopathy was at least as likely as not proximately due to or the result of his low back condition and directly related to his lumbar stenosis condition. Such results in irritation/pinching of the sciatic nerve from his herniated disc with IVDS and stenosis and the developing of shooting pain, tingling and numbness of the Veteran's bilateral lower extremities. The Veteran has not afforded a VA peripheral nerves examination as directed. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Agency of Original Jurisdiction's compliance with the Board's remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). Therefore, the Board further VA evaluation is needed. The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the diagnosed heart disabilities including myocardial infarction, coronary artery disease, PCI with stent placement and valvular heart disease and any neuropathy disability, to include bilateral lower extremity radiculopathy. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after October 2021. 3. Schedule the Veteran for a VA heart examination conducted by a medical doctor to assist in determining the nature and etiology of the diagnosed heart disabilities. The examiner must review the record and should note that review in the reports. The examiner should address the June 2019 private opinion of record. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all heart disabilities found. (b) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified heart disability had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified heart disability is due to or the result of his posttraumatic stress disorder (PTSD) with major depressive disorder or any of the Veteran's other service-connected disabilities. (d) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified recurrent heart disability has been aggravated (increased) by his posttraumatic stress disorder (PTSD) with major depressive disorder or any of the Veteran's other service connected disabilities. 4. Schedule the Veteran for a VA peripheral nerves examination conducted by a medical doctor to assist in determining the nature and etiology of any neuropathy disability, to include bilateral lower extremity radiculopathy and symptoms of numbness, tingling, and weakness in his arms and legs. The examiner must review the record and should note that review in the reports. A rationale for all opinions should be provided. The possibility of Parkinson's Disease or other systemic disorder must be addressed. The examiner should: (a) Diagnose all neuropathy disabilities found. (b) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified neuropathy disability had its onset during active service or is related to any incident of service. (c) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified neuropathy disability is due to or the result of the bilateral pes planus or any of the Veteran's other service-connected disabilities. (d) Opine whether it is at least as likely as not (a 50 percent probability or greater) that any identified neuropathy disability has been aggravated (increased) by the bilateral pes planus or any of the Veteran's other service connected disabilities. A. Snoparsky Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, 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.