Citation Nr: 22012141 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 16-49 247 DATE: March 2, 2022 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is denied. Entitlement to service connection for bilateral hearing loss is denied. REMANDED Entitlement to service connection for headaches is remanded. Entitlement to service connection for a left foot musculoskeletal disability is remanded. Entitlement to service connection for a right foot musculoskeletal disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance is remanded. FINDINGS OF FACT 1. The evidence of record persuasively weighs against finding that the Veteran has had PTSD at any time during or approximate to the pendency of the claim. 2. The evidence of record persuasively weighs against finding that the Veteran's bilateral hearing loss had its onset in service, manifested to a compensable degree within one year of separation from service, or is otherwise caused by or related to the Veteran's active service. CONCLUSIONS OF LAW 1. The criteria for service connection for PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for bilateral hearing loss have not been met. 38 U.S.C. §§ 1101, 1110, 1131, 5103, 5103A, 5107; 38 C.F.R. § 3.102, 3.303, 3.304, 3.307, 3.309, 3.385. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1977 to July 1980, with additional service in the Army Reserve. These matters come to the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision which, in pertinent part, denied entitlement to service connection for PTSD, bilateral hearing loss, tinnitus, headaches, lumbar spine, bilateral foot, bilateral ankle, and bilateral knee disabilities, and SMC based on the need for aid and attendance. In February 2020, the Veteran and his spouse testified before the undersigned Veterans Law Judge at a Board videoconference hearing. A copy of the transcript is of record. In April 2020 and May 2021, the Board remanded the matters for further development, to include obtaining outstanding VA and private treatment records and VA examinations and medical opinions. In an August 2021 rating decision, VA granted service connection for tinnitus, a lumbar spine disability, a left knee disability, and bilateral tinea pedis. As the grants of service connection represents a maximum grant of the benefit sought on appeal for these issues, these issues no longer remain pending before the Board. The Board notes that the December 2021 Supplemental Statement of the Case (SSOC) included the issue of entitlement to a total disability rating based upon individual unemployability (TDIU). TDIU was denied in a March 2020 rating decision and appealed to the Board in a March 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement) under the Appeals Modernization Act. As the only claims before the Board in the instant appeal are those for service connection, the Board finds that TDIU is not raised pursuant to Rice v. Shinseki, 22 Vet. App. 447, 453 (2009), and the issue is not currently before the Board. Entitlement to TDIU will be addressed in a separate decision at a later time. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 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 generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The U.S. Court of Appeals for Veterans Claims (Court) has held that "Congress specifically limits entitlement to service-connected disease or injury to cases where such incidents have resulted in a disability. In the absence of proof of a present disability, there can be no valid claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); see also Rabideau v. Derwinski, 2 Vet. App. 141, 143-44 (1992). Where the evidence shows a "chronic disease" in service or "continuity of symptoms" after service, the disease shall be presumed to have been incurred in service. For the showing of a "chronic" disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With a chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). Additionally, where a veteran served ninety days or more of active service, and certain chronic diseases become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137 (2012); 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Specific to claims of service connection for hearing loss, impaired hearing is considered a disability for VA purposes when the auditory threshold in any of the frequencies of 500, 1,000, 2,000, 3,000, or 4,000 Hertz is 40 decibels or greater; the thresholds for at least three of these frequencies are 26 or greater; or when speech recognition scores using the Maryland CNC Test are less than 94 percent. 38 C.F.R. § 3.385. In evaluating claims of service connection for hearing loss, it is observed that the threshold for normal hearing is from zero to 20 decibels, with higher threshold levels indicating some degree of hearing loss. Hensley v. Brown, 5 Vet. App. 155 (1993). 1. Entitlement to service connection for posttraumatic stress disorder (PTSD). The Veteran contends that service connection is warranted for PTSD. Specifically, he contends that his PTSD has been misdiagnosed as anxiety disorder. Initially, the Board notes that the Veteran is service-connected for his unspecified anxiety disorder. The question for the Board is whether the Veteran has a separate current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of PTSD and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Turning to the evidence of record, Social Security Administration (SSA) records associated with the claims file in October 2017 contain a September 1994 Sacramento County mental health assessment in which the Veteran reported life stressors and flashbacks and nightmares to his military service. The clinician provided diagnoses of PTSD, adjustment disorder, substance abuse, and antisocial personality disorder. A February 1995 psychiatric evaluation reflects diagnoses of polysubstance abuse and substance-induced mood disorder. A January 1999 psychiatric evaluation reflects diagnoses of paranoid schizophrenia versus bipolar affective disorder with paranoid personality disorder, history of substance abuse, and personality disorder not otherwise specified, with anti-social and paranoid features. The SSA Disability Determination and Transmittal form reflects a primary diagnosis of personality disorders. VA treatment records reflect the Veteran first sought mental health treatment with VA in November 2010. The Veteran reported anger issues as a child which had escalated as an adult and led to incarcerations and a hospitalization. The Veteran reported an incident during service in which his sergeant intentionally cut his fingers and that he had nightmares over this incident. The treating clinician diagnosed a mood disorder. VA mental health treatment records dated from November 2012 through June 2014 reflect that the Veteran saw Dr. H. for the first time in November 2012. After examining the Veteran, Dr. H. diagnosed mood disorder and possible personality traits or disorder. Dr. H indicated that the Veteran did not meet the full criteria for PTSD and the clinician suspected the Veteran was seeking secondary gain from his symptoms. In August 2014, the Veteran filed a claim for service connection for PTSD. In an August 2014 statement, he reported that he had recurring nightmares about incidents and abuses during service. An October 2014 PTSD screen during a VA primary care visit was positive; however, the Veteran's clinician noted the Veteran was followed by Mental Health for anxiety and mood problems. VA mental health treatment records from December 2014 continue to reflect that the Veteran did not meet the criteria for a diagnosis of PTSD. In a May 2015 private treatment record, the Veteran's treating clinician indicated that the Veteran was having nightmares and flashbacks of military service and was suffering from PTSD. An August 2015 VA PTSD examination report reflects that after reviewing the claims file and examining the Veteran, the examiner found that the Veteran did not meet the DSM-5 criteria for a diagnosis of PTSD. The examiner further indicated that due to inconsistencies between the Veteran's reports and the record, the examiner was unable to accept the Veteran's report as to symptoms and could not assign a diagnosis. A September 2015 VA mental health treatment note reflects the Veteran requested Dr. H. fill out a Disability Benefits Questionnaire form for PTSD. The clinician declined to do so, and the Veteran requested to switch providers. VA mental health treatment records through September 2018 reflect that the Veteran asserted that he had PTSD and wanted it documented in his file. A March 2019 VA PTSD examination report reflects that the after reviewing the record and examining the Veteran, the Veteran did not meet the DSM-5 criteria for a diagnosis of PTSD. The examiner found that the Veteran did meet the criteria for a diagnosis of unspecified anxiety disorder and opined that it was at least as likely as not that this was related to his military service. In April 2019, the Veteran was granted service connection for unspecified anxiety disorder (claimed as PTSD), which was evaluated at 70 percent disabling. A September 2019 VA examination report based on an in-person interview and review of the record reflects that the Veteran did not meet the DSM-5 criteria for a diagnosis of PTSD. The examiner found that the Veteran did meet the criteria for unspecified anxiety disorder and cannabis use disorder as a progression of his unspecified anxiety disorder. An October 2019 VA PTSD screen was positive, and the Veteran asserted during the clinical visit that his PTSD had been misdiagnosed as anxiety. A January 2020 VA PTSD screen was also positive but the Veteran's treating mental health clinician noted the Veteran was already receiving mental health treatment. During the February 2020 Board hearing, the Veteran indicated that he had been diagnosed with PTSD by his treating VA clinicians. In April 2020, the Board remanded the matter for a new VA examination and medical opinion that considered the 1994 psychiatric treatment record diagnosing PTSD and the January 2020 positive PTSD screen. The Board also directed VA to obtain outstanding military treatment records and records associated with psychiatric hospitalizations in the 1980s. In April 2020, the Veteran submitted a VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), for the Solano State Penitentiary mental hospital in the 1980s and Sacramento Mental Health in the 1990s. An April 2020 response from Sacramento Mental Health was negative. Solano State Penitentiary did not respond to VA's request for records. The Veteran also reported mental health treatment from the McClellan VAMC since 2015 and with the SSA. The Board notes that VAMC and SSA records are associated with the record, and that SSA records contain medical and psychiatric treatment records from the California Department of Corrections and the Sacramento County Mental Health Treatment Center. A December 2020 VA PTSD examination report based on an in-person examination and review of the record reflects that the Veteran did not meet the DSM-5 criteria for a diagnosis of PTSD. The examiner explained that a positive PTSD screen did not mean that the Veteran met the criteria for a diagnosis of PTSD and that prior psychiatric examinations did not demonstrate a clear and convincing diagnosis of PTSD under the DSM-5 criteria. The examiner further noted that upon review of the record, the Veteran's treating VA clinicians and prior examiners had not diagnosed PTSD. However, the December 2020 VA examiner indicated that the Veteran met the DSM-5 criteria for a diagnosis of unspecified anxiety disorder and cannabis use disorder as a progression of his unspecified anxiety disorder. In March 2021, the Veteran submitted a VA Form 21-4142a, General Release for Medical Provider Information to the Department of Veterans Affairs (VA), for the Solano State Penitentiary mental hospital and Sacramento Mental Health. In October 2021, VA notified the Veteran that his VA Form 21-4142a was being returned because it was incomplete. To date, the Veteran has not provided a completed form. However, as discussed above, SSA records contain medical and psychiatric treatment records from the California Department of Corrections and the Sacramento County Mental Health Treatment Center. Upon review, the Board finds that the evidence of record persuasively weighs against finding that the Veteran has had PTSD at any time during or approximate to the pendency of the claim. Although the record reflects a self-report of PTSD symptoms and the Veteran asserts that his treating VA clinicians have diagnosed him with PTSD, the record does not reflect that any of the Veteran's treating VA clinicians have diagnosed him with PTSD nor is PTSD reflected as an active problem in his medical records. The Board acknowledges the diagnosis of PTSD made in 1994 by Sacramento County Mental Health but notes that this was twenty years prior to the Veteran's claim. The Board also acknowledges the private May 2015 treatment record in which the Veteran's clinician noted the Veteran was suffering from PTSD. However, it appears that this was based on a self-report by the Veteran and the evidence does not show that such a diagnosis was made pursuant to the DSM-5 criteria. On the other hand, pertinent treatment records and VA examinations during this same period are all negative for a diagnosis of PTSD pursuant to the DSM-5 criteria, despite the Veteran's assertions to his providers that he has PTSD. Thus, the Board finds that the weight of the evidence is against a finding that the Veteran has a diagnosis of PTSD for VA compensation purposes. See 38 C.F.R. § 3.304(f); see also 38 C.F.R. § 4.125 (a) (stating that the diagnosis of PTSD must comply with the criteria set forth in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition, of the American Psychiatric Association (DSM-5)). While the Veteran and his spouse believe he has a current diagnosis of PTSD, they are not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the competent medical evidence above, which reflects that the Veteran does not meet the DSM-5 diagnostic criteria for PTSD and has not at any point during the appeal period. Finally, the Board stresses that even if the Veteran did have a diagnosis of PTSD or that his PTSD is misdiagnosed as anxiety as he asserts, such that an additional grant of service connection of PTSD would be warranted or his claim recharacterized, it would not result in a separate disability rating from his currently service-connected anxiety disorder or additional compensation payment. All psychiatric disabilities are rated together as one under the General Rating Formula for Mental Disorders; and, all of the Veteran's psychiatric symptoms are considered under that criteria. See 38 C.F.R. § 4.130. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in disability. See 38 U.S.C. § 1110. Thus, where, as here, the probative evidence indicates that the Veteran does not have a current diagnosis of PTSD at any point during the appeal period, there can be no valid claim for service connection. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer, supra. In light of the foregoing, service connection for PTSD must be denied. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for PTSD. As such, that doctrine is not applicable in the instant claim, and his claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for bilateral hearing loss. The Veteran contends that service connection is warranted for bilateral hearing loss. Specifically, he contends that work in the kitchens during service was very loud and he first noticed hearing problems in service. The Veteran's DD Form 214 reflects that his military occupational specialty (MOS) was that of a food service specialist, which has a low probability of exposure to hazardous noise during service. However, the Veteran's DD Form 214 also reflects that the Veteran received an expert rifle badge. The Veteran's June 1987 entrance examination audiogram shows puretone thresholds of 25, 15, 15, 15, and 15 decibels in the right ear and 25, 15, 10, 15, and 10 decibels in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. The Veteran denied hearing loss or ear, nose, or throat trouble. A separation examination is not associated with the Veteran's period of active service. However, a February 1982 audiogram associated with the Veteran's Reserve service shows puretone thresholds of 15, 0, 10, 5, and 10 decibels in the right ear and 5, 5, 0, 0, and 0 decibels in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. The Veteran denied hearing loss or ear, nose, or throat trouble. The Board finds that the in-service audiograms do not meet the thresholds to be considered a disability for VA purposes. Furthermore, the Veteran's service treatment records are otherwise silent for complaints of or treatment for hearing loss, and he denied hearing loss throughout service. Post-service VA treatment records contain a February 2010 audiology consult. The Veteran denied a subjective decrease in hearing but reported that others told him that he is always asking them to repeat themselves. The Veteran reported kitchen noise exposure during service and that he continued to work in food service for 29 years after service. The Veteran's hearing could not be tested due to cerumen impaction, but an April 2010 follow-up visit revealed hearing within normal limits bilaterally. The audiogram revealed puretone thresholds of 10, 5, 10, 5, and 5 decibels in the right ear and 10, 5, 5, 0, and 0 decibels in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech recognition was 100 percent bilaterally, although the word list utilized for testing was not indicated. The Veteran was afforded a VA examination in December 2020. Audiometric testing revealed pure tone thresholds of 60, 70, 65, 65, and 60 decibels in the right ear and 40, 50, 50, 45, and 40 decibels in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech audiometry revealed speech recognition ability of 98 and 96 percent in the right and left ears, respectively. However, the examiner indicated that puretone thresholds were not valid for ratings purposes due to the extent of wax occlusion seen on otoscopy and conductive components in the right ear. The examiner recommended a repeat audiologic evaluation after an ear cleaning. The examiner diagnosed mixed hearing loss in the right ear and sensorineural hearing loss in the left ear. The examiner noted that the Veteran's MOS had a low probability of noise exposure but that he received an expert rifle badge during service, which would indicate noise exposure. The examiner further noted that the Veteran's entrance examination showed hearing within normal limits, but a separation examination was not associated with the record. However, an April 2010 VA audiologic evaluation revealed normal hearing many years after service. The examiner explained that there was not sufficient evidence to suggest that permanent noise-induced hearing loss can develop much later in one's lifetime, long after cessation of that noise exposure. Therefore, it was less likely than not that the Veteran's hearing loss was caused by exposure to hazardous noise during his military service. The Veteran was afforded a VA examination in June 2021. Audiometric testing revealed pure tone thresholds of 60, 50, 50, 55, and 60 decibels in the right ear and 55, 60, 50, 50, and 50 decibels in the left ear at 500, 1000, 2000, 3000, and 4000 Hertz, respectively. Speech audiometry revealed speech recognition ability of 60 and 56 percent in both ears. The examiner diagnosed bilateral sensorineural hearing loss. The examiner noted that the Veteran's MOS had a low probability of noise exposure and that there were no complaints or reports of hearing loss during service or within a reasonable time frame after service. Absent any evidence supporting acoustic trauma or a significant decline in hearing during service or within a reasonable time frame following service, the examiner opined that it was less likely than not that the Veteran's hearing loss was the result of or caused by service. In an addendum December 2021 opinion, the examiner again noted that there was no record of hearing loss during service or shortly after service. Thus, it was less likely than not that the Veteran's hearing loss began during service, manifested within one year of discharge from service, or was noted during service with continuity after service. The Board finds that the Veteran meets the threshold criteria for establishing a current bilateral hearing loss disability for VA purposes in accordance with 38 C.F.R. § 3.385. However, the evidence of record weighs against a finding that any current hearing loss disability was present during his active service, or within a year of his separation from active service. While sensorineural hearing loss is considered a "chronic" disease under 38 C.F.R. § 3.309(a), service connection based upon the presence of a chronic condition and continuity of symptomatology is not warranted in the Veteran's claim. 38 C.F.R. §§ 3.303(b), 3.307, 3.309. The evidence weighs against a finding that a hearing loss disability was present during his active service or at any point during his Reserve service. The Veteran's service treatment records do not reflect the presence of a hearing loss disability for VA purposes at that time. Further, the medical evidence of record does not reflect the presence of a hearing disability for VA purposes until December 2020, decades after separation from service. Additionally, while the Veteran testified during the February 2020 Board hearing that he first noticed his hearing loss during service, the Veteran denied subjective hearing loss during a February 2010 VA audiology consult. As his more recent statements conflict with his earlier statements during contemporaneous treatment, the Board finds the Veteran's statements regarding continuity of symptomatology since service to be uncredible and gives them little probative weight. Consequently, the Board finds that the Veteran has not continuously experienced a hearing loss disability for VA purposes since service, or within a year of separation from service. Thus, while bilateral sensorineural hearing loss has been diagnosed post-service, it is necessary to establish a link between any current hearing loss and his in-service noise exposure. In Hensley v. Brown, the Court noted that 38 C.F.R. § 3.385, "does not preclude service connection for a current hearing disability where hearing was within normal limits on audiometric testing at separation from service." The Court explained that: [W]hen audiometric test results at a veteran's separation from service do not meet the regulatory requirements for establishing a "disability" at that time, he or she may nevertheless establish service connection for a current hearing disability by submitting evidence that the current disability is causally related to service. 5 Vet. App. at 159-60. Unfortunately, the competent evidence of record also does not support that the Veteran's current bilateral hearing loss is causally related to his active service. The Board finds that the December 2020 and June 2021 VA examiners' opinions, taken together, are persuasive. The opinions are informed by a thorough review and analysis of the Veteran's service treatment records, in-service noise exposure, post-service occupational noise exposure, post-service audiologic tests, including normal audiologic results in February 2010, the medical literature, and medical expertise. The examiners' opinions reflect clear and unequivocal conclusions regarding the relationship between the Veteran's in-service noise exposure, his in-service audiograms, his claimed noise-induced bilateral hearing loss, his post-service occupational noise exposure, and onset of bilateral hearing loss. The reasoning adequately shows that the examiners' conclusions are supported by the relevant and material information. The opinions are factually accurate, fully articulated, and based on sound reasoning. Thus, the opinions carry significant probative weight. The Board acknowledges that a claimant is generally competent to introduce lay testimony of observable symptoms of disability and continuity of such symptoms. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). However, as a lay person, the Veteran is not competent to provide a medical diagnosis or nexus regarding his current bilateral hearing loss disability and whether his current disability is related to his in-service noise exposure; such a matter requires medical expertise and laboratory testing. See id. at 1377 (noting general competence to testify as to symptoms but not to provide medical diagnosis). As such, the Board finds the Veteran's representations in this regard to be of extremely limited probative value and significantly outweighed by the objective medical evidence of record. While the Board is sympathetic to the Veteran's claim, the weight of the evidence indicates that the Veteran's military service did not result in his current bilateral hearing loss disability. As the preponderance of the evidence is against the Veteran's claim of service connection for bilateral hearing loss, the benefit of the doubt doctrine is not applicable. The claim is denied. See 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). REASONS FOR REMAND 1. Entitlement to service connection for headaches is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for headaches at this time. In May 2021, the Board remanded the claim for a new VA examination and medical opinion, finding that January 2021 VA examination and medical opinion was inadequate. The Board directed the examiner to consider whether the Veteran's disability was related to his reports of alleged hits to his head during fights in service. The Veteran was afforded a VA examination and medical opinion in July 2021. The examiner provided a diagnosis of tension headaches. The examiner noted that the Veteran reported intermittent symptoms during service and his current symptoms were intermittent. The examiner noted that service treatment records were negative for headaches and opined that it was less likely than not that his headaches were incurred in or caused by service. In a December 2021 addendum opinion, the examiner opined that the Veteran's headaches less likely than not began during service, to include related to alleged hits to the head, manifested within one year of service, or were noted during service with continuity of the same symptomatology since service. The examiner restated her previous rationale. The Board finds these opinions inadequate, as the opinions appear to be based, at least in part, on the absence of complaints of or treatment for the headaches during service, and the rationale, to include whether his headaches were related to fights and alleged hits to the head during service, are conclusory, with no explanation or rationale provided. The Board finds that a remand is warranted for an addendum opinion as to the nature and etiology of the Veteran's headaches. 2. Entitlement to service connection for a left foot musculoskeletal disability is remanded. 3. Entitlement to service connection for a right foot musculoskeletal disability is remanded. 4. Entitlement to service connection for a left ankle disability is remanded. 5. Entitlement to service connection for a right ankle disability is remanded. 6. Entitlement to service connection for a right knee disability is remanded. The Board cannot make a fully-informed decision on the issues of entitlement to service connection for bilateral foot, bilateral ankle, and right knee disabilities at this time. In May 2021, the Board remanded the claims for new VA examinations and medical opinions, finding that January 2021 VA examinations and medical opinions were inadequate. The Board directed the examiner(s) to consider whether the Veteran's disabilities were related to the rigors of service. The Veteran was afforded VA examinations and medical opinions in July 2021. As to the Veteran's feet, the examiner provided diagnoses of bilateral degenerative arthritis and pes planus. The examiner noted that service treatment records were negative for degenerative arthritis and pes planus and that tinea pedis, which was diagnosed during service, does not cause degenerative arthritis or pes planus. As to the Veteran's ankles, the examiner provided a diagnoses of bilateral ankle equinus. The examiner noted that service treatment records were negative for ankle equinus. As to the Veteran's right knee, the examiner provided a diagnosis of right knee strain. The examiner noted that service treatment records were negative for right knee strain. Thus, the examiner opined that the Veteran's bilateral foot, bilateral ankle, and right knee disabilities were less likely than not incurred in or caused by service. The Board finds these opinions inadequate, as the opinions appear to be based, at least in part, on the absence of complaints of or treatment for the disabilities during service and did not consider whether the Veteran's currently diagnosed disabilities were otherwise related to the rigors of service. The Board finds that a remand is warranted for addendum opinions as to the nature and etiology of the Veteran's bilateral foot, bilateral ankle, and right knee disabilities. 7. Entitlement to special monthly compensation (SMC) based on the need for aid and attendance is remanded. Finally, because a decision on the remanded service connection issues could significantly impact a decision on the issue of entitlement to SMC, the issues are inextricably intertwined. A remand of the claim for SMC is required. The matters are REMANDED for the following actions: 1. Obtain the Veteran's VA treatment records from November 2021 to the present. 2. Obtain an addendum opinion from an appropriate clinician as to the nature and etiology of the Veteran's headaches. The examiner must review the claims file. The examiner is asked to provide a response to the following: Is it at least as likely as not that the Veteran's headaches (1) began during active service, to include related to alleged hits to his head during fights, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 3. Obtain an addendum opinion from an appropriate clinician as to the nature and etiology of the Veteran's bilateral foot, bilateral ankle, and right knee disabilities. The examiner must review the claims file. The examiner is asked to provide a response to the following: For the Veteran's bilateral foot degenerative arthritis, is it at least as likely as not that bilateral foot degenerative arthritis (1) began during active service, to include related to the rigors of service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? For the Veteran's bilateral pes planus, bilateral ankle equinus, and right knee strain, is the Veteran's bilateral pes planus, bilateral ankle equinus, and/or right knee strain at least as likely as not related to service, including the rigors of service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 4. After completing the above, and any other development as may be indicated, the Veteran's claims should be readjudicated based on the entirety of the evidence. If the claims remain denied, the Veteran and his representative should be issued a supplemental statement of the case (SSOC). An appropriate period of time should be allowed for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Owen, 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.