Citation Nr: 24012012 Decision Date: 03/14/24 Archive Date: 03/14/24 DOCKET NO. 20-29 615 DATE: March 14, 2024 ORDER Entitlement to service connection for obstructive sleep apnea is granted. REMANDED Entitlement to service connection for bilateral plantar fascitis is remanded. FINDING OF FACT There is persuasive medical evidence that indicates that the Veteran has a current diagnosis of obstructive sleep apnea that is secondary to his service-connected posttraumatic stress disorder (PTSD).?? CONCLUSION OF LAW The?criteria for entitlement to service connection for?obstructive sleep apnea?have been met.? 38?U.S.C. §§?1110,?5107;?38?C.F.R. §§?3.102, 3.303, 3.304, 3.310.??? REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 2004 to June 2009, and from January 5 to 14, 2016, with additional service in the Army and Air Force National Guard. This case comes to the Board of Veterans' Appeals (Board) from a May 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office. The Veteran attended a virtual Board hearing before the undersigned Veterans Law Judge in November 2022. Obstructive Sleep Apnea The Board finds that there is sufficient?evidence?to find that entitlement to service connection for sleep apnea is warranted.?? Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service.??38?U.S.C. §?1110;?38?C.F.R. §?3.303(a).? Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38?C.F.R. §?3.310(a). This permits service connection not only for a disability caused by a service-connected disability, but also for the degree of disability resulting from aggravation of a disability by a service-connected disability. See Allen v. Brown, 7?Vet. App.?439, 448 (1995). In this case, there is evidence that the Veteran's sleep apnea has been permanently aggravated by his service-connected psychiatric disorder, diagnosed as PTSD with alcohol use disorder. The evidence clearly shows that the Veteran has a current diagnosis of sleep apnea. The Veteran underwent a private sleep study in April 2014, and he was diagnosed with moderate obstructive sleep apnea. The Veteran has reported having symptoms of snoring, restless sleep, and daytime sleepiness. The Veteran submitted an October 2017 statement from a colleague who said that that while they were both in the Air Force National Guard in 2012, he witnessed the Veteran snoring loudly, choke and stop breathing while sleeping, and having extreme daytime sleepiness. At the November 2022 Board hearing, the Veteran discussed how he started having problems sleeping around 2008, and his wife testified that she did witness her husband snoring and stopping breathing during sleep while he was in service. She also discussed how when his PTSD symptom flare up, this also caused his sleep apnea to worsen. There is no probative medical evidence of record which links the Veteran's sleep apnea directly to his service or which finds that sleep apnea had its onset during the Veteran's service, and therefore service connection on a direct basis is not warranted. The Veteran and his representative have primarily argued, however, that sleep apnea is not directly related to service, but has been caused or aggravated by his service-connected PTSD. The Board finds that there is probative medical evidence which supports finding that the Veteran's sleep apnea is secondary to his PTSD, and service connection can be granted on this basis. The Veteran has submitted a private evaluation from psychologist P.W. He discussed the Veteran's PTSD and its symptoms at great length, including social isolation, moderate depression, suspiciousness, poor memory, moderate deficits in abstract thinking, flashbacks, and problems staying asleep at night ever since leaving the military. He wrote that the Veteran had both insomnia and sleep apnea. The psychologist discussed several medical articles which discussed the relationship between psychiatric disorders and sleep apnea, including one that addressed how weight gain is commonly associated with psychiatric medications and this contributes to sleep apnea, and several that addressed a possible neurological link between PTSD and the subsequent development of sleep apnea. He wrote that it was his professional opinion that more likely than not, the Veteran's sleep apnea was directly related to his service-connected PTSD. He wrote that the cause and effect of PTSD to sleep apnea was shown through additional problems with anxiety and depression caused by his traumatic experiences in military service, and that his disorders had a circular effect, where the Veteran's PTSD increased his sleep apnea, which then in turn exacerbated his PTSD symptoms. A medical opinion has therefore been provided by a competent psychologist who reviewed the?Veteran's?medical records and conducted a clinical interview with the Veteran. He provided a thorough medical opinion that is consistent with the evidence of record, and?which was accompanied by extensive rationale, including many well-cited references to medical literature. The Board therefore finds this medical opinion to be highly probative evidence that weighs in favor of the claim.??See Prejean v. West, 13?Vet. App.?444, 448-9 (2000).?? There are no other medical opinions in the record which come to any differing opinions regarding the Veteran's sleep apnea and its relationship to PTSD. In sum, the Veteran?currently has?a diagnosis of obstructive sleep apnea, and there is persuasive and probative evidence which shows that the disorder was caused or aggravated by his service-connected PTSD. The claim is granted.?? REASONS FOR REMAND Plantar Fasciitis The Veteran contends that he has plantar fasciitis, which began during his active duty service and has been continued since that time. At the November 2022 Board hearing, the Veteran discussed how he had to march and stand for many hours at a time for ceremonies in service, and that his feet would become really painful. He stated that ever since he was discharged from active duty in 2009, his feet having continued to be very painful on and off, especially with a lot of walking. The Veteran has credibly alleged that his plantar fasciitis symptoms started in service and continued since that time, but he has not yet been afforded a VA examination to address this issue. The Board therefore remands this claim so that an examination can be provided to the Veteran. The matters are REMANDED for the following action: 1. Obtain all VA treatment records since February 2022. 2. Arrange for the Veteran to undergo an examination of the feet with a podiatrist or other appropriate physician specialist to determine the nature and etiology of any diagnosed right or left foot disability. The examiner must be provided access to the entire claims file, and must specify in the report that these records have been reviewed. The examiner should then address: a) What are the Veteran's current diagnoses of the right and left feet? b) For each disorder diagnosed, address whether is it at least as likely as not that the disorder had its onset during, or is otherwise related to service. Please address the Veteran's assertions that his plantar fasciitis developed when he had to march and stand for many hours at a time during ceremonies in service, and that he has had chronic foot pain ever since. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. If the examiner finds the Veteran's lay statements not to be credible, he/she must explain what evidence supports this finding. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mary E. Rude, 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.