HYPERTENSION

JONATHAN HAGER · 2025 · Case ID: A25062964

MIXED

Summary

The veteran, who served from May 1997 to May 2000, September 2002 to August 2004, and June 2009 to July 2010, appeals the denial of service connection for hypertension secondary to PTSD and the effective date for his right ankle strain claim. The Board granted service connection for hypertension secondary to PTSD, finding the private medical opinion more persuasive than the VA opinions. The private opinion linked the hypertension to PTSD and NSAID use for service-connected musculoskeletal disabilities, citing medical literature and VA's own Federal Register statements acknowledging a link between PTSD and cardiovascular disease. The Board found the VA opinions inadequate for dismissing the link without addressing specific facts or VA's own findings, and applied the benefit of the doubt doctrine due to equipoise in the evidence. For the right ankle strain, the Board granted an initial rating of 20 percent, finding the veteran's symptoms, particularly during flare-ups, more nearly approximated marked limitation of motion under DC 5271. However, the Board denied an earlier effective date for the right ankle strain, concluding that no formal or informal claim for this specific condition was raised prior to June 5, 2019, despite the veteran's claims for other foot and ankle issues and the presence of some right ankle treatment records.

Rationale

Private medical opinion found hypertension more likely than not related to PTSD and NSAID use.; VA opinions found less likely than not, based on inaccurate factual premise and lack of specific discussion.; Benefit of the doubt applied due to equipoise in evidence.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

220105-210246

Full Decision Text

Citation Nr: A25062964
Decision Date: 07/24/25 Archive Date: 07/24/25

DOCKET NO. 220105-210246
DATE: July 24, 2025

ORDER

Entitlement to service connection for hypertension, secondary to service-connected post-traumatic stress disorder (PTSD), on a causation basis, is granted.

Entitlement to an initial rating of 20 percent for right ankle strain from June 5, 2019, is granted, subject to controlling regulations governing the payment of monetary awards.

Entitlement to an effective date prior to June 5, 2019, for service connection of right ankle strain is denied.

FINDINGS OF FACT

1. The Veteran's hypertension is caused by service-connected PTSD.

2. Symptoms of the Veteran's right ankle disability have throughout the claim period more nearly approximated marked limitation of motion but have not more nearly approximated ankylosis in plantar flexion between 30 and 40 degrees or in dorsiflexion between 0 and 10 degrees.

3. There is no document prior to the June 5, 2019, VA Form 21-526 EZ, that constitutes a formal or informal claim for benefits relating to right ankle strain.

CONCLUSIONS OF LAW

1. The criteria for service connection for hypertension, secondary to service-connected PTSD, on a causation basis, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.310.

2. The criteria for an initial rating of 20 percent, but no higher, for right ankle disability are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC) 5271.

3. The criteria for an earlier effective date for service connection for right ankle strain have not been met. 38 U.S.C. § 5110; 38 C.F.R. § 3.400.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from May 1997 to May 2000, September 2002 to August 2004, and June 2009 to July 2010.

This case comes before the Board of Veterans' Appeals (Board) from a January 2021 rating decision by the Department of Veterans Affairs (VA) agency of original jurisdiction (AOJ). In that decision, the AOJ on higher level review, granted service connection for right ankle strain with an evaluation of 20 percent effective June 5, 2019, and 10 percent from December 11, 2020, and continued the previous denial of service connection for hypertension as secondary to PTSD after an October 2021 rating decision that identified duty to assist errors. Previously, the Veteran filed an October 2020 VA Form 20-0996 Request for Higher Level Review for the above claims after an October 2019 rating decision that denied service connection for the above claims.

In the January 5, 2022, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, the Board may only consider the evidence of record at the time of the October 2019 AOJ decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran with, or within 90 days from receipt of, the VA Form 10182 and evidence of record as of the date of the associated with the claims file while the record was closed because the claim was pending adjudication after identification of a duty to assist error during a Higher-Level Review. 38 U.S.C. § 7113(a); 38 C.F.R. §§ 3.103(c)(2)(ii), 20.301; 38 C.F.R. § 20.303. If evidence was submitted more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered.
.F.R. § 20.303. If evidence was submitted more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

1. Entitlement to service connection for hypertension, secondary to service-connected PTSD is granted.

Service connection is warranted for disability that is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a).

In a July 2019 VA examination, the Veteran was diagnosed with hypertension. The current disability requirement has thus been met. Moreover, in an April 2014 rating decision, the Veteran was granted service connection for PTSD.

The remaining question is thus whether the Veteran's hypertension is proximately due to or the result of his service-connected PTSD.

In a July 2019 VA opinion, the clinician found it was less likely than not that the Veteran's hypertension was proximately due to or the result of the Veteran's PTSD. The clinician noted that the Veteran has been diagnosed with essential hypertension. The clinician, following a thorough review of the medical literature, found that there was no single identifiable cause for the Veteran's hypertension as the Veteran had multiple risk factors for hypertension. However, the clinician noted that PTSD is not mentioned as a specific risk factor for hypertension in the medical literature. Thus, the clinician opined that the medical evidence does not support a conclusion that the Veteran's hypertension was proximately due to or the result of the Veteran's service-connected PTSD.

In an October 2019 VA opinion, the clinician found it was less likely than not that the Veteran's hypertension was proximately due to or the result of the Veteran's PTSD. The clinician reported the relevant risk factors for hypertension in the medical literature and the Veteran's relevant medical evidence. The clinician opined, based on the medical literature, there is no evidence of a direct link between the Veteran's hypertension and his PTSD. Thus, the clinician found that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected PTSD.

In a January 2021 VA opinion, the clinician found it was less likely than not that the Veteran's hypertension was proximately due to or the result of the Veteran's PTSD. The clinician opined the etiology of hypertension consists of multiple factors including genetic, lifestyle, and environmental. However, PTSD is a disorder of mental health and not a known source or cause of hypertension. Thus, the clinician found that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected PTSD.

In a January 2022 private medical opinion, the clinician opined it was more likely than not that the Veteran's hypertension was due to or the result of his service-connected PTSD as well as the medications used to treat his service-connected musculoskeletal disabilities. In coming to her conclusion, the clinician reviewed the medical literature as well as the Veteran's medical evidence. She opined that PTSD could lead to biochemical changes that can lead to the development of hypertension. Further she opined, and as noted by the medical literature, NSAIDs can lead to the development of and cause aggravation of hypertension. She reported that the Veteran is noted to have used NSAIDs chronically over a significant period of time in order to treat his service-connected musculoskeletal disabilities. Thus, the clinician found that it was at least as likely as not that the Veteran's hypertension was related to his service-connected PTSD and medications used to treat service connected musculoskeletal disabilities.

For the following reasons entitlement to service connection for hypertension secondary to the Veteran's service-connected PTSD is warranted.

The January 2022 private opinion supports service connection for hypertension on a secondary, causation basis. There is no requirement in VA's laws or regulations that a service-connected disease must be the "sole cause" of a disability in order to satisfy the causation requirement for secondary or direct service connection. See 38 U.S.C. § 1110 (providing that compensation is warranted for disability resulting from injury or disease in service without specifying the degree to which the injury must result in disability or indicating that it must be the sole cause); Gajeski v. Collins, No. 24-4992, 2025 U.S. App. Vet. Claims LEXIS 942, *10-11 ("A veteran is entitled to compensation for a 'disability resulting from personal injury suffered or disease contracted' in or related to service. 38 U.S.C. § 1110. And 'the causation standard of § 1110 is simply standard but-for causation.' Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023). But-for causation is a broad standard that 'is not limited to a single cause and effect, but rather contemplates multi-causal links.' Id. This means that establishing one factor as a but-for cause does not necessarily eliminate all other factors as but-for causes. See Bostock v. Clayton Cnty., Ga., 590 U.S. 644, 656 (2020) (explaining that, in the context of Title VII, but-for causation means that a defendant cannot avoid liability 'just by citing some other[non-discriminatory] factor that contributed to its challenged employment decision'"); Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). With regard to secondary service connection in particular, the Federal Circuit found that, in order to be interpreted consistent with 38 U.S.C. § 1110, 38 C.F.R. § 3.310 must allow for a broad "but for" causation standard that contemplates multiple different causes of a current disability and allowing for one of those causes to satisfy the nexus requirement. Spicer, 61 F.4th at 1364.

Moreover, the benefit of the doubt doctrine does not require a definitive conclusion that requires a certain level of confidence or that the hypertension be conclusively attributed to one specific cause. Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) ("in keeping" with the benefit of the doubt rule, which is the standard of proof for veterans benefits, "Congress has not mandated that a medical principal must have reached the level of scientific consensus to support a claim for veterans benefits"). Rather, the evidence need only be approximately evenly balanced as to whether PTSD is one cause of the hypertension. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The above medical opinion meets this standard.

On the other hand, the July 2019, October 2019, and January 2021 VA opinions are inadequate. In all three opinions, the clinician indicated that hypertension was not likely caused by PTSD because "PTSD is not a known cause of hypertension". Further, they noted hypertension causes many other diseases, but "there are not studies supporting a direct or indirect cause and effect between PTSD and hypertension." This is an inaccurate factual premise as VA itself has noted the epidemiologically confirmed association between PTSD and hypertension in the Federal Register. Specifically, VA found that a presumption of service connection is warranted to hypertensive vascular disease for prisoners of war (POWs). This presumption is based on several medical studies indicating that veterans who have a long-term history of PTSD have a high risk of developing cardiovascular disease and myocardial infarction; thus, since POWs have a relatively high rate of PTSD incurrence, they would presumably be at greater risk of cardiovascular disease to include hypertension. See Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004). Specifically, VA found that "evidence of an association between PTSD and cardiovascular disease lends support to our conclusion that cardiovascular disease is associated with POW experience,"
thus, since POWs have a relatively high rate of PTSD incurrence, they would presumably be at greater risk of cardiovascular disease to include hypertension. See Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 70 Fed. Reg. 37040 (June 28, 2005); Presumptions of Service Connection for Diseases Associated with Service Involving Detention or Internment as a Prisoner of War, 69 Fed. Reg. 60083 (Oct. 7, 2004). Specifically, VA found that "evidence of an association between PTSD and cardiovascular disease lends support to our conclusion that cardiovascular disease is associated with POW experience," 70 Fed. Reg. 37040, 37041 and "The 2003 VA study... did find a statistically significant increased incidence of hypertension and chronic heart disease among World War II veterans with PTSD... The conclusion that PTSD may be associated with cardiovascular disorders is also supported by a 1997 study finding that Vietnam veterans diagnosed with PTSD had a significantly increased risk of circulatory disease many years after service. (Boscarino JA. Diseases Among Men 20 Years After Exposure to Severe Stress: Implications for Clinical Research and Medical Care. Psychosom Med 1997; 59:605-14)." 69 Fed. Reg. 60083, 60087.

Rather than addressing VA's own statements in the Federal Register or the medical studies which show a causal relationship between PTSD and a cardiovascular disease entity like hypertension, the July 2019, October 2019, and January 2021 clinicians simply dismissed the possibility, instead focusing on completely unrelated medical phenomena. Therefore, the clinician's negative etiological opinions warrant no probative weight, as they were based on an inaccurate factual premise, Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely") (citing Reonal v. Brown, 5 Vet. App. 458, 461 (1993)), and relied on the absence of general medical literature supporting nexus without discussing the specific facts of the case is inadequate. Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018).

While the Board could remand the claim for another medical opinion, a request for another opinion could be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); Andrews, 34 Vet. App. at 225 ("Remand is inappropriate where the predominant purpose is not to allow the Board to make a fully informed decision unencumbered by error but to allow VA to obtain more evidence so that it can properly deny the claim").

Thus, the evidence is approximately evenly balanced as to whether the Veteran's PTSD was a cause of his hypertension. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for hypertension, secondary to PTSD, on a causation basis, is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Entitlement to an initial 20 percent rating for right ankle strain is granted.

Disability evaluations are determined by evaluating the extent to which a Veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing his symptomatology with the criteria set forth in VA's Rating Schedule. 38 U.S.C.A. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10. If two evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that evaluation; otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7.

Where an award of service connection for a disability has been granted and the assignment of an initial evaluation for that disability is disputed, separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged. Fenderson v. West, 12 Vet. App. 119 (1999). Here, however, as shown below, the evidence warrants a uniform 20 percent rating.

The Veteran's right ankle strain is rated under 38 C.F.R. § 4.71a, DC 5271. Under DC 5271, a 10 percent rating
otherwise, the lower evaluation will be assigned. 38 C.F.R. § 4.7.

The Veteran's right ankle strain is rated under 38 C.F.R. § 4.71a, DC 5271. Under DC 5271, a 10 percent rating is warranted for moderate (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) limitation of ankle motion. A 20 percent rating is warranted for marked (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion) limited motion.

In addition to considering range of motion findings, Board must also evaluate evidence of a Veteran's inability to perform "normal working movements" with "strength, speed, coordination, or endurance." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011) (citing 38 C.F.R. § 4.40); see also DeLuca v. Brown, 8 Vet. App. 202, 205-06 (1995). For rating purposes, all "possible manifestations" of functional loss must be evaluated, and one such manifestation cannot be evaluated to the exclusion of others. See Mitchell, 25 Vet. App. at 36-37; 38 C.F.R. § 4.40 ("Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled.")

In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court found an orthopedic examination inadequate where the examiner declined to provide an estimate of the degree of additional loss of motion due to flare-ups because such would require resort to speculation. Id. at 29, 36.

During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a was amended, effective February 7, 2021.

If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g); Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110 (g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110; Kuzma, 341 F. 3d 1327. The criteria that is more favorable to the Veteran will be applied. Therefore, the Board will consider the Veteran's claim under the former criteria throughout the appeal period and under the new rating criteria from February 7, 2021.

Prior to the regulatory change noted above, under DC 5271, a 10 percent rating was warranted for moderate limitation of ankle motion, and a 20 percent rating was warranted for marked limitation of ankle motion. The terms "moderate" and "marked" were not defined in VA regulations prior to the regulatory change.

"Moderate," as an adjective, is defined as "not violent, severe, or intense"; "limited in scope or effect." "Marked," as an adjective, is defined as "having a distinctive or emphasized character." Merriam-Webster Dictionary, online.

The RO granted service connection and assigned an initial rating of 20 percent for right ankle strain effective from June 5, 2019, VA examination, and an evaluation of 10 percent effective from December 11, 2020. The appeal period therefore begins on the June 5, 2019, date of claim.

During a July 2019 VA examination, the Veteran reported moderate discomfort in his right ankle that increased to severe discomfort approximately three times a week. He used over the counter medication, ice, and elevation to treat his symptoms of right ankle pain. The Veteran reported flare-ups when walking for long periods. The clinician noted functional loss and functional impairment with the Veteran having problems with twisting and turning the right ankle while walking. The clinician noted the Veteran's initial range of motion (ROM) was abnormal. Further, the clinician reported that the ranges of ankle motion were dorsiflexion to 10 degrees and plantar flexion to 40 degrees. The clinician reported that abnormal range of motion did not contribute to functional loss in that there was exhibited pain noted with dorsiflexion and plantar flexion during the examination, but the pain did not result in or cause functional loss. There was no evidence of pain on weight bearing. Further, there was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue or objective evidence of crepitus. The Veteran was able to perform repetitive use testing with no additional loss of function or ROM after three repetitions. The clinician noted that the Veteran's right ankle was not being examined immediately after repetitive use over time and the examination is neither medically consistent nor inconsistent with the Veteran's statements describing function loss with repetitive use over time. Further, the clinician reported pain, weakness, fatiguability, and incoordination did not significantly limit functional ability with repeated use over time. The clinician reported the examination was not being conducted during a flare-up, but the examination is medically consistent with the Veteran's statement describing functional loss during flare-ups. The clinician reported that pain significantly limited the Veteran's functional ability during a flare-up. The clinician was able to describe functional loss in terms of ROM as dorsiflexion to 5 degrees and plantar flexion to 40 degrees. The clinician reported there were no additional contributing factors for the Veteran's right ankle strain. The Veteran's right ankle muscle strength was rated as normal 5/5. Further, no muscle atrophy or ankylosis was noted. The clinician reported that right ankle instability was suspected. The clinician reported the Veteran did not have shin splints, stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus, or talus, or talectomy. No other pertinent physical findings were reported. The clinician reported the Veteran constantly used a brace to assist in locomotion. The clinician noted the Veteran's right ankle strain had a functional impact with the Veteran reporting problems with walking at a fast pace and turning quickly while walking. The clinician reported there was no evidence of pain on passive ROM or evidence or pain when the joint was used with non-weight bearing.

In a January 2021 VA examination, the Veteran reported recurring right ankle pain that began in service. Further, the Veteran reported his symptoms of right ankle pain have continued to the present and worsened. He managed his pain symptoms with over-the-counter medication. The Veteran reported flare-ups with symptoms of numbness and throbbing in the right ankle. The Veteran reported functional impairment with pain upon walking and standing. Further, the Veteran reported driving long distances can bother his right ankle. The clinician noted the Veteran's initial ROM was abnormal with the ranges of ankle motion as dorsiflexion to 10 degrees and plantar flexion to 20 degrees. The clinician noted the Veteran's abnormal ROM contributed to function loss with the Veteran having difficulty with stairs. The clinician noted pain on both dorsiflexion and plantar flexion. Moreover, the clinician reported localized tenderness or pain on palpation of the joint or associated soft tissue with severity being reported as six out of ten. The clinician noted there was pain on weight bearing and objective evidence of crepitus. The Veteran was able to perform repetitive use testing with no additional loss of ROM noted. The clinician reported that the Veteran was not being examined immediately after repetitive use over time, however, the examination is medically consistent with the Veteran's statement describing functional loss with repetitive use over time. The clinician noted pain, fatigue, weakness, and lack of endurance significantly limited the functional ability of the Veteran's right ankle with repeated use over a period of time. The clinician described the functional loss in terms of ROM as dorsiflexion to 10 degrees and plantar flexion to 20 degrees. The clinician noted that the examination was
out of ten. The clinician noted there was pain on weight bearing and objective evidence of crepitus. The Veteran was able to perform repetitive use testing with no additional loss of ROM noted. The clinician reported that the Veteran was not being examined immediately after repetitive use over time, however, the examination is medically consistent with the Veteran's statement describing functional loss with repetitive use over time. The clinician noted pain, fatigue, weakness, and lack of endurance significantly limited the functional ability of the Veteran's right ankle with repeated use over a period of time. The clinician described the functional loss in terms of ROM as dorsiflexion to 10 degrees and plantar flexion to 20 degrees. The clinician noted that the examination was not being conducted during a flare-up, but the examination is medically consistent with the Veteran's statements describing functional loss during flare up. Further, pain, fatigue, weakness, and lack of endurance significantly limited the right ankle's ability during a flare up. The clinician described the functional loss in terms of ROM as dorsiflexion to 10 degrees and plantar flexion to 20 degrees. The clinician noted the Veteran had disturbance of locomotion and interference with standing because of his right ankle strain. The Veteran's right ankle muscle strength was rated as normal 5/5. Further, no muscle atrophy or ankylosis was noted. The clinician reported that right ankle instability was suspected. The clinician reported the Veteran did not have shin splints, stress fractures, achilles tendonitis, achilles tendon rupture, malunion of calcaneus, or talus, or talectomy. No other pertinent physical findings were reported. The clinician reported the Veteran did not use any assistive devices. The clinician noted the Veteran's right ankle strain had a functional impact as the Veteran would struggle to perform occupational tasks that involve standing and walking. The clinician reported there was no evidence of pain on passive ROM or evidence of pain when the joint was used with non-weight bearing.

In an April 2022 brief, the Veteran's representative argued that the Veteran was entitled to a rating of 20 percent disabling for his right ankle strain with an effective date not later than September 10, 2013. Further, the representative argued, that that current effective date of June 5, 2019, does not contemplate that the Veteran's right ankle strain was reasonably raised during the AOJ's adjudication Veteran's primary disabilities of left knee osteoarthritis right first metatarsalgia and arthritis, and torn left gastrocnemius muscle.

For the following reasons, an initial disability rating of 20 percent for right ankle strain under the prior rating criteria is warranted.

Throughout the claim period, the evidence of record reflected that the symptoms of the Veteran's right ankle strain more nearly approximated marked limitation of motion. The Veteran competently and credibly reported pain, instability, and weakness, that limited the motion of his right ankle. Further, the Veteran reported during flare-ups the pain was significantly worse; his flare-ups occur when walking for an extended period of time. The Veteran reported functional loss and functional impairment of the right ankle that effected his ability to work by limiting his ability to walk and stand. Further, the Veteran used medication to manage his pain and even then, his ability to walk and stand was affected by his right ankle strain. Jandreau v. Nicholson, 492 F.3d 1372, 1377, n.4 (Fed. Cir. 2007).

The clinicians in the VA examinations noted that pain in the Veteran's right ankle caused a reduction in the Veteran's ability to walk and stand. Moreover, while testing was not conducted during a flare-up, it is plausible that increased right ankle pain during flare-ups encompassed additional right ankle motion loss to more nearly approximate marked right ankle limitation of motion. 38C.F.R. §4.71a, DC 5271; English v. Wilkie, 30 Vet. App. 347 (2018) (Board must adequately explain how it considered his functional loss due to pain, including during flare-ups). Therefore, the loss of range of motion during flare-ups has resulted in symptoms more nearly approximating marked limitation of motion warranting 20 percent under DC 5271, consistent with 38 C.F.R. §§ 4.40 and 4.45 as interpreted in DeLuca, 8 Vet. App. at 204-7, and Mitchell, 25 Vet. App. at 44. This is the maximum rating for limitation of ankle motion under DC 5271.

The Board notes that the Veteran used medication that provided some relief from his symptoms. The Board is required "to discount beneficial medication effects when relevant rating criteria do not specifically contemplate medication use." Ingram v. Collins, 38 Vet. App. 130, 131 (2025). Moreover, VA must also consider whether there is additional functional loss and/or limitation of motion due to factors such as pain, weakness, premature or excess fatigability, and incoordination. Chavis v. McDonough, 34 Vet. App. 1, 10-12 (2021); DeLuca, 8 Vet. App. at 204; 38 C.F.R. §§ 4.40, 4.45. The limitation of the right ankle is consistent with the marked limitation warranting a 20 percent rating, but neither the examinations nor the Veteran's statements reflected that, during the appeal period the limitation experienced by the right ankle more nearly approximated ankylosis. There was no indication of loss of motion, to include during flare-ups and discounting the beneficial effects of the medication, that approximated fixation of the joint.

For the above reasons, the evidence is at least evenly balanced as to whether the symptoms and impairment caused by the Veteran's right ankle strain more nearly approximate the criteria for a 20 percent rating. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to an increased rating of 20 percent for right ankle strain is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 4.3. However, the evidence is neither evenly balanced nor approximately so as to whether a rating higher than 20 percent is warranted. Rather, the evidence persuasively weighs against such a rating. The benefit of the doubt doctrine is therefore not for application in this regard. Lynch v. McDonough, 21 F.4th 776, 781-82 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side, or another is the benefit of the doubt doctrine not for application).

The Board has considered the Veteran's claim and decided entitlement based on the evidence. The Board notes the Veteran's February 2025 affidavit, there the Veteran reported that while he is currently unemployed, he is recovering from left ankle surgery and waiting for his primary care physician to release him to return to work. Neither the Veteran nor his representative have raised any other issues, nor have any other issues been reasonably raised by the record, with respect to his claim. See Doucette v. Shulkin, 28 Vet. App. 366, 369-70 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record).

3. Entitlement to an earlier effective date for the grant of service connection for right ankle strain is denied.

The Veteran's Representative in his April 2022 brief contended that the Veteran is entitled to an effective date of September 10, 2013, because the issue was reasonably raised as part of his previous claims for service connection for left knee arthritis, right first metatarsalgia and arthritis, and torn left gastrocnemius muscle, and service connection for right ankle disability has been granted as secondary to these disabilities.

Generally, the effective date for a grant of service connection on an original claim is the day following the date of separation from active service or the date entitlement arose, if the claim is received within one year after separation from active service; otherwise, date of receipt of claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i).

VA amended its adjudication regulations on March 24, 2015, to require that all claims governed by VA's adjudication regulations be filed on standard forms prescribed by the Secretary, regardless of the type of claim or posture in which the claim arises. The amendments, however, are only effective for claims and appeals filed on or after March 24, 2015.

Prior to March 24, 2015, a "claim" was defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evid
receipt of claim, or date entitlement arose, whichever is later. 38 U.S.C. § 5110(a); 38 C.F.R. § 3.400(b)(2)(i).

Prior to March 24, 2015, a "claim" was defined broadly to include a formal or informal communication in writing requesting a determination of entitlement or evidencing an intent to apply for benefits. 38 C.F.R. § 3.1(p); Brannon v. West, 12 Vet. App. 32, 34-35 (1998). Any communication indicating intent to apply for a benefit under the laws administered by the VA was considered an informal claim provided it identified, but not necessarily with specificity, the benefit sought. 38 C.F.R. § 3.155(a). To determine when a claim was received under the relevant regulations prior to their recent amendment, the Board must review all communications that may be construed as an application or claim. Quarles v. Derwinski, 3 Vet. App. 129, 134 (1992). Any communication or action that demonstrates an intent to apply for an identified benefit may be considered an informal claim. 38 C.F.R. § 3.155 a). Thus, the essential elements of a claim prior to March 24, 2015, are "(1) an intent to apply for benefits, (2) an identification of the benefits sought, and (3) a communication in writing." Brokowski v. Shinseki, 23 Vet. App. 79, 84 (2009).

Moreover, the Federal Circuit reversed the Court and held in Sellers v. Wilkie, 965 F. 3d 1328 (Fed. Cir. 2020) that a claim must identify the sickness, disease, or injury for which compensation is sought, with at least at a high level of generality, before VA's duty to assist in the development of the claim is triggered.

For the following reasons, entitlement to an effective date of prior to June 5, 2019, for right ankle strain is denied.

A review of the Veteran's claims file reflects that he applied for VA compensation benefits for a broken left foot, torn calf muscle, right foot sprain, post-traumatic stress disorder, and sleep apnea in a September 10, 2013, VA Form 21-526 EZ. However, there is no evidence in the claims file that the Veteran submitted any formal or informal claim of service connection for right ankle strain at any time prior to June 5, 2019.

A September 2013 private clinic note, indicated that the Veteran suffered a left plantaris tendon injury in service and continued to have trouble with it, and that he could dorsiflex the left ankle "only to neutral. The right ankle will dorsiflex a good 10-15 degrees," and noted that the Veteran was "not really tender to palpation. X-rays did not show any pathology." In an April 2014 VA foot conditions examination, the examiner indicated "reports bilateral multiple in service ankle/foot injuries; bilateral casting; no surgery." Further, in an August 2014 private treatment record, the clinician noted that the Veteran's right ankle dorsiflexion was to 10-15 degrees.

The Board is sympathetic to the Veteran and notes the arguments made by his representative in the April 2022, brief, that the Veteran's right ankle strain was reasonably raised during the adjudication of the primary disabilities of left knee osteoarthritis, right first metatarsalgia and arthritis, and torn left gastrocnemius muscle and therefore should have been developed after the Veteran filed his September 10, 2013, VA 21-526EZ. However, the record does not support the conclusion that the Veteran was seeking service connection for a right ankle disability. The Veteran's representative did not point to any documents submitted with the formal claim for compensation for broken left foot, torn calf muscle, foot sprain right, PTSD, and sleep apnea from which it could be inferred that he also sought compensation for a right ankle disability (as opposed to left foot or right foot), and there are no such documents apparent to the Board on review of the record. See Foreman v. Wilkie, No. 19-4420, 2020 U.S. App. Vet. Claims LEXIS 531, at * 10 (Mar. 30,
-526EZ. However, the record does not support the conclusion that the Veteran was seeking service connection for a right ankle disability. The Veteran's representative did not point to any documents submitted with the formal claim for compensation for broken left foot, torn calf muscle, foot sprain right, PTSD, and sleep apnea from which it could be inferred that he also sought compensation for a right ankle disability (as opposed to left foot or right foot), and there are no such documents apparent to the Board on review of the record. See Foreman v. Wilkie, No. 19-4420, 2020 U.S. App. Vet. Claims LEXIS 531, at * 10 (Mar. 30, 2020) (mem dec) (Bartley, C.J.) ("Taken together, Sellers [v. Wilkie, 965 F.3d 1328, 1338 (Fed. Cir. 2019)] and Shea [v. Wilkie, 926 F.3d 1362, 1370 (Fed. Cir. 2019)] direct VA to examine the documents submitted with a formal claim for service connection for a specifically listed disability or disabilities to determine whether that claim also includes an informal claim for service connection for an unlisted disability." See also Bethea v. Derwinski, 2 Vet. App. 252, 254 (1992) (single judge decisions may be relied upon for any persuasiveness or reasoning they contain). The above documents do not show an informal claim for a right ankle disability, as the right ankle is only mentioned in connection with the left ankle, to note that the right ankle had better range of motion than the left.

Moreover, although there is evidence of treatment for potential right ankle strain in the Veteran's medical records, there was no language associated with any claim prior to June 5, 2019, pointing to any records mentioning right ankle troubles in a way that, even when most sympathetically read, would properly be understood as seeking benefits for right ankle strain. See Sellers v. Wilkie, 965 F.3d 1328 (Fed. Cir. 2020) (a document that identifies a sickness, disease, or injury relating to the disability for which compensation was sought, even at a high level of generality, can constitute a claim); Shea v. Wilkie, 926 F.3d 1362, 1368-69 (Fed. Cir. 2019) (VA "must look beyond the four corners" of a claim-stating document "when the documents themselves point elsewhere," such as to medical records).

In addition, the Veteran's representative appears to argue that the fact that service connection was ultimately granted for the right ankle disability secondary to the disabilities for which he had previously filed claims reflects that the grant of service connection for the secondary, right ankle, disability should be the same as the effective dates for service connection for the primary disabilities. However, a claim for service connection for a primary disability does not necessarily encompass a claim for secondary service connection, Manzanares v. Shulkin, 863 F.3d 1374, 1379 (Fed. Cir. 2017), and such claims are distinct for effective date purposes, Ellington v. Peake, 541 F.3d 1364, 1369-71 (Fed. Cir. 2008).

Finally, under the former legal authority, 38 C.F.R. § 3.157(b)(1) (in effect prior to March 24, 2015) provides that the date of outpatient or hospital examination or date of admission to a VA or uniformed services hospital will be accepted as the date of receipt of a claim. However, 38 C.F.R. § 3.157(b)(1) "makes clear that a medical examination report will only be considered an informal claim for an increase in disability benefits if service connection has already been established for the disability. MacPhee v. Nicholson, 459 F.3d 1323, 1327 (Fed. Cir. 2006); Massie v. Shinseki, 25 Vet. App. 123, 134 (2011), aff'd 724 F.3d 1325 (Fed. Cir. 2013) (§ 3.157(b)(1) requires that a report of examination or hospitalization indicate that the veteran's service-connected disability worsened since the time it was last evaluated because, "[w]ithout such a requirement, every medical record generated by the Veterans Health Administration and received by VA that could possibly be construed as a report of examination would trigger the provisions of § 3.157(b)(1)," creating an unnecessary and unwarranted adjudicative burden on VA).
(Fed. Cir. 2006); Massie v. Shinseki, 25 Vet. App. 123, 134 (2011), aff'd 724 F.3d 1325 (Fed. Cir. 2013) (§ 3.157(b)(1) requires that a report of examination or hospitalization indicate that the veteran's service-connected disability worsened since the time it was last evaluated because, "[w]ithout such a requirement, every medical record generated by the Veterans Health Administration and received by VA that could possibly be construed as a report of examination would trigger the provisions of § 3.157(b)(1)," creating an unnecessary and unwarranted adjudicative burden on VA). This regulation is therefore not for application in connection with the instant claim.

The Veteran had admirable service and made sacrifices for his country, and the Board is sympathetic to his contentions. However, the Board is bound by the laws and regulations that apply to claims for veterans benefits and it has no discretion in this regard. 38 U.S.C. § 7104(c); 38 C.F.R. § 20.105. Those laws and regulations make clear that an earlier effective date for the award of service connection for right ankle strain is not warranted. Although the Board is required to "render a decision which grants every benefit that can be supported in law," it regrets that there is no basis in law to grant an earlier effective date as, even assuming entitlement arose prior to the June 5, 2019 date of claim, the appropriate effective date is the date of claim.

For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether an earlier date for the award of service connection for right ankle strain is warranted. Rather, the evidence persuasively weighs against an earlier effective date. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application as to this matter. Lynch v. McDonough, 21 F. 4th 776, 781-82 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application).

Jonathan Hager

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J.D. Strain, Associate 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.

Analyze in VA Law Explorer