RESIDUALS OF ENCEPHALITIS

A. P. SIMPSON · 2025 · Case ID: A25064689

MIXED

Summary

The veteran, who served in the Coast Guard from January 1988 to August 1995, appeals the denial of service connection for traumatic brain injury (TBI), left ankle disorder, and gastroesophageal reflux disease (GERD). The Board denied service connection for TBI, finding the veteran's post-service assertions of head injuries were not credible due to consistent denials during service and lack of TBI diagnosis in medical records. For the left ankle disorder, the Board found the evidence weighed against a current disability, noting only a resolved in-service sprain and a gap of over 25 years before new complaints, with a VA examiner finding no objective evidence of a current disorder. Regarding GERD, the Board acknowledged the veteran's claim of onset during service and aggravation by service-connected PTSD, but found the evidence weighed against in-service onset due to denials in service records and a post-service diagnosis. The Board also found the VA examiner's opinion that GERD was less likely than not related to PTSD unpersuasive due to the examiner's finding that the GERD had remained stable since its 2002 onset, predating the PTSD service connection. The Board remanded claims for right hip, right ankle, and bilateral foot disorders for inadequate VA medical opinions, specifically requiring nexus opinions on causation and aggravation by service-connected knee disabilities.

Rationale

No in-service head injury documented; Veteran denied head injury during service evaluations; Post-service medical records lack TBI diagnosis; Veteran's post-service claims contradicted by contemporaneous records

Service Branch

COAST GUARD

Special Benefit

NO SPECIAL BENEFIT

Docket No.

220405-233335

Full Decision Text

Citation Nr: A25064689
Decision Date: 07/30/25 Archive Date: 07/30/25

DOCKET NO. 220405-233335
DATE: July 30, 2025

ORDER

1. Entitlement to service connection for a traumatic brain injury (TBI) is denied.

2. Entitlement to service connection for a left ankle disorder is denied.

3. Entitlement to service connection for gastroesophageal reflux disease (GERD) is denied.

REMANDED

4. Entitlement to service connection for a right hip disorder prior to November 3, 2021 is remanded.

5. Entitlement to service connection for a right ankle disorder is remanded.

6. Entitlement to service connection for a right foot disorder is remanded.

7. Entitlement to service connection for a left foot disorder is remanded.

FINDINGS OF FACT

1. The evidence persuasively weighs against a finding that the Veteran has had a TBI or residuals of TBI at any time during the pendency or in close proximity to filing the service-connection claim, to include symptoms that cause functional impairment of earning capacity.

2. The evidence persuasively weighs against a finding that the Veteran has had a left ankle disorder at any time during the pendency or in close proximity to filing the service-connection claim, to include symptoms that cause functional impairment of earning capacity.

3. The evidence persuasively weighs against finding that the Veteran's current GERD had its onset in service, is caused by or otherwise related to his service, or is caused or aggravated by the service-connected posttraumatic stress disorder (PTSD).

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for TBI have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 4.124a, Diagnostic Code (DC) 8045.

2. The criteria for entitlement to service connection for a left ankle disorder have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

3. The criteria for entitlement to service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active duty from January 1988 to August 1995.

These matters come to the Board on appeal from a September 2021 rating decision, which was issued to the Veteran on October 1, 2021, and which, in pertinent part, denied service connection for TBI, right hip, bilateral ankle, and bilateral foot disorders, as well as a March 2022 rating decision, which, in pertinent part, denied service connection for GERD. The Veteran appealed the denials of service connection to the Board.

In the April 2022 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Evidence Submission docket under the Appeals Modernization Act (AMA). In an Evidence Submission docket, the Board may consider only the evidence of record at the time of the October 1, 2021 and March 14, 2022 rating decisions on appeal, as well as any evidence submitted by the Veteran and his representative on and within 90 days from receipt of the VA Form 10182, which 90-day period ended on July 4, 2022. 38 C.F.R. § 20.303. The record reflects that the Veteran and his representative did not submit any new, relevant evidence within the 90-day window following receipt of the April 2022 VA Form 10182.

If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in this decision. 38 C.F.R. § 20.300. If the Veteran would like VA to consider any evidence that was added to the claims file 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
10182.

On November 3, 2021, the Veteran filed a claim for service connection for bilateral thigh (pain motion) on a VA Form 21-526EZ, Application for Disability Compensation and Related Compensation Benefits. In a March 2022 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for right hip osteoarthritis, claimed as a bilateral thigh condition, effective November 3, 2021, and assigned an initial noncompensable (zero percent disability rating) for this disability. Accordingly, the Board has recharacterized the issue of entitlement to service connection for a right hip disorder as it is listed on the first page of this decision.

The Board also notes that on August 10, 2022, the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxins (PACT) Act was passed, which in pertinent part, expanded healthcare access for veterans who participated in toxic exposure risk activities (TERAs). 38 U.S.C. §§ 101(37), 101(38). Per the PACT Act, when a claimant whose active service subjected the veteran to participation in a TERA files a claim to service connect a disability and there is evidence of a current disability, VA must provide the veteran with a VA examination and obtain a medical opinion addressing the possibility of a nexus between the claimed disability and the TERA. See 38 U.S.C. § 1168(a)(1). However, the Veteran does not contend, and the evidence does not suggest, that he participated in TERAs during his active duty. Thus, TERA examinations and medical opinions are not required in connection with the Veteran's claims for service connection.

VA's duty to assist includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). Generally, a VA medical examination or medical opinion is required for a service-connection claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in-service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) insufficient competent medical evidence on file for the VA to make a decision on the claim. Id. The VA examination and/or medical opinion must be adequate to decide the claim. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).

While the record reflects that the AOJ provided the Veteran with a VA examination in connection with his claim for service connection for GERD, the examiner did not address whether the Veteran's GERD was caused by or otherwise related to his active duty. The Board does not find that a medical opinion for direct service connection for GERD was warranted because the competent and credible evidence does not show that an event, injury, or disease occurred in-service related to the Veteran's GERD. The Veteran was not provided with a VA examination or medical opinion in connection with the claim for service connection for TBI, and the Board finds that neither were warranted, as the evidence persuasively weighs against finding that the Veteran has had a TBI or residuals of TBI, to include persistent or recurrent symptoms of a TBI at any time during the pendency or in close proximity to filing the service-connection claim. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one of the criteria was not met for these claims. McLendon, 20 Vet. App. at 81; 38 U.S.C. § 5103A(d)(2); 38 C.F.R. §
a VA examination or medical opinion in connection with the claim for service connection for TBI, and the Board finds that neither were warranted, as the evidence persuasively weighs against finding that the Veteran has had a TBI or residuals of TBI, to include persistent or recurrent symptoms of a TBI at any time during the pendency or in close proximity to filing the service-connection claim. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one of the criteria was not met for these claims. McLendon, 20 Vet. App. at 81; 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). Therefore, VA had no duty to provide a medical examination and/or medical opinion for the TBI claim or a medical opinion addressing direct service connection for the GERD claim.

Service Connection, Generally

The Veteran contends that he has TBI that is caused by his active duty and that he has a left ankle disorder that is caused by his active duty and/or caused by his service-connected right and left knee disabilities. Furthermore, he contends that his current GERD is caused and/or aggravated by his service-connected PTSD.

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994).

Service connection may also be established on a secondary basis 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). Establishing service connection on a secondary basis requires evidence (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439 (1995).

The United States Court of Appeals for Veterans Claims (Court) has held that Congress specifically limited entitlement to service-connected benefits to cases where there is a current disability. The requirement of a current disability is "satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim." See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). When the record contains a recent diagnosis of disability prior to the filing of a claim for benefits based on that disability, the report of diagnosis is relevant evidence that must be addressed in determining whether a current disability existed at the time the claim was filed or during its pendency. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013). In the absence of proof of a current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Degmetich v. Brown, 104 F.3d 1328, 1333 (1997). However, a formal diagnosis is not required to satisfy the current disability element for all service-connection claims. See Saunders v. Wilkie, 886 F.3d 1356 (holding that pain alone may constitute a current disability if it functionally impairs earning capacity).

The Secretary shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102.

In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal
for all service-connection claims. See Saunders v. Wilkie, 886 F.3d 1356 (holding that pain alone may constitute a current disability if it functionally impairs earning capacity).

In deciding claims, it is the Board's responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss each and every piece of evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the claims file shows, or fails to show, with respect to the claims. See Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000).

1. TBI

The Veteran contends that he has TBI that was caused by his active duty. For example, he asserted in a January 2021 VA Form 21-526EZ that he hit his head on a regular basis while on boats in service. He stated that he was tall and had to "always duck pretty far." He stated that when they would do "a surf entry," he hit his head hard enough to split it wide open and still had a scar from the incident.

After a careful reviewed the evidence of record, the Board finds that the evidence persuasively weighs against a finding that the Veteran has had TBI at any time during the pendency or in close proximity to filing the service-connection claim, to include symptoms that cause functional impairment of earning capacity. The reasons for the Board's decision follow.

While the record shows that the Veteran served aboard ships and boats in the United States Coast Guard during service, his service treatment records do not show a disease, symptoms, or injury indicative of a head injury or TBI. For example, the Veteran denied ever having a head injury in the March 1987 pre-service induction Report of Medical History, and his head, face, neck, and scalp were determined to be clinically normal in the Report of Medical Examination from the same date. Likewise, the January 1988 service enlistment Report of Medical History shows that he denied ever having a head injury. Additionally, a June 1988 Air Crew Candidate evaluation and an April 1992 overseas physical evaluation also showed that he denied having a head injury and his head, face neck, and scalp were determined to be clinically normal at those times. Significantly, the Veteran denied ever having a head injury in the January 1995 service separation Report of Medical History and his head, face, neck, and scalp were determined to be clinically normal in the January 1995 Report of Medical Examination at service separation.

Post-service treatment records further show that the Veteran has not been diagnosed with a TBI or residuals of a TBI by a medical professional. For example, the Veteran underwent a VA examination for PTSD in August 2017, during which the examiner determined that the Veteran did not have more than one mental disorder diagnosed and that he did not have a diagnosed TBI. The examiner reiterated that there was no diagnosis of TBI when asked to state if a diagnosis of TBI existed, was it possible to differentiate what portion of the occupational and social impairment indicated above was caused by the TBI. Very similar findings regarding the lack of TBI or its residuals were noted in a July 2018 VA examination for PTSD.

After the Veteran filed the present claim for service connection in January 2021, he underwent additional VA examinations for PTSD in February 2021 and June 2021, during which the examiners again determined that the Veteran did not have a diagnosis of TBI.

In a November 2021 written statement, the Veteran asserted that he was constantly hitting his head aboard ships during service. He stated that he remembered a few times that he was dazed for a few minutes and then shook it off and went on his way. He stated that when the boat hit the surf, his head would bounce off of the top of the pilot position. He stated that he would be in the surf constantly for rescues and surf trainings. He asserted that the lifeboats and the whaler were the ones he spent most of his time on
underwent additional VA examinations for PTSD in February 2021 and June 2021, during which the examiners again determined that the Veteran did not have a diagnosis of TBI.

In a November 2021 written statement, the Veteran asserted that he was constantly hitting his head aboard ships during service. He stated that he remembered a few times that he was dazed for a few minutes and then shook it off and went on his way. He stated that when the boat hit the surf, his head would bounce off of the top of the pilot position. He stated that he would be in the surf constantly for rescues and surf trainings. He asserted that the lifeboats and the whaler were the ones he spent most of his time on in while in the surf. He stated that he attached pictures to show how the ships were thrown around and how the crew was stationed, including a picture of one of the boats where he was previously stationed; however, the Board notes that it cannot consider these photographs in adjudicating the Veteran's claim as they were submitted during a period of time when the Board is unable to consider evidence in this AMA appeal.

After a thorough review of the Veteran's claims file, including the Veteran's lay statements, service treatment records, and post-service VA and private treatment records, including the August 2017, July 2018, February 2021, and June 2021 VA examination reports, the Board finds that the evidence persuasively weighs against a finding that the Veteran has had a TBI or residuals of a TBI at any time during the pendency of the claim or in close proximity to filing the service-connection claim, to include symptoms that cause functional impairment that affects earning capacity. The private treatment records show the Veteran seeking treatment for various complaints, and none of them involve symptoms related to a head injury or injuries. When he went to establish care at VA in April 2018, he reported that his medical history involved PTSD symptoms, tinnitus, hereditary hemochromatosis, low back pain, bilateral knee pain, and exposure to blood-borne pathogen. There was no report of a head injury or head injuries.

The Board acknowledges that the Veteran asserted in January 2021 and November 2021 written statements that he frequently hit his head due to his height or the rough waters while he was onboard ships or boats during service. However, the Board notes that the Veteran affirmatively stated during in-service evaluations, including in March 1987, January 1988, June 1988, April1 1992, and January 1995, that he never had a head injury and the examiners specifically determined that his head, face, neck, and scalp and neurological system were normal following clinical evaluations. Thus, the Board determines that his post-service assertions, including in January 2021 and November 2021, that he had numerous in-service head injuries or traumas to the head that would cause a TBI, which were made approximately more than 25 years following service separation, are not credible as they are contradicted by the evidence contemporaneous to service, which statements tend to be reliable. Further, the Veteran certified the truth of his statements when he signed the Reports of Medical History, which further supports the credibility of such statements. In other words, the Board finds that the Veteran's denials of a head injury over an eight-year period while in service are credible.

The Board finds the August 2017, July 2018, February 2021, and June 2021 VA examination reports to be probative evidence that persuasively weighs against a finding that the Veteran has a current TBI prior to and during the appeal as these examiners possessed the necessary education, training, and expertise to provide the requested findings and opinions. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). The examiners performed the necessary psychiatric testing and determined that based on the Veteran's self-report symptoms and history, review of the record, and applicable medical principles, the Veteran did not have signs or symptoms of a TBI, which is likely because the Veteran was not reporting that he had a TBI at that time. The VA examiners' opinions and findings considered an accurate history and were supported by detailed rationales that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Overall, the only evidence indicating the presence of this disability prior to and during the appeal period comes from the Veteran's statements to VA adjudicators. While the Board acknowledges the Veteran's subjective complaints of a TBI, the record does not show that these symptoms cause functional impairment that affects earning capacity following an individualized assessment of the degree of impairment caused by the Veteran's reported symptoms. See Saunders, 886 F.3
was not reporting that he had a TBI at that time. The VA examiners' opinions and findings considered an accurate history and were supported by detailed rationales that considered the lay and medical evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

Overall, the only evidence indicating the presence of this disability prior to and during the appeal period comes from the Veteran's statements to VA adjudicators. While the Board acknowledges the Veteran's subjective complaints of a TBI, the record does not show that these symptoms cause functional impairment that affects earning capacity following an individualized assessment of the degree of impairment caused by the Veteran's reported symptoms. See Saunders, 886 F.3d at 1356. More importantly, the Board finds as fact that there was no TBI in service.

Accordingly, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for TBI is warranted. Rather, the evidence persuasively weighs against the claim for service connection. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch v. McDonough, 21 F.4th 776 (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).

2. Left Ankle Disorder

The Veteran contends that he has a current left ankle disorder that is caused or aggravated by his service-connected disabilities. For example, he asserted in the January 2021 VA Form 21-526EZ that private chiropractic treatment notes showed that his bilateral ankle disorders were secondary to his service-connected bilateral knee disabilities.

After a careful reviewed the evidence of record, the Board finds that the evidence persuasively weighs against a finding that the Veteran has had a left ankle disorder at any time during the pendency of his service connection claim, to include pain that causes functional impairment that affects earning capacity. The reasons for the Board's decision follow.

While the record shows that the Veteran has documented in-service complaints and treatment for a left ankle sprain, the probative post-service VA and private treatment records, including a July 2021 VA examination for the ankles, show that he has not had a left ankle disorder at any time during the pendency or in close proximity to filing his service connection claim in January 2021, to include pain that causes functional impairment that affects earning capacity. Specifically, the Veteran's May 1994 service treatment records show that he complained of a left ankle sprain for one day. He reported that he had an injury while playing basketball and that he heard a "pop" when the injury occurred. He reported that he was able to continue playing basketball. Following an evaluation, he was assessed with a left ankle sprain.

The Veteran was seen two days later in May 1994 for a follow up, during which he reported that his symptoms were improving. He had no other complaints. Following an evaluation, he was assessed with a resolving ankle sprain on the left. The Veteran's subsequent service treatment records, including the January 1995 service separation evaluation, show that this left ankle sprain had resolved. For example, the January 1995 service separation Report of Medical Examination shows that the Veteran's lower extremities, including his feet, were determined to be clinically normal. Furthermore, although he reported a positive history of swollen or painful joints, cramps in his legs, arthritis, rheumatism, bursitis, broken bones, and trick or locked knees, he denied having any foot trouble and he did not endorse abnormal symptoms associated with his left ankle at service separation.

In fact, the evidence does not show that the Veteran complained of or was treatment for a left ankle disorder prior to January 2021, at which time, he filed the present claim for service connection. Thus, the record shows that there is a more than 25-year gap between service separation in August 1995 and his complaints of or treatment for left ankle symptoms, including pain, in January 2021.

In connection with the present claim, the Veteran submitted two letters from a private chiropractor, Dr. Suzy Sarmasti, in which she stated that she had treated the Veteran for neuromusculoskeletal complaints since January 2007. In the January 2021 letter, Dr. Sarmasti stated that this was a follow-up to a similar letter she wrote in June 2018. In the June 2018 letter, this doctor did not discuss a left ankle disorder or abnormal symptoms located in this ankle. In the January 2021 letter, Dr. Sarmasti further stated that the Veteran had a history of chronic left knee pain from an injury-related degeneration. She stated that this knee required a complete joint replacement, and that over the years, the Veteran has "suffered from chronic neck pain and headaches, low back pain, left ankle pain[,] and lumbar spine disc and nerve inflammation." She noted that although the Veteran was healthy, fit, compliant, and responsive to care, he continued to have recurring episodes of these complaints. She noted that his gait was impacted by his degenerative left knee, and she opined that it was her professional opinion that it is at least as likely as not that his knee problems have directly contributed to his neck pain, headaches, ankle pain, and lumbar region problems.

The Veteran was afforded a VA examination for his ankles in July 2021, during which the examiner determined after an in-person examination, a review of the Veteran's records, and consideration of the Veteran's self-reported history and symptoms that although the Veteran had a right ankle disorder, including a lateral collateral ligament sprain, he did not have a left ankle disorder, to include limited range of motion or pain. The examiner noted that the Veteran had a May 1994 injury to his left ankle, with a diagnosis of an ankle sprain, with improved symptoms and with no other complaints. The examiner noted the Veteran reported that he wore boots for stabilization, with his right being worse than this left. A physical examination of the left ankle showed that initial and repetitive-use testing showed normal range of motion, with the Veteran being able to planter flex to 45 degrees and dorsiflex to 20 degrees in active and passive range of motion testing. There was no evidence of pain in weightbearing and non-weightbearing, on active and passive range of motion testing, or on rest/non-movement. There was no pain that caused functional loss, crepitus, or localized tenderness or pain on palpation of the joint or associated soft tissue. There was also no muscle atrophy, ankylosis, or joint instability, such as positive anterior drawer and talar tilt tests, in the left ankle. The examiner reiterated that the Veteran reported wearing boots to assist with normal mode of locomotion, with the Veteran reporting that the side was worse than the left. The examiner expressly remarked that there was no objective evidence of a current left ankle disorder at this time, to include objective evidence of instability; therefore, a diagnosis for this ankle was not warranted.

Given this evidence, the Board finds that the evidence persuasively weighs against a finding that the Veteran has had a left ankle disorder at any time during the pendency or in close proximity to filing the service-connection claim, to include symptoms that cause functional impairment of earning capacity. While the record contains the January 2021 letter by Dr. Sarmasti, in which this private chiropractor merely stated that the Veteran has suffered from chronic left ankle pain, the Board does not find this doctor's statements to be probative as to the presence of a current left ankle disorder as the letter does not contain any additional rationale or clinical findings to support the statement of a current disability. In contrast, the Board finds the July 2021 VA examination report to be probative evidence that persuasively weighs against a finding that the Veteran has a current left ankle disorder, as this examiner possessed the necessary education, training, and expertise to provide the requested findings and opinions. See Grottveit, 5 Vet. App. at 93. The examiner performed clinical testing and determined that based on the Veteran's self-report symptoms and history, review of the record that included citations to his service treatment records, and applicable medical principles, the Veteran did not have a left ankle disorder. In fact, the VA examiner also provided a medical opinion explaining why a diagnosis for the left ankle was not warranted. This medical opinion is supported by a well-reasoned rationale, which was based on a review of and citation to the service treatment records, post-service VA and/or private treatment records, lay statements from the Veteran, medical principles, and supporting medical treatise evidence. The VA examiner's opinion considered an accurate history, which is that after the in-service injury, the Veteran did not continue to experience ongoing symptoms, and was supported by a detailed rationale that considered the lay
self-report symptoms and history, review of the record that included citations to his service treatment records, and applicable medical principles, the Veteran did not have a left ankle disorder. In fact, the VA examiner also provided a medical opinion explaining why a diagnosis for the left ankle was not warranted. This medical opinion is supported by a well-reasoned rationale, which was based on a review of and citation to the service treatment records, post-service VA and/or private treatment records, lay statements from the Veteran, medical principles, and supporting medical treatise evidence. The VA examiner's opinion considered an accurate history, which is that after the in-service injury, the Veteran did not continue to experience ongoing symptoms, and was supported by a detailed rationale that considered the lay and medical evidence. Nieves-Rodriguez, 22 Vet. App. at 304.

Overall, the Board notes that the only evidence indicating the presence of this disability prior to and during the appeal period comes from the January 2021 letter by Dr. Sarmasti, which the Board finds is not probative as to the presence of a current left ankle disorder, as well as the Veteran's statements to VA adjudicators and the July 2021 VA examiner. Even if the Board accepted Dr. Sarmasti's conclusion, it finds that it outweighed by the July 2021 medical opinion. While the Board acknowledges the Veteran's subjective complaints of a left ankle disorder, the record does not show that these symptoms cause functional impairment that affects earning capacity following an individualized assessment of the degree of impairment caused by the Veteran's reported symptoms. See Saunders, 886 F.3d at 1356.

Accordingly, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for a left ankle disorder is warranted. Rather, the evidence persuasively weighs against the claim for service connection. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch, 21 F.4th at 776.

3. GERD

The Veteran contends that his GERD is caused by his active duty and/or caused or aggravated by his service-connected PTSD. For example, the Veteran asserted during the February 2022 VA examination that he developed new onset of chronic symptoms consistent with GERD during service. He told the examiner that he did not seek medical attention during service. He also reported to this examiner that his symptoms have worsened since service, which he indicated may be due to his PTSD. Additionally, the Veteran asserted in the November 2021 VA Form 21-526EZ that his GERD, which he stated began or worsened in 2000, was secondary to his PTSD. He contended that he developed GERD due to stress from his service-connected PTSD.

The Board has carefully reviewed the evidence of record and finds that the evidence persuasively weighs against the claim for service connection for GERD. The reasons follow.

Initially, as to evidence of a current disability, the record shows that the Veteran was diagnosed with GERD during the appeal. For example, a February 2022 VA examination for esophageal conditions shows that he was diagnosed with GERD since 2002. In fact, the March 2022 rating decision on appeal shows that the AOJ made a favorable finding that the Veteran was diagnosed with a disability during the appeal. Thus, the first element of direct and secondary service connection is met.

The Board further notes that in the March 2022 rating decision, the AOJ also made a favorable finding that the Veteran's PTSD, which the Veteran contends caused or aggravated his GERD, is service connected. The record shows that service connection for PTSD was established since May 14, 2018. Thus, this element of secondary service connection is also met.

As to evidence of an in-service disease or injury, the Board notes that although it acknowledges the Veteran's statements in November 2021, as well as his statements to the February 2022 VA examiner, that he developed GERD during service, the evidence persuasively weighs against finding that the Veteran experienced symptoms of GERD in service. Specifically, the Veteran's service treatment records do not document signs or symptoms indicative of GERD during service, and, in fact, support his denial of such symptoms. For example, the Veteran denied having frequent indigestion and stomach, liver, or intestinal trouble in the March 1987, January 1988, June 1988, April 1992, and January 1995 Reports of Medical History.

Post-service treatment records show that the Veteran used omeprazole medication for his GERD symptoms in a May 2019 VA treatment record. Likewise, a May 2019 private treatment record shows that he had an upper endoscopy performed in 2002, which showed antral gastritis and GERD
service. Specifically, the Veteran's service treatment records do not document signs or symptoms indicative of GERD during service, and, in fact, support his denial of such symptoms. For example, the Veteran denied having frequent indigestion and stomach, liver, or intestinal trouble in the March 1987, January 1988, June 1988, April 1992, and January 1995 Reports of Medical History.

Post-service treatment records show that the Veteran used omeprazole medication for his GERD symptoms in a May 2019 VA treatment record. Likewise, a May 2019 private treatment record shows that he had an upper endoscopy performed in 2002, which showed antral gastritis and GERD, but no evidence of a hiatal hernia or Barrett's esophagus. He was noted to have had a swallow evaluation performed recently that showed moderate GERD, but no mass effect. He started a 40 milligram dose of omeprazole in the previous month, which seemed to help most of his symptoms.

After the Veteran filed the present claim for service connection in November 2021, he underwent a VA examination, during which the examiner noted that the Veteran reported that his GERD had its onset during service. As indicated above, he reported that he had a new onset of chronic symptoms consistent with GERD but did not seek medical attention during service. However, the examiner expressly determined that the Veteran developed GERD in 2002, or approximately more than six years following active duty separation in August 1995. The examiner determined that the Veteran's GERD stayed the same since onset, but indicated that the Veteran reported that his symptoms have worsened, which he indicated may be due to his PTSD.

Following an in-person examination, review of the Veteran's records, and notation of the Veteran's self-reported symptoms and history, the examiner opined that the Veteran's GERD was less likely than not proximately due to or the result of the Veteran's service-connected PTSD. The examiner explained that GERD is caused by various mechanisms that can be classified as intrinsic, structural, or both, leading to the disruption of the esophagogastric junction barrier resulting in exposure of the esophagus to acidic gastric contents. As such, the examiner opined that a direct causal relationship was not identified. However, the examiner stated that there was evidence of GERD associated with PTSD demonstrating that persistent GERD occurred more often among those with comorbid PTSD. The examiner stated that while a direct causal nexus is not found, based on published research associating psychological stress with increased symptoms of gastroesophageal reflux and clinical experience, it was reasonable that the Veteran's GERDs symptoms are at least as likely as not aggravated beyond normal progression by his PTSD. The examiner stated that a baseline reference can reasonably be established by the absence of documented reflux symptoms during service, and that onset of his symptoms can reasonably be established by report of reflux in 2002 esophagogastroduodenoscopy (EGD) study, approximately seven years following discharge from service.

Given this evidence, the Board finds that the evidence persuasively weighs against finding that the Veteran's GERD had its onset in service or is otherwise caused or related to his active duty. While the Veteran initially asserted that his GERD was only secondary to his service-connected PTSD in the November 2021 VA Form 21-526EZ, he contended during the February 2022 VA examination that his current GERD had its onset during service. However, the Board finds such statements to not be credible as they are contradicted by the evidence contemporaneous with his service. Specifically, a review of the Veteran's service treatment records does not show documented signs or symptoms indicative of GERD but does show that he affirmatively denied having frequent indigestion and stomach, liver, or intestinal trouble throughout his service, including during the January 1995 service separation evaluation. Furthermore, the May 2019 private treatment record, as well as the February 2022 VA examination report, show that the Veteran developed GERD in 2002, or approximately more than six years following service separation in August 1995, following an EGD study. This is a situation where the facts affirmatively refute the Veteran's allegations of the onset of GERD during active duty and is persuasive evidence that weighs against finding that his GERD has been continuous since active duty. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Therefore, continuity of symptomatology is not established by the medical evidence or the Veteran's own statements. Accordingly, to the extent that the Veteran now asserts that his GERD onset in service and have been present since that time, the Board finds such statements are not credible.

The Board further finds that the evidence persuasively weighs against finding that
August 1995, following an EGD study. This is a situation where the facts affirmatively refute the Veteran's allegations of the onset of GERD during active duty and is persuasive evidence that weighs against finding that his GERD has been continuous since active duty. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006). Therefore, continuity of symptomatology is not established by the medical evidence or the Veteran's own statements. Accordingly, to the extent that the Veteran now asserts that his GERD onset in service and have been present since that time, the Board finds such statements are not credible.

The Board further finds that the evidence persuasively weighs against finding that the Veteran's GERD is caused or aggravated by his service-connected PTSD. In that regard, the Board has considered the Veteran's assertions in November 2021 and during the February 2022 VA examination that the stress from his PTSD has caused him to develop GERD or that such gastroesophageal symptoms have become worse due to his PTSD. However, while the Veteran was competent to report symptoms related to his GERD, including feelings of pain, nausea, and indigestion, as well as using omeprazole medication to treat his symptoms, determining the precise cause of the Veteran's GERD is not a simple question, as there are conceivably multiple potential causes of the Veteran's GERD, as evidenced by the February 2022 VA examiner. In this case, the facts are complex enough that the Veteran's intuition about the cause of his GERD is not sufficient to establish a nexus between the disorder and his service and/or service-connected disability. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011) (Lance, J., concurring) ("The question of whether a particular medical issue is beyond the competence of a layperson - including both claimants and Board members - must be determined on a case-by-case basis."). Accordingly, his opinions regarding the causal connection between his GERD and his service and/or service-connected PTSD are not probative.

In contrast, the February 2022 VA examiner's opinions are competent evidence as to the nexus requirement of secondary service connection. The Board finds this examiner's findings and medical opinion that the Veteran's GERD was less likely than not proximately due to or the result of his service-connected PTSD and that a direct causal relationship was not shown to be highly probative evidence regarding the causal relationship between the Veteran's current GERD and his service-connected psychiatric disability, as this examiner possessed the necessary education, training, and expertise to provide the requested opinion. See Grottveit, 5 Vet. App. at 93. In addition, the VA examiner provided a thorough rationale for the opinion, which included an explanation that GERD is caused by various mechanisms that can be classified as intrinsic, structural, or both, leading to the disruption of the esophagogastric junction barrier resulting in exposure of the esophagus to acidic gastric contents. This opinion was based on a review of and citation to the Veteran's records, lay statements from the Veteran, medical treatise evidence, and supporting clinical evidence. The VA examiner's opinion considered an accurate history and was supported by a detailed rationale, and the examiner's rationale considered the lay and medical evidence. Nieves-Rodriguez, 22 Vet. App. at 304.

The Board acknowledges that in the February 2022 VA medical opinion, the examiner stated that while a direct causal nexus is not found, based on published research associating psychological stress with increased symptoms of gastroesophageal reflux and clinical experience, it was reasonable that the Veteran's GERDs symptoms are at least as likely as not aggravated beyond normal progression by his PTSD. The examiner further stated that a baseline reference can reasonably be established by the absence of documented reflux symptoms during service, and that onset of his symptoms can reasonably be established by report of reflux in 2002 EGD study, approximately seven years following discharge from service. However, the Board determines that this examiner's opinion regarding aggravation is not probative as the examiner indicated in the examination report that the Veteran's GERD had stayed the same since onset in 2002. Thus, it is not feasible for the Veteran's GERD to be aggravated by his PTSD, which was not service connected until May 2018, or approximately 16 years following onset of GERD in 2002. Thus, as the examiner's opinion regarding aggravation is based on an inaccurate factual premise, it is not probative.

Significantly, the Veteran has not presented or identified another probative medical opinion that supports the claim for service connection for GERD or other competent and credible evidence of a relationship between the post-service GERD and his service and/or service-connected PTSD. VA adjudicators are not free to
as the examiner indicated in the examination report that the Veteran's GERD had stayed the same since onset in 2002. Thus, it is not feasible for the Veteran's GERD to be aggravated by his PTSD, which was not service connected until May 2018, or approximately 16 years following onset of GERD in 2002. Thus, as the examiner's opinion regarding aggravation is based on an inaccurate factual premise, it is not probative.

Significantly, the Veteran has not presented or identified another probative medical opinion that supports the claim for service connection for GERD or other competent and credible evidence of a relationship between the post-service GERD and his service and/or service-connected PTSD. VA adjudicators are not free to ignore or disregard the medical conclusions of a VA physician, and are not permitted to substitute their own judgment on a medical matter. Colvin v. Derwinski, 1 Vet. App. 171 (1991); Willis v. Derwinski, 1 Vet. App. 66 (1991).

For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for GERD is warranted. Rather, the evidence persuasively weighs against the claim for service connection. The benefit of the doubt doctrine, see 38 U.S.C. § 5107(b), is therefore not for application. Lynch, 21 F.4th at 776.

REASONS FOR REMAND

4. - 7. Right Hip Disorder Prior to November 3, 2021, Right Ankle Disorder, and Right and Left Foot Disorders

The Board finds that the claims for service connection for a right hip disorder prior to November 3, 2021, right ankle disorder, and bilateral foot disorder should be remanded for addendum VA medical opinions.

One of the effects of the AMA is to narrow the set of circumstances in which the Board must remand appeals to the AOJ for further development instead of immediately deciding them directly. Nevertheless, even under the AMA, the Board still has the duty to remand issues when necessary to correct a pre-decisional duty-to-assist error or to satisfy a regulatory or statutory duty. 38 C.F.R. § 20.802(a).

As discussed above, VA's duty to assist includes providing a medical examination and/or obtaining a medical opinion when necessary to make a decision on the claim, as defined by law. See 38 U.S.C. § 5103A; 38 C.F.R. §§ 3.159(c)(4), 3.326(a); McLendon, 20 Vet. App. at 83. Additionally, the VA examination and/or opinion must be adequate to decide the claim. Barr, 21 Vet. App. at 312. To be considered adequate, a medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves-Rodriguez, 22 Vet. App. at 2958).

The Board determines that the July 2021 VA medical opinions, which are authored by the same examiner, for the claims of entitlement to service connection for a right hip disorder, right ankle disorder, and right and left foot disorders are inadequate to adjudicate these claims. Accordingly, pre-decisional duty-to-assist errors occurred for these claims.

Specifically, in regard to the claim for service connection for a right hip disorder prior to November 3, 2021, the Board notes that the July 2021 VA examiner did not provide a nexus opinion answering whether the Veteran's right hip disorder was caused by his active duty and/or caused or aggravated by the service-connected bilateral knee disability because she determined that the Veteran did not have a right hip disorder at that time. However, the Board notes that an August 2021 VA radiology report showed that after the Veteran complained of bilateral hip pain, x-ray studies showed an impression of mild degenerative changes of both hips, which indicates that the Veteran was diagnosed with arthritis in the right hip prior to the issuance of the rating decision on appeal in October 2021. Thus, on remand, the AOJ should obtain an addendum VA medical opinion regarding the causal connection between the Veteran's right hip disorder, to including arthritis, and his active duty and service-connected right and left knee disabilities.

The July 2021 VA examiner's opinions regarding the claims for service connection for the right ankle disorder, as well as the bilateral foot disorder, are also inadequate, as the examiner failed to discuss whether the Veeran's service-connected right and left knee disabilities aggravated his right ankle, right foot, and/or left foot. Specifically, although the examiner opined that the Veteran's right ankle and bilateral foot disorder were not proximately due to or the result of the Veteran's service-connected disabilities, to include right and left
, on remand, the AOJ should obtain an addendum VA medical opinion regarding the causal connection between the Veteran's right hip disorder, to including arthritis, and his active duty and service-connected right and left knee disabilities.

The July 2021 VA examiner's opinions regarding the claims for service connection for the right ankle disorder, as well as the bilateral foot disorder, are also inadequate, as the examiner failed to discuss whether the Veeran's service-connected right and left knee disabilities aggravated his right ankle, right foot, and/or left foot. Specifically, although the examiner opined that the Veteran's right ankle and bilateral foot disorder were not proximately due to or the result of the Veteran's service-connected disabilities, to include right and left knee osteoarthritis, she did not address whether these disorders were aggravated by the service-connected bilateral knee disabilities. Thus, on remand, the AOJ should obtain addendum VA medical opinions addressing aggravation of these disorders by the service-connected bilateral knee disabilities.

The matters are REMANDED for the following action:

Refer the claims file to a medical professional to obtain addendum medical opinions. Schedule an examination if the examiner deems it necessary for purposes of providing an opinion. The examiner should have access to the claims file.

The AOJ must provide the examiner with a copy of the below facts.

To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record of where this evidence is located within the Veteran's VBMS file:

" The Veteran had active duty from January 1988 to August 1995.

" The Veteran is service connected for status-post left knee replacement and right knee osteoarthritis.

" The Veteran contends that his current right hip disorder, including arthritis, was caused by his active duty and/or is caused or aggravated by his service-connected right and left knee disabilities. Additionally, he contends that his right ankle and bilateral foot disorders are caused and/or aggravated by the service-connected right and left knee disabilities.

" A March 1987 Report of Medical Examination shows that the Veteran's lower extremities system was determined to be clinically normal (item 37). See VBMS entry with Document Type, "Medical Treatment Record - Non-Government," Receipt Date 01/19/2021, with "#1" in the Subject field, at p. 27.

" A June 1988 Air Crew Candidate Report of Medical Examination shows that the Veteran's lower extremities system was determined to be clinically normal (item 37). See VBMS entry with Document Type, "STR - Medical," Receipt Date 01/19/2021, with "#1" in the Subject field, at p. 59.

" An April 1992 overseas physical Report of Medical Examination shows that the Veteran's lower extremities system was determined to be clinically normal (item 37). See VBMS entry with Document Type, "STR - Medical," Receipt Date 01/19/2021, with "#1" in the Subject field, at p. 54.

" The January 1995 service separation Report of Medical Examination shows that the Veteran's lower extremities system was determined to be clinically normal (item 37). See VBMS entry with Document Type, "STR - Medical," Receipt Date 01/19/2021, with "#1" in the Subject field, at p. 48.

" In the January 1995 service separation Report of Medical History, the Veteran endorsed a positive history of swollen or painful joints and cramps in his legs and documented that this involved painful knees at times (items 11 & 25). See VBMS entry with Document Type, "STR - Medical," Receipt Date 01/19/2021, with "#1" in the Subject field, at pp. 50-51.

" In January 2021, the Veteran claimed that he had a bilateral hip disorder, bilateral ankle disorder, and bilateral foot disorder secondary to the service-connected bilateral knee disabilities. See VBMS entry with Document Type, "VA 21-526EZ, Fully Developed Claim (Compensation)," Receipt Date 01/19/2021, at p. 2.

" The Veteran underwent VA examinations for the hips and thighs, ankles, and foot disorders in July 2021. Following an in-person examination, the examiner determined that the Veteran did not have a right hip disorder. See VBMS entries with Document Type, "C&P Exam," Receipt Date 08/04/2021, with "DBQ MUSC Hip & Thigh" in the Subject field, "DBQ MUSC Ankle" in the Subject field, and "DBQ MUSC Foot Conditions Including Flatfoot (Pes Planus)" in the Subject field.

" The examiner opined that the Veteran's right ankle and bilateral foot disorders were not prox
01/19/2021, at p. 2.

" The examiner opined that the Veteran's right ankle and bilateral foot disorders were not proximately due to or the result of the Veteran's service-connected disabilities, to include right and left knee osteoarthritis. See VBMS entry with Document Type, "C&P Exam," Receipt Date 08/04/2021, with "DBQ Medical Opinion" in the Subject field, at pp. 1-5.

" An August 2021 VA radiology report showed that after the Veteran complained of bilateral hip pain, x-ray studies showed an impression of mild degenerative changes of both hips, which indicates that the Veteran was diagnosed with arthritis in the right hip. See VBMS entry with Document Type, "Medical Treatment Record - Government Facility," Receipt Date 08/09/2021, at p. 4.

" The Board determines that the medical opinions obtained during the July 2021 VA examinations regarding the cause of the Veteran's right hip, right ankle, and bilateral foot disorders are inadequate. Specifically, the examiner did not provide nexus opinions regarding the right hip disorder as she determined that he did not have a right hip disorder. As indicated above, the evidence shows that he was diagnosed with arthritis in this hip following an x-ray study in August 2021. Furthermore, while the examiner opined that the Veteran's right ankle and bilateral foot disorders were not proximately due to or the result of the Veteran's service connected disabilities, to include right and left knee osteoarthritis, she failed to address whether these disorders were aggravated by the service-connected bilateral knee disabilities.

" Aggravation is different from causation in that it did not cause the disability but rather caused a worsening of functionality.

" The examiner's review of the record is NOT restricted to the evidence listed above. This list is provided to assist the examiner in locating potentially relevant evidence.

After a review of the record, including this Remand, the examiner should:

(a.) Provide an opinion as to whether the Veteran's current right hip disorder, to include arthritis, had its onset in service or is otherwise related to the Veteran's service from January 1988 to August 1995. Please explain upon what facts, medical principles, and/or medical literature the opinion is based.

(b.) Provide an opinion as to whether the Veteran's current right hip disorder is caused by his service-connected right and/or left knee disabilities. Please explain upon what facts, medical principles, and/or medical literature the opinion is based.

(c.) If the answer to (b.) is in the negative, provide an opinion as to whether the Veteran's current right hip disorder is aggravated by the service-connected right and/or left knee disabilities. Aggravation is different from causation in that it did not cause the disability but rather caused a worsening of functionality. Please explain upon what facts, medical principles, and/or medical literature the opinion is based.

(d.) If the examiner finds that the service-connected right and/or left knee disabilities caused an increase in severity or worsening of functionality of the right hip disorder, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the right hip disorder prior to aggravation. If the examiner is unable to establish a baseline for the right hip disorder prior to the aggravation, he or she should state such and explain why a baseline cannot be determined.

In rendering the above requested opinions, the examiner should take as fact that the Veteran has a current right hip disability as he was diagnosed with mild degenerative changes in both hips in August 2021.

(e.) Provide opinions as to whether the Veteran's current right ankle, right foot, and/or left foot disorders are aggravated by the service-connected right and/or left knee disabilities. Aggravation is different from causation in that it did not cause the disability but rather caused a worsening of functionality. Please explain upon what facts, medical principles, and/or medical literature the opinion is based.

(f.) If the examiner finds that the service-connected right and/or left knee disabilities caused an increase in severity or worsening of functionality of the right ankle, right foot, and/or left foot disorders, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the right ankle, right foot, and/or left foot disorders prior to aggravation. If the examiner is unable to establish a baseline for the right ankle, right foot, and/or left foot disorders prior to the aggravation, he or she should state such and explain why a baseline cannot be determined.

The examiner is asked to provide a rationale for each opinion given. If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what if any additional evidence would be necessary before an opinion could be rendered.

A. P. SIMPSON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board A. Hodzic, 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.

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