MIGRAINE

MICHAEL A. HERMAN · 2025 · Case ID: A25102172

MIXED

Summary

The veteran, who served in the United States Army from August 1987 to June 1988, appeals the denial of service connection for bilateral hallux valgus, degenerative arthritis of the feet, and bilateral flat feet, while also seeking service connection for migraines, hypertension, GERD, cervical strain, left hip condition, and bilateral plantar fasciitis. The veteran claimed these conditions were secondary to his service-connected depressive disorder, insomnia disorder, panic disorder, and lumbar spine degenerative arthritis. The Board granted service connection for migraines, hypertension, GERD, cervical strain, left hip condition, and bilateral plantar fasciitis. For migraines, hypertension, and GERD, the Board found a nexus to the veteran's service-connected psychiatric conditions based on a private medical opinion from Dr. S.B., which linked these conditions to factors like increased cortisol and sympathetic nervous system hyperreactivity associated with depression and anxiety. The Board found the evidence in approximate balance for these claims, resolving doubt in the veteran's favor. For cervical strain, left hip condition, and plantar fasciitis, the Board also found the evidence in approximate balance, linking them to gait dysfunction caused by the service-connected lumbar spine disability, often citing Dr. S.B.'s opinion and invoking the benefit-of-the-doubt standard. The claims for hallux valgus, degenerative arthritis of the feet, and bilateral flat feet were denied. The Board found the evidence weighed against a nexus for hallux valgus and degenerative arthritis, noting negative VA opinions and lack of contrary evidence. For flat feet, the Board found the condition pre-existed service and was not aggravated, as service records were silent on complaints and no evidence supported aggravation.

Rationale

Private medical opinion linked migraines to MDD; Evidence in approximate balance; Benefit of the doubt invoked

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

241119-495877

Full Decision Text

Citation Nr: A25102172
Decision Date: 11/25/25 Archive Date: 11/25/25

DOCKET NO. 241119-495877
DATE: November 25, 2025

ORDER

Entitlement to service connection for migraines is granted.

Entitlement to service connection for hypertension is granted.

Entitlement to service connection for gastroesophageal reflux disease is granted.

Entitlement to service connection for cervical strain is granted.

Entitlement to service connection for left hip condition is granted.

Entitlement to service connection for bilateral plantar fasciitis is granted.

Entitlement to service connection for bilateral hallux valgus is denied.

Entitlement to service connection for degenerative arthritis of the feet is denied.

Entitlement to service connection for bilateral flat feet is denied.

FINDINGS OF FACT

1. The Veteran's migraines, hypertension, and gastroesophageal reflux disease (hereafter "GERD") are caused by his service-connected depressive disorder, insomnia disorder and panic disorder.

2. The Veteran's cervical strain, left hip disorder, and bilateral fasciitis are caused by his service-connected lumbosacral spine degenerative arthritis with degenerative disc disease and intervertebral disc syndrome.

3. The Veteran's bilateral hallux valgus did not begin during active service; and, the persuasive weight of the evidence is against a nexus between hallux valgus and active service and/or a service-connected disability.

4. The Veteran's degenerative arthritis of the bilateral feet did not begin during active service or within one year of discharge; and, the persuasive weight of the evidence is against a nexus between degenerative arthritis of the bilateral feet and active service and/or a service-connected disability.

5. The Veteran's flat feet pre-existed active service and were not aggravated by such service; and, the persuasive weight of the evidence is against a nexus between flat feet and active service and/or a service-connected disability.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for migraines have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for entitlement to service connection for hypertension have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for entitlement to service connection for GERD have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. The criteria for entitlement to service connection for cervical strain have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

5. The criteria for entitlement to service connection for left hip condition have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

6. The criteria for entitlement to service connection for bilateral plantar fasciitis have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

7. The criteria for entitlement to service connection for bilateral hallux valgus have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

8. The criteria for entitlement to service connection for degenerative arthritis of the feet have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

9. The criteria for entitlement to service connection for bilateral flat feet have not been met. 38 U.S.C. §§ 1110, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from August 1987 to June 1988.

These matters come before the Board of Veterans' Appeals (Board) on appeal of rating decisions issued on March 14, 2024, and August 19, 2024, by the
3.307, 3.309, 3.310.

9. The criteria for entitlement to service connection for bilateral flat feet have not been met. 38 U.S.C. §§ 1110, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from August 1987 to June 1988.

These matters come before the Board of Veterans' Appeals (Board) on appeal of rating decisions issued on March 14, 2024, and August 19, 2024, by the agency of original jurisdiction (AOJ) of the Department of Veterans Affairs (VA). The Veteran, through counsel, filed a VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement (NOD)), on November 19, 2024. He chose the evidence submission docket. This means that he had 90 days from the date VA received his 10182 to submit additional evidence (i.e., February 17, 2025). The Board sent a docketing notification letter to the Veteran dated December 27, 2024.

The Veteran submitted additional evidence within the allotted period. The allotted period has since expired. The Board will proceed with a final decision.

Service Connection - Legal Criteria

Service connection may be granted for a disability resulting from disease or injury incurred coincident with or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing direct service connection generally requires competent evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Establishing service connection on a secondary basis requires evidence sufficient to show (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. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

Service connection for certain chronic diseases, including arthritis, listed at 38 C.F.R. § 3.309(a) may be established on a presumptive basis if the chronic disease was shown as chronic in service; manifested to a compensable degree within a presumptive period (1 year, in the case of arthritis) after separation; or was noted in service with continuity of symptomatology since service. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

The U.S. Court of Appeals for the Federal Circuit has held that pain causing functional impairment may be considered a disability even in the absence of a diagnosed condition. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). However, to establish the presence of a disability, a veteran will need to show that his pain reaches the level of a functional impairment of earning capacity. Id.

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). An approximate balance of the evidence includes but is not limited to equipoise. Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021). Evidence is not in "approximate balance" or "nearly equal" when the evidence persuasively favors one side or the other. Id.

Service Connection - Migraines

The Veteran seeks service connection for migraines. He asserts they are caused by his service-connected depressive disorder, insomnia disorder and panic disorder.

The AOJ conceded favorable findings that the Veteran has a current disability and that primary disabilities of tinnitus, lumbar spine, and bilateral knees are service-connected. The Veteran is also service
(b). An approximate balance of the evidence includes but is not limited to equipoise. Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021). Evidence is not in "approximate balance" or "nearly equal" when the evidence persuasively favors one side or the other. Id.

Service Connection - Migraines

The Veteran seeks service connection for migraines. He asserts they are caused by his service-connected depressive disorder, insomnia disorder and panic disorder.

The AOJ conceded favorable findings that the Veteran has a current disability and that primary disabilities of tinnitus, lumbar spine, and bilateral knees are service-connected. The Veteran is also service-connected for depressive disorder, insomnia disorder and panic disorder. The remaining element of service connection on a secondary basis is a nexus between migraines and a service-connected disability(ies).

The Veteran submitted a medical opinion from Dr. S.B. received on February 14, 2025. Dr. S.B. reviewed the claims file and opined that it is at least as likely as not that the Veteran's headaches are secondary to his service-connected acquired psychiatric disorder. Dr. S.B. explained that major depressive disorder (MDD) prevalence rates have been demonstrated to be increased in those with headaches in multiple different cohort studies. He identified the chemical interactions of those who experience MDD and the development of headaches. In particular, MDD is associated with both lower levels of cortisol and elevations of several proinflammatory cytokines, which have also been implicated in migraine headaches. Referencing the same, Dr. S.B. stated "I am convinced [the Veteran's] headaches are at least likely than not secondary to his service-connected MDD."

The evidence is at least in approximate balance as to whether there is a nexus between the Veteran's migraines and his service-connected acquired psychiatric disorder. Dr. S.B. explained that depressive disorder (including MDD) can cause hyperreactivity of the sympathetic nervous system and that dysfunction of the autonomic system and the hypothalamic-pituitary-adrenal (HPA) axis have been identified as possible etiological factors. His findings are reasonable and consistent with his expertise as a medical professional. The Board affords his conclusions significant probative weight in this matter.

The AOJ obtained a medical opinion received on October 9, 2023. The examiner issued a negative nexus opinion between migraines and several service-connected disabilities. Yet, he did not address the contention that the acquired psychiatric disorder caused the headaches. Dr. S.B.'s opinion stands unchallenged by any competent medical evidence. Accordingly, with the benefit of the doubt resolved in the Veteran's favor, a grant of service connection for is warranted. See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) (holding that this low standard of proof is "unique" to the VA process, and "the nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding such benefits.").

Service Connection - Hypertension

The Veteran seeks service connection for hypertension. He asserts that it is caused by his service-connected depressive disorder, insomnia disorder and panic disorder.

The AOJ conceded favorable findings that the Veteran has a current disability and that primary disabilities of the bilateral knees are service-connected. The Veteran is also service-connected for depressive disorder, insomnia disorder and panic disorder. The remaining element of service connection on a secondary basis is a nexus between hypertension and a service-connected disability.

In that regard, the Board turns again to Dr. S.B.'s opinion, who concluded that the Veteran's diagnosis of hypertension is at least as likely than not secondary to his MDD. A general reference was made to there being "numerous literature findings" that associated MDD and hypertension. There is considerable evidence suggesting that hyperreactivity of the sympathetic nervous system and genetic influences are the underlying mechanisms in the relationship between depression and hypertension. He added that the use of antidepressive agents contributed to the development of hypertension as well.

A negative opinion was obtained by VA in October 2023. The focus of this opinion was on whether a relationship existed between the Veteran's hypertension and service connected orthopedic disability. It was probative as to that question. However, there was no discussion of whether the Veteran's hypertension was secondary to his psychiatric disability, i.e., MDD.

The Board finds that the evidence is at least in approximate balance as to whether there exists a nexus between the Veteran's hypertension and his service-connected acquired psychiatric disorder. Dr. S.B. reasoned that the Veteran's psychiatric disorder can cause hyperreactivity of the sympathetic nervous system which leads to hypertension. The VA examiner did not address
development of hypertension as well.

In summary, the evidence is at least in approximate balance as to whether there is a nexus between the Veteran's hypertension and his service-connected depressive disorder, insomnia disorder and panic disorder. The claim is granted.

Service Connection - GERD

The Veteran seeks service connection for GERD. He asserts that it is caused by his service-connected depressive disorder, insomnia disorder and panic disorder.

The AOJ conceded favorable findings that the Veteran has a current disability and that primary disabilities of the bilateral knees and lumbar spine are service-connected. The Veteran is also service-connected for depressive disorder, insomnia disorder and panic disorder. The remaining element of service connection on a secondary basis is a nexus between GERD and a service-connected disability.

Dr. S.B. provided an opinion linking the Veteran's GERD to his service connected psychiatric disorder. The opinion is less clear in terms of rationale. The opinion appears to state that the Veteran's MDD causes increased cortisol that in turn caused the reflux leading to the GERD diagnosis. Dr. S.B. stated there is established research showing that abnormal cortisol levels have been shown repeatedly to have a strong nexus to the release of gastritis and GERD. Patients with anxiety or depression are at an increased risk for the development of reflux symptoms. Notably, it was seen that patients with depression had a 3.2-fold increased risk of reflux symptoms and that those with anxiety had a 1.7-fold increased risk; subjects with both anxiety and depression presented a 2.8 -fold increased risk compared with subjects without anxiety/depression.

Once again, there exists a situation where Dr. S.B. linked GERD to a service-connected acquired psychiatric disorder and a VA examiner did not address this theory. Dr. S.B. reasoned that interplay between psychological stress and the release of cortisol may cause the release of elevated gastric secretions and many studies have shown that patients with anxiety or depression are at an increased risk for the development of reflux symptoms. Dr. S.B.'s medical opinion is entitled to significant probative weight.

In summary, the evidence is at least in approximate balance as to whether the Veteran's GERD is caused by his service-connected depressive disorder, insomnia disorder and panic disorder. The claim is granted.

Service Connection - Cervical Strain

The Veteran seeks service connection for a cervical strain. He asserts that it is caused by his service-connected lumbosacral spine degenerative arthritis with degenerative disc disease and intervertebral disc syndrome.

The AOJ conceded favorable findings that the Veteran has a current disability and that primary disabilities of the right knee, radiculopathy, and lumbar spine are service-connected. The remaining element of service connection on a secondary basis is a nexus between a cervical strain and a service-connected disability.

A VA examiner issued a negative nexus opinion regarding a nexus between the cervical strain and the right knee disability on November 9, 2022. However, within the opinion, the examiner stated that the Veteran "has some issues with his lumbar and thoracic spine. This would be more likely to affect his cervical spine than his knee." The Veteran is service-connected for a lumbar spine disability. Under a generous reading of the opinion, the examiner appears to suggest that a lumbar spine disability can affect the cervical spine disability and that it is more likely to have done so than the knee in this case. This tends to support a nexus. Although there is not much detail in the opinion, the Board will not remand this matter to obtain negative evidence. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that the Board will not remand for negative evidence). The Board will adopt the most favorable possible interpretation of the medical opinion, invoke the approximate balance standard, and concede a nexus in this case.

In summary, the evidence is at least in approximate balance as to whether
reading of the opinion, the examiner appears to suggest that a lumbar spine disability can affect the cervical spine disability and that it is more likely to have done so than the knee in this case. This tends to support a nexus. Although there is not much detail in the opinion, the Board will not remand this matter to obtain negative evidence. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that the Board will not remand for negative evidence). The Board will adopt the most favorable possible interpretation of the medical opinion, invoke the approximate balance standard, and concede a nexus in this case.

In summary, the evidence is at least in approximate balance as to whether the Veteran's cervical strain is caused by his service-connected lumbosacral spine degenerative arthritis with degenerative disc disease and intervertebral disc syndrome. The benefit-of-the-doubt standard is invoked. The claim is granted.

Service Connection - Left Hip Condition

The Veteran seeks service connection for a left hip condition. He asserts that he has a qualifying left hip condition caused by his service-connected lumbar spine and bilateral disabilities.

The AOJ conceded favorable findings that the Veteran has a service-connected disability and that primary disabilities are service-connected. The remaining element of secondary service connection is a nexus.

Dr. S.B. reasoned that the Veteran's lumbar spinal disease has caused an ongoing gait dysfunction which led to compensatory injuries to his left hip and both feet (plantar fasciitis). A detailed explanation was provided with respect to the interplay between how lower extremity disabilities cause gait dysfunction (interference in how an individual walks) and the development of problems impacting the spine and hips. Essentially, Dr. S.B. indicated that the body adapts to an injury in the lower limbs, and that that adaptation causes additional stress on other joints such as the lumbar spine and hips. Acknowledging the negative VA opinions of record, he stated the examiners failed to sufficiently consider the impact that the Veteran's gait change had on his total body system.

The evidence is at least in approximate balance as to whether there is a nexus between the Veteran's left hip condition and his service-connected lumbar spine disability. Dr. S.B. issued a reasonable medical opinion explaining that even a small gait change over the years can result in changes in other weight-bearing joints and tissues including the hips and feet. He cited to medical studies in support of his opinion. His findings are entitled to probative weight.

A VA examiner issued negative nexus opinion on April 30, 2024. She reasoned, among other things, that:

There is no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis, or shortening of the injured limb resulting in length discrepancy of more than 5cm so that the individuals gait pattern has been altered to the extent that clinically there is an obvious Trendelenburg gait. This level of severity is not supported based on record review, history or exam. It is not unusual for two joints to share properties in the same person, but one joint's disease does not 'spread' to another or cause damage to it (Oxford's Textbook on Orthopedics and Trauma). There is no evidence of muscle atrophy, joint ankylosis, joint instability, neurologic deficit, fracture nonunion/malunion, or leg length discrepancy resulting in significant gait alteration (Trendelenburg gait). Therefore, the claimed left hip condition is less likely than not proximately due to or the result of left knee strain with instability.

However, the examiner's opinion is conclusory because she found that record review, history or exam did not support an altered gait, but she did not explain why she believed that was the case. Dr. S.B. disagreed and linked the Veteran's left hip condition to an altered gait caused by service-connected lumbar spine and knee disabilities. As the competent medical evidence disagrees over a nexus, and there is no compelling reason to favor the negative opinion over the positive one, the Board will invoke the approximate balance standard and concede a nexus.

In summary, the evidence is at least in approximate balance as to whether the Veteran's left hip condition is caused by his service-connected lumbosacral spine degenerative arthritis with degenerative disc disease and intervertebral disc syndrome. The benefit-of-the-doubt standard is invoked. The claim is granted.

Service Connection - Plantar Fasciitis

The Veteran seeks service connection for bilateral plantar fasciitis. He asserts that the disease is caused by his service-connected lumbosacral spine degenerative arthritis
. As the competent medical evidence disagrees over a nexus, and there is no compelling reason to favor the negative opinion over the positive one, the Board will invoke the approximate balance standard and concede a nexus.

Service Connection - Plantar Fasciitis

According to the Mayo Clinic, plantar fasciitis (PLAN-tur fas-e-I-tis) is one of the most common causes of heel pain. It involves inflammation of a thick band of tissue that runs across the bottom of each foot and connects the heel bone to the toes, known as the plantar fascia. See Plantar Fasciitis, Mayo Clinic, https://www.mayoclinic.org/diseases-conditions/plantar-fasciitis/symptoms-causes/ (last accessed November 6, 2025).

The AOJ conceded favorable findings that the Veteran has a current disability and that primary disabilities of the bilateral knees and lumbar spine are service-connected. The remaining element of service connection on a secondary basis is a nexus between plantar fasciitis and a service-connected disability.

Dr. S.B. provided the same medical opinion quoted in the section above. He cited medical studies in support of his finding. His opinion is entitled to weight.

The VA examiner opined, among other things, as follows:

there is no mechanism for causation of foot disorders by spinal disease, or knee disease. Available records are silent for any specific event or circumstance which would provide a likely exception to this general rule in this case. This also applies to aggravation, with no mechanism for causation of, or aggravation of, any foot disorder, by knee or spinal disorders, which are separate systems with separate functions.

The evidence is at least in approximate balance as to whether there is a nexus between the Veteran's plantar fasciitis and his service-connected lumbar spine disability. Dr. S.B. issued a reasonable medical opinion explaining that even a small gait change over the years can result in changes in other weight-bearing joints and tissues including the hips and feet. He cited to medical studies in support of his opinion. His findings are entitled to probative weight.

The VA examiner found that there was no mechanism for causation of plantar fasciitis by a lumbar spine disability. However, his findings are contradicted by Dr. S.B.'s opinion, which cited numerous medical reference materials which are purportedly supportive of an altered gait causing symptoms in other areas. Given that the medical experts disagree about whether literature supports a casual nexus, the Board will resolve reasonable doubt in the Veteran's favor on this element.

The VA examination did not document an abnormal gait on February 8, 2023. Yet, even though the Veteran's gait may have been normal at the time of the exam, this does not exclude a history of abnormal gait. The Veteran is competent to report that pain from his service-connected disabilities causes him to walk differently than he otherwise would. His private medical expert has linked such reports to the claimed disability. The Board will invoke the approximate balance standard and concede a nexus in this case. See 38 U.S.C. § 5107(b); Wise, 26 Vet. App. at 531.

In summary, the evidence is at least in approximate balance as to whether the Veteran's plantar fasciitis is caused by his service-connected lumbosacral spine degenerative arthritis with degenerative disc disease and intervertebral disc syndrome. The benefit-of-the-doubt standard is invoked. The claim is granted.

Service Connection - Hallux Valgus

The Veteran seeks service connection for bilateral hallux valgus. He generally asserts that service connection should be granted for the disease.

According to the Cleveland Clinic, hallux valgus (more commonly known as "bunion") is a bony bump that forms at the base of the big toe. The bump develops on the inside edge of the big toe joint - the metatarsophalangeal (MTP) joint. The MTP joint is where the base of the big toe meets the foot. The medical term for bunions is hallux valgus. See Bunions (Hallux Valgus), Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/143
ux Valgus

The Veteran seeks service connection for bilateral hallux valgus. He generally asserts that service connection should be granted for the disease.

The AOJ conceded favorable findings that the Veteran has a current disability and that primary disabilities of the bilateral knees and lumbar spine are service-connected. The remaining element of service connection on a secondary basis is a nexus between hallux valgus and a service-connected disability. The evidence weighs against this aspect of the appeal.

Notably, the VA examiner explained that hallux valgus is caused by shoes or boots with narrow toe boxes, combined with activities such as walking, stairs or hiking. He explained that there is no causal mechanism by which it can be caused or aggravated by a service-connected lumbar spine or bilateral knee disability. The Board will afford his opinion probative weight on this issue.

The Veteran's attorney argued that the VA examiner failed to consider whether an altered gait or posture because of his spine, knees, and back could have led to the development or aggravation of his bilateral plantar fasciitis. He did not make the same argument for hallux valgus. See Medical Treatment Record -Non-Government Facility, February 14, 2025 (p.15) (containing attorney's brief which did not provide argument for hallux valgus). The VA examiner indicated that he reviewed the Veteran's e-folder, which contained his allegations that hallux valgus was caused or aggravated by his lumbar spine or knee disabilities. Although the VA examiner did not explicitly discuss such contentions, there is no clear evidence that he did not consider the contentions. The law imposes no reasons or bases standard on VA examiners. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012).

In his aforementioned and discussed opinion, Dr. S.B. did not address the Veteran's diagnosis of hallux valgus, flat feet, or degenerative arthritis of the bilateral feet or link any of these to active service or a service-connected disability. His opinion exclusively referenced plantar fasciitis, despite the fact that he noted that the VA examination report diagnosed hallux valgus, flat feet, and degenerative arthritis. If the Veteran would like to obtain clarification from Dr. S.B. and submit an addendum opinion addressing hallux valgus, flat feet, or degenerative arthritis of the bilateral feet he remains free to do so by filing a supplemental claim within a year of this decision. 38 C.F.R. § 3.2501.

In summary, the persuasive weight of the evidence is against a nexus between hallux valgus and a service-connected lumbar spine or knee disability. The benefit-of-the-doubt is not invoked. The claim is denied.

Service Connection - Degenerative Arthritis of the Feet

The Veteran seeks service connection for degenerative arthritis of the feet. He generally asserts that service connection should be granted for the disease.

The AOJ conceded favorable findings that the Veteran has a current disability and that primary disabilities of the bilateral knees and lumbar spine are service-connected. The remaining element of service connection on a secondary basis is a nexus between degenerative arthritis of the feet and a service-connected disability.

This appeal must fail for similar reasons as the issue of hallux valgus discussed above. The VA examiner issued a negative nexus opinion finding that there is no there is no mechanism for causation of foot disorders (including degenerative arthritis) by spinal disease, or knee disease. He reviewed the claims file and considered the Veteran's history. His opinion stands unchallenged by competent medical evidence. The Board will afford his findings probative weight. Neither the Veteran's attorney nor Dr. S.B. provided specific evidence or argument linking degenerative arthritis to service-connected lumbar spine and knee disabilities.

Service connection is not warranted under the chronic disease presumption. The evidence does not show arthritis manifesting as a chronic disease within one year of the Veteran's discharge from active service. 38 C.F.R. § 3.309.

In summary,
finding that there is no there is no mechanism for causation of foot disorders (including degenerative arthritis) by spinal disease, or knee disease. He reviewed the claims file and considered the Veteran's history. His opinion stands unchallenged by competent medical evidence. The Board will afford his findings probative weight. Neither the Veteran's attorney nor Dr. S.B. provided specific evidence or argument linking degenerative arthritis to service-connected lumbar spine and knee disabilities.

In summary, the persuasive weight of the evidence is against a nexus between degenerative arthritis and service-connected lumbar spine and knee disabilities. The benefit-of-the-doubt is not invoked. The claim is denied.

Service Connection - Flat Feet

The Veteran seeks service connection for flat feet (pes planus). He generally asserts that service connection should be granted for the disease.

Every person employed in the active service is presumed to be in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment. 38 U.S.C. § 1111.

To be "noted" within the meaning of the presumption of soundness statute, the condition must be recorded in the entrance examination report. Crowe v. Brown, 7 Vet. App. 238, 245 (1994). History of pre-service existence of a disease does not constitute notation of such condition. Id. at 240. However, the disease does not need to be symptomatic at the time of the evaluation. See Verdon v. Brown, 8 Vet. App. 529, 530 (1996) (holding that "bunions" were noted at induction examination where orthopedic examiner diagnosed "bunions," despite also stating "no problem [with] feet.").

If a preexisting disorder is noted upon entry into service, the Veteran cannot bring a claim for service connection for that disorder, but the Veteran may bring a claim for service-connected aggravation of that disorder. A preexisting disability will be presumed to have been aggravated by service where there is an increase in disability during such service, unless there is a specific finding that the increase is due to the natural progression of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306 (a). However, to avail themselves of this presumption of aggravation, initially, the burden is on the Veteran to establish an increase in severity in service. Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Horn v. Shinseki, 25 Vet. App. 231 (2012). If the Veteran demonstrates an increase in severity in service, then the presumption of aggravation attaches, and the burden shifts to VA to rebut the presumption by clear and unmistakable evidence (obvious or manifest) that the worsening of the preexisting disability was due to its natural progression. 38 C.F.R. § 3.306 (b).

The occurrence of symptoms, in the absence of an increase in the underlying severity, does not constitute aggravation of the disability. See Davis v. Principi, 276 F.3d 1341, 1345 (Fed. Cir. 2002); 38 C.F.R. § 3.306(a). Furthermore, temporary, or intermittent flare-ups of a preexisting condition during service are not sufficient to be considered aggravation of the condition, unless the underlying condition, as contrasted to symptoms, worsens. See Jensen v. Brown, 4 Vet. App. 304, 306-07 (1993); Hunt v. Derwinski, 1 Vet. App. 292 (1991).

If the evidence establishes that a pre-existing disability worsened during a period of qualifying service, then the presumption of aggravation attaches. To rebut the presumption, VA must show by clear and unmistakable evidence that worsening is due to the natural progress of the disability. See Quirin v. Shinseki, 22 Vet. App. 390, 396 (2009). Clear and unmistakable evidence has been defined as evidence that "cannot be misinterpreted and misunderstood, i.e., it is undebatable." Vanerson v. West, 12 Vet. App. 254, 258-59 (1999).

According to
); Hunt v. Derwinski, 1 Vet. App. 292 (1991).

According to the Cleveland Clinic, pes planus means having flat feet - or one flat foot - with little-to-no arch in the sole. Pes planus can manifest during childhood. The feet may have also lose their natural arches due to a medical condition. See Pes Planus, Cleveland Clinic, https://my.clevelandclinic.org/health/diseases/flat-feet-pes-planus (last accessed November 6, 2025).

Flat feet was noted on the Veteran's enlistment examination. See STR-Medical, March 2, 2022 (p.48). The clinician checked the box for "abnormal" feet. He wrote "pes planus moderate. Denies symptoms.". In the summary of defects and diagnoses, the clinician wrote "pes planus asymptomatic." Id. at 49. The presumption of soundness does not attach. The Veteran has the burden of showing aggravation of flat feet during active service to an approximate balance standard.

The Veteran has not produced such evidence. Service medical records do not show any complaints of foot pain or foot symptoms attributable to flat feet. The Veteran did not discernably allege that his pre-existing flat feet were aggravated by active service. The attorney made no arguments relevant to aggravation of pre-existing flat feet in his appellate brief. The Veteran's private medical expert did not link flat feet to active service or a service-connected disability despite doing so for plantar fasciitis. Likewise, a VA examiner issued a negative nexus opinion on September 30, 2023, finding that there is no mechanism for causation or aggravation of any foot disorder (including flat feet) by knee or spinal disorders. His opinion is entitled to probative weight. The attorney did not challenge the examiner's findings regarding degenerative arthritis, flat feet, or hallux valgus. The Board can see no reasonable basis to find aggravation of pre-existing flat feet. An essential element of service connection based on the presumption of aggravation is not met. Secondary service connection is not warranted. The claim is denied.

MICHAEL A. HERMAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board D. Reed, 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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