POSTTRAUMATIC STRESS DISORDER (PTSD)

S. B. MAYS · 2026 · Case ID: A26000420

GRANTED

Summary

The Veteran, who served from October 1985 to April 1992, appeals the denial of service connection for migraines, lumbar spine degenerative disc disease, right hip strain, and bilateral ankle sprains. All claimed conditions were sought as secondary to already service-connected feet disabilities, including bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture. The Board found the Veteran's PTSD to be service-connected, which was a favorable finding for the migraines claim. The primary evidence considered for the secondary claims was a private medical opinion from W.H., a licensed clinician, which linked the Veteran's migraines to PTSD and the lumbar spine, hip, and ankle conditions to the service-connected feet disabilities. W.H.'s opinions were found to be competent, credible, and probative, citing medical literature to support the biomechanical link between the feet conditions and the subsequent issues. The Board noted that multiple VA examinations were inadequate, either failing to address aggravation or providing unfavorable nexus opinions without sufficient rationale or by making unsupported conclusions. The Board found the evidence in relative equipoise for all secondary claims, applying the benefit of the doubt doctrine. Consequently, service connection for migraines, lumbar spine degenerative disc disease, right hip strain, and bilateral ankle sprains, as secondary to the service-connected feet disabilities, was granted.

Rationale

Private opinion by W.H. found migraines related to PTSD.; VA opinions were inadequate (failed to address aggravation or were not responsive).; Evidence in relative equipoise, benefit of doubt applied.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250425-541087

Full Decision Text

Citation Nr: A26000420
Decision Date: 01/05/26 Archive Date: 01/05/26

DOCKET NO. 250425-541087
DATE: January 5, 2026

ORDER

Service connection for migraines, as secondary to service-connected posttraumatic stress disorder (PTSD), is granted.

Service connection for lumbar spine degenerative disc disease, as secondary to service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture, is granted.

Service connection for right hip strain, as secondary to service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture, is granted.

Service connection for right ankle lateral collateral ligament sprain, as secondary to service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture, is granted.

Service connection for left ankle lateral collateral ligament sprain, as secondary to service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture, is granted.

FINDINGS OF FACT

1. Resolving any reasonable doubt in favor of the Veteran, her migraine headaches are causally related to her service-connected PTSD.

2. Resolving any reasonable doubt in favor of the Veteran, her lumbar spine degenerative disc disease is causally related to her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture.

3. Resolving any reasonable doubt in favor of the Veteran, her right hip strain is causally related to her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture.

4. Resolving any reasonable doubt in favor of the Veteran, her right ankle lateral collateral ligament sprain is causally related to her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture.

5. Resolving any reasonable doubt in favor of the Veteran, her left ankle lateral collateral ligament sprain is causally related to her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture.

CONCLUSIONS OF LAW

1. The criteria for service connection for migraines, as secondary to service-connected PTSD, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for lumbar spine degenerative disc disease, as secondary to service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for service connection for right hip strain, as secondary to service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. The criteria for service connection for right ankle lateral collateral ligament sprain, as secondary to service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

5. The criteria for service connection for left ankle lateral collateral ligament sprain, as secondary to service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REAS
tarsal fracture, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from October 1985 to April 1992.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from August 2024 and October 2024 Appeals Modernization Act (AMA) rating decisions and March 2025 higher level review by a Department of Veterans Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ), that denied the Veteran's claims for service connection for migraines, a back disability, a right hip disability, and right and left ankle disabilities, finding that there is no evidence of a diagnosed migraines disability, and that the Veteran's back, right hip, and right and left ankle disabilities are not secondary to the service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture (also abbreviated "Feet Disabilities" herein). The March 2025 rating decision noted favorable findings: Regarding the claimed migraines disability, the AOJ recognized that the primary disability of PTSD is service-connected; Regarding the back disability, the AOJ recognized a current diagnosis of lumbar spine degenerative disc disease, and that the Veteran is service-connected for the Feet Disabilities; Regarding the right hip disability, the AOJ recognized a current diagnosis of right hip strain and that the Veteran is service-connected for the Feet Disabilities; and Regarding the right and left ankle disabilities, the AOJ recognized a current diagnoses of bilateral ankle lateral collateral ligament sprain and that the Veteran is service-connected for the Feet Disabilities. The Board is bound by favorable findings unless they are rebutted by clear and unmistakable error. 38 U.S.C. § 5104A.

In April 2025, the Veteran initiated this appeal to the Board with the filing of a Decision Review Request-Notice of Disagreement (VA Form 10182), requesting direct review by a Veterans Law Judge on the evidence of record at the time of the rating decisions. In May 2025 correspondence, the Board acknowledged the appeal and informed the Veteran and his attorney that the appeal had been placed on the Board's direct review docket. Therefore, the Board may only consider the evidence of record at the time of the AOJ's rating decisions on appeal, here as of August 27, 2024 or the migraines claim, and October 23, 2024 for the back, right hip, and right and left ankle claims. 38 U.S.C. § 7113(a). The Board cannot consider evidence submitted after the AOJ issued the decisions on appeal. 38 C.F.R. § 20.301.

The Veteran has the right to select a different Board review option by submitting a new VA Form 10182 within one year from the date the AOJ mailed the March 2025 decision on appeal, or within 60 days of the date the Board received the VA Form 10182, whichever date is later. 38 C.F.R. § 20.202(c)(2); see Williams v. McDonough, 37 Vet. App. 305 (2024). The Board recognizes that the period to change AMA dockets under 38 C.F.R. § 20.202(c)(2) has not yet elapsed. However, given that the decision herein constitutes a full grant of the benefits sought on appeal, there is no prejudice to the Veteran in proceeding with adjudication of the claim.

Preliminary Matters

Regrettably, despite affording the Veteran numerous VA examinations in recent years, not one of the 18 VA medical opinions relevant to the instant claims is adequate for adjudication purposes. Although the April 2024 private opinions by W.H. address both direct and secondary service connection, the manner in which the opinions were written renders the direct nexus opinions unclear. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion comes, in part, from its being fully articulated). Therefore, only W.H.'s opinions addressing secondary service connection are discussed below as they are generally more clearly written, and therefore of greater probative weight. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993) (The credibility and weight to be attached to a medical opinion are within the Board's province as finder of fact.). Given that the record reflects that VA provided the Veteran with a copy of her claims file, it is reasonable to conclude that W.H. reviewed this evidence in forming her April 2024 opinions.

Service Connection - Applicable Laws and Regulations

Service connection may be granted for a disability resulting from a 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). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection is also warranted for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection under 38 C.F.R. § 3.310(a) is warranted where a non-service-connected disability would have been less severe but for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability. Spicer v. McDonough, 61 F.4th 1360, 1364-66 (2023) (invalidating the requirement of "proximate cause" and instead holding "but for" causation or aggravation is enough to show entitlement to secondary service connection).

Migraines are considered a "chronic" disease under 38 C.F.R. § 3.309(a). Therefore, in this instance the presumptive service connection provisions under 38 C.F.R. § 3.303(b) for service connection based on "chronic" symptoms in service and "continuous" symptoms since service must be considered. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For the showing of chronic diseases in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b).

If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic' disease became manifest to a degree of 10 percent within one year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. Here, the Veteran served on active duty more than 90 days; however, the record does not demonstrate onset or diagnosis of migraines
service connection. 38 C.F.R. § 3.303(b).

In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or?unpersuasive and?provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7?Vet. App.?36, 39-40 (1994). Competency of evidence differs from weight and credibility.

A lay person is competent to report on the onset and reoccurrence of current symptomatology. See Layno v. Brown, 6?Vet. App.?465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge).? The Board must determine, on a?case-by-case?basis, whether a veteran's particular disability is the type of disability for which lay evidence may be competent. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007).

Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez, 22?Vet. App. at 304. Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical evidence. See?Bloom v. West, 12 Vet. App. 185, 187 (1999).

VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a claimant prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 21 F.4th 776, 781 (2021); Ortiz?v.?Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001).

Migraines

The Veteran asserts entitlement to service connection for migraines as secondary to her service-connected PTSD. See April 2024 Supplemental Claim; April 2024 Medical Opinion of W.H.

Initially, the Board recognizes that the Veteran has been diagnosed with headaches and migraines. See, e.g., November 2018 VA Headaches Disability Benefits Questionnaire (DBQ); April 2024 Evaluation and Opinions by W.H., F.N.P. Treatment records reflect that the Veteran reported the onset of headaches in 2010.

In 2015, a VA psychologist noted that the Veteran would get headaches and nausea as physiological reactivity to stressor cues, which had occurred five times in the past month. See October 2015 VA PTSD DBQ.

In June 2023, the Veteran underwent a VA headaches examination. The examiner noted that the Veteran reported headache pain and sensitivity to light and sound associated with her headaches. However, the examiner stated that she was unable to diagnose headaches and that "additional evidence is needed at this time," although there is no indication in the examination DBQ what evidence was needed, and the record reflects no corrective action by the AOJ. The June 2023 medical opinion recognizes a diagnosis of migraine headaches, and although the examiner opined that the Veteran's migraines are not caused by her service-connected PTSD, she did not address the issue of aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995)
3, the Veteran underwent a VA headaches examination. The examiner noted that the Veteran reported headache pain and sensitivity to light and sound associated with her headaches. However, the examiner stated that she was unable to diagnose headaches and that "additional evidence is needed at this time," although there is no indication in the examination DBQ what evidence was needed, and the record reflects no corrective action by the AOJ. The June 2023 medical opinion recognizes a diagnosis of migraine headaches, and although the examiner opined that the Veteran's migraines are not caused by her service-connected PTSD, she did not address the issue of aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). Therefore, the June 2023 VA headaches examination is inadequate for adjudication purposes. Furthermore, while the June 2023 VA opinion is probative as to a current diagnosis of migraines, it is inadequate as to their etiology. Id. The Board notes that a May 2024 VA headaches examination reflects that the Veteran does not have a headaches diagnosis and that she does not experience headache pain. As these findings are inconsistent with the record, including treatment records and the prior VA and private examinations discussed above, the Board assigns the May 2024 DBQ no probative weight.

While the Board could remand the claim for yet another attempt to schedule a VA examination, the current evidence is sufficient to decide the claim. A remand could therefore be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) ("The development of evidence in connection with claims for service connection will be accomplished when deemed necessary but it should not be undertaken when evidence present is sufficient for this determination"); Mariano v. Principi, 17 Vet. App. 305, 312 (2003).

An April 2024 medical opinion by private clinician W.H. diagnosed migraine headaches. W.H. explained that medical "research has identified female gender and history of PTSD as being predictors for persistent posttraumatic headache syndromes" and as a female with PTSD "she is predictably [at] threefold risk for headache syndrome ... when compared to her non-PTSD female counterparts." She added: "There is a large body of research connecting PTSD with chronic headaches." W.H. concluded that it is at least as likely as not that the Veteran's headaches are caused by her service-connected PTSD. See April 2024 Evaluation and Opinion by W.H., A.P.R.N., F.N.P.-B.C.

The April 2024 private medical opinion regarding secondary service connection is competent, credible and probative: It was authored by a licensed clinician (board certified in family medicine) who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of her headaches and PTSD; the opinion was based on a review of the evidence of record as well as lay statements of the Veteran. On the whole, the opinion is consistent with the medical evidence of record, including the October 2015 VA PTSD DBQ clinically associating the Veteran's headaches with her PTSD, and it contains clear conclusions connected by a reasoned medical explanation as to secondary service connection, citing to specific medical literature. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no medical opinions or other competent medical evidence of record that weighs against the April 2024 opinion. Accordingly, the Board finds the opinion probative, competent and persuasive medical evidence in this case.

The Board finds that the evidence in this case, at the very least is in relative equipoise as to whether the Veteran's migraines are secondary to her service-connected PTSD. Accordingly, the benefit-of-the-doubt doctrine is applicable and resolving any reasonable doubt in favor of the Veteran, service connection for migraines as secondary to PTSD is warranted. The appeal is granted. See 38?U.S.C. §§?5107; 38?C.F.R. §§?3.102, 3.303, 3.310.

Lumbar Spine Degenerative Disc Disease

The Veteran asserts entitlement to service connection for a back disability as secondary to her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture. See April 2024 Supplemental Claim; April 2024 Medical Opinion of W.H.

As an initial matter, the March 2025 rating decision reflects the favorable findings that the Veteran has a current diagnosis of lum
PTSD is warranted. The appeal is granted. See 38?U.S.C. §§?5107; 38?C.F.R. §§?3.102, 3.303, 3.310.

Lumbar Spine Degenerative Disc Disease

As an initial matter, the March 2025 rating decision reflects the favorable findings that the Veteran has a current diagnosis of lumbar spine degenerative disc disease and she is service connected for bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture. The Board is bound by these favorable findings as they are not rebutted by clear and unmistakable error. 38 U.S.C. § 5104A; Shedden, supra. Therefore, the dispositive issue is whether there is a medical nexus between the Veteran's lumbar spine degenerative disc disease and the service-connected Feet Disabilities.

The Veteran's treatment records reflect complaints of back pain. See, e.g., April 2023 and June 2023 VA treatment records; September 2021 private treatment records. However, the treatment records do not clearly reflect the etiology of her back symptoms.

Since 2023, the Veteran has been afforded at least two VA back examinations and VA examiners have issued no fewer than four VA medical opinions addressing secondary service connection have been issued. See June 2023 VA Back Conditions DBQ and June 2023 VA Medical Opinion; June 2024 VA Back Conditions DBQ and June 2024 VA Medical Opinion; September 2024 VA Medical Opinion. Notwithstanding that 38?C.F.R. § 3.310 has been on the books for decades, and the United States Court of Appeals for Veterans Claims (Court) has repeatedly held that a VA medical opinion must address both causation and aggravation to be adequate for adjudication purposes, all of the aforementioned VA opinions address causation, but not aggravation. See Allen, 7 Vet. App. at 448; El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). Furthermore, the June 2024 and September 2024 VA opinions do not address a favorable April 2024 private opinion submitted by the Veteran, which is discussed below. Although the AOJ requested addendums to consider the private April 2024 opinion, the VA examiner's October 2024 reply is not responsive to the AOJ's request in that it does not mention the April 2024 private opinion. Unfortunately, the AOJ took no corrective action. For these reasons, the June 2023, June 2024, and September 2024 VA opinions, as well as the October 2024 addendum, are assigned no probative weight.

The April 2024 medical opinion by private clinician W.H. confirmed the Veteran's diagnosis of degenerative disc disease of the lumbar spine. W.H. opined that the Veteran's service-connected feet disabilities "led to the predictable sequela of an altered gate, causing back pain. W.H. emphasized that it is well described in medical literature that "gate changes can lead to chronic instability of the axial spine, with subsequent ascending and descending axial and appendicular skeleton pain, disuse, and pain alterations." W.H. added: "Research has also concluded that quite commonly, spinal disc heights, angles, alignment, and chronic pain with changes above and below the level of injury frequently occur and remain undiagnosed for many years." W.H. concluded that the nature of the Veteran's "chronic foot pain and unfortunate sequela," and considering the relevant medical literature, make it at least as likely as not that the Veteran's degenerative disc disease of the lumbar spine is "directly related" to her service-connected feet disabilities.

The April 2024 private medical opinion regarding secondary service connection
lead to chronic instability of the axial spine, with subsequent ascending and descending axial and appendicular skeleton pain, disuse, and pain alterations." W.H. added: "Research has also concluded that quite commonly, spinal disc heights, angles, alignment, and chronic pain with changes above and below the level of injury frequently occur and remain undiagnosed for many years." W.H. concluded that the nature of the Veteran's "chronic foot pain and unfortunate sequela," and considering the relevant medical literature, make it at least as likely as not that the Veteran's degenerative disc disease of the lumbar spine is "directly related" to her service-connected feet disabilities.

The April 2024 private medical opinion regarding secondary service connection is competent, credible and probative: It was authored by a licensed clinician who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of her lumbar spine and service-connected feet disabilities; the opinion was based on a review of the evidence of record as well as lay statements of the Veteran. On the whole, the opinion is consistent with the medical evidence of record, including no fewer than nine VA examinations from April 2015 to November 2022 that reflect recurrent bilateral foot pain associated with the Veteran's service-connected feet disabilities, and VA treatment records reflecting an antalgic gait and her relatively consistent use of a cane to aid in ambulation. See, e.g., April 2023 VA Physical Therapy Consult; August 2023 VA Primary Care Note. The opinion also reflects clear conclusions connected by a reasoned medical explanation as to secondary service connection, citing to specific medical literature. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no medical opinions or other competent medical evidence of record that weighs against the April 2024 opinion. Accordingly, the Board finds the opinion probative, competent and persuasive medical evidence in this case.

The Board finds that, overall, the evidence in this case, at the very least is in relative equipoise as to whether the Veteran's lumbar spine degenerative disc disease is secondary to her service-connected feet disabilities. Accordingly, the benefit-of-the-doubt doctrine is applicable and resolving any reasonable doubt in favor of the Veteran, service connection for lumbar spine degenerative disc disease as secondary to the service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture is warranted. The appeal is granted. See 38?U.S.C. §§?5107; 38?C.F.R. §§?3.102, 3.303, 3.310.

Right Hip Strain

The Veteran asserts entitlement to service connection for a right hip disability as secondary to her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture. See April 2024 Supplemental Claim; April 2024 Medical Opinion of W.H.

As an initial matter, the March 2025 rating decision reflects the favorable findings that the Veteran has a current diagnosis of right hip strain and she is service connected for the disability of bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture. The Board is bound by these favorable findings as they are not rebutted by clear and unmistakable error. 38 U.S.C. § 5104A; Shedden, supra. Therefore, the dispositive issue is whether there is a medical nexus between the Veteran's right hip strain and the service-connected Feet Disabilities.

The Veteran's private treatment records reflect complaints of right hip pain. See, e.g., September 2021 Progress Notes. However, VA and private treatment records do not clearly reflect the etiology of a right hip disorder.

In December 2022, the Veteran underwent a VA examination, at which time she reported right hip pain and a clicking sensation. She said the pain flared with prolonged standing. However, the VA examiner concluded that there was insufficient objective evidence to warrant a diagnosis. Nevertheless, the examiner opined that the Veteran's claimed right hip disability was less likely than not caused by her service-connected left knee joint osteoarthritis and/or right knee patellofemoral pain syndrome because medical literature does not support causation of a disability of a hip disorder by an opposing knee disability. However, the December 2022 VA opinion only addresses causation. See Allen, 7 Vet. App. at 448 (opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition).
. She said the pain flared with prolonged standing. However, the VA examiner concluded that there was insufficient objective evidence to warrant a diagnosis. Nevertheless, the examiner opined that the Veteran's claimed right hip disability was less likely than not caused by her service-connected left knee joint osteoarthritis and/or right knee patellofemoral pain syndrome because medical literature does not support causation of a disability of a hip disorder by an opposing knee disability. However, the December 2022 VA opinion only addresses causation. See Allen, 7 Vet. App. at 448 (opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). Therefore, the opinion is inadequate for adjudication purposes.

In June 2023, the Veteran again underwent a VA examination. The examiner concluded that the Veteran's right hip was normal. However, the examiner opined that the Veteran's right hip and right knee patellofemoral pain syndrome are not medically related because the right hip is a separate entity from the right knee and no medical literature demonstrates a causal relationship between the two joints. Given that the June 2023 VA opinion addresses causation, but not aggravation, it is inadequate for adjudication purposes. Id.

In June 2024, the Veteran again underwent a VA examination. The diagnosis was bilateral hip strain. The examiner opined that the Veteran's right hip strain was less likely than not caused by her service-connected feet disabilities, explaining that the feet and right hip are separate bodily entities and no medical literature demonstrates a causal relationship between the hip and foot. Given that the June 2024 VA opinion addresses causation, but not aggravation, it is inadequate for adjudication purposes. Id.

A September 2024 VA medical opinion concludes that the Veteran's right hip strain was not caused by her service-connected feet disabilities, explaining that orthopedic literature does not indicate that an injury to one joint would have any significant impact on another, opposite uninjured joint unless the injury caused major muscle or nerve damage, partial or incomplete paralysis, or shortening of the injured limb resulting in a length discrepancy that caused an altered gait pattern, and that such is not shown in the record. Furthermore, the examiner noted that a disease in one joint does not "spread" to another joint or cause damage to it. However, the examiner did not provide an opinion addressing aggravation. Id. Therefore, the September 2024 VA opinion is inadequate for adjudication purposes.

Although the AOJ requested an addendum to consider the April 2024 private opinion, the VA examiner's October 2024 reply is not responsive to the AOJ's request in that it does not mention the April 2024 private opinion. Unfortunately, the AOJ took no corrective action. For these reasons, the October 2024 VA opinion is inadequate for adjudication purposes.

The April 2024 medical opinion by private clinician W.H. asserts that the Veteran has "the predictable sequela of an altered gate [and] hip pain[.]" W.H. added that the Veteran endorsed "aching, locking, stiffness, and giving out" of her right hip. W.H. explained that "numerous bodies of literature conclude that the biomechanics of posture, kinetic gait characteristics, and skeletal alignment can be dramatically altered from the bottom of the foot extending proximally into ... the hips," resulting in physical limitations and pain. W.H. concluded: "Based on the ... evidence, the [Veteran's] chronic bilateral hip pain is directly related to her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and history of tarsal fracture."

The April 2024 private medical opinion regarding secondary service connection is competent, credible and probative: It was authored by a licensed clinician who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of her right hip and service-connected feet disabilities; the opinion was based on a review of the evidence of record as well as lay statements of the Veteran. On the whole, the opinion is consistent with the medical evidence of record, including no fewer than nine VA examinations from April 2015 to November 2022 that reflect recurrent bilateral foot pain associated with the Veteran's service-connected feet disabilities, and VA treatment records reflecting an antalgic gait and her relatively consistent use of a cane to aid in ambulation. See, e.g., April 2023 VA Physical Therapy Consult; August 2023 VA Primary Care Note. The opinion also reflects clear conclusions connected by a reasoned medical explanation as to secondary service connection, citing to specific medical literature. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no medical opinions or other competent medical evidence of record that weighs against the April 2024 opinion. Accordingly, the Board finds the opinion probative, competent and persuasive medical evidence in this case.

The Board finds that, overall, the evidence in this case, at the very least is in relative equipoise as to whether the Veteran's right hip strain is secondary to her service-connected Feet Disabilities. Accordingly, the benefit-of-the-doubt doctrine is applicable and resolving any reasonable doubt in favor of the Veteran, service connection for right hip strain as secondary to the service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture is warranted. The appeal is granted. See 38?U.S.C. §§?5107; 38?C.F.R. §§?3.102, 3.303, 3.310.

Right and Left Ankle Lateral Collateral Ligament Sprain

The Veteran asserts entitlement to service connection for right and left ankle disabilities as secondary to her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture. See April 2024 Supplemental Claim; April 2024 Medical Opinion of W.H.

As an initial matter, the March 2025 rating decision reflects the favorable findings that the Veteran has current diagnoses of right and left ankle lateral collateral ligament sprain, and she is service connected for the disability of bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture. The Board is bound by these favorable findings as they are not rebutted by clear and unmistakable error. 38 U.S.C. § 5104A; Shedden, supra. Therefore, the dispositive issue is whether there is a medical nexus between the Veteran's right and left ankle disorders and the service-connected Feet Disabilities.

The Veteran's VA treatment records reflect complaints of bilateral ankle pain, swelling, and diminished muscle strength. See, e.g., April 2018, May 2019, April 2023, June 2023 VA treatment records. However, the treatment records do not clearly reflect the etiology of these symptoms.

In November 2022, the Veteran underwent a VA examination. The examiner concluded that the Veteran had no diagnosable ankle disorder. Nevertheless, the examiner opined that the undiagnosed disorder is less likely than not related to service because the Veteran's service treatment records do not reflect diagnosis of an ankle disability that demonstrates a chronic pattern of disability related to an ankle condition. Given that the examiner provided no diagnosis, the opinion is assigned no probative weight.

In June 2023, the Veteran underwent a VA examination. However, the examiner concluded that the Veteran's right ankle was normal and rendered no diagnosis and provided no right ankle opinion.

In June 2024, the Veteran again underwent a VA examination. The diagnosis was bilateral lateral collateral ligament sprain. The VA examiner issued two unfavorable medical opinions, but neither one addresses aggravation. Id. See Allen, 7 Vet. App. at 448 (opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). Moreover, September 2024 unfavorable VA opinions do not address aggravation. Id. Therefore, the June 2024 and September 2024 VA opinions are inadequate for adjudication purposes. Although the AOJ requested an addendum to consider the April 2024 private opinion, the VA examiner's October 2024 reply is not responsive to the AOJ's request in that it does not mention the April 2024 private opinion. Unfortunately, the AOJ took no corrective action. For these reasons, the October 2024 VA opinion is inadequate for adjudication purposes.

The April 2024 medical opinion by private clinician W.H. asserts that medical research "confirms that the biomechanical relationship and the kinetics involved with [the Veteran's] ankle complaints are consistent with sequela of her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture." W.H. added, the Veteran "has experienced the common sequela of an altered gate, [including] bilateral ankle pain." W.H. opined that the Veteran's "bilateral ankle pain ... is directly related to her service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and history of tarsal fracture" due to alterations in her gate, posture, and ambulation.

The April 2024 private medical opinion regarding secondary service connection is competent, credible and probative: It was authored by a licensed clinician who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of her bilateral ankle and service-connected feet disabilities; the opinion was based on a review of the evidence of record as well as lay statements of the Veteran. On the whole, the opinion is consistent with the medical evidence of record, including no fewer than nine VA examinations from April 2015 to November 2022 that reflect recurrent bilateral foot pain associated with the Veteran's service-connected feet disabilities, and VA treatment records reflecting an antalgic gait and her relatively consistent use of a cane to aid in ambulation. See, e.g., April 2023 VA Physical Therapy Consult; August 2023 VA Primary Care Note. The opinion also reflects clear conclusions connected by a reasoned medical explanation as to secondary service connection, citing to specific medical literature. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no medical opinions or other competent medical evidence of record that weighs against the April 2024 opinion. Accordingly, the Board finds the opinion probative, competent and persuasive medical evidence in this case.

The Board finds that, overall, the evidence in this case, at the very least is in relative equipoise as to whether the Veteran's bilateral ankle lateral collateral ligament sprains are secondary to her service-connected feet disabilities. Accordingly, the benefit-of-the-doubt doctrine is applicable and resolving any reasonable doubt in favor of the Veteran, service connection for right and left ankle lateral collateral ligament sprains as secondary to the service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture is warranted. The appeal is granted. See 38?U.S.C. §§?5107; 38?C.F.R. §§?3.102, 3.303, 3.310.

S. B. MAYS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Farrell, Counsel
. Accordingly, the benefit-of-the-doubt doctrine is applicable and resolving any reasonable doubt in favor of the Veteran, service connection for right and left ankle lateral collateral ligament sprains as secondary to the service-connected bilateral pes planus, plantar fasciitis, Morton's disease, right foot dorsal exostosis, and status post foot tarsal fracture is warranted. The appeal is granted. See 38?U.S.C. §§?5107; 38?C.F.R. §§?3.102, 3.303, 3.310.

S. B. MAYS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Farrell, 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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