HEMORRHOIDS EXTERNAL OR INTERNAL

L. B. CRYAN · 2026 · Case ID: 26004741

MIXED

Summary

The Veteran served in the United States Army from August 1980 to August 1984 and again from February 1985 to January 2008, receiving a dishonorable discharge for the latter period of service. The Board previously determined a statutory bar to VA benefits for service from October 2003 to January 2008. The Veteran appeals the denial of service connection for hemorrhoids and psychiatric conditions, including PTSD, depressive disorder, and unspecified personality disorder. He also appeals the denial of increased ratings for residuals of stress fractures of the right and left feet prior to July 5, 2023, but was granted 20% ratings for these conditions from that date forward. The case was remanded for further development and adjudication on entitlement to service connection for seizures and loss of bladder control, as well as entitlement to TDIU. The Board found the evidence weighed against service connection for hemorrhoids and psychiatric conditions, citing lack of nexus and pre-existing conditions. The Board granted the increased ratings for the foot residuals, resolving doubt in the Veteran's favor. The Board noted the Veteran's claim for TDIU was raised due to his inability to maintain employment, expanding the appeal to include this issue.

Rationale

Evidence persuasively weighs against nexus to TERA; No direct service connection established

Service Branch

ARMY

Special Benefit

TDIU

Docket No.

16-58 838A

Full Decision Text

Citation Nr: 26004741
Decision Date: 04/17/26 Archive Date: 04/17/26

DOCKET NO. 16-58 838A
DATE: April 17, 2026

ORDER

Service connection for hemorrhoids is denied.

Service connection for psychiatric disorders include posttraumatic stress disorder (PTSD), depressive disorder, and unspecified personality disorder is denied.

A disability rating in excess of 10 percent for residuals of stress fracture of the right foot prior to July 5, 2023 is denied.

A disability rating in excess of 10 percent for residuals of stress fracture of the left foot prior to July 5, 2023 is denied.

A disability rating of 20 percent for service-connected for residuals of stress fracture of the right foot from July 5, 2023 is granted.

A disability rating of 20 percent for residuals of stress fracture of the left foot from July 5, 2023 is granted.

REMANDED

Entitlement to service connection for a disability manifested by seizures is remanded.

Entitlement to service connection for loss of bladder control (claimed as urinary tract condition) is remanded.

Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded.

FINDINGS OF FACT

1. The evidence persuasively weighs against finding that the Veteran's hemorrhoids are caused by or related to an honorable period of active duty to include as due to toxic exposure risk activity (TERA).

2. The evidence persuasively weighs against finding that the Veteran's diagnosis of PTSD is related to fear of hostile military activity and the evidence does not show that the Veteran engaged in combat with enemy or that his PTSD is related to a claimed stressor that is supported by credible evidence.

3. The evidence shows that the Veteran's depressive disorder is related to his alcohol dependence and withdrawals and direct service connection for an alcohol use disorder is barred as a matter of law and the evidence persuasively weighs against finding that the Veteran's current depressive disorder is caused by or aggravated by his service-connected disabilities.

4. The Veteran's unspecified personality disorder is a congenital/developmental defect that pre-existed service and the evidence persuasively weighs against finding that it was not subject to a superimposed disease or injury during service that resulted in additional disability.

5. The Veteran's residuals of stress fracture of the right foot are manifested by no more than moderate symptoms prior to July 5, 2023.

6. The Veteran's residuals of stress fracture of the right foot more nearly approximates moderately severe symptoms from July 5, 2023.

7. The Veteran's residuals of stress fracture of the left foot are manifested by no more than moderate symptoms prior to July 5, 2023.

8. The Veteran's residuals of stress fracture of the left foot more nearly approximates moderately severe symptoms from July 5, 2023.

CONCLUSIONS OF LAW

1. The criteria for service connection for hemorrhoids are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for a psychiatric disorder include PTSD, depressive disorder, and unspecified personality disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

3. The criteria for a disability rating in excess of 10 percent for residuals of stress fracture of the right foot prior to July 5, 2023 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284.

4. Resolving all reasonable doubt in the Veteran's favor, the criteria for a 20 percent disability rating for residuals of stress fracture of the right foot from July 5, 2023 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284.

5. The criteria for a disability rating in excess of 10 percent for residuals of stress fracture of the left foot prior to July 5, 2023 are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4
20 percent disability rating for residuals of stress fracture of the right foot from July 5, 2023 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284.

6. Resolving all reasonable doubt in the Veteran's favor, the criteria for a 20 percent disability rating for residuals of stress fracture of the left foot from July 5, 2023 are met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5284.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served in the United States Army with active duty from August 1980 to August 1984 and from February 1985 to January 2008.

According to the Veteran's DD Form 214, the Veteran had a dishonorable discharge for the period of service from February 1985 to January 2008. In an October 2012 decision, the Board determined that there was a statutory bar to VA benefits under 38 U.S.C. § 5303(a) for the Veteran's period of service from October 15, 2003 through January 29, 2008, but not earlier.

This case is before the Board of Veterans' Appeals (Board) on appeal from a September 2013 Regional Office (RO) rating decision. In that rating decision, the RO confirmed and continued the previous denial of service connection for seizures, loss of bladder control, hemorrhoids, tinnitus, PTSD, and left Achilles tendon tear, granted service connection for degenerative disc disease of the cervical spine and assigned a 30 percent disability rating, effective October 26, 2011, and denied a disability rating in excess of 10 percent for stress fracture of the right foot, and a disability rating in excess of 10 percent for stress fracture of the left foot.

The Veteran's notice of disagreement (NOD) was received in September 2013. The RO issued a statement of the case (SOC) in October 2016. The Veteran's VA Form 9, substantive appeal to the Board, was received in December 2016.

In January 2023, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the testimony is associated with the claims file.

In April 2023 and May 2024, the Board remanded the case to the RO for further development and adjudicative action.

Regarding characterization of the appeal, the Veteran raised the issue that he was unable to obtain or maintain employment due to his service-connected disabilities to include his residuals of stress fractures of his feet after the AOJ issued the most recent SSOC in September 2024. See May 2025 VA 21-8949 and May 2025 supplemental claim form (asserting that TDIU was raised as part of the Veteran's increased rating claims for residuals of stress fractures of the feet). Thus, the Board has now expanded the appeal to include the issue of entitlement to a TDIU. See Rice v. Shinseki, 22 Vet. App. 447, 453-54 (2009) (a claim for TDIU; either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating).

Service Connection

Establishing service connection generally requires competent evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. 38 C.F.R. § 3.303; see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Pursuant to 38 C.F.R. § 3.303(b), a claim
DIU; either expressly raised by the Veteran or reasonably raised by the record, involves an attempt to obtain an appropriate rating for a disability and is part of the claim for an increased rating).

Service Connection

Establishing service connection generally requires competent evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. 38 C.F.R. § 3.303; see Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Pursuant to 38 C.F.R. § 3.303(b), a claimant may establish the second and third elements by demonstrating continuity of symptomatology for specific chronic disabilities listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

Service connection also may be established on a secondary basis for a disability that is due to, or the result of, a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection as secondary to a service-connected disability requires a current disability that was either caused or aggravated by a service-connected disability. 38 C.F.R. § 3.310(a). In reaching this determination as to aggravation of a nonservice-connected disability, consideration is required as to the baseline level of severity of the nonservice-connected disease or injury (prior to the onset of aggravation by service-connected condition), in comparison to the current level of severity of the nonservice-connected disease or injury. See Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead holding that a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

1. Entitlement to service connection for hemorrhoids.

The Veteran contends that his hemorrhoids had their onset during active duty and occurred as a result of his duties in the Army. See June 2008 claim. The Veteran testified that his hemorrhoids started in 1982 and he has received treatment since that time. See January 2023 Hearing Transcript.

The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that, while the Veteran has a current diagnosis of hemorrhoids, the evidence of record persuasively weighs against finding that the Veteran's diagnosis of hemorrhoids had their onset in or is otherwise is caused by or related to an event, injury, or disease to include TERA during an honorable period of active duty.

A November 2018 VA treatment record shows that the Veteran reported that he had hemorrhoids. Internal heamorrhoids were listed on the active problem list. A December 2018 VA treatment record documents that the Veteran sought a suppository for hemorrhoid condition. A July 2024 VA examiner diagnosed the Veteran with hemorrhoids. Thus, the Veteran has a current diagnosis of the claimed disability.

The Veteran's service treatment records do not show that the Veteran complained of or sought treatment for hemorrhoids during a period of honorable active service. Report of Medical History forms dated in November 1983 and January 1989 show that the Veteran denied having now or ever having piles or rectal disease. An April 1998 Report of Medical History form shows that the Veteran denied a past or current medical history of hemorrhoids or rectal disease. An October 2005 service treatment record shows that the Veteran complained of symptomatic hemorrhoids. The assessment was external hemorrhoids. However, this was during a period of service that is barred from VA benefits under 38 U.S.C. § 5303(a).

The Board notes that the Veteran testified at the Board hearing that the onset of his hemorrhoids began in 1982. He also reported in a June 2009 VA examination that the onset of his hemorrhoids was in the 1980's. He noted that he had onset blood with bowel movements and he did not initially seek treatment. The Veteran is competent to report observable symptoms, such as in this case, rectal bleeding during service. However, the Veteran's post-service lay statements contradict the statements provided by the Veteran during active duty. Specifically, as noted above, the Veteran denied having now or ever having piles (hemorrhoids) or rectal disease in the Report of Medical History forms dated in November 1983, January 1989, and April 1998. Furthermore, the
oids began in 1982. He also reported in a June 2009 VA examination that the onset of his hemorrhoids was in the 1980's. He noted that he had onset blood with bowel movements and he did not initially seek treatment. The Veteran is competent to report observable symptoms, such as in this case, rectal bleeding during service. However, the Veteran's post-service lay statements contradict the statements provided by the Veteran during active duty. Specifically, as noted above, the Veteran denied having now or ever having piles (hemorrhoids) or rectal disease in the Report of Medical History forms dated in November 1983, January 1989, and April 1998. Furthermore, the contemporaneous medical records show that the Veteran was first diagnosed with hemorrhoids during a period of service that is barred from VA benefits under 38 U.S.C. § 5303(a). Accordingly, the Veteran's statements regarding the onset of his hemorrhoids or symptoms of hemorrhoids are not credible and are of low probative value.

Under the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), effective from August 10, 2022, Section 303 implemented 38 U.S.C. § 1168, which provides that a disability examination and medical opinion should be requested for certain non-presumptive conditions involving toxic exposure risk activity (TERA). For such claims, VA is required to provide a disability examination and medical opinion when the Veteran submits a claim for compensation, has evidence of a disability, had evidence of participation in a TERA, and such evidence is not sufficient to establish service connection for the disability. A Veteran can claim participation in a TERA explicitly or implicitly through service in a location presumed associated with toxic exposure, or records showing participation in a TERA; or, if VA has conceded exposure in a prior claim, or the file has a claim attributable to toxic exposure. Other ways to claim or establish participation in a TERA include, when a Veteran's MOS is associated with toxic exposure; when medical records suggest exposure to a toxic substance, chemical, or airborne hazard such as VHA exposure screening; or, with any other relevant evidence of record to include garrison exposures.

In a July 2024 TERA memorandum, the AOJ determined that the Veteran participated in a TERA through his service in Saudi Arabia from January 1991 to May 1991. The Veteran did not have any other TERA exposure. An individual longitudinal exposure record (ILER) was associated with the claims file in July 2024. It documents that the Veteran may have been exposure to a variety of environmental and chemical hazards that carried potential health risks to include sarin, phosphonofluoridic acid, methyl-, cyclohexyl ester. Gulf war oil well fire, smoke, naphthalene, particulates not otherwise specified, o-xylene, ethyl benzene, p-xylene, toluene, vanadium, benzene, m-xylene, and iron.

A July 2024 VA examiner provided the opinion that the Veteran's hemorrhoids are less likely than caused by the indicated TERA, after considering the total protentional through all applicable military deployments of the Veteran and the synergistic, combined effect of all TERA. She explained peer reviewed medical literature does not support a nexus between hemorrhoids and the Veteran's TERA. The examiner concluded that the Veteran has symptoms of urinary frequency due to alcohol use disorder. In a July 2024 addendum opinion, the examiner stated that hemorrhoids have multiple causes, most commonly from straining during bowel movements and having chronic constipation and diarrhea. There is no objective medical evidence of any of these conditions while in service or in his testimony. Hemorrhoids can be chronic or recurrent. There is no objective medical evidence of chronic or recurrent hemorrhoids. This medical opinion is persuasive and probative as to the issue of whether the Veteran's current hypertension is caused by or related to the Veteran's TERA during active duty, because the examiner provided clear explanation for the medical opinion based on the evidence of record, medical studies, and clinical experience.

Based on the foregoing, the evidence persuasively weighs against finding that the onset of the Veteran's hemorrhoids began during a period of honorable military service and/or is caused by or related to an event, injury, or disease to include TERA during an honorable service period. In reaching this conclusion, the benefit of the doubt doctrine is not applicable. Accordingly, service connection for hemorrhoids is not warranted.

2. Entitlement to service connection for a psychiatric disorder.

The Veteran contends that he has a psychiatric disorder due to fear of hostile military activity while deployed in 1991 to Dhahran and Riyadh in Saudi Arabia and later
examiner provided clear explanation for the medical opinion based on the evidence of record, medical studies, and clinical experience.

2. Entitlement to service connection for a psychiatric disorder.

The Veteran contends that he has a psychiatric disorder due to fear of hostile military activity while deployed in 1991 to Dhahran and Riyadh in Saudi Arabia and later to Bosnia. See June 2020 lay statement and January 2023 Hearing Transcript.

There are particular requirements for establishing PTSD in 38 C.F.R. § 3.304(f) that are separate from those for establishing service connection generally. Arzio v. Shinseki, 602 F.3d 1343, 1347 (Fed. Cir. 2010). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125(a), a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. 38 C.F.R. § 3.304(f). However, if a stressor claimed by a veteran is related to fear of hostile military or terrorist activity and a VA psychiatrist or psychologist, or a psychiatrist or psychologist with whom VA has contracted, confirms that the claimed stressor is adequate to support a diagnosis of PTSD and that the veteran's symptoms are related to the claimed stressor, in the absence of clear and convincing evidence to the contrary, and provided the claimed stressor is consistent with the places, types, and circumstances of the veteran's service, the veteran's lay testimony alone may establish the occurrence of the claimed in-service stressor. 38 C.F.R. § 3.304(f)(3).

A diagnosis of PTSD must be established in accordance with 38 C.F.R. § 4.125(a), which mandates that, for VA purposes, all mental disorder diagnoses must conform to the American Psychiatric Association's Diagnostic and Statistical Manual for Mental Disorders (DSM). During the pendency of the Veteran's appeal, the VA amended the applicable regulations to transition to the use of the DSM-5. See 80 Fed. Reg. 14308 (March 19, 2015). The provisions of the final rule indicate that for claims that were initially certified for appeal to the Board, the Court of Appeals for Veterans Claims (CAVC), or the U.S. Court of Appeals for the Federal Circuit prior to August 4, 2014, DSM-IV will apply. For all applications for benefits received by VA or pending before the AOJ on or after August 4, 2014, DSM-V will apply.

The question presented in this case is whether the Veteran has a current disability that began during service or is at least as likely as not (i.e., likelihood is approximately balanced or nearly equal, if not higher) related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has current diagnoses of PTSD and major depressive disorder, the evidence of record persuasively weighs against finding that his diagnoses began during service or are otherwise related to an in-service injury, event, or disease or the Veteran's claimed in-service stressors to include fear of hostile military activity. The evidence also persuasively weighs against finding that the Veteran's depressive disorder or alcohol disorder is due to or the result of or aggravated beyond its natural progression by service-connected disability. Furthermore, the diagnosis of an unspecified personality disorder is a congenital/developmental defect that pre-existed service and the evidence persuasively weighs against finding that it was not subject to a superimposed disease or injury during service that resulted in additional disability.

With respect to the Veteran's service connection claim for a psychiatric disorder, VA treatment records show that the Veteran was diagnosed with PTSD, major depressive disorder, and unspecified personality disorder. The Board notes that VA examiners in June 2009, June 2013, and June 2014 show that the Veteran was not diagnosed with PTSD. However, a VA psychiatrist diagnosed the Veteran with PTSD. See May 2024 VA treatment record. As the diagnosis of PTSD was provided by VA psychiatrist, it is presumed to be in accordance with DSM-5. See Cohen v. Brown, 10 Vet. App. 128, 140 (1997) (holding that VA may presume that a diagnosis made by a mental health care professional was made
's service connection claim for a psychiatric disorder, VA treatment records show that the Veteran was diagnosed with PTSD, major depressive disorder, and unspecified personality disorder. The Board notes that VA examiners in June 2009, June 2013, and June 2014 show that the Veteran was not diagnosed with PTSD. However, a VA psychiatrist diagnosed the Veteran with PTSD. See May 2024 VA treatment record. As the diagnosis of PTSD was provided by VA psychiatrist, it is presumed to be in accordance with DSM-5. See Cohen v. Brown, 10 Vet. App. 128, 140 (1997) (holding that VA may presume that a diagnosis made by a mental health care professional was made in accordance with the DSM-IV). Thus, the evidence of record shows that the Veteran has current diagnoses of the claimed disability.

As an initial matter, congenital or developmental defects, which include personality disorders, are not "diseases" or "injuries" within the meaning of applicable legislation, and therefore service connection for them is generally precluded by regulation. 38 C.F.R. §§ 3.303(c), 4.9. See also 38 C.F.R. § 4.127 ("personality disorders are not diseases or injuries for compensation purposes and... disability resulting from them may not be service-connected"). Thus, if a disorder is a "defect," a veteran is precluded from receiving disability benefits to compensate him for the effects of that disorder. Winn v. Brown, 8 Vet. App. 510, 516 (1996). In contrast, disability benefits may be awarded for congenital diseases. Quirin v. Shinseki, 22 Vet. App. 390, 394 (2009). Generally, a congenital disease, "by its very nature, preexisted the claimant's military service," and service connection for disability due to such disease typically turns on "whether manifestations of the disease in service constituted 'aggravation' of the condition." VAOPGCPREC 82-90, 55 Fed. Reg. 45,711 (Oct. 30, 1990). In addition, disability resulting from a psychiatric disorder that is superimposed upon a personality disorder may be service connected. 38 C.F.R. § 4.127. In determining whether a disorder is disease or defect, the rule is that "a congenital or developmental condition that is progressive in nature-that can worsen over time-is a disease rather than a defect." O'Bryan v. McDonald, 771 F.3d 1376, 1380 (Fed. Cir. 2014).

In addition, service connection may not be established as directly related to service for a disability deemed to be the result of abuse of alcohol or drugs. See 38 U.S.C. § 1110; 38 C.F.R. § 3.1(n), 3.301.

The Veteran's service treatment records shows that Veteran the Veteran denied depression or excessive worry or nervous trouble of any sort in the Report of Medical History forms dated in November 1982, January 1989and June 2005. In an April 1998 Report of Medical History form, the Veteran stated he didn't know if he had or ever had nervous trouble of any sort, depression, or excessive worry. He stated that he had frequent trouble sleeping. However, in an April 2002 service treatment record the Veteran checked yes to feeling "down" (blue, depressed) most of the time and that he had many stresses in his life. An April 2003 VA treatment record diagnosed the Veteran with alcohol abuse. A September 2003 service treatment record shows that the Veteran was positive for depression and anxiety. In an April 2007 Report of Medical History form, which was during a period of service that is barred from VA benefits, the Veteran stated yes to ever having or having now nervous trouble of any sort, habitual stammering or stuttering, loss of memory or amnesia, frequent trouble sleeping. He denied having or ever having counseling of any type, depression or excessive worry, being evaluated or treated for a mental condition, attempted suicide or use of illegal drugs or abuse of prescription drugs. The evidence shows that while the Veteran had symptoms of depression and anxiety in service, he was not diagnosed with PTSD or depressive disorder during an honorable period of service.

With respect to the diagnosis of a personality disorder, the evidence shows that the Veteran's personality disorder did not have a superimposed disease or injury such that it resulted in additional disability. A July 2024 VA examiner documented that the Veteran was diagnosed with a personality disorder in the August 2010, June 2013, and June 2014 VA examinations. The examine provided the opinion that the Veteran's personality disorder is less likely than not related to his military service and at least as likely as not due to genetics and childhood trauma. The examiner found it persuasive that the Veteran endorsed physical abuse by his father in the August 2010 VA examination and that he reported in the June 2014 VA examination that he went to psychologists as a child for "anger" issues, was suspended from high school for anger, and he had a DUI at the age of 17. The examiner further noted that the evidence shows the Veteran's mental health concerns started in childhood and were not aggravated beyond natural progression by his military service. The July 2024 medical opinion is persuasive as to whether an injury, event, or illness during an honorable period of service caused an additional disability from a psychiatric disorder that is superimposed upon his personality disorder and/or aggravated his personality disorder, because the examiner provided a clear explanation based on the evidence of record and general medical knowledge. Accordingly, the evidence persuasively weighs against finding that the Veteran's honorable period of service resulted in a disability from a psychiatric disorder that is superimposed upon a personality disorder.

Regarding the Veteran's service connection claim for PTSD, the Veteran asserts that while station in Saudi Arabia in 1991 (during an honorable period of service), he had guard duty, which exposure him to the threat of being shot. He heard guns, howitzers, motors, various fighting vehicles, and helicopters shooting ammunition at targets. See June 2010 stressor statement. The loud noises filled his heart with adrenaline and fear. The Veteran's service personnel record shows that the military occupational specialty was listed as legal noncommissioned officer (NCO), US Army legal clerk (71D20), while he was stationed in Saudi Arabia from January 1991 to May 1991. The Veteran's does not allege and the evidence does not show that the Veteran engaged in combat. However, his alleged stressors inservice stressors are related to fear of hostile military activity. The Veteran's fear of hostile military activity while serving in Saudi Arabia is consistent with places, types, and circumstances of his service.

Regarding whether the Veteran's current diagnosis of PTSD is related to fear of hostile military activity, the claims file contains a negative medical opinion. Specifically, a July 2024 VA examiner provided the opinion that the Veteran does not meet the Veteran does not meet criteria for PTSD due to fear of hostile military activity. In support of his medical opinion, the examiner noted that in April 2015, the Veteran denied fear of hostile military activity, quoting the Veteran stating "I never feared for my life. I got cockier. I got more dangerous from deployment. We hid fear by embracing our job. We thought we were invincible." The examiner explained the Veteran's lay statements of experiencing fear of hostile military activity are not credible based on the documentation in a July 2012 treatment record and a June 2014 VA examination in which the standardized testing revealed that the Veteran was over-reporting and malingering. The examiner also found it persuasive that the Veteran did not meet criteria for PTSD due to fear of hostile military activity on four separate VA examinations conducted by four separate examiners. This medical opinion is persuasive and probative as to the issue of whether the Veteran's current PTSD is related to fear of hostile military activity as the examiner provided a clear explanation for the medical opinion based a review of the claims file to include medical and lay evidence and medical expertise. The examiner provided a clear link between the evidence of record and his medical opinion.

Furthermore, the claims file contains a negative medical opinion with respect to whether the Veteran's current diagnosis of depressive disorder is related to an honorable period of active military service. In this regard, the examiner provided the opinion that the Veteran's depressive disorder was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness to include the in-service stressor of fear of hostile military activity. The Veteran's depression is at least as likely as not due to life stressors including being arrested for DUI, multiple marriages, and being dishonorably discharged. The examiner explained that the Veteran in an April 2015 VA treated record denied fear of hostile military activity. Furthermore, the examiner noted the June 2014 VA examiner administered standardized testing and deemed that the Veteran was over-reporting and malingering. In July 2012, the Veteran was administered standardized testing and was deemed that he was over-reporting. The July 2024 VA examiner concluded that the Veteran's lay statements are not credible based on his over-reporting on standardized tests in 2012 and 2014. The examiner explained that the Veteran's diagnosis of depression does not appear to be due to fear of hostile military activity. The examiner concluded that the Veteran's depression is at least as likely as not secondary to his alcohol use, which has been severe and chronic since he was 17. The Board finds that this medical is probative and persuasive as to the issue of whether the Veteran's depressive disorder is related to active military service as the examiner provided a clear rationale based on the medical and lay evidence of record and general medical knowledge. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning).

Regarding whether the Veteran's major depressive disorder or alcohol use disorder is secondary to the Veteran's service-connected disabilities, a July 2024 examiner provided a negative opinion. Specifically, the July 2024 VA examiner provided the opinion that the Veteran's psychiatric disorders are less likely than not due to, the result of, or aggravated beyond their natural progression by the Veteran's pain associated with his service-connected disabilities. The examiner explained that the Veteran did not report any clinically significant psychiatric symptoms related to pain. He endorsed mild (non-clinically significant) distress related to pain to include that his activities are limited due to pain; however, the examiner concluded that this did not suggest the presence of a psychiatric condition. The examiner stated that the Veteran's feelings/reactions were within the realm of normal. The examiner further stated that it is natural for people with nerve pain to have low motivation at times; but this is not indicative of aggravation beyond natural progression of his psychiatric disabilities. The July 2024 VA medical opinion is supported by full, clearly stated rationale and provided an explanation linking the medical evidence and the opinion. Thus, the medical opinion is competent and probative evidence on the question of whether the Veteran's current psychiatric disabilities are caused by or aggravated by his service-connected disabilities.

Although the Veteran believes that his current psychiatric disorders are caused by or related to active service to include fear of hostile military activity and/or is secondary to his service-connected disabilities, he is not competent to provide a nexus opinion. He is competent to report observable symptoms such as anxiety or depressed mood; however, the diagnosis of a psychiatric disorder and the etiology thereof requires medical expertise. See Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"). The Veteran's lay statements on this question are therefore not competent. To the extent that the Veteran's lay statements as to his symptoms are competent, they are outweighed by the probative opinions of the trained health care professionals discussed above. There is also no competent medical evidence of record that indicates the Veteran's current psychiatric disorders are etiologically related to active military service.

Based on the foregoing, the evidence persuasively weighs against finding that the Veteran's psychiatric disabilities had their onset during active military service and his PTSD and depressive disorder are not related to active military service to include fear of hostile military activity, and he does not have a disability resulting from a psychiatric disorder that is superimposed upon a personality disorder. The evidence persuasively weighs against finding that the Veteran's current psychiatric disabilities are due to, the result of, or aggravated beyond their natural
statements as to his symptoms are competent, they are outweighed by the probative opinions of the trained health care professionals discussed above. There is also no competent medical evidence of record that indicates the Veteran's current psychiatric disorders are etiologically related to active military service.

Based on the foregoing, the evidence persuasively weighs against finding that the Veteran's psychiatric disabilities had their onset during active military service and his PTSD and depressive disorder are not related to active military service to include fear of hostile military activity, and he does not have a disability resulting from a psychiatric disorder that is superimposed upon a personality disorder. The evidence persuasively weighs against finding that the Veteran's current psychiatric disabilities are due to, the result of, or aggravated beyond their natural progression by his service-connected disabilities. As the evidence persuasively weighs against the Veteran's claim of entitlement to service connection for a psychiatric disability to include PTSD, depressive disorder, alcohol dependence, and personality disorder, the benefit of the doubt doctrine is therefore not for application and the claim is not warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

Increased Rating

1. Entitlement to a disability rating in excess of 10 percent for residuals of stress fracture of the right foot.

2. Entitlement to a disability rating in excess of 10 percent for residuals of stress fracture of the left foot.

The Veteran is seeking a higher rating because he experienced bilateral foot pain. He is unable to stand or walk for prolonged periods of time. See January 2023 Board hearing. He also asserts that his pes planus and bunions were caused by, aggravated by, or a progression of his service-connected residuals of stress fracture of the feet. Id.

Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities, which is based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Any reasonable doubt regarding a degree of disability will be resolved in favor of the veteran. 38 C.F.R. § 4.3. When the evidence is in relative equipoise, the veteran is accorded the benefit of the doubt. 38 U.S.C. § 5107(b).

In general, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). However, staged ratings are appropriate in any increased-rating claim in which distinct time periods with different ratable symptoms can be identified. Hart v. Mansfield, 21 Vet. App. 505 (2007).

The Veteran's residuals of stress fracture of the right and left foot are rated under 38 C.F.R. § 4.71a, Diagnostic Code 5284, for other foot injuries. Under Diagnostic Code 5284, a 10 percent rating is warranted for moderate other foot injuries. A 20 percent rating is warranted for moderately severe other foot injuries. A 30 percent rating is warranted for severe other foot injuries. A Note to Diagnostic Code 5284 instructs that with actual loss of use of the foot rate as a maximum 40 percent. 38 C.F.R. § 4.71a, Diagnostic Code 5284.

According to MERRIAM WEBSTER, "moderate" means "tending toward the mean or average amount or dimension". See www.merriam-webster.com/dictionary/moderate. "Severe" means "of a great degree". See www.merriam-webster.com/dictionary/severe. While there is no specific dictionary definition for "moderately severe," the Board infers that "moderately severe" would be somewhere between "average in amount" and "very great; intense." Moderately severe is more serious than moderate, but not as extreme as severe.

When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria.").

While Diagnostic Code 5284 is not based on limitation of motion, the United States Court of Appeals for Veterans Claims (Court) held that the plain language of § 4.59 indicates that the regulation is not limited to the evaluation of musculoskeletal disabilities under diagnostic codes predicated on range of motion measurements. See Southall-Norman v. McDonald, 28 Vet. App. 346 (2016).

Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011).

In Correia v. McDonald, 28 Vet. App. 158 (2016), the Court held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion and in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint."

In Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination.

The Board finds that the evidence of record persuasively weighs against a rating in excess of 10 percent for residuals of stress fracture of the right and left foot prior to July 5, 2023. In the July 2013 VA examination, the Veteran reported that he experienced generalized foot pain and that both entire feet hurt from top to bottom. The examiner noted that the Veteran was very vague about the specific areas of pain.

However, even considering the Veteran's lay reports of symptoms and functional loss, the degree of additional limitation reflected by the statements generalized foot pain did not result in symptoms more nearly approximating moderately severe other foot injuries. Specifically, the July 2013 VA examination reveals that the Veteran did not have bilateral weak foot. There was no objective evidence of tenderness to palpation or manipulation, weakness, or muscle atrophy upon examination of the bilateral foot. The Veteran was able to rise onto the ball of both feet and heels without difficulty or reported pain. X-rays showed degenerative or traumatic arthritis of both feet. The evidence shows that the Veteran did not use any assistive device. Furthermore, the July 2013 VA examiner determined that the Veteran's residuals of stress fractures of the bilateral feet did not impact his ability work. The examiner specifically noted that the Veteran's residuals of stress fractures of the bilateral feet should not preclude physical or sedentary employment. The evidence does not indicate that the Veteran's residuals of stress fracture of either foot interferes with his activities of daily living. A June 2015 VA treatment record documents that the Veteran had foot pain
. The Veteran was able to rise onto the ball of both feet and heels without difficulty or reported pain. X-rays showed degenerative or traumatic arthritis of both feet. The evidence shows that the Veteran did not use any assistive device. Furthermore, the July 2013 VA examiner determined that the Veteran's residuals of stress fractures of the bilateral feet did not impact his ability work. The examiner specifically noted that the Veteran's residuals of stress fractures of the bilateral feet should not preclude physical or sedentary employment. The evidence does not indicate that the Veteran's residuals of stress fracture of either foot interferes with his activities of daily living. A June 2015 VA treatment record documents that the Veteran had foot pain. He was observed to have small bunions with flexible hammertoes. He was sent for a consultation for Anti Shox Insoles. A June 2016 VA treatment record documents that the Veteran complained of bilateral foot pain rated 8 out of 10; however, it was associated with his nonservice-connected flat foot and bunion. An April 2017 VA treatment record shows that the Veteran had left foot pain secondary to nonservice-connected hallux valgus deformity. As the Veteran's residuals of stress fracture of the right and left foot did not result in any functional impairment due to his bilateral foot pain and did not result in the use of assistive devices prior to July 5, 2023, the Veteran's residuals of stress fracture of the right and left foot do not more nearly approximate moderately severe or severe foot injury.

Nonetheless, the evidence is at least approximately balanced as to whether the residuals of stress fracture of the right and left foot more nearly approximates moderately severe foot injury from July 5, 2023. The July 2023 and July 2024 VA examinations show that the Veteran reported sharp constant pain in both feet. The July 2023 VA examiner noted that the Veteran reported that he had tolerable/manageable constant level of pain in his feet rated as an 8 out of 10. However, depending on the level of activity and the weather (cold and damp), the pain level would increase to an intolerable level of greater than 10 out of 10. He would take over the counter and prescribed pain medication, drink a lot of liquor, and rest his feet. The pain would resolve back to its tolerable level within 24 hours. The Veteran reported significant limitations in running, jumping, climbing, distance walking, and prolonged standing.

The July 2023 VA examination shows that the Veteran had residuals of stress fracture of both feet. The Veteran also had bilateral pes planus and hallux valgus. The examiner noted that the Veteran had bilateral foot pain on examination and the pain contributed to functional loss. The contributing factors of disability were less movement than normal, instability of station, disturbance of locomotion, interference with standing, pain, fatigue, and lack of endurance for both feet. The procured evidence also suggested that such contributing factors of disability significantly limited functional ability during flare-ups and/or after repeated use over time. The examiner explained that the Veteran's pain in both feet limited range of motion which impacted weight bearing, activity equilibrium, and full use of the feet. There was evidence of pain with passive motion, active motion, weight-bearing, nonweight-bearing, on rest/non-movement for both feet. The examiner noted that the Veteran described that the pain in his feet was constant. The Veteran regularly used a cane. The examiner determined that the Veteran's bilateral foot condition would significantly impact his ability to function in a purely physical work environment requiring heavy lifting, distance walking, prolonged standing, running, and climbing.

In June 2024, the Board remanded this claim, because the July 2023 examination report was not clear what symptoms were attributable to the Veteran's service-connected residuals of stress fracture of the bilateral foot versus his nonservice-connected bilateral pes planus and hallux valgus. Furthermore, during the January 2023 Board hearing, the Veteran asserted that his bilateral pes planus and hallux valgus were a progression or secondary to his service-connected residuals of stress fracture of both feet. In a July 2024 VA medical opinion, the VA examiner provided the opinion that the Veteran's bilateral pes planus and hallux valgus are not medically related to the Veteran's residuals of stress fracture of the bilateral foot. The examiner explained that bilateral pes planus and hallux valgus are separate entities entirely from residuals of stress fracture of the bilateral feet. A thorough review of medical literature failed to demonstrate a causal relationship. The examiner stated that the claims file does not support that pes planus and hallux valgus are progressions of the Veteran's service-connected disability and that during
planus and hallux valgus were a progression or secondary to his service-connected residuals of stress fracture of both feet. In a July 2024 VA medical opinion, the VA examiner provided the opinion that the Veteran's bilateral pes planus and hallux valgus are not medically related to the Veteran's residuals of stress fracture of the bilateral foot. The examiner explained that bilateral pes planus and hallux valgus are separate entities entirely from residuals of stress fracture of the bilateral feet. A thorough review of medical literature failed to demonstrate a causal relationship. The examiner stated that the claims file does not support that pes planus and hallux valgus are progressions of the Veteran's service-connected disability and that during the July 2024 VA examination there was no evidence of pes planus or hallux valgus. The July 2024 medical opinion is probative as to the issue of whether the Veteran's bilateral pes planus or hallux valgus is caused by, aggravated by, or considered a progression of the Veteran's service-connected residuals of stress fracture of the feet as the examiner provided a clear explanation based on the evidence of record.

The July 2024 VA examination shows that the Veteran had plantar fasciitis, degenerative arthritis, and residuals of stress fracture of both feet. The Veteran denied any current treatment for his feet. The Veteran reported that he had constant pain in his feet and it was hard to walk. The examiner stated that the Veteran did not report any flare-ups that impacted the function of his feet and he did not report any functional loss or functional impairment to include with repeated use over time. The examiner noted that the Veteran had residual pain for the bilateral stress fractures from 2000 and he had been diagnosed with arthritis of the bilateral first metatarsophalangeal joints. The examiner described the severity of the residuals of stress fracture of the feet as mild. The examiner documented that there was pain on physical examination for both feet, but the pain did not contribute to functional loss, because the pain was subjective only. Procured evidence did not suggest pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability during flare-ups or after repeated use over time. There was evidence of pain with active motion, because the Veteran reported pain with walking. The examiner noted that the Veteran did use any assistive devices. The examiner determined that the Veteran' arthritis of the feet is separate and unrelated to the Veteran's service-connected residuals of stress fractures of the bilateral feet. The examiner provided the opinion that the Veteran's residuals of stress fractures of the bilateral feet did not impact his ability to perform any type of occupational task.

The Board notes that there are significant discrepancies between the July 2023 VA examination and the July 2024 VA examination. The July 2024 VA examiner did not provide any explanation for such a drastic change in the Veteran's disability picture from the July 2023 VA examination. As noted above, it is unclear what symptoms were attributable to the Veteran's service-connected residuals of stress fracture of the bilateral foot versus is nonservice-connected bilateral pes planus and hallux valgus in the July 2023 VA examination. The July 2024 VA examination did not provide any clarification on that issue. It appears that some of the Veteran's symptoms of nonservice-connected bilateral pes planus and arthritis overlap with his symptoms of residuals of stress fractures of the bilateral feet. The Court has held that when a claimant has both service-connected and nonservice-connected disabilities, the Board must attempt to discern the effects of each disability and, where such distinction is not possible, attribute such effects to the service-connected disability. See Mittleider v. West, 11 Vet. App. 181 (1998). Thus, the Board will attribute the symptoms documented in the July 2023 that are not specifically noted as being a symptom of his bilateral pes planus and bilateral hallux valgus to his service-connected residuals of stress fractures of the bilateral feet.

From July 5, 2023, the evidence shows that the Veteran's residuals of stress fractures of both feet resulted in less movement than normal, instability of station, disturbance of locomotion, interference with standing, pain, fatigue, and lack of endurance for both feet. His symptoms significantly limited functional ability during flare-ups and/or after repeated use over time. There was objective evidence of pain. The Veteran's pain in both feet limited his range of motion which impacted weight bearing, activity equilibrium, and full use of the feet. Accordingly, as the evidence shows persistent pain, reduced mobility, difficulty with some weight-bearing activities to include the inability to engage in distance walking and standing, and significantly impact his ability to function in a physical work environment, this evidence supports that the Veteran
the evidence shows that the Veteran's residuals of stress fractures of both feet resulted in less movement than normal, instability of station, disturbance of locomotion, interference with standing, pain, fatigue, and lack of endurance for both feet. His symptoms significantly limited functional ability during flare-ups and/or after repeated use over time. There was objective evidence of pain. The Veteran's pain in both feet limited his range of motion which impacted weight bearing, activity equilibrium, and full use of the feet. Accordingly, as the evidence shows persistent pain, reduced mobility, difficulty with some weight-bearing activities to include the inability to engage in distance walking and standing, and significantly impact his ability to function in a physical work environment, this evidence supports that the Veteran's residuals of stress fractures of both feet more nearly approximates moderately-severe foot injury.

However, the evidence does not show that the Veteran's residuals of stress fractures of both feet result in deformity, muscle atrophy, or chronic weakness. His symptoms also do not prevent him from walking shorter distances or distances that are typical for engaging in daily activities. The evidence also shows that the Veteran can stand for moderate periods of time. Accordingly, the medical and lay evidence does not reflect that the Veteran's residuals of stress fractures of both feet more nearly approximate severe foot injury.

Where applicable rating criteria do not contemplate the ameliorative effects of medication, the severity of a disability must be considered outside any relief obtained by medication. Jones v. Shinseki, 26 Vet. App. 56, 63 (2012) (holding that when relevant rating criteria do not specifically contemplate medication use, the beneficial effects of that medication must be discounted); see also Ingram v. Collins, 38 Vet. App. 130, 138 (2025) (reaffirming the central holding of Jones relative to assessing the severity of musculoskeletal disability in particular). The criteria under Diagnostic Code 8284 do not contain any explicit reference to medication. The July 2023 VA examination report documents that the Veteran reported that when his pain level increases to a greater of 10 out of 10 (depending on activity level and weather), he takes over the counter medication, prescribed pain medication, and he drinks a lot of liquor. As the Veteran reported that he takes only takes his medication to treat his flare-ups of pain it is reasonable to presume that at the July 2023 VA examination the Veteran was describing his symptoms prior to taking any medication to treat such symptoms and he was likely not using any medication at the time of the examination. Thus, the Board did not consider any ameliorative effects of medication in assessing the level of impairment caused by the Veteran's residuals of stress fractures of the bilateral feet as the record shows that there was none to discount.

The Board has also considered the other Diagnostic Codes pertaining to the foot. Other disability ratings may be assigned only if the symptomatology for a disability is not duplicative or overlapping with the symptomatology of any other disability. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994); see also Lyles v. Shulkin, 29 Vet. App. 107 (2017). In Scott v. Wilkie, the Federal Circuit expressly adopted the Court's holding that disabilities specifically listed in the rating schedule may only be rated under Diagnostic Codes which specifically pertain to them. Scott v. Wilkie, 920 F.3d 1375 (Fed. Cir. 2019) (citing Copeland v. McDonald, 27 Vet. App. 333, 336 (2015)). The Federal Circuit also expressly adopted the Court's holding that unlisted conditions may be rated by analogy to Diagnostic Codes that may not describe the unlisted disability but addresses disabilities that may be productive of similar symptoms. Scott, 920 F.3d 1375 (citing Yancy v. McDonald, 27 Vet. App. 484, 493 (2016). Finally, the Federal Circuit concluded that the Board must also consider assigning separate ratings under analogous Diagnostic Codes, when rating an unlisted service-connected foot disability exhibiting distinct manifestations, even when service connection has also been granted for one of the eight conditions listed in the rating schedule. Id.

Here, the Veteran's residuals of stress fractures of the feet is unlisted and rated by analogy to other injuries of the foot. The Board has considered whether the Veteran is entitled to a higher disability rating under alternative Diagnostic Codes. Diagnostic Codes 5269 (plantar fasciitis, 5276, (acquired flat foot), 5278 (claw foot), and 5283 (tarsal, or metatarsal bones, malunion of, or nonunion of) are the only diagnostic codes which evaluate the foot that provide for disability ratings more than 10 percent. The medical evidence clearly shows that the Veteran does not have bilateral acquired claw foot or malunion or nonunion of the metatarsal bones. The medical evidence reflects that the Veteran has pes planus or flat foot; however, he is not in receipt of service connection for this disability and as discussed in detail above is not caused by, aggravated by, or a progression of the Veteran's service-connected residuals of stress fractures of the feet. The July 2024 VA examiner diagnosed the Veteran with bilateral plantar fasciitis of the feet. However, the Veteran is not service-connected for bilateral plantar fasciitis and the July 2024 VA examiner opined that the Veteran's plantar fasciitis is a medically separate diagnosis from the Veteran's service-connected residuals of bilateral stress fractures.

In conclusion, the Board finds that the evidence of record persuasively weighs against a rating in excess of 10 percent for stress fracture of the right and left foot prior to July 5, 2023. As the evidence of record persuasively weighs against a rating in excess of 10 percent for either foot prior to July 5, 2023, the benefit-of-the-doubt rule does not apply. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). However, the evidence is at least evenly balanced as to whether a 20 percent disability rating is warranted for residuals of stress fracture of the right and left foot from July 5, 2023.

REASONS FOR REMAND

1. Entitlement to service connection for a disability manifested by seizures.

Regarding the Veteran's service connection claim for a disability manifested by seizures, he contends that his seizures began during active duty. He attributed his seizures to boxing during active duty. In May 2024, the Board remanded the Veteran's service connection for a disability manifested by seizures to obtain medical opinion to determine whether the Veteran's seizures are associated with a known clinical diagnosis and if so whether such disability is caused by or related to an event, injury, or disease during the Veteran's honorable period of active duty from August 1980 to August 1984 and from February 1985 through October 14, 2003. A July 2024 VA seizure disorder examination shows that the Veteran was diagnosed with alcohol dependence with withdrawal delirium/seizures with an onset of 2019. Severe withdrawal from alcohol can cause delirium tremens, which is known to cause seizures. The examiner further notes that the entrance exam, separation exam, and DD2 808 were silent for seizures. The DD 2807 states neurologic problems on review of systems, however no exam during the military states the veteran had seizures. The examiner also noted that images are silent for seizure activity.

In a July 2024 medical opinion, the VA examiner determined that the Veteran's there is a lack of substantiating evidence supporting a nexus between the current diagnosis of Alcohol dependence with withdrawal delirium/Seizures and military service. The examiner explained that the Veteran was diagnosed with alcohol dependence with withdrawal delirium/seizures in 2019 many years after separation from service.

Direct service connection for an alcohol or opioid use disorder is barred as a matter of law. However, in providing a diagnosis of the Veteran's current seizure symptoms, the examiner only addressed the medical evidence in 2019. The relevant appeal period stems from an October 2012 claim for seizures. An October 2003 service treatment record (during a period of service that is barred from VA benefits) notes that the Veteran was a recently arrived inmate with multiple neurological problems including unspecified organic brain syndrome with episodes of tremors with unclear etiology. A July 2012 VA neuropsychology consult note shows that MRI evaluations of his brain reveal positive findings, including subcortical white matter and periventricular ischemic demyelination which is out of proportion to his age group. A March 2015 VA treatment record shows that the Veteran was provided with an EEG for questionable seizures. The EEG was unremarkable. Typical right arm and whole body shaking was captured during study without an associated EEG abnormality. The neurologist determined that the symptoms were nonepileptic in nature. Furthermore, a March 2019 VA treatment record documents that the Veteran was prescribed medication to treat his seizures. As the July 2024 VA examiner only referenced the 2019 post-service treatment records in her medical opinion, it appears that the examiner might not have reviewed these VA treatment records and these treatment records may alter the diagnosis that was provided in the July 2024 VA examination and the subsequent medical opinion. Accordingly, a new VA medical opinion is necessary prior to adjudicating the claim on appeal.

2. Entitlement to service connection for loss of bladder control (claimed as urinary tract condition).

In May 2024, the Board remanded the Veteran's service connection for loss of bladder control (claimed as urinary tract condition) in part to obtain a medical opinion regarding whether the Veteran's current bladder symptoms were caused by or aggravated by the Veteran's service-connected degenerative disc disease of the lumbar spine. A July 2024 VA examiner diagnosed the Veteran with urinary micturition. In an August 2024 addendum opinion, the examiner provided the opinion that the Veteran's loss of bladder control is not caused or aggravated by the Veteran's degenerative disc disease of lumbar spine. She explained that the Veteran's loss of bladder control is due to the Veteran's severe alcohol use disorder and frequent treatments for alcohol withdrawal seizures due to delirium tremens. The examiner stated that cauda equina is the only known medical condition that causes loss of bladder control directly due to a lumbar spine pathology. She noted that the claims file is silent for cauda equina. However, an April 2003 service treatment record documents that the Veteran had a spinal mass on civilian MRI and he was diagnosed with acute cauda equina syndrome with intermittent mild urinary incontinence, duration a few weeks. He had a laminectomy and incisional biopsy of the mass at L3 in April 2003. Accordingly, as a VA examiner indicated that cauda equina can cause loss of bladder control and the Veteran's service treatment records during a period of service that was deemed honorable, a medical opinion is necessary regarding whether the Veteran's current urinary micturition is caused by or related to the Veteran's in-service diagnosis of cauda equina syndrome prior to adjudicating this claim.

3. Entitlement to a TDIU.

The Veteran contends that his service-connected disabilities prevent him from securing or following any substantially gainful occupation. See May 2025 VA Form 21-8940. The Veteran raised the issue of entitlement to a TDIU as part of the Veteran's increased rating claims for residuals of stress fracture of the feet in May 2025. However, the claims file does not contain any recent VA examinations that assess the current nature of his symptoms for his service-connected degenerative joint disease of the cervical spine, bilateral upper extremity radiculopathy, degenerative disc disease of the thoracolumbar spine, bilateral lower extremity sciatic radiculopathy, and migraines. Furthermore, if the Veteran does not report for any scheduled examination or an examination vendor was unable to arrange an examination for the Veteran, documentation must be obtained and associated with the claims file showing that notice scheduling the examination was sent to the Veteran's last known address of record and/or a report of contact indicating that the Veteran was contacted to schedule an examination. Thus, the AOJ must complete additional development prior to adjudicating this claim. Furthermore, the issue of entitlement to a TDIU is inextricably intertwined with the claims remanded in this decision. See Harris v. Derwinski, 1 Vet. App. 180 (1991). As such, on
iculopathy, and migraines. Furthermore, if the Veteran does not report for any scheduled examination or an examination vendor was unable to arrange an examination for the Veteran, documentation must be obtained and associated with the claims file showing that notice scheduling the examination was sent to the Veteran's last known address of record and/or a report of contact indicating that the Veteran was contacted to schedule an examination. Thus, the AOJ must complete additional development prior to adjudicating this claim. Furthermore, the issue of entitlement to a TDIU is inextricably intertwined with the claims remanded in this decision. See Harris v. Derwinski, 1 Vet. App. 180 (1991). As such, on remand, the AOJ should readjudicate the issue of entitlement to a TDIU following the necessary development on remand.

The matters are REMANDED for the following action:

1. Obtain a VA medical opinion regarding the Veteran's service connection claim for disability manifested by seizures.

Only arrange for the Veteran to undergo a VA examination if one is deemed necessary in the judgment of the individual designated to provide the medical opinion. If an examination is scheduled, and the Veteran does not report for any scheduled examination or an examination vendor was unable to arrange an examination for the Veteran, documentation must be obtained and associated with the claims file showing that notice scheduling the examination was sent to the Veteran's last known address of record and/or a report of contact indicating that the Veteran was contacted to schedule an examination.

The claims file, including a copy of this remand, must be made available to the medical professional for review, and the medical professional should indicate that the claims folder was reviewed.

This reason for this remand relates to the prior medical opinion which was not based on all of the neurological evidence of record, and only addressed evidence from 2019; however, as noted above and below, records dating back to 2003 relate to neurological brain problems, and the Veteran filed a claim for seizures in 2012. The medical professional is requested to review all pertinent records associated with the claims file and provide answers to the following:

Whether the Veteran's seizures are attributed to any known clinical diagnosis.

The medical professional is referred to the following evidence: an October 2003 service treatment record that notes the Veteran had multiple neurological problems including unspecified organic brain syndrome with episodes of tremors with unclear etiology, a June 2007 EEG report, a June 2009 VA examination, a July 2012 VA neuropsychology consult note that discuses MRI evaluations of the Veteran's brain, a March 2015 VA treatment record that documents the results of an EEG, and a March 2019 VA treatment record that shows the Veteran was prescribed Levetiracetam 750 mg for seizure disorder.

The examiner should also be aware that the Veteran had a dishonorable period of service (and is therefore barred from obtaining benefits) from October 15, 2003 through January 29, 2008, but not earlier. Additionally, service connection for a primary alcohol or opioid use disorder is barred as a matter of law. As such, the examiner is asked to opine as to whether the onset of symptoms likely began (i) during the period beginning on October 15, 2003; (ii) during service prior to October 15, 2003; or, (iv) after service; and, whether, or to what extent the Veteran's seizures were caused by his alcohol and drug use.

(a.) If the Veteran's seizures are attributed to a known clinical diagnosis other than alcohol dependence with withdrawal delirium/seizures, whether it is at least as likely as not (i.e., likelihood is approximately balanced, or nearly equal if not higher) that such disability is related to the Veteran's honorable period of active duty from August 1980 to August 1984 and from February 1985 through October 14, 2003.

(b.) If the answer to (a) is negative, then whether the Veteran's seizures are at least as likely as not (likelihood is approximately balanced, or nearly equal if not higher) related to or otherwise caused by TERA? In providing this opinion, the medical professional is requested to consider the total potential exposure through all applicable military deployments and service during his honorable period of active duty service, as well as the synergistic and combined effect of all TERA.

(c.) If the answer to (b) is negative, then please opine as to the more likely cause of the Veteran's seizures and provide a complete rationale for the conclusions reached.

A complete, clearly stated rationale for the conclusions reached-to include identification of evidence and medical authority relied upon-must be provided. The medical professional should discuss any medical literature and/or studies used in offering his or her opinion.

In rendering each requested opinion(s), the
higher) related to or otherwise caused by TERA? In providing this opinion, the medical professional is requested to consider the total potential exposure through all applicable military deployments and service during his honorable period of active duty service, as well as the synergistic and combined effect of all TERA.

(c.) If the answer to (b) is negative, then please opine as to the more likely cause of the Veteran's seizures and provide a complete rationale for the conclusions reached.

In rendering each requested opinion(s), the medical professional must consider and discuss all in and post-service medical and other objective evidence of record.

2. Obtain a VA medical opinion regarding the Veteran's service connection claim for loss of bladder control (claimed as urinary tract condition).

Only arrange for the Veteran to undergo a VA examination if one is deemed necessary in the judgment of the individual designated to provide the medical opinion.

The claims file, including a copy of this remand, must be made available to the medical professional for review, and the medical professional should indicate that the claims folder was reviewed.

The medical professional is requested to review all pertinent records associated with the claims file and offer an opinion as to whether the Veteran's urinary maturation and/or any other diagnosed urinary disability or urinary symptoms is at least as likely as not (i.e., likelihood is approximately balanced, or nearly equal if not higher) had its onset in or is otherwise caused by or medically related to the Veteran's honorable period of active duty service (August 1980 to August 1984 and from February 1985 through October 14, 2003) to include the in-service documented acute cauda equina syndrome with intermittent mild urinary incontinence resulting in laminectomy and incisional biopsy of a mass at L3 in April 2003. Why or why not?

A complete, clearly stated rationale for the conclusions reached-to include identification of evidence and medical authority relied upon-must be provided. The medical professional is referred to the August 2024 VA addendum opinion asserting that cauda equina is the only known medical condition that causes loss of bladder control directly due to a lumbar spine pathology.

3. Develop the Veteran's claim for entitlement to a TDIU to include providing the Veteran with VA examinations regarding his service-connected service-connected degenerative joint disease of the cervical spine, bilateral upper extremity radiculopathy, degenerative disc disease of the thoracolumbar spine, bilateral lower extremity sciatic radiculopathy, and migraines, as well as, any other development deemed necessary.

If the Veteran does not report for any scheduled examination or an examination vendor was unable to arrange an examination for the Veteran, documentation must be obtained and associated with the claims file showing that notice scheduling the examination was sent to the Veteran's last known address of record and/or a report of contact indicating that the Veteran was contacted to schedule an examination.

4. Readjudicate the remanded claims on appeal, including entitlement to a TDIU. If the benefits sought on appeal remain denied, issue a supplemental SOC (SSOC) and provide the Veteran with the opportunity to respond thereto. Thereafter, subject to legacy appellate procedure, the appeal should be returned to the Board for further consideration, if in order.

In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand.

L. B. CRYAN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Berry, 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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