ANKLE IMPAIRMENT OF

A. C. MACKENZIE · 2026 · Case ID: A26023347

MIXED

Summary

The veteran, who served from June 1968 to March 1970, appeals the denial of service connection for several conditions. The veteran sought service connection for left ankle, left hip, lower back, right ankle, gastroesophageal reflux disease (GERD), and hiatal hernia. The Agency of Original Jurisdiction (AOJ) denied these claims. The Board of Veterans' Appeals (Board) reviewed the evidence of record as of the AOJ decision date, plus any evidence submitted within 90 days of the appeal. The Board applied the three-element test for service connection, requiring evidence of a current disability, in-service incurrence or aggravation, and a causal relationship. For GERD and hiatal hernia, the Board considered the possibility of secondary service connection to a psychiatric disability and service-connected GERD, respectively, noting the evidence was in approximate balance. The Board granted service connection for the left ankle, left hip, lower back, right ankle, GERD, and hiatal hernia. However, entitlement to service connection for a bilateral foot condition was remanded due to pre-decisional duty-to-assist errors. Specifically, the VA examinations were found inadequate for failing to explain conclusions, providing contradictory nexus opinions, and lacking opinions on secondary aggravation. The Board also noted insufficient evidence to determine if the veteran had a diagnosable foot condition with functional impairment.

Rationale

Evidence in approximate balance regarding secondary causation; Benefit of the doubt applied in favor of the veteran

Special Benefit

NO SPECIAL BENEFIT

Docket No.

251110-594417

Full Decision Text

Citation Nr: A26023347
Decision Date: 03/16/26 Archive Date: 03/16/26

DOCKET NO. 251110-594417
DATE: March 16, 2026

ORDER

Entitlement to service connection for a left ankle condition is granted.

Entitlement to service connection for a left hip condition is granted.

Entitlement to service connection for a lower back condition is granted.

Entitlement to service connection for a right ankle condition is granted.

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

Entitlement to service connection for hiatal hernia is granted.

REMANDED

Entitlement to service connection for bilateral foot condition is remanded.

FINDINGS OF FACT

1. The evidence of record is clear and unmistakable that the Veteran's left ankle condition preexisted service; however, the evidence of record is not clear and unmistakable that his left ankle condition was not aggravated by his active service.

2. The evidence of record is at least in approximate balance as to whether the Veteran's left hip condition was caused by the altered gait resulting from his service-connected knee disabilities.

3. The evidence of record is at least in approximate balance as to whether the Veteran's lower back condition was caused by the altered gait resulting from his service-connected knee disabilities.

4. The evidence of record is at least in approximate balance as to whether the Veteran's right ankle condition was caused by the altered gait resulting from his service-connected knee disabilities.

5. The evidence of record is at least in approximate balance as to whether the Veteran's GERD condition was caused by his service-connected psychiatric disability with residuals of TBI.

6. The evidence of record is at least in approximate balance as to whether the Veteran's hiatal hernia condition was caused by his now service connected GERD disability.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a left ankle condition have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for entitlement to service connection for a left hip condition have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for entitlement to service connection for a lower back condition have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. The criteria for entitlement to service connection for a right ankle condition have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

5. The criteria for entitlement to service connection for GERD have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

6. The criteria for entitlement to service connection for hiatal hernia have been 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 had active military service from June 1968 to March 1970.

This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2025 Appeals Modernization Act (AMA) rating decision that considered the evidence of record on that date. In its decision, the Agency of Original Jurisdiction (AOJ) denied the claim on appeal. The Veteran timely appealed this decision to the Board by requesting the AMA Evidence submission docket.

Under the AMA Evidence Submission docket, the Board may only consider the evidence of record at the time of the agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the appellant with, or within 90 days from receipt of the VA Form 10182. 38 C.F.R. § 20.303.

The Veteran asserts that he experiences multiple specific conditions as a result of his active service. Pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Board has, where appropriate, recharacterized the Veteran's claims to include any relevant condition, including those specific conditions previously identified by the Veteran. As emphasized in Clemons, though a Veteran may only seek service connection for a particular condition, the Veteran's claim cannot be limited only to that diagnosis but must rather be considered a claim for any relevant disability that may be reasonably encompassed.

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004).

Service connection also may be established on a secondary basis for disability that is proximately due to, or the result of, or aggravated by a service-connected disability. Establishing secondary service connection requires evidence of: (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) indication the current disability was either (a) caused or (b) is being aggravated by the service-connected disability. 38 C.F.R. § 3.310(a) and (b); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc).

Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013).

1. Entitlement to service connection for a left ankle condition

The Veteran asserts that he experiences a status post oblique fracture of the left distal fibula with degenerative arthritis and instability condition that arose during or as a result of his active service, including as secondary to his service-connected knee disabilities, or that preexisted his service and was aggravated by service.

A Veteran is presumed to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304(b). This statutory provision is known as the "presumption of soundness." Consideration of the presumption of soundness applies only when a disease or injury not noted upon entry to service later manifests in service, and a question arises as to whether it pre-existed service. Gilbert v. Shinseki, 26 Vet. App. 48, 55 (2012), aff'd 749 F.3d 1370 (Fed. Cir. 2014).

The term "noted," in 38 U.S.C. § 1111, refers to "[o]nly such conditions as are recorded in examination reports." 38 C.F.R. § 3.304(b). A "[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions." 38 C.F.R. § 3.304(b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994).

Where a condition is not "noted" at entrance examination, VA may rebut the presumption of soundness with clear and unmistakable evidence (obvious or manifest) of two things: first, that the condition pre-existed service and, second,
.C. § 1111, refers to "[o]nly such conditions as are recorded in examination reports." 38 C.F.R. § 3.304(b). A "[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions." 38 C.F.R. § 3.304(b)(1); see also Crowe v. Brown, 7 Vet. App. 238, 245 (1994).

The clear and unmistakable evidence standard is an onerous one, and it requires that the evidence be "undebatable." Laposky v. Brown, 4 Vet. App. 331, 334 (1993); Vanerson v. West, 12 Vet. App. 254, 258 (1999). VA, and not the Veteran, has the burden of showing such clear and unmistakable evidence of both the pre-existence prong and the non-aggravation prong to overcome the presumption of soundness. See Wagner v. Principi, 370 F.3d 1089, 1097 (Fed. Cir. 2004).

In situations like this one where a disability is not "noted" on clinical observation at service entrance, the existence of a pre-service disability may still be shown by clear and unmistakable evidence consisting of the Veteran's own admissions of having such pre-service disability, even where there is a "lack of contemporaneous clinical evidence or recorded history." See Horn v. Shinseki, 25 Vet. App. 231, 237-38 (2012) (citations omitted).

If a pre-existing disorder is noted upon entry into service, service connection may be granted based on aggravation during service of that disorder. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). A pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air service where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Clear and unmistakable evidence (obvious or manifest) is required to rebut the presumption of aggravation where the pre-service disability underwent an increase in severity during service. 38 C.F.R. § 3.306(b).

In Wagner v. Principi, 370 F.3d 1089, 1096 (2004), the United States Court of Appeals for the Federal Circuit held if a preexisting disorder is noted upon entry into service, the veteran cannot bring a claim for service connection for that disorder, but the veteran may bring a claim for service-connected aggravation of that disorder. In that case, 38 U.S.C. § 1153 applies and the burden falls on the veteran to establish an increase in disability during service. Wagner, 370 F.3d at 1096; Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). If the presumption of aggravation attaches, the burden shifts to the government to show by clear and unmistakable evidence that there has been no increase in the severity of the preexisting condition or that any increase was the result of natural progression. Id.; see also 38 C.F.R. § 3.306(b).

In the Veteran's service treatment records (STRs), an October 1967 treatment note indicates that he experienced a left distal fibula fracture two weeks earlier. Additional notes indicate he received treatment from November 1967 to January 1968. The Veteran's May 1968 Report of Medical History (RMH) notes a history of left leg fracture; however, his May 1968 enlistment medical examination is negative for a leg condition. July and August 1968 treatment records indicate complaints of left ankle or leg pain. His January 1970 expiration of term of service (ETS) medical examination is negative for a leg condition.

In an April 2022 statement in support of his claim, the Veteran asserted that he experienced a left leg compound fracture in October 1967, eight months prior to enlisting. He asserted he was experiencing swelling in his leg at the time of his entrance examination, but his medical examiner informed him that
1967 to January 1968. The Veteran's May 1968 Report of Medical History (RMH) notes a history of left leg fracture; however, his May 1968 enlistment medical examination is negative for a leg condition. July and August 1968 treatment records indicate complaints of left ankle or leg pain. His January 1970 expiration of term of service (ETS) medical examination is negative for a leg condition.

In an April 2022 statement in support of his claim, the Veteran asserted that he experienced a left leg compound fracture in October 1967, eight months prior to enlisting. He asserted he was experiencing swelling in his leg at the time of his entrance examination, but his medical examiner informed him that he was in good enough condition to continue with the enlistment process. The Veteran asserted that he experienced leg pain throughout service, especially during assignments that required physical labor or training. Finally, he asserted he had experienced chronic leg pain since leaving service.

During the Veteran's April 2025 VA examination for ankle conditions, the VA examiner noted diagnoses for degenerative arthritis of the left ankle, healed left distal fibula, and left ankle instability.

In an April 2025 VA medical opinion, the VA examiner opined that the Veteran's left ankle condition clearly and unmistakably preexisted service and clearly and unmistakably had not been aggravated by service. They noted that degenerative arthritis was consistent with natural aging, ankle instability was the result of his pre-service injury, and his left leg fracture had healed prior to service. The examiner also noted that he was able to complete service without issue.

The Board notes that there is no discussion of the Veteran's statements or of his documented in-service complaints of left ankle pain; therefore, the Board lends the April 2025 VA medical opinion only some probative value.

In an August 2025 addendum VA medical opinion, the VA examiner opined that the diagnosed status post oblique fracture of the left distal fibula with degenerative arthritis and left ankle instability was at least as likely as not aggravated beyond natural progression by the treatment the Veteran received; however, in their rationale, they stated the diagnosed condition was not aggravated beyond its natural progression by service, and his left ankle treatment during service was only acute in nature.

The Board notes that although the VA examiner likely meant that the condition was less likely than not aggravated by service, they provided a positive opinion followed by a rationale supporting a negative opinion. Additionally, they did not use the "clear and unmistakable" standard concerning potential aggravation of a preexisting condition. Consequently, the Board lends the August 2025 VA medical opinion only limited probative weight.

In November 2025, the Veteran submitted a medical opinion by a private physician who opined that his active service clearly and unmistakably aggravated his preexisting left ankle injury, which they characterized as likely still healing. They reviewed his medical history and the medical evidence of record in detail and concluded that his physical training and duties had aggravated the preexisting condition, as evidenced by the Veteran's statements and documented treatment for left ankle pain during service. Given the detail and length of the opinion, the author's ability to review the entire medical record, and their expertise, the Board lends the November 2025 private medical opinion significant probative weight.

The Board finds that the Veteran's left ankle condition clearly and unmistakably preexisted service. Although it was not noted on his entrance medical examination, there are multiple medical records from shortly before service documenting the injury, and it was also documented on his entrance Report of Medical History. The Veteran has admitted the condition was present prior to service, and he has asserted that it was ongoing during his entrance medical examination and continued through service. Based on these facts, the Board finds that the Veteran's left ankle condition clearly and unmistakably preexisted service; therefore, the presumption of soundness is rebutted. Consequently, the presumption of aggravation applies to the preexisting left ankle condition.

Next, the Board finds that it is not clear and unmistakable that the Veteran's preexisting left ankle condition was not aggravated by service. The Veteran has asserted experiencing left ankle pain throughout service, and there is documented treatment for left ankle pain in his STRs. Although the VA medical opinions of record indicate that his claimed condition was not aggravated by service, the November 2025 private medical opinion indicates that the condition was clearly and unmistakably aggravated by service. Based on these facts, the Board finds that the criteria for service-connected aggravation of the preexisting left ankle condition have been met.

Accordingly, entitlement to service connection for a left ankle condition is granted, based on service-connected aggravation of a preexisting condition.

2. to 4. Entitlement to service connection for a left hip condition, entitlement to service connection for a lower back condition, and entitlement to service connection for a right ankle condition

The Veteran asserts that he experiences left
is documented treatment for left ankle pain in his STRs. Although the VA medical opinions of record indicate that his claimed condition was not aggravated by service, the November 2025 private medical opinion indicates that the condition was clearly and unmistakably aggravated by service. Based on these facts, the Board finds that the criteria for service-connected aggravation of the preexisting left ankle condition have been met.

Accordingly, entitlement to service connection for a left ankle condition is granted, based on service-connected aggravation of a preexisting condition.

2. to 4. Entitlement to service connection for a left hip condition, entitlement to service connection for a lower back condition, and entitlement to service connection for a right ankle condition

The Veteran asserts that he experiences left hip, lower back, and right ankle conditions that arose during or as a result of his active service, including as secondary to his service-connected left and right knee disabilities. As these claims involve largely the same facts and law, they are considered together in this decision.

The Veteran's May 1968 enlistment medical examination is negative for hip, back, or right ankle conditions; therefore, the Veteran is presumed sound upon entrance to service. His STRs reflect complaints of right ankle pain in July 1968; however, they are otherwise negative for the claimed conditions. His January 1970 ETS medical examination and Report of Medical History are negative for evidence of the claimed conditions.

The Veteran's post-service VA and private treatment records are negative for evidence of the claimed conditions during the 12-month period immediately following separation from active service or for medical opinions supporting his claims.

In January 2025, the Veteran filed a claim for service connection for these conditions and asserted that they were secondary to his service-connected knee disabilities.

During the Veteran's January 2025 VA examination for hip conditions, the VA examiner noted diagnosis for left hip strain. The Veteran reported the gradual onset of left hip pain since 2000.

During the Veteran's January 2025 VA examination for back conditions, the VA examiner noted diagnoses for degenerative arthritis of the spine and degenerative disc disease other than intervertebral disc syndrome (IVDS). The Veteran reported experiencing chronic back pain since 1968.

During the Veteran's January 2025 VA examination for ankle conditions, the VA examiner noted diagnosis for right ankle sprain. The Veteran reported the gradual onset of right ankle pain since 2000.

In an April 2025 VA medical opinion, the VA examiner checked the box indicating that the Veteran's claimed conditions were at least as likely as not secondary to a service-connected condition; however, they also checked the box indicating that they were less likely than not secondary to a service-connected condition. The rationales provided for each opinion supported finding that the conditions were less likely than not caused by his knee disabilities. In their rationales, the VA examiner indicated that the conditions were less likely due to his knee disabilities and more likely due to obesity and ageing. The examiner did not address the possibility of secondary aggravation or whether his knee disabilities caused or contributed to the onset of obesity.

Given the errors in the April 2025 VA medical opinions, the Board lends the April 2025 VA medical opinions only limited probative weight.

In a May 2025 statement in support of his claims, the Veteran asserted that his knee disabilities caused him to walk with a limp, and he believed his altered gait had caused his back, hip, and ankle disabilities.

During the Veteran's June 2025 VA examination for back conditions, the VA examiner noted diagnoses for degenerative arthritis, degenerative disc disease other than IVDS, and levocurvature in the lumbar spine.

During the Veteran's June 2025 VA examination hip conditions, the VA examiner noted a diagnosis for left hip degenerative arthritis.

During the Veteran's June 2025 VA examination for ankle conditions, the VA examiner noted a diagnosis for right ankle sprain.

In a June 2025 addendum VA medical opinion, the VA examiner opined that the Veteran's right ankle condition was less likely than not caused by his knee disabilities. In their rationale, the examiner stated that the ankle condition was most likely caused by a right ankle injury.

In a June 2025 addendum VA medical opinion, the VA examiner opined that the Veteran's back conditions were less likely than not caused by his knee disabilities. In their rationale, the examiner stated that the back conditions were most likely caused by aging and normal wear and tear.

In a June 2025 addendum VA medical opinion, the VA examiner opined that the Veteran's hip condition was less likely than not caused by his knee disabilities. In their rationale, the examiner stated that the hip condition was most likely caused by aging and normal wear and tear.

In an August 2025 addendum VA medical opinion, the VA examiner opined that the Veteran's diagnosed right ankle condition was less likely than not caused by service,
injury.

In an August 2025 addendum VA medical opinion, the VA examiner opined that the Veteran's diagnosed right ankle condition was less likely than not caused by service, as his documented right ankle condition during service was acute and resolved during service.

In a November 2025 medical opinion authored by a private physician, the physician opined that the Veteran's back, left hip, and right ankle conditions were all at least as likely as not caused by the altered gait caused by his service-connected knee conditions. The physician provided a detailed review of the Veteran's medical history, relevant medical studies, and the prior medical opinions of record. They concluded that the most likely cause of his back, left hip, and right ankle conditions was his altered gait, which was caused by his knee disabilities.

Based on the detail of the opinion, the quality of the rationales for their conclusions, the author's ability to examine the medical evidence of record-including previous medical opinions, and the author's expertise, the Board lends the November 2025 private medical opinion significant probative weight.

The Board finds the evidence of record is at least in approximate balance as to whether the Veteran's claimed conditions are secondary to the altered gait caused by his service-connected knee disabilities. The Veteran's STRs are negative for back and left hip conditions, and there is only one reference to right ankle treatment, which was not reflected in his separation medical examination or RMH. Although the VA medical opinions of record all indicate that his claimed conditions are less likely than not related to his service-connected knee disabilities, the November 2025 private medical opinion indicates that these conditions are all at least as likely as not due to his knee disabilities. Although there are more negative VA medical opinions, the November 2025 private medical opinion is significantly more detailed and comprehensive. Based on these facts, the Board finds the evidence of record is in approximate balance.

Accordingly, entitlement to service connection for a left hip condition is granted. Additionally, entitlement to service connection for a lower back condition is granted. Finally, entitlement to service connection for a right ankle condition is granted.

5. Entitlement to service connection for GERD

The Veteran asserts that he experiences GERD that is secondary to nonsteroidal anti-inflammatory drug (NSAID) use, prescribed to treat his service-connected knee disabilities and as secondary to his service-connected psychiatric disability.

The Veteran's STRs are negative for evidence of complaints, treatment, or diagnosis of GERD.

The Veteran's post-service VA and private treatment records are negative for evidence of GERD during the 12-month period immediately following separation from active service or for medical opinions supporting his claim.

In January 2025, the Veteran filed a claim for service connection and claimed that his GERD was secondary to NSAIDs prescribed to treat his knee disability pain.

During the Veteran's January 2025 VA examination for esophageal conditions, the VA examiner noted diagnoses for GERD and hiatal hernia.

In an April 2025 VA medical opinion, the VA examiner checked the box indicating that the Veteran's claimed GERD was at least as likely as not secondary to a service-connected condition; however, they also checked the box indicating that it was less likely than not secondary to a service-connected condition. The rationale provided supported finding that the condition was less likely than not caused by his knee disabilities or medication prescribed for their treatment. In their rationale, the VA examiner indicated that GERD was more likely due to obesity and aging. Joint disabilities did not have a mechanism by which to cause GERD, and the Veteran predominantly uses a topical cream to treat his knees, which would not cause GERD. The examiner did not address the possibility of secondary aggravation or whether his knee disabilities caused or contributed to the onset of obesity.

In November 2025, the Veteran submitted a medical opinion from a private physician supporting his claim. In the opinion, the physician provided a detailed review of the Veteran's medical history and relevant medical literature and concluded that his GERD was at least as likely as not caused by his psychiatric disability. The physician noted that his disability resulted in anxiety, depression, hypervigilance, and other symptoms and relevant medical studies showed a strong correlation between patients exhibiting these symptoms and much higher chance of developing GERD. Chronic psychiatric symptoms were found to result in nervous system and digestive system disruptions, leading to an
not cause GERD. The examiner did not address the possibility of secondary aggravation or whether his knee disabilities caused or contributed to the onset of obesity.

In November 2025, the Veteran submitted a medical opinion from a private physician supporting his claim. In the opinion, the physician provided a detailed review of the Veteran's medical history and relevant medical literature and concluded that his GERD was at least as likely as not caused by his psychiatric disability. The physician noted that his disability resulted in anxiety, depression, hypervigilance, and other symptoms and relevant medical studies showed a strong correlation between patients exhibiting these symptoms and much higher chance of developing GERD. Chronic psychiatric symptoms were found to result in nervous system and digestive system disruptions, leading to an increased risk of the onset of GERD. Given the detailed, well-supported rationale and the author's chance to review the Veteran's medical history, the Board lends this opinion significant probative weight.

The Board finds the evidence of record is at least in approximate balance as to whether the Veteran's claimed GERD was caused by his service-connected psychiatric disability with residuals of TBI. The Board lends the November 2025 private medical opinion significant probative weight, and no other medical evidence addresses this etiological theory. Based on these facts, the Board finds that the criteria for service connection have been met. Accordingly, entitlement to service connection for gastroesophageal reflux disease (GERD) is granted.

6. Entitlement to service connection for hiatal hernia

The Veteran asserts that he experiences a hernia that is secondary to NSAID use, as prescribed to treat his service-connected knee disabilities, and as secondary to his claimed GERD condition.

The Veteran's STRs are negative for evidence of complaints, treatment, or diagnosis of hernia.

The Veteran's post-service VA and private treatment records are negative for evidence of hernias during the 12-month period immediately following separation from active service or for medical opinions supporting his claim.

In January 2025, the Veteran filed a claim for service connection and claimed that his GERD and hernia were secondary to NSAIDs prescribed to treat his knee disability pain.

During the Veteran's January 2025 VA examination for esophageal conditions, the VA examiner noted diagnoses for GERD and hiatal hernia.

In an April 2025 VA medical opinion, the VA examiner checked the box indicating that the Veteran's claimed hernia was at least as likely as not secondary to a service-connected condition; however, they also checked the box indicating that it was less likely than not secondary to a service-connected condition. The rationale provided supported finding that the condition was less likely than not caused by his knee disabilities or medication prescribed for their treatment. In their rationale, the VA examiner indicated that his hernia was more likely due to obesity and aging. Joint disabilities did not have a mechanism by which to cause hernias, and the Veteran predominantly uses a topical cream to treat his knees, which would not cause GERD. The examiner did not address the possibility of secondary aggravation or whether his knee disabilities caused or contributed to the onset of obesity.

In November 2025, the Veteran submitted a medical opinion from a private physician supporting his claim. In the opinion, the physician provided a detailed review of the Veteran's medical history and relevant medical literature and concluded that his claimed hernia was at least likely as not secondary to his GERD. The physician noted that relevant literature supported the conclusion that GERD was a cause of hiatal hernias. GERD occurred when the lower esophageal sphincter (LES), a muscle that prevents stomach acid from backing up into the esophagus, weakens or relaxes inappropriately, allowing acid to flow into the esophagus. Over time, this chronic inflammation and irritation could cause the diaphragm to weaken, allowing the stomach to bulge through the hiatus (opening) in the diaphragm. Based on their review of the relevant literature and the Veteran's medical history, the author concluded that his hernia was at least as likely as not caused by his GERD. Given the detailed, well-supported rationale and the author's chance to review the Veteran's medical history, the Board lends this opinion significant probative weight.

The Board notes that as of this decision, the Board's GERD has been determined to be service connected.

The Board finds the evidence of record is at least in approximate balance as to whether the Veteran's claimed hernia was caused by his service-connected GERD. The Board lends the November 2025 private medical opinion significant probative weight, and no other medical evidence addresses this etiological theory. Based on these facts, the Board finds that the criteria for service connection have been met. Accordingly, entitlement to service connection for hiatal hernia is granted.

REASONS FOR REMAND

1. Entitlement to service connection for bilateral foot condition is remanded.

The Veteran asserts that he experiences a bilateral foot
this opinion significant probative weight.

The Board notes that as of this decision, the Board's GERD has been determined to be service connected.

REASONS FOR REMAND

1. Entitlement to service connection for bilateral foot condition is remanded.

The Veteran asserts that he experiences a bilateral foot condition that arose during or as a result of service, including as secondary to his service-connected left and right knee disabilities.

The Board finds that this issue must be remanded to correct pre-decisional duty-to-assist errors.

First, during the Veteran's January 2025 VA examination for foot conditions, the Veteran reported occasional swelling of his feet and pain with prolonged walking; however, the VA examiner indicated that his subjective reports of pain did not result in functional loss. No explanation was provided for this conclusion.

Second, in the April 2025 VA medical opinion, the VA examiner checked the box indicating that the Veteran's bilateral foot condition was at least as likely as not secondary to a service-connected condition; however, they also checked the box indicating that the Veteran's bilateral foot condition was less likely than not secondary to a service-connected condition.

Finally, no VA medical opinion was provided addressing the possibility of secondary aggravation of the Veteran's claimed disability by his service-connected knee disabilities.

Based on these facts, the Board finds the January 2025 VA examination and April 2025 VA medical opinion inadequate for adjudication purposes. As these facts were before the AOJ at the time of the rating decision on appeal, the AOJ's reliance on this examination and opinion constitute pre-decisional DTA errors that must be corrected on remand.

The Board has considered the November 2025 medical opinion by a private physician that the Veteran submitted in support of his claim. Although the author indicates that his claimed condition is at least as likely as not secondary to his knee disabilities, they do not provide a diagnosis and do not indicate whether his claimed condition results in functional impairment beyond repeating his reports of occasional swelling and pain. Moreover, the author stated that they did not conduct an examination of the Veteran. Consequently, although the Board makes no conclusion regarding the probative weight of this opinion regarding the etiology of the Veteran's claimed condition, the Board finds that the November 2025 opinion does not contain sufficient information to conclude whether he has a diagnosable condition or whether his reports of pain result in functional impairment.

Additionally, the Veteran's VA treatment records are negative for evidence of complaints, treatment, or diagnosis for foot pain or a foot condition.

Based on these facts, the Board finds that there is insufficient evidence to determine whether the Veteran has a diagnosable condition, including pain that results in functional impairment, at this time.

Accordingly, this issue is REMANDED for the following action:

Afford the Veteran a VA examination with a qualified clinician to determine the nature and etiology of the Veteran's claimed bilateral foot condition. The electronic claims file, including a copy of this remand, must be reviewed by the examiner. All indicated studies and testing must be conducted, and all pertinent symptomatology must be reported in detail.

After a review of the claims file, the examiner should address the following matters:

(a) Identify all diagnosable conditions present during the period on appeal (from December 6, 2024 onward), including any reports of pain that result in functional impairment. If the examiner concludes that the Veteran's reports of pain do not result in a functional impairment of earning capacity, they should provide a rationale for that conclusion.

(b) For each diagnosed condition, is it at least as likely as not (at least an approximate balance of positive and negative evidence) that the Veteran's condition was caused or aggravated (worsened beyond natural progression) by his service-connected knee disabilities or their treatment?

"Aggravation" covers situations where: 1) there is worsening directly due to a service-connected disability; and/or 2) the claimed disability would have been less severe but for the service-connected disability because the service-connected disability results in the inability to treat the claimed disability.

(Continued on the next page)

A complete rationale should be provided for all opinions and conclusions.

A. C. MACKENZIE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Hixon, Evan

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

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