GASTROESOPHAGEAL REFLUX DISEASE (GERD)

S. B. MAYS · 2026 · Case ID: A26026431

GRANTED

Summary

The Veteran served from December 2003 to February 2008, including service in the Southwest Asia theater of operations. The Veteran appealed the denial of service connection for GERD, lumbosacral strain, bilateral knee strain, and erectile dysfunction, claiming these conditions were secondary to his service-connected chronic tendonitis of the right ankle. The Board found favorable findings from the RO regarding current diagnoses of these conditions and service connection for the right ankle tendonitis. The Board reviewed multiple VA examinations which were found to be deficient for failing to adequately address nexus or aggravation, or for misinterpreting the claims file. The Board then considered a private medical opinion from R.P., D.O., which found the Veteran's GERD, lumbosacral strain, bilateral knee strain, and erectile dysfunction to be at least as likely as not secondary to his service-connected right ankle condition and/or the NSAID medications taken for it. This opinion was found to be competent, credible, and probative, applying medical literature to the Veteran's circumstances and addressing aggravation. The Board found the evidence in approximate balance, applying the benefit of the doubt doctrine. Service connection for GERD, lumbosacral strain, right knee strain, left knee strain, and erectile dysfunction were granted as secondary to the service-connected chronic tendonitis of the right ankle.

Rationale

Favorable finding of current GERD diagnosis and service-connected right ankle tendonitis.; Deficient VA opinions found to have low probative weight.; Competent, credible, and probative private medical opinion establishing nexus.

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250923-591566

Full Decision Text

Citation Nr: A26026431
Decision Date: 03/24/26 Archive Date: 03/24/26

DOCKET NO. 250923-591566
DATE: March 24, 2026

ORDER

Service connection for gastroesophageal reflux disease (GERD) is granted.

Service connection for lumbosacral strain is granted.

Service connection for right knee strain is granted.

Service connection for left knee strain is granted.

Service connection for erectile dysfunction is granted.

FINDINGS OF FACT

1. Resolving reasonable doubt in favor of the Veteran, his GERD was caused or aggravated by his service-connected chronic tendonitis of the right ankle.

2. Resolving reasonable doubt in favor of the Veteran, his lumbosacral strain was caused or aggravated by his service-connected chronic tendonitis of the right ankle.

3. Resolving reasonable doubt in favor of the Veteran, his right knee strain was caused or aggravated by his service-connected chronic tendonitis of the right ankle.

4. Resolving reasonable doubt in favor of the Veteran, his left knee strain was caused or aggravated by his service-connected chronic tendonitis of the right ankle.

5. Resolving reasonable doubt in favor of the Veteran, his erectile dysfunction was caused or aggravated by his service-connected chronic tendonitis of the right ankle.

CONCLUSIONS OF LAW

1. The criteria to establish service connection for GERD are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

2. The criteria to establish service connection for lumbosacral strain are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria to establish service connection for right knee strain are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

4. The criteria to establish service connection for left knee strain are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

5. The criteria to establish service connection for erectile dysfunction are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from December 2003 to February 2008, including service in the Southwest Asia theater of operations.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2025 Appeals Modernization Act (AMA) rating decision from a Department of Veterans Affairs (VA) Regional Office, the agency of original jurisdiction (AOJ), that denied the Veteran's claims for service connection for a low back disability, right and left knee disabilities, GERD, and erectile dysfunction, finding that the evidence does not establish a nexus between the disabilities and service or as secondary to his service-connected chronic tendonitis of the right ankle. The February 2025 rating decision noted favorable findings that the Veteran has current diagnoses of right and left knee strain, lumbosacral strain, GERD, and erectile dysfunction, that he participated in a toxic exposure risk activity while deployed to Iraq, and that the primary disability for the secondary service connection claims, chronic tendonitis of the right ankle, is service-connected. The Board is bound by favorable findings unless they are rebutted by clear and unmistakable error. 38 U.S.C. § 5104A.

The February 2025 rating decision on appeal found that new and relevant evidence had been received to readjudicate the claims of service connection for right and left knee and low back disabilities. These are favorable findings by the AOJ that are binding on the Board. Thus, the Board may address the service connection claims on the merits. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c).

In September 2025, the Veteran, through his attorney, initiated this appeal to the Board with the filing of a Decision Review Request-Notice of Disagreement (VA Form 10182), requesting direct review by a Veterans Law Judge on the evidence of record at the time of the rating decision. In November 2025 correspondence, the Board acknowledged the appeal and informed the Veteran and his attorney that the appeal had been placed on the Board's direct review docket. Therefore, the Board may only consider the evidence of record at the time of the AOJ's rating decision on appeal, here as of February 21
U.S.C. § 5104A; 38 C.F.R. § 3.104(c).

Service Connection

Applicable Laws and Regulations

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

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

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

There is an alternative means of establishing service connection where a veteran served 90 days or more of active service, and certain chronic diseases, including GERD and erectile dysfunction, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. Id. Here, the Veteran served on active duty more than 90 days; however, the evidence does not demonstrate diagnosis of GERD or erectile dysfunction or any symptoms resulting in functional impairment of earning capacity until many years after his separation from service. Therefore, the provisions of 38 C.F.R. § 3.303(b) and § 3.309(a) are not for application. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

The Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) requires a determination of a veteran's toxic exposure risk activity (TERA) and establishes presumption of in-service exposure to burn pit and other environmental hazards for certain disabilities based on service in the Southwest Asia theater. Here, the record reflects that the Veteran served in Southwest Asia. However, the disabilities claimed by the Veteran in this case are not among the enumerated disabilities for which service connection can be presumed under the PACT Act. Therefore, the presumptive service connection provisions under the PACT Act are not for application. Nevertheless, the PACT Act requires the AOJ to obtain a VA medical opinion addressing in-service exposures if TERA is implicated.

A lay person is competent
xics Act of 2022 (PACT Act) requires a determination of a veteran's toxic exposure risk activity (TERA) and establishes presumption of in-service exposure to burn pit and other environmental hazards for certain disabilities based on service in the Southwest Asia theater. Here, the record reflects that the Veteran served in Southwest Asia. However, the disabilities claimed by the Veteran in this case are not among the enumerated disabilities for which service connection can be presumed under the PACT Act. Therefore, the presumptive service connection provisions under the PACT Act are not for application. Nevertheless, the PACT Act requires the AOJ to obtain a VA medical opinion addressing in-service exposures if TERA is implicated.

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

Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Nieves-Rodriguez v. Peake, 22?Vet. App. 295, 304 (2008). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical evidence. See?Bloom v. West, 12 Vet. App. 185, 187 (1999).

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

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

GERD

The Veteran seeks service connection for GERD, to include as secondary to his service-connected chronic tendonitis of the right ankle. See, e.g., April 2023 Statement in Support of Claim. Specifically, he asserts that taking Ibuprofen and Naproxen for chronic tendonitis of the right ankle caused his GERD. Id.

Initially, the February 2025 rating decision reflects the favorable findings that the Veteran has a current diagnosis of GERD and that he has been awarded service connection for chronic tendonitis of the right ankle. The Board is bound by these favorable findings as they are not rebutted by clear and unmistakable error. 38 U.S.C. § 5104A; Shedden, supra. Thus, the dispositive issue in this case is whether the evidence establishes a nexus between the Veteran's GERD and his service-connected chronic tendonitis of the right ankle.

The Veteran's service treatment records are negative for symptoms, complaints, or diagnosis of GERD. 2013 VA treatment notes show that the Veteran reported taking Ibuprofen for pain and he was given a prescription for Naproxen for pain, both nonsteroidal anti-inflammatory drugs (NSAIDs). See Dorland's Illustrated Medical Dictionary at 923, 1251 (31st ed. 2007). The earliest post-service evidence of GERD is reflected in a 2021 VA treatment record that shows that the Veteran endorsed reflux but was not taking medication for it. See July 2021 VA Pulmonary Consult. GERD was initially diagnosed during an October 2021 sleep study and the Veteran was given a prescription for the medication Famotidine. See December 2021 VA Primary Care Note. The treatment records also
notes show that the Veteran reported taking Ibuprofen for pain and he was given a prescription for Naproxen for pain, both nonsteroidal anti-inflammatory drugs (NSAIDs). See Dorland's Illustrated Medical Dictionary at 923, 1251 (31st ed. 2007). The earliest post-service evidence of GERD is reflected in a 2021 VA treatment record that shows that the Veteran endorsed reflux but was not taking medication for it. See July 2021 VA Pulmonary Consult. GERD was initially diagnosed during an October 2021 sleep study and the Veteran was given a prescription for the medication Famotidine. See December 2021 VA Primary Care Note. The treatment records also show that the Veteran reported taking Ibuprofen for pain. See March 2022 VA Secure Messaging. However, the post-service treatment records do not address the etiology of the Veteran's GERD.

The Veteran is competent to report the circumstances giving rise to the initial observable symptoms, as well as the nature of the symptoms during and after service; however, he has not been shown to be competent to diagnose more complex medical problems, such as GERD, or to opine as to the etiology of such disorders, which are medical questions. See Jandreau, 492 F.3d at 1376-77.

Notably, in September 2023, the Veteran was afforded a VA ankle conditions examination, which reflects diagnosis of chronic tendonitis of the right ankle and notes that the Veteran was taking NSAIDs for right ankle pain.

Also in September 2023, the Veteran underwent a VA esophageal conditions examination, at which time the examiner confirmed the diagnosis of GERD. The Veteran reported that his GERD is related to his service in Iraq and/or secondary to his service-connected right ankle disability. The VA examiner opined that it is less likely than not that the Veteran's GERD was caused by his conceded hazardous exposures while deployed to Southwest Asia: "There is no medical or scientific evidence available at this time that provides indication of a relationship between development of [GERD] and the TERA. There are risk factors outside of military service (hereditary, congenital, smoking history, weight, age, etc.) that far outweigh the factors identified in the TERA." However, the opinion does not explain why greater weight was assigned to risk factors outside of the Veteran's military service. See Nieves-Rodriguez, supra. Accordingly, the Board assigns this opinion low probative weight.

The September 2023 VA examiner also opined that it is less likely than not that the Veteran's GERD was caused by his right ankle disability, noting only that a review of the National Institutes of Health Internet site at www.pubmed.gov supported the unfavorable opinion. See Nieves-Rodriguez, 22 Vet. App. at 302-04 (a central issue in determining the probative value of a medical opinion is whether the examiner provides the required explanation for conclusions). Furthermore, the opinion does not address aggravation. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). For these reasons, the Board assigns the September 2023 VA opinion no probative weight.

The Veteran underwent a second VA examination in October 2024, which confirmed the GERD diagnosis. The examiner opined that it is less likely than not that the Veteran's GERD was caused by his service-connected right ankle disability, explaining that "[c]urrent medical understanding does not support a connection between chronic tendonitis in the ankle and the development of GERD, as these conditions typically involve unrelated physiological pathways and risk factors. There is no evidence to suggest GERD would be related to any treatment for the service connected ankle condition; there is more likely a dietary etiology." However, the opinion does not address the Veteran's April 2023 statement asserting that his GERD was caused by taking Ibuprofen and Naproxen for his service-connected right ankle disability. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (VA examiner impermissibly ignored the Veteran's lay assertions regarding the nature of the disability). Critically, the opinion does not address aggravation. See Allen, supra. For these reasons, the Board assigns the October 2024 opinion no probative weight.

While the Board could remand the claim for yet another attempt to obtain a probative VA medical opinion, the current evidence is sufficient to decide the claim. A remand could therefore be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible
uprofen and Naproxen for his service-connected right ankle disability. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (VA examiner impermissibly ignored the Veteran's lay assertions regarding the nature of the disability). Critically, the opinion does not address aggravation. See Allen, supra. For these reasons, the Board assigns the October 2024 opinion no probative weight.

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

In submitting his October 2024 claim for compensation, the Veteran included the September 2024 medical opinion of non-VA provider R.P., D.O., who opined, in part, that the Veteran's GERD is at least as likely as not secondary to his use of NSAIDS for service-connected chronic tendonitis of the right ankle: "He has taken medications such as Ibuprofen and Naproxen to manage the pain from his tendonitis and began experiencing symptoms of GERD after routinely using these medications." R.P. added that the use of NSAIDs "has been associated with an increased risk of GERD. This relationship is supported by multiple studies that demonstrate [that] NSAIDs [is] an independent risk factor for GERD, with odds ratios indicating a significant correlation." R.P. emphasized that the "mechanisms by which NSAIDs exacerbate GERD symptoms are multifaceted. NSAIDs can impair the protective mucosal barrier of the gastrointestinal tract, leading to increased gastric acid exposure and subsequent esophageal irritation." As noted, R.P. compared the Veteran's use of NSAIDS to the cited medical literature. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (indicating that greater probative weight may be derived from a medical opinion that applies medical literature to a veteran's individual circumstances).

R.P.'S September 2024 medical opinion is competent, credible and probative: It was authored by a licensed physician who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of his GERD; the opinion was based on a review of the evidence of record as well as lay statements of the Veteran. The opinion is consistent with the medical evidence of record, and contains clear conclusions connected by a reasoned medical explanation. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no medical opinions or other competent medical evidence of record that weighs against this opinion. Accordingly, the Board finds R.P.'s September 2024 medical opinion highly probative, competent and persuasive medical evidence in this case.

Based on this body of evidence, including the competent and credible lay and medical evidence of record, the Board finds that, overall, the evidence in this case, at the very least reflects an approximate balance of positive and negative evidence. Accordingly, the benefit-of-the-doubt doctrine is applicable and service connection for GERD, as secondary to the service-connected chronic tendonitis of the right ankle, is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; see Lynch, supra.

Lumbosacral Strain

The Veteran seeks service connection for a low back disability, to include as secondary to his service-connected chronic tendonitis of the right ankle. See, e.g., April 2023 Statement in Support of Claim.

Initially, the February 2025 rating decision reflects the favorable findings that the Veteran has a current diagnosis of lumbosacral strain and that he has been awarded service connection for chronic tendonitis of the right ankle. The Board is bound by these favorable findings as they are not rebutted by clear and unmistakable error. 38 U.S.C. § 5104A; Shedden, supra. Thus, the dispositive issue in this case is whether the evidence establishes a nexus between the Veteran's lumbosacral strain and his service-connected chronic tendonitis of the right ankle.

The Veteran's service treatment records include an October 2007 Post-Deployment Health Assessment in which he noted that he experienced back pain while in Iraq. However,
5 rating decision reflects the favorable findings that the Veteran has a current diagnosis of lumbosacral strain and that he has been awarded service connection for chronic tendonitis of the right ankle. The Board is bound by these favorable findings as they are not rebutted by clear and unmistakable error. 38 U.S.C. § 5104A; Shedden, supra. Thus, the dispositive issue in this case is whether the evidence establishes a nexus between the Veteran's lumbosacral strain and his service-connected chronic tendonitis of the right ankle.

The Veteran's service treatment records include an October 2007 Post-Deployment Health Assessment in which he noted that he experienced back pain while in Iraq. However, there are no other references to back pain or treatment for a back injury. Neither the service treatment records nor the service personnel records include a separation examination. The earliest post-service evidence of lumbosacral strain is the September 2023 VA examination. Thereafter, VA treatment records reflect complaints of back pain. See, e.g., December 2024 VA Primary Care Note. However, the post-service treatment records do not address the etiology of the Veteran's lumbosacral strain.

The Veteran is competent to report the circumstances giving rise to the initial observable symptoms, as well as the nature of the symptoms during and after service; however, he has not been shown to be competent to diagnose more complex medical problems, such as a spine disorder, or to opine as to the etiology of such disorders, which are medical questions. See Jandreau, 492 F.3d at 1376-77.

In September 2023, the Veteran underwent a VA back conditions examination, which reflects a diagnosis of lumbosacral strain. The VA examiner opined that the Veteran's lumbosacral strain is less likely than not related to service, explaining that there is "a lack of evidence for a chronic back condition in the [service treatment records]" or evidence for a chronic back condition "stemming from service." However, by indicating that the post-service diagnosis must be reflected in the service records impermissibly applies a higher evidentiary standard than VA's standard of proof of "at least as likely as not" required for a favorable nexus opinion. See Jones v. Shinseki, 23 Vet. App. 382, 388 n.1 (2016) (the more-likely-than-not standard of the law does not require medical certainty). The VA examiner also opined that it is less likely than not that the Veteran's lumbosacral strain was caused by his right ankle disability, noting only that a review of the National Institutes of Health Internet site at www.pubmed.gov supported the unfavorable opinion. See Nieves-Rodriguez, 22 Vet. App. at 302-04 (a central issue in determining the probative value of a medical opinion is whether the examiner provides the required explanation for conclusions). Furthermore, the opinion does not address aggravation. See Allen, 7 Vet. App. at 448 (opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). For these reasons, the Board assigns the September 2023 VA opinion no probative weight.

In October 2024, the Veteran underwent a VA back conditions examination. The examiner acknowledged the diagnosis of lumbosacral strain during the September 2023 VA examination but concluded that the absence of subsequent treatment for lumbosacral strain suggested resolution of an acute strain rather than a chronic disorder and concluded that the Veteran does not have a back disability. However, the absence of evidence of treatment does not contradict a veteran's statements about his or her symptom history or render such lay evidence not credible. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (2006). For these reasons, the Board assigns the October 2024 VA examination report no probative weight.

The AOJ apparently recognized the deficiencies in the October 2024 VA examination as it conceded the current diagnosis of lumbosacral strain reflected in the September 2023 VA examination, as reflected in the February 2025 rating decision. There is no basis in the record on appeal to rebut the AOJ's finding, which, as noted above, is binding on the Board.

While the Board could remand the claim for yet another attempt to obtain a probative VA medical opinion, the current evidence is sufficient to decide the claim. A remand could therefore be construed as obtaining additional evidence for the sole purpose of denying a claim, which is impermissible. 38 C.F.R. § 3.304(c) ("The development of evidence in
deficiencies in the October 2024 VA examination as it conceded the current diagnosis of lumbosacral strain reflected in the September 2023 VA examination, as reflected in the February 2025 rating decision. There is no basis in the record on appeal to rebut the AOJ's finding, which, as noted above, is binding on the Board.

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

In the September 2024 medical opinion submitted with the Veteran's October 2024 claim for compensation, non-VA provider R.P., D.O. opined, in part, that the Veteran's lumbosacral strain is at least as likely as not secondary to his service-connected chronic tendonitis of the right ankle: "Ankle problems can significantly contribute to lower back issues through various biomechanical and physiological mechanisms. The relationship between ankle instability and lower back pain ... has been documented in several studies, indicating that dysfunction in the ankle can lead to compensatory changes in the kinetic chain, ultimately affecting the lumbar region." R.P. emphasized that the "prevalence of lower back pain among athletes with ankle injuries further underscores this connection. Studies have indicated that athletes who experience ankle injuries often report concurrent lower back pain, suggesting a direct correlation between the two [and] [o]ccupational studies have shown that individuals with foot and ankle pain are significantly more likely to report lower back pain[.]" By comparison, R.P. noted the Veteran's activities that trigger low back pain, specifically, jumping, yard work, sports, and weight-based exercises. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (indicating that greater probative weight may be derived from a medical opinion that applies medical literature to a veteran's individual circumstances).

R.P.'S September 2024 medical opinion is competent, credible and probative: It was authored by a licensed physician who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of lumbosacral strain; the opinion was based on a review of the evidence of record as well as lay statements of the Veteran. The opinion is consistent with the medical evidence of record, and contains clear conclusions connected by a reasoned medical explanation. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no medical opinions or other competent medical evidence of record that weighs against this opinion. Accordingly, the Board finds R.P.'s September 2024 medical opinion highly probative, competent and persuasive medical evidence in this case.

Based on this body of evidence, including the competent and credible lay and medical evidence of record, the Board finds that, overall, the evidence in this case, at the very least reflects an approximate balance of positive and negative evidence. Accordingly, the benefit-of-the-doubt doctrine is applicable and service connection for lumbosacral strain, as secondary to the service-connected chronic tendonitis of the right ankle, is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; see Lynch, supra.

Right and Left Knee Strain

The Veteran seeks service connection for right and left knee disabilities, to include as secondary to his service-connected chronic tendonitis of the right ankle. See, e.g., April 2023 Statement in Support of Claim.

Initially, the February 2025 rating decision reflects the favorable findings that the Veteran has a current diagnosis of bilateral knee strain and that he has been awarded service connection for chronic tendonitis of the right ankle. The Board is bound by these favorable findings as they are not rebutted by clear and unmistakable error. 38 U.S.C. § 5104A; Shedden, supra. Thus, the dispositive issue in this case is whether the evidence establishes a nexus between the Veteran's bilateral knee strain and his service-connected chronic tendonitis of the right ankle.

The Veteran's service treatment records are negative for symptoms, complaints, or diagnosis of an ankle injury or disease. The earliest post-service evidence of a knee disability is reflected in the Veteran's April 2023 statement. The September 2023 VA knee and lower leg examination reflects
and that he has been awarded service connection for chronic tendonitis of the right ankle. The Board is bound by these favorable findings as they are not rebutted by clear and unmistakable error. 38 U.S.C. § 5104A; Shedden, supra. Thus, the dispositive issue in this case is whether the evidence establishes a nexus between the Veteran's bilateral knee strain and his service-connected chronic tendonitis of the right ankle.

The Veteran's service treatment records are negative for symptoms, complaints, or diagnosis of an ankle injury or disease. The earliest post-service evidence of a knee disability is reflected in the Veteran's April 2023 statement. The September 2023 VA knee and lower leg examination reflects clinical diagnosis of bilateral knee strain. During the VA examination, the Veteran reported that his knee symptoms onset in 2023 and asserted that his knee strain is related to service in Iraq or is secondary to his service-connected chronic tendonitis of the right ankle.

The Veteran is competent to report the circumstances giving rise to the initial observable symptoms, as well as the nature of the symptoms during and after service; however, he has not been shown to be competent to diagnose more complex medical problems, such as a knee disorder, or to opine as to the etiology of such disorders, which are medical questions. See Jandreau, 492 F.3d at 1376-77.

As noted above, the September 2023 VA knee and lower leg examination reflects diagnosis of bilateral knee strain. The VA examiner opined that the Veteran's bilateral knee strain is less likely than not related to the service-connected chronic tendonitis of the right ankle noting only that a review of the National Institutes of Health Internet site at www.pubmed.gov supported the unfavorable opinion. See Nieves-Rodriguez, 22 Vet. App. at 302-04 (a central issue in determining the probative value of a medical opinion is whether the examiner provides the required explanation for conclusions). Furthermore, the opinion does not address aggravation. See Allen, 7 Vet. App. at 448 (opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). For these reasons, the Board assigns the September 2023 VA opinion no probative weight.

In October 2024, the Veteran underwent a VA knee and lower leg examination. The examiner noted that the treatment records reflect no right knee symptoms and a February 4, 2013 treatment record show that the Veteran was seen for left knee pain but that the "acute nature of the condition and lack of ongoing care suggest resolution" rather than a chronic disability and concluded that the Veteran had no right or left knee disability. However, the February 4, 2013 VA treatment record referenced by the examiner shows that the Veteran was seen for allergies, not left knee pain, which is suggestive that the examiner's review of the claims file was less than thorough. See Nieves-Rodriguez, supra. Furthermore, an April 2013 VA treatment record reflects that the Veteran reported "intermittent" left knee pain that he attributed to an injury during basic training, which resulted in knee swelling at that time. The VA examiner failed to consider the Veteran's statements in this regard. See Dalton, 21 Vet. App. at 39-40 (VA examiner impermissibly ignored the Veteran's lay assertions regarding the nature of the disability). Moreover, the absence of evidence of treatment does not contradict a veteran's statements about his or her symptom history or render such lay evidence not credible. See Buchanan, supra. For these reasons, the Board assigns the October 2024 VA examination no probative weight.

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

In the September 2024 medical opinion submitted with the Veteran's October 2024 claim for compensation, non-VA provider R.P., D.O. opined, in part, that the Veteran's bilateral knee strain is at least as likely as not secondary to his service-connected chronic tendonitis of the right ankle, explaining that the Veteran "stands unevenly and leans to one side, which has contributed to the development of knee pain in both knees ... cracking, popping, and crunching ... worse with high impact activities[.]" R.P. added, in part, that ankle problems can "significantly influence knee health and function through various biomechanical and physiological mechanisms." Noting that the relationship between the ankle and knee joints is complex, R.P. emphasized that "alterations in ankle function can lead to compensatory changes in knee biomechanics, potentially resulting in knee disorders[.]" By comparison, R.P. noted the Veteran's report that he stands unevenly and leans to one side, which has contributed to the development of bilateral knee pain, and concluded, "in my medical opinion, his bilateral knee condition is at least as likely as not secondary to his service-connected ankle condition." See Bailey, 30 Vet. App. at 60.

R.P.'S September 2024 medical opinion is competent, credible and probative: It was authored by a licensed physician who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of his bilateral knee strain; the opinion was based on a review of the evidence of record as well as lay statements of the Veteran. The opinion is consistent with the medical evidence of record, and contains clear conclusions connected by a reasoned medical explanation. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no medical opinions or other competent medical evidence of record that weighs against this opinion. Accordingly, the Board finds R.P.'s September 2024 medical opinion highly probative, competent and persuasive medical evidence in this case.

Based on this body of evidence, including the competent and credible lay and medical evidence of record, the Board finds that, overall, the evidence in this case, at the very least reflects an approximate balance of positive and negative evidence. Accordingly, the benefit-of-the-doubt doctrine is applicable and service connection for right knee strain and left knee strain, as secondary to the service-connected chronic tendonitis of the right ankle, is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; see Lynch, supra.

Erectile Dysfunction

The Veteran seeks service connection for erectile dysfunction, to include as secondary to his service-connected chronic tendonitis of the right ankle. See, e.g., April 2023 Statement in Support of Claim. Specifically, he asserts that his chronic and pervasive right ankle pain has caused his erectile dysfunction and that medication prescribed for erectile dysfunction is not always effective. Id.

Initially, the February 2025 rating decision reflects the favorable findings that the Veteran has current diagnosis of erectile dysfunction and that he has been awarded service connection for chronic tendonitis of the right ankle. The Board is bound by these favorable findings as they are not rebutted by clear and unmistakable error. 38 U.S.C. § 5104A; Shedden, supra. Thus, the dispositive issue in this case is whether the evidence establishes a nexus between the Veteran's erectile dysfunction and his service-connected chronic tendonitis of the right ankle.

The Veteran's service treatment records are negative for symptoms, complaints, or diagnosis of erectile dysfunction. The earliest post-service evidence of the disorder is a 2023 VA treatment record noting that the Veteran was prescribed Sildenafil Citrate for erectile dysfunction. See February 2023 VA Mental Health Outpatient Note. As discussed above, 2013 VA treatment notes show that the Veteran reported taking Ibuprofen for pain and he was given a prescription for Naproxen for pain, both NSAIDs. See Dorland's Illustrated Medical Dictionary at 923, 1251 (31st ed. 2007). The Veteran continued to take Ibuprofen for pain in 2022. See March 2022 VA Secure Messaging. However, the post-service treatment records do not associate the Veteran's erectile dysfunction with use of these pain medications or otherwise address the etiology of his erectile dysfunction.

The Veteran is competent to report the circumstances giving rise to the initial observable symptoms, as well as the nature of the symptoms during and after service; however
discussed above, 2013 VA treatment notes show that the Veteran reported taking Ibuprofen for pain and he was given a prescription for Naproxen for pain, both NSAIDs. See Dorland's Illustrated Medical Dictionary at 923, 1251 (31st ed. 2007). The Veteran continued to take Ibuprofen for pain in 2022. See March 2022 VA Secure Messaging. However, the post-service treatment records do not associate the Veteran's erectile dysfunction with use of these pain medications or otherwise address the etiology of his erectile dysfunction.

The Veteran is competent to report the circumstances giving rise to the initial observable symptoms, as well as the nature of the symptoms during and after service; however, he has not been shown to be competent to diagnose more complex medical problems, such as erectile dysfunction, or to opine as to the etiology of such disorders, which are medical questions. See Jandreau, 492 F.3d at 1376-77.

In September 2023, the Veteran underwent a VA male reproductive disorders examination. The diagnosis was erectile dysfunction. The Veteran reported that he believed his erectile dysfunction is related to his service in Iraq and/or secondary to his service-connected right ankle disability. The VA examiner opined that the Veteran's erectile dysfunction is less likely than not related to the service-connected chronic tendonitis of the right ankle noting only that a review of the National Institutes of Health Internet site at www.pubmed.gov supported the unfavorable opinion. See Nieves-Rodriguez, 22 Vet. App. at 302-04 (a central issue in determining the probative value of a medical opinion is whether the examiner provides the required explanation for conclusions). Furthermore, the opinion does not address aggravation. See Allen, 7 Vet. App. at 448 (opinion regarding secondary service connection is inadequate if it does not address both causation and aggravation of the nonservice-connected condition). For these reasons, the Board assigns the September 2023 VA opinion no probative weight.

The September 2023 VA examiner also opined that the Veteran's erectile dysfunction is less likely than not related to the Veteran's conceded TERA. "There is no medical or scientific evidence available at this time that provides indication of a relationship between development of [erectile dysfunction] and the TERA. There are risk factors outside of military service (hereditary, congenital, smoking history, weight, age, etc.) that far outweigh the factors identified in the TERA." However, the opinion does not explain why greater weight was assigned to risk factors outside of the Veteran's military service. See Nieves-Rodriguez, supra. Accordingly, the Board assigns the September 2023 TERA opinion low probative weight.

In October 2024, the Veteran underwent a VA examination and the examiner confirmed the diagnosis of erectile dysfunction. The examiner opined that it is less likely than not that the Veteran's erectile dysfunction was caused by his service-connected chronic tendonitis of the right ankle "[g]iven the lack of association between these conditions in current medical literature and the absence of relevant findings in the Veteran's [claims] file[.]" The examiner added, "There are no documented factors, such as pain or limitations from the ankle condition, that would plausibly affect the physiological pathways contributing to erectile function." However, the opinion does not consider the Veteran's statement that his chronic and pervasive right ankle pain caused erectile dysfunction. See Dalton, supra. Furthermore, the opinion addresses causation, but not aggravation. See Allen, supra. For these reasons, the Board assigns the October 2024 VA opinion no probative weight.

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

In the September 2024 medical opinion submitted with the Veteran's October 2024 claim for compensation, non-VA provider R.P., D.O. opined, in part, that the Veteran's erectile dysfunction is at least as likely as not secondary to his service-connected chronic tendonitis of the right ankle and use of NSAIDs for chronic pain. R.P. acknowledged the Veteran's statement that he experienced difficulty achieving and maintaining an erection due to chronic and pervasive right ankle pain and that prescribed medications are not always effective. R.P. explained that "[a]nkle pain, particularly when chronic, can significantly impact sexual function, including erectile dysfunction ... due to the interplay of pain, psychological distress, and reduced physical activity." R.P. added that a medical study shows that "chronic pain can lead to a decrease in sexual desire due to restricted sexual activity, which is a common precursor to erectile dysfunction" and that another study shows that erectile dysfunction is common among male "patients with chronic pain conditions." R.P. noted that NSAIDS, which the Veteran takes for right ankle pain, cause inhibition of cyclooxygenase, leading to decreased prostaglandin levels, which are crucial ... for increased blood flow necessary for achieving an erection." By comparison, R.P. noted the Veteran's use of NSAIDs and acknowledged the Veteran's statement that right ankle pain aggravated erectile dysfunction. See Bailey, 30 Vet. App. at 60.

R.P.'S September 2024 medical opinion is competent, credible and probative: It was authored by a licensed physician who reviewed the Veteran's claims file and was therefore familiar with the Veteran's symptoms, diagnoses, and treatment of his erectile dysfunction; the opinion was based on a review of the evidence of record as well as lay statements of the Veteran. The opinion is consistent with the medical evidence of record, and contains clear conclusions connected by a reasoned medical explanation. See Nieves-Rodriguez, 22 Vet. App. at 301-02. Notably, there are no medical opinions or other competent medical evidence of record that weighs against the opinion. Accordingly, the Board finds the September 2024 medical opinion of R.P. highly probative, competent and persuasive medical evidence in this case.

Based on this body of evidence, including the competent and credible lay and medical evidence of record, the Board finds that, overall, the evidence in this case, at the very least reflects an approximate balance of positive and negative evidence. Accordingly, the benefit-of-the-doubt doctrine is applicable and service connection for erectile dysfunction, as secondary to the service-connected chronic tendonitis of the right ankle, is warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 3.310; see Lynch, supra.

S. B. MAYS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Farrell, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

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