FLATFOOT BILATERAL ACQUIRED

DUSTIN L. WARE · 2026 · Case ID: A26032005

MIXED

Summary

The Veteran served in the U.S. Army from August 1978 to December 1978. The Veteran appeals the denial of service connection for several conditions, including bilateral pes planus, gout with hallux valgus in both feet and wrists, degenerative arthritis in both wrists and ankles, membranous nephropathy, hypertension, and bilateral lower extremity varicose veins. The Board granted service connection for all these conditions, finding that the evidence persuasively weighed in favor of service connection for pes planus and gout-related conditions, and resolving reasonable doubt in the Veteran's favor for the degenerative arthritis, membranous nephropathy, hypertension, and varicose veins, finding them caused by NSAID use for the service-connected foot and ankle conditions. The Board remanded claims for service connection for left and right knee degenerative arthritis. The Veteran reported bilateral knee pain during active service and a gout diagnosis in 1984, self-managing symptoms due to lack of insurance. A September 2022 VA examination confirmed bilateral knee osteoarthritis and gout, but the examiner rendered a negative nexus opinion for direct service connection, citing silent service treatment records. The Board found this opinion inadequate as it was based on an inaccurate premise regarding the Veteran's service connection status at the time of the opinion.

Rationale

Evidence persuasively weighs in favor of service connection; Criteria for service connection met

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250218-522997

Full Decision Text

Citation Nr: A26032005
Decision Date: 04/07/26 Archive Date: 04/07/26

DOCKET NO. 250218-522997
DATE: April 7, 2026

ORDER

Entitlement to service connection for bilateral pes planus is granted.

Entitlement to service connection for left foot gout with hallux valgus is granted.

Entitlement to service connection for right foot gout with hallux valgus is granted.

Entitlement to service connection for left wrist degenerative arthritis with gout is granted.

Entitlement to service connection for right wrist degenerative arthritis with gout is granted.

Entitlement to service connection for left ankle degenerative arthritis with gout is granted.

Entitlement to service connection for right ankle degenerative arthritis with gout is granted.

Entitlement to service connection for membranous nephropathy is granted.

Entitlement to service connection for hypertension is granted.

Entitlement to service connection for left lower extremity varicose veins is granted.

Entitlement to service connection for right lower extremity varicose veins is granted.

REMANDED

Entitlement to service connection for left knee degenerative arthritis is remanded.

Entitlement to service connection for right knee degenerative arthritis with gout is remanded.

FINDINGS OF FACT

1. The evidence of record persuasively weighs in favor of finding that the Veteran's bilateral pes planus is related to his military service.

2. The evidence of record persuasively weighs in favor of finding that the Veteran's left foot gout with hallux valgus is related to his military service.

3. The evidence of record persuasively weighs in favor of finding that the Veteran's right foot gout with hallux valgus is related to his military service.

4. Resolving reasonable doubt in the Veteran's favor, his left wrist degenerative arthritis with gout is related to his military service.

5. Resolving reasonable doubt in the Veteran's favor, his right wrist degenerative arthritis with gout is related to his military service.

6. Resolving reasonable doubt in the Veteran's favor, his left ankle degenerative arthritis with gout is related to his military service.

7. Resolving reasonable doubt in the Veteran's favor, his right ankle degenerative arthritis with gout is related to his military service.

8. Resolving reasonable doubt in the Veteran's favor, his membranous nephropathy is caused by NSAID use for treating his service-connected wrist, ankle, and foot conditions.

9. Resolving reasonable doubt in the Veteran's favor, his hypertension is caused by NSAID use for treating his service-connected wrist, ankle, and foot conditions.

10. Resolving reasonable doubt in the Veteran's favor, his left lower extremity varicose veins are caused by NSAID use for treating his service-connected wrist, ankle, and foot conditions.

11. Resolving reasonable doubt in the Veteran's favor, his right lower extremity varicose veins are caused by NSAID use for treating his service-connected wrist, ankle, and foot conditions.

CONCLUSIONS OF LAW

1. The criteria for service connection for bilateral pes planus have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

2. The criteria for service connection for left foot gout with hallux valgus have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

3. The criteria for service connection for right foot gout with hallux valgus have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

4. The criteria for service connection for left wrist degenerative arthritis with gout have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

5. The criteria for service connection for right wrist degenerative arthritis with gout have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

6. The criteria for service connection for left ankle degenerative arthritis with gout have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

7. The criteria for service connection for right ankle degenerative arthritis with gout have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

8. The criteria for service connection for membranous nephropathy have been met. 38 U
have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

6. The criteria for service connection for left ankle degenerative arthritis with gout have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

7. The criteria for service connection for right ankle degenerative arthritis with gout have been met. 38 U.S.C. §§ 1131; 38 C.F.R. §§ 3.303, 3.304.

8. The criteria for service connection for membranous nephropathy have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

9. The criteria for service connection for hypertension have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

10. The criteria for service connection for left lower extremity varicose veins have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

11. The criteria for service connection for right lower extremity varicose veins have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the U.S. Army from August 1978 to December 1978.

This matter comes before the Board of Veterans' Appeals (Board) from a February 12, 2025, Higher-Level Review (HLR) rating decision issued by a Department of Veterans Affairs (VA) regional office (RO), which is the agency of original jurisdiction (AOJ).

On a February 18, 2025, VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the February 5, 2025, AOJ decision, which was later subject to HLR in the February 12, 2025, rating decision on appeal. 38?C.F.R. § 20.301. If evidence was submitted during the period after the AOJ issued the decision, which was subsequently subject to higher-level review, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claims of service connection for left and right knee degenerative arthritis, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

The Board notes that it has thoroughly reviewed the evidence of record in conjunction with this case. However, the Board has limited its discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Thus, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal.

Service Connection

Service connection may be granted for a disability resulting from injury or disease that was incurred in, or aggravated by, military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease diagnosed after a veteran's discharge when all the evidence, including that pertinent to
. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Thus, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal.

Service Connection

Service connection may be granted for a disability resulting from injury or disease that was incurred in, or aggravated by, military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. Service connection may be granted for any disease diagnosed after a veteran's 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).

To substantiate a claim of service connection, there must be evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009).

Service connection may also 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). Service connection for a disability can be granted on a secondary basis if a Veteran has a (1) current disability; (2) a separate disability already subject to service connection; and (3) the first disability is due to or the result of or is aggravated by the service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. Secondary service connection is warranted for any incremental increase in disability, meaning any additional impairment of earning capacity above the degree of disability existing before the increase, in a nonservice-connected disability resulting from a service-connected disability, regardless of its permanence. See Ward v. Wilkie, 31 Vet. App. 233 (2019).

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 Veteran. See Gabrielson v. Brown, 7 Vet. App. 36, 39 40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination about the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994).

When considering whether lay evidence is competent, the Board must determine, on a case-by-case basis, whether a Veteran's disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). A Veteran is competent to report symptoms because this requires only personal knowledge, not medical expertise, as it comes to them through their senses. See Layno, 6 Vet. App. 465, 469. Lay testimony is competent to establish the presence of observable symptomatology, where the determination is not medical in nature and is capable of lay observation. Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence may establish a diagnosis of a simple medical condition, a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377.

If the evidence is competent, the Board must then determine if the evidence is credible, or worthy of belief. Barr, supra. After determining the competency and credibility of evidence, the Board must then weigh its probative value. In this regard, the Board may properly consider internal inconsistency, facial plausibility, and consistency with other evidence submitted on behalf of the claimant. Caluza v. Brown, 7 Vet. App. 498, 511-12 (1995).

After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C
later support a diagnosis by a medical professional. Jandreau, 492 F.3d 1372, 1377.

After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (the benefit-of-the-doubt rule applies if the competing evidence is in approximate balance). If the evidence is not in approximate balance or nearly equal, the claim is to be denied. Id.

1. Entitlement to service connection for bilateral pes planus is granted.

2. Entitlement to service connection for left foot gout with hallux valgus is granted.

3. Entitlement to service connection for right foot gout with hallux valgus is granted.

The Veteran contends that his bilateral flat feet and left and right foot gout with hallux valgus are the result of his military service. August 2022 VA Form 21-526EZ.

In the rating decision on appeal, the AOJ conceded that the Veteran has current diagnoses of bilateral flatfeet and left foot gout with hallux valgus. See 38 C.F.R. § 3.104(c). The Board also notes that the Veteran's October 2024 VA Foot Conditions examination reflects current diagnoses of right foot gout and hallux valgus. The Board thus finds that the current disability element of service connection has been established. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009).

The Board notes that the Veteran's October 1978 Report of Medical History reflects that the Veteran checked "YES" to foot trouble, with the notation of "AIT R [right] ankle."

The Veteran was first afforded a VA Foot Conditions examination in September 2022. The VA examiner confirmed the Veteran's diagnosis of gout in both feet. The Veteran reported onset of his condition in 1984, with current symptoms of constant swelling and stiffness in his feet. The Veteran treats his condition with colchicine and allopurinol. The Board acknowledges that the September 2022 VA examiner rendered a positive nexus opinion regarding the Veteran's claimed feet conditions and a service-connected condition of "arthritis due to trauma." The Board notes, however, that at the time of this opinion, the Veteran was only service connected for tinnitus and was not service connected for any arthritis condition. As such, this positive nexus opinion is based on an inaccurate factual premise and is therefore inadequate for adjudication purposes. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012).

In an August 2023 VA Form 21-4138, the Veteran reported that prior to his military service, he had no issues with his feet, knees, ankles, or wrists. During basic training, however, he began experiencing aching, throbbing sensations in his feet, ankles, knees, and hands, which he attributed to physical activities such as running, road marches, and jumping. The Veteran reported that once he joined the National Guard, he noticed that his big toe was swollen and, during a sick call visit, he was diagnosed with gout. Due to lack of health insurance over the years, the Veteran stated that he learned to cope with the pain and self-treated with Epsom salt soaks and would only seek medical treatment for flare-ups. The Veteran reported that he current experiences flare-ups at least once per week, leading to limited range of motion, swelling, and tenderness of his feet, ankles, knees, and wrists, as well as the inability to tolerate covers touching his feet while sleeping. He
, knees, and hands, which he attributed to physical activities such as running, road marches, and jumping. The Veteran reported that once he joined the National Guard, he noticed that his big toe was swollen and, during a sick call visit, he was diagnosed with gout. Due to lack of health insurance over the years, the Veteran stated that he learned to cope with the pain and self-treated with Epsom salt soaks and would only seek medical treatment for flare-ups. The Veteran reported that he current experiences flare-ups at least once per week, leading to limited range of motion, swelling, and tenderness of his feet, ankles, knees, and wrists, as well as the inability to tolerate covers touching his feet while sleeping. He is limited to wearing open sandals and often relies on a cane for support while walking or standing. The Veteran stated that his gout causes ongoing pain and mobility limitations which make it difficult to carry out daily activities effectively.

In another August 2023 VA Form 21-4138, the Veteran stated that during basic training, he experienced several instances of twisting and spraining his left ankle, which resulted in consistent aching and throbbing sensations in his left foot, left ankle, and left knee. The Veteran also stated that while on National Guard training in 1985 or 1986, a fellow soldier accidentally tapped his left leg/knee with a jeep. The Veteran stated that he did not seek proper medical attention for these injuries and relied on self-medicating methods of rest, ice, and over-the-counter medications to manage his discomfort. The Veteran stated that his lingering issues with his left foot, left ankle, and left knee have persisted since that time and continue to affect his daily life due to pain and limited mobility which hinder his ability to perform regular tasks.

In a September 2024 VA Form 21-4138, the Veteran reported that he believes that the physical demands and tough daily activities during his military service, including push-ups, wheelbarrows, bear crawls, road marches, running, and jumping, have played a big part of his foot and wrist gout conditions. The Veteran stated that during road marches, he had to carry a heavy backpack and had to keep a constant grip on his rifle while marching, which put a lot of strain on his wrists. The Veteran reported that he had to run on concrete and jump on and off of obstacles, sometimes while carrying heavy gear, which added even more stress. The Veteran stated that he had to wear his combat boots all day and sometimes run in them, which was not comfortable. The Veteran believes that the strain from these activities impacted his wrists and joints in his feet, contributing to his gout.

In support of his claim, the Veteran submitted an October 2024 Independent Medical Evaluation rendered by Dr. H.S., D.O. Dr. H.S. acknowledged reviewing the Veteran's medical records and claims file, as well as conducted additional medical research, in rendering their evaluation. Dr. H.S. opined that it was at least as likely as not that the Veteran's military service significantly contributed to his foot and wrist osteoarthritis and gouty arthritis. Dr. H.S. acknowledged the Veteran's statements regarding road marches, carrying heavy backpacks and rifles, and his military exercises, while also not seeking proper medical treatment for his symptoms. Dr. H.S. stated that post-traumatic arthritis is a condition triggered by acute joint trauma that can lead to osteoarthritis or chronic inflammatory arthropathies. Dr. H.S. also stated that joint injuries, with or without associated disruption of the articular surface, frequently lead to a progressive process known as acute post-traumatic arthritis, especially when there is continued loading of the joints. Dr. H.S. stated that this can occur at any age, in any joints, and may develop from any kind of acute physical trauma. Dr. H.S. noted that inflammation occurring immediately after joint injury plays a key role in the onset of chronic post-traumatic arthritis. Dr. H.S. acknowledged that the Veteran also suffers from gout, which is a type of inflammatory arthritis. Dr. H.S. stated that recent studies illustrate that joint damage may promote the development of gout at affected sites. Dr. H.S. opined that the Veteran's injuries during service would have been the initiating factor in his development of both osteoarthritis and gouty arthritis. Dr. H.S. noted that the Veteran treated these conditions with non-steroidal anti-inflammatory drugs (NSAIDs) on a chronic basis and at high doses, including notations in his medical records that he was taking up to a bottle of ibuprofen per week as well as indomethacin and Excedrin for his joint pain. Dr. H.S. acknowledged that the Veteran's service treatment records (STRs) do not reflect complaints of joint pain, but the Veteran
studies illustrate that joint damage may promote the development of gout at affected sites. Dr. H.S. opined that the Veteran's injuries during service would have been the initiating factor in his development of both osteoarthritis and gouty arthritis. Dr. H.S. noted that the Veteran treated these conditions with non-steroidal anti-inflammatory drugs (NSAIDs) on a chronic basis and at high doses, including notations in his medical records that he was taking up to a bottle of ibuprofen per week as well as indomethacin and Excedrin for his joint pain. Dr. H.S. acknowledged that the Veteran's service treatment records (STRs) do not reflect complaints of joint pain, but the Veteran reported that he did not seek medical care and chose to treat these conditions on his own. Dr. H.S. stated that medical studies demonstrate that it is actually quite common for military injuries to go unreported or underreported, including a 2016 study finding that approximately half of musculoskeletal injuries in a surveyed Army Infantry Brigade Combat Team were not reported, most commonly due to fear that an injury may affect future career opportunities and to avoid military "profiles." Dr. H.S. therefore opined that based on all evidence, it is at least as likely as not that the Veteran's foot chronic pain and osteoarthritis/gout had their onset during service and are causally related to his military service.

The Veteran was afforded a second VA Foot Conditions examination in October 2024. The VA examiner confirmed the Veteran's diagnoses of bilateral flat foot (pes planus), bilateral hammer toes, bilateral hallux valgus, and bilateral gout. The Veteran reported onset of his feet symptoms in 1981. While unable to recall any specific trauma or injury, the Veteran believed his foot pain was secondary to performing military exercises and activities such as running, repetitive motion, and heavy lifting while wearing military boots. His symptoms of pain, swelling, and stiffness in his feet have continued to the present time. The Veteran treats his condition with Tylenol, colchicine, and allopurinol. In rendering a negative nexus opinion, the VA examiner stated that the Veteran's STRs are silent for bilateral foot complaints during service and therefore a nexus cannot be established. The Board finds that this opinion is wholly inadequate as it is based on an inaccurate factual premise, as the Veteran's October 1978 STRs reflect a complaint of foot problems. A medical examination based on an inaccurate factual premise is inadequate for rating purposes and may be discounted entirely. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely").

The Board therefore finds that the evidence of record persuasively weighs in favor of finding that the Veteran's bilateral pes planus (flat feet), left foot gout with hallux valgus, and right foot gout with hallux valgus are related to his military service. Therefore, an award of service connection for bilateral pes planus (flat feet), left foot gout with hallux valgus, and right foot gout with hallux valgus are warranted. 38 C.F.R. §§ 3.303, 3.304.

4. Entitlement to service connection for left wrist degenerative arthritis with gout is granted.

5. Entitlement to service connection for right wrist degenerative arthritis with gout is granted.

The Veteran contends that his left and right wrist conditions are the result of his military service. August 2022 VA Form 21-526EZ.

In the rating decision on appeal, the AOJ conceded that the Veteran has current diagnoses of left and right wrist degenerative arthritis with gout. See 38 C.F.R. § 3.104(c). The Board thus finds that the current disability element of service connection has been established. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009).

The Veteran was first afforded a VA Wrist Conditions examination in September 2022. The VA examiner noted that the Veteran is right hand dominant. The VA examiner confirmed the Veteran's diagnoses of left and right degenerative arthritis, other than post-traumatic and gout of both wrists. The Veteran reported onset of his condition in 1980, stating that he experienced wrist pain attributed to being in the shooting range. The Veteran reported intermittent pain, stiffness, and "locking up" of his wrists, as well as flare-ups of his wrist gout. The Veteran treats his condition with Tylenol, colchicine, and allopurinol. In rendering a negative nexus opinion as to direct service connection, the VA examiner stated that the Veteran's STRs and medical records are silent for bilateral wrist arthritis chronicity or continuation of treatment while the Veteran was in service and within a compensable period after service. Therefore, the Veteran's bilateral wrist arthritis was less likely than not incurred in or caused by his military service.

The Board acknowledges that the September 2022 VA examiner also rendered a positive nexus opinion regarding the Veteran's claimed bilateral wrist arthritis and gout conditions and a service-connected condition of "arthritis due to trauma." The Board notes, however, that at the time of this opinion, the Veteran was only service connected for tinnitus and was not service connected for any arthritis condition. As such, this positive nexus opinion is based on an inaccurate factual premise and is therefore inadequate for adjudication purposes. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012).

In support of his claim, the Veteran submitted an October 2024 Independent Medical Evaluation rendered by Dr. H.S., D.O. Dr. H.S. acknowledged reviewing the Veteran's medical records and claims file, as well as conducted additional medical research, in rendering their evaluation. Dr. H.S. opined that it was at least as likely as not that the Veteran's military service significantly contributed to his foot and wrist osteoarthritis and gouty arthritis. Dr. H.S. acknowledged the Veteran's statements regarding road marches, carrying heavy backpacks and rifles, and his military exercises, while also not seeking proper medical treatment for his symptoms. Dr. H.S. stated that post-traumatic arthritis is a condition triggered by acute joint trauma that can lead to osteoarthritis or chronic inflammatory arthropathies. Dr
by Dr. H.S., D.O. Dr. H.S. acknowledged reviewing the Veteran's medical records and claims file, as well as conducted additional medical research, in rendering their evaluation. Dr. H.S. opined that it was at least as likely as not that the Veteran's military service significantly contributed to his foot and wrist osteoarthritis and gouty arthritis. Dr. H.S. acknowledged the Veteran's statements regarding road marches, carrying heavy backpacks and rifles, and his military exercises, while also not seeking proper medical treatment for his symptoms. Dr. H.S. stated that post-traumatic arthritis is a condition triggered by acute joint trauma that can lead to osteoarthritis or chronic inflammatory arthropathies. Dr. H.S. also stated that joint injuries, with or without associated disruption of the articular surface, frequently lead to a progressive process known as acute post-traumatic arthritis, especially when there is continued loading of the joints. Dr. H.S. stated that this can occur at any age, in any joints, and may develop from any kind of acute physical trauma. Dr. H.S. noted that inflammation occurring immediately after joint injury plays a key role in the onset of chronic post-traumatic arthritis. Dr. H.S. acknowledged that the Veteran also suffers from gout, which is a type of inflammatory arthritis. Dr. H.S. stated that recent studies illustrate that joint damage may promote the development of gout at affected sites. Dr. H.S. opined that the Veteran's injuries during service would have been the initiating factor in his development of both osteoarthritis and gouty arthritis. Dr. H.S. noted that the Veteran treated these conditions with non-steroidal anti-inflammatory drugs (NSAIDs) on a chronic basis and at high doses, including notations in his medical records that he was taking up to a bottle of ibuprofen per week as well as indomethacin and Excedrin for his joint pain. Dr. H.S. acknowledged that the Veteran's service treatment records (STRs) do not reflect complaints of joint pain, but the Veteran reported that he did not seek medical care and chose to treat these conditions on his own. Dr. H.S. stated that medical studies demonstrate that it is actually quite common for military injuries to go unreported or underreported, including a 2016 study finding that approximately half of musculoskeletal injuries in a surveyed Army Infantry Brigade Combat Team were not reported, most commonly due to fear that an injury may affect future career opportunities and to avoid military "profiles." Dr. H.S. therefore opined that based on all evidence, it is at least as likely as not that the Veteran's wrist chronic pain and osteoarthritis/gout had their onset during service and are causally related to his military service.

The Veteran was afforded a second VA Wrist Conditions examination in October 2024. The VA examiner confirmed the Veteran's diagnoses of left and right degenerative arthritis, other than post-traumatic and gout of both wrists. The Veteran reported onset of his wrist symptoms in 1982. While unable to recall any specific trauma or injury, the Veteran believed his wrist pain was secondary to performing military exercises and activities such as repetitive motion, firing weapons, heavy lifting, and performing push-ups. His symptoms of pain, decreased range of motion, and occasional swelling have continued to the present time. The Veteran noted that his wrist pain increases with activity. The Veteran treats his condition with Tylenol and allopurinol. In rendering a negative nexus opinion, the VA examiner stated that the Veteran's STRs are silent for bilateral wrist complaints during service and therefore a nexus cannot be established.

Given the positive and negative opinions of record, the Board finds that evidence of record is, at worst, in approximate balance as to whether the Veteran's left and right wrist degenerative arthritis with gout was incurred in or is otherwise related to his military service. Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's left and right wrist degenerative arthritis with gout is the result of his military service. Therefore, service connection for left and right wrist degenerative arthritis with gout are warranted. 38 C.F.R. §§ 3.303, 3.304; Lynch, 21 F.4th 776 (Fed. Cir. 2021).

6. Entitlement to service connection for left ankle degenerative arthritis with gout is granted.

7. Entitlement to service connection for right ankle degenerative arthritis with gout is granted.

The Veteran contends that his left and right ankle conditions are the result of his military service. August 2022 VA Form 21-526EZ.

In the rating decision on appeal, the AOJ conceded that the Veteran has current diagnosis of left ankle degenerative arthritis with gout. See 38 C.F.R. §
wrist degenerative arthritis with gout are warranted. 38 C.F.R. §§ 3.303, 3.304; Lynch, 21 F.4th 776 (Fed. Cir. 2021).

6. Entitlement to service connection for left ankle degenerative arthritis with gout is granted.

7. Entitlement to service connection for right ankle degenerative arthritis with gout is granted.

The Veteran contends that his left and right ankle conditions are the result of his military service. August 2022 VA Form 21-526EZ.

In the rating decision on appeal, the AOJ conceded that the Veteran has current diagnosis of left ankle degenerative arthritis with gout. See 38 C.F.R. § 3.104(c). The Board also notes that the Veteran's September 2022 VA Ankle Conditions examination reflects current diagnoses of right ankle degenerative arthritis, other than post-traumatic, and right ankle gout. The Board thus finds that the current disability element of service connection has been established. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009).

The Board notes that the Veteran's October 1978 Report of Medical History reflects that the Veteran checked "YES" to foot trouble, with the notation of "AIT R [right] ankle."

The Veteran was first afforded a VA Ankle Conditions examination in September 2022. The VA examiner confirmed the Veteran's diagnoses of left and right ankle degenerative arthritis, other than post-traumatic, with gout. The Veteran reported onset of his condition in 1984, stating that he experienced ankle pain during active service. The Veteran stated that he was diagnosed with gout and arthritis in 1984. The Veteran currently experiences ankle pain. The Veteran treats his condition with colchicine and allopurinol. In rendering a negative nexus opinion as to direct service connection, the VA examiner stated that the Veteran's STRs and medical records are silent for bilateral ankle arthritis chronicity or continuation of treatment while the Veteran was in service and within a compensable period after service. Therefore, the Veteran's bilateral ankle arthritis was less likely than not incurred in or caused by his military service.

The Board acknowledges that the September 2022 VA examiner also rendered a positive nexus opinion regarding the Veteran's claimed bilateral ankle arthritis and gout and a service-connected condition of "arthritis due to trauma." The Board notes, however, that at the time of this opinion, the Veteran was only service connected for tinnitus and was not service connected for any arthritis condition. As such, this positive nexus opinion is based on an inaccurate factual premise and is therefore inadequate for adjudication purposes. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012).

In another August 2023 VA Form 21-4138, the Veteran stated that during basic training, he experienced several instances of twisting and spraining his left ankle, which resulted in consistent aching and throbbing sensations in his left foot, left ankle, and left knee. The Veteran also stated that while on National Guard training in 1985 or 1986, a fellow soldier accidentally tapped his left leg/knee with a jeep. The Veteran stated that he did not seek proper medical attention for these injuries and relied on self-medicating
sandals and often relies on a cane for support while walking or standing. The Veteran stated that his gout causes ongoing pain and mobility limitations which make it difficult to carry out daily activities effectively.

Dr. H.S. stated that an acute injury to the ankle due to twisting is often a precipitating cause of longstanding pain and damage to the ankle. Dr. H.S. noted that osteoarthritis begins when healthy bone/cartilage experiences an injury or chronic increased load. Dr. H.S. found that the Veteran's personal account of events stated that he experienced an injury along with chronic loading of his foot and ankle joints during his long road marches and physical demands of service. Dr. H.S. reported that post-traumatic arthritis is the most common cause of ankle arthritis, causing anywhere from 70-90% of cases among patients who present with osteoarthritis. Dr. H.S. noted that post-traumatic arthritis is a condition triggered by an acute joint trauma that can lead to osteoarthritis or chronic inflammatory arthropathies. Dr. H.S. stated that joint injuries, with or without associated disruption of the articular surface, frequently lead to a progressive process known as acute post-traumatic arthritis. Dr. H.S. noted that this is especially true when there is continued loading of the joints. Dr. H.S. stated that this can occur at any age, in any joints, and may develop from any kind of acute physical trauma. Dr. H.S. noted that inflammation occurring immediately after joint injury plays a key role in the onset of chronic post-traumatic arthritis. Dr. H.S. stated that there is a strong nexus between previous ankle sprains and future ankle sprains. Dr. H.S. noted that although the Veteran did not have ankle surgery until 1976 and again in the 1980's, his initial ankle injury in 1969 predisposed him to future ankle sprains and injuries. Dr. H.S. opined that this was at least as likely as not the precipitating cause of his chronic ankle sprains and instability that eventually required surgery and resulted in post-traumatic ankle arthritis.

Dr. H.S. acknowledged that the Veteran also suffers from gout, which is a type of inflammatory arthritis. Dr. H.S. stated that recent studies illustrate that joint damage may promote the development of gout at affected sites. Dr. H.S. opined that the Veteran's injuries during service would have been the initiating factor in his development of both osteoarthritis and gouty arthritis. Dr. H.S. noted that the Veteran treated these conditions with non-steroidal anti-inflammatory drugs (NSAIDs) on a chronic basis and at high doses, including notations in his medical records that he was taking up to a bottle of ibuprofen per week as well as indomethacin and Excedrin for his joint pain. Dr. H.S. acknowledged that the Veteran's service treatment records (STRs) do not reflect complaints
. H.S. stated that recent studies illustrate that joint damage may promote the development of gout at affected sites. Dr. H.S. opined that the Veteran's injuries during service would have been the initiating factor in his development of both osteoarthritis and gouty arthritis. Dr. H.S. noted that the Veteran treated these conditions with non-steroidal anti-inflammatory drugs (NSAIDs) on a chronic basis and at high doses, including notations in his medical records that he was taking up to a bottle of ibuprofen per week as well as indomethacin and Excedrin for his joint pain. Dr. H.S. acknowledged that the Veteran's service treatment records (STRs) do not reflect complaints of joint pain, but the Veteran reported that he did not seek medical care and chose to treat these conditions on his own. Dr. H.S. stated that medical studies demonstrate that it is actually quite common for military injuries to go unreported or underreported, including a 2016 study finding that approximately half of musculoskeletal injuries in a surveyed Army Infantry Brigade Combat Team were not reported, most commonly due to fear that an injury may affect future career opportunities and to avoid military "profiles."

Dr. H.S. concluded that considering all evidence, it is at least as likely as not that the Veteran's chronic ankle pain and osteoarthritis/gout are causally related to his military service, to include that the Veteran's ankle sprain during service also at least as likely as not was an initiating injury that led to progressive pain and disability related to post-traumatic arthritis.

The Veteran was afforded a second VA Ankle Conditions examination in October 2024. The VA examiner confirmed the Veteran's diagnoses of left and right ankle degenerative arthritis, other than post-traumatic, with gout. The Veteran reported onset of his ankle symptoms in 1982. While unable to recall any specific trauma or injury, the Veteran believed his ankle pain was secondary to performing military exercises and activities such as repetitive motion, firing weapons, heavy lifting, and performing push-ups. The Veteran also noted that he was diagnosed with gout in the past. His symptoms of pain and decreased range of motion have continued to the present time. The Veteran noted that his ankle pain increases with activity. The Veteran treats his condition with Tylenol. In rendering a negative nexus opinion, the VA examiner stated that the Veteran's STRs are silent for left and right ankle complaints during service and therefore a nexus cannot be established. The Board finds that this opinion is wholly inadequate as it is based on an inaccurate factual premise, as the Veteran's October 1978 STRs reflect a complaint of foot problems with the notation of "AIT R [right] ankle." A medical examination based on an inaccurate factual premise is inadequate for rating purposes and may be discounted entirely. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) ("If the opinion is based on an inaccurate factual premise, then it is correct to discount it entirely").

Given the positive and negative opinions of record, the Board finds that evidence of record is, at worst, in approximate balance as to whether the Veteran's left and right ankle degenerative arthritis with gout was incurred in or is otherwise related to his military service. Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's left and right ankle degenerative arthritis with gout is the result of his military service. Therefore, service connection for left and right ankle degenerative arthritis with gout are warranted. 38 C.F.R. §§ 3.303, 3.304; Lynch, 21 F.4th 776 (Fed. Cir. 2021).

8. Entitlement to service connection for membranous nephropathy is granted.

The Veteran contends that his kidney condition is the result of his military service. August 2022 VA Form 21-526EZ.

In the rating decision on appeal, the AOJ conceded that the Veteran has current diagnosis of membranous nephropathy. See 38 C.F.R. § 3.104(c). The Board thus finds that the current disability element of service connection has been established. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009).

The Veteran was first afforded a VA Kidney Conditions (Nephrology) examination in September 2022. The VA examiner confirmed the Veteran's diagnosis of kidney failure. The Veteran reported that he was advised of his kidney failure in 202
of membranous nephropathy. See 38 C.F.R. § 3.104(c). The Board thus finds that the current disability element of service connection has been established. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009).

The Veteran was first afforded a VA Kidney Conditions (Nephrology) examination in September 2022. The VA examiner confirmed the Veteran's diagnosis of kidney failure. The Veteran reported that he was advised of his kidney failure in 2021, which was an incidental finding during another procedure. The Veteran thereafter began experiencing swelling of his lower limb. The Veteran has received kidney infusions twice since his diagnosis, with additional infusions scheduled. The Board acknowledges that the September 2022 VA examiner rendered a positive nexus opinion regarding the Veteran's claimed kidney failure and a service-connected condition of "arthritis due to trauma." The Board notes, however, that at the time of this opinion, the Veteran was only service connected for tinnitus and was not service connected for any arthritis condition. As such, this positive nexus opinion is based on an inaccurate factual premise and is therefore inadequate for adjudication purposes. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012).

In August 2023, the Veteran submitted a medical study regarding the association of chronic kidney disease with prior tinnitus. This study suggests that chronic kidney disease patients have a higher likelihood of having suffered from tinnitus before their chronic kidney disease was diagnosed, but there was no data suggesting that tinnitus is a predictor of subsequent chronic kidney disease.

The Veteran was afforded a second VA Kidney Conditions (Nephrology) examination in November 2023. The VA examiner confirmed the Veteran's diagnosis of membranous nephropathy. The Veteran reported being informed of his condition in 2021 during a procedure, which was an incidental finding. The Veteran was treated with two infusions of Rituximab. The Veteran did not anticipate additional infusions but was being monitored. The Veteran reported symptoms of swelling in the lower legs. In rendering a negative nexus opinion, the VA examiner stated that the Veteran did not have kidney failure upon enlistment and his separation examination does not document a diagnosis of kidney failure. The VA examiner stated that the Veteran's kidney failure was incidentally noted two years ago. The VA examiner found that the Veteran's type of kidney failure is categorized as an autoimmune disease. The VA examiner explained that an autoimmune disease is caused when your body's defense system turns against you and harms your body when it should be protecting you. The VA examiner therefore opined that there is no nexus between the Veteran's kidney failure and his military service.

In March 2024, the Veteran submitted medical articles suggesting that chronic kidney failure and other kidney issues may be caused by use or overuse of over-the-counter pain medications.

The Veteran was afforded a third VA Kidney Conditions (Nephrology) examination in March 2024. The VA examiner confirmed the Veteran's diagnosis of unspecified renal failure. The Veteran reported that his condition has worsened, resulting in fatigue and urinary dysfunction. The Veteran reported receiving unspecified infusions every three months. In rendering a negative nexus opinion, the VA examiner opined that it is less likely than not that the Veteran's kidney failure was incurred in or caused by his service-connected tension headaches. The VA examiner noted that the Veteran's medical records show two normal eGFRs in 2019 and 2023, and there are no other abnormal results to support a diagnosis of renal failure during and after military service. The VA examiner stated that there is no sufficient evidence to show that the Veteran has a renal condition caused by his tension headaches, so no nexus is established.

In a July 2024 VA addendum opinion, a VA examiner noted that headaches do not represent an established primary etiology of kidney failure in medical literature. The VA examiner explained that while heavy NSAID use may be associated with increased use, there is no evidence that the Veteran's NSAID use was excessive or otherwise significantly deviated from the standard of care. The VA examiner noted that the Veteran's March 2024 examination demonstrated normal kidney function and no functional impact, which falls within the projected natural history of the condition and does not represent aggravation of the condition beyond its natural progression. The VA examiner therefore opined that it is less likely than not that the Veteran's kidney failure is proximately due to or the result of, or aggravated beyond its natural progression by, the Veteran's service-connected tension headaches or related NSA
headaches do not represent an established primary etiology of kidney failure in medical literature. The VA examiner explained that while heavy NSAID use may be associated with increased use, there is no evidence that the Veteran's NSAID use was excessive or otherwise significantly deviated from the standard of care. The VA examiner noted that the Veteran's March 2024 examination demonstrated normal kidney function and no functional impact, which falls within the projected natural history of the condition and does not represent aggravation of the condition beyond its natural progression. The VA examiner therefore opined that it is less likely than not that the Veteran's kidney failure is proximately due to or the result of, or aggravated beyond its natural progression by, the Veteran's service-connected tension headaches or related NSAID use.

The Veteran was afforded another VA Kidney Conditions (Nephrology) examination in October 2024. The VA examiner confirmed the Veteran's diagnosis of membranous nephropathy. The Veteran reported onset of his condition in 2021 as a result of an incidental finding after complaining of edema to his lower extremities. The Veteran was treated with Rituximab infusions, the last in October 2022, but he remains under the care of nephrology for his condition. The Veteran also reported current symptoms of fatigue and muscle cramps. In rendering a negative nexus opinion, the VA examiner stated that the Veteran's STRs are silent for wrist complaints and therefore a nexus cannot be established. The Board presumes that this is a typographical error and, as no opinion was proferred as to the Veteran's kidney failure, rejects this opinion as inadequate for adjudication purposes.

Given the positive and negative opinions of record, the Board finds that evidence of record is in approximate balance as to whether the Veteran's membranous nephropathy is the result of his military service, to include as secondary to his service-connected wrist, ankle, and foot conditions. Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's membranous nephropathy is caused by NSAID use for treatment of his service-connected wrist, ankle, and foot conditions. Therefore, service connection for membranous nephropathy on a secondary basis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, 21 F.4th 776 (Fed. Cir. 2021).

9. Entitlement to service connection for hypertension is granted.

The Veteran contends that his hypertension is the result of his military service. August 2023 VA Form 21-526EZ.

In the rating decision on appeal, the AOJ conceded that the Veteran has current diagnosis of hypertension. See 38 C.F.R. § 3.104(c). The Board thus finds that the current disability element of service connection has been established. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F
21 F.4th 776 (Fed. Cir. 2021).

9. Entitlement to service connection for hypertension is granted.

The Veteran contends that his hypertension is the result of his military service. August 2023 VA Form 21-526EZ.

In August 2023, the Veteran submitted a medical study suggesting a positive association between tinnitus and arterial hypertension, particularly in older patients.

The Veteran was afforded a VA Hypertension examination in September 2023. The VA examiner confirmed the Veteran's diagnosis of hypertension. The Veteran reported onset of his condition in the late 1980's after seeking treatment for feeling dizzy and seeing stars frequently. The Veteran started on medication to treat his symptoms, which has moderately controlled his condition but his blood pressure has been increasing the last few months. In rendering a negative nexus opinion, the VA examiner stated that the Veteran had no deployments and no known toxic exposures. The VA examiner noted that the Veteran's blood pressure readings were normal in service. The VA examiner stated that the Veteran was diagnosed after his military service. The VA examiner noted that the Veteran reported daily cigarette smoking, which is a known risk factor for having elevated blood pressure. The VA examiner explained that while tinnitus can be a symptom of elevated blood pressure or caused by damage associated with some blood pressure medications, there is no medical literature to support the claim that the Veteran's elevated blood pressure was caused by his tinnitus. Therefore, there is no nexus between the Veteran's hypertension and his tinnitus.

In November 2023, the Veteran submitted a medical study suggesting a relationship between hypertension and episodic primary headaches and chronic primary headaches. The Board notes that at this time, the Veteran was service connected for tension headaches associated with tinnitus.

The Veteran was afforded a second VA Hypertension examination in February 2024. The VA examiner confirmed the Veteran's diagnosis of hypertension. The Veteran reported onset of his condition in the 1980s, stating that he was concerned about hypertension around the time he was leaving the service. The Veteran could not recall when he was started on blood pressure medication. In rendering a negative nexus opinion, the VA examiner stated that while uncontrolled hypertension may result in headaches, the opposite has not been shown to be true in medical literature, that tension headaches directly or proximately cause hypertension. Therefore, a nexus cannot be established.

In March 2024, the Veteran submitted a medical article from the National Kidney Foundation suggesting a relationship between chronic kidney disease and high blood pressure/hypertension, as well as medical articles suggesting that pain medicines such as NSAIDs, ibuprofen, acetaminophen, and naproxen can raise your blood pressure or keep your blood pressure medicine from working the way it should.

The Veteran was afforded a third VA Hypertension examination in March 2024. The VA examiner confirmed the Veteran's diagnosis of hypertension. The Veteran reported onset of his condition in 1982, with both onset and current symptoms of dizziness, fatigue, and inability to sleep well. The Veteran is prescribed Amlodipine, Lisinopril, and Metoprolol to treat his hypertension. In rendering a negative nexus opinion, the VA examiner opined that it is less likely than not that the Veteran's hypertension is caused by his service-connected tension headaches due to lack of evidence in the medical record.

In a July 2024 VA addendum opinion, the VA examiner stated that headaches do not represent an established primary etiology of hypertension in medical literature. The VA examiner noted that while heavy NSAID use may be associated with increased use, there is no evidence that the Veteran's NSAID use was excessive or otherwise significantly deviated from the standard of care. The VA examiner stated that the Veteran's March 2024 examination demonstrated elevated blood pressure which is well controlled on three antihypertensive medications, which falls within the projected natural history of the condition and does not represent aggravation beyond its natural progression. The VA examiner therefore opined that it is less likely than not that the Veteran's hypertension is proximately due to or the result of, or aggravated beyond its natural progression by, the Veteran's service-connected tension headaches or related NSAID use.

In support of his claim, the Veteran submitted an October 2024 Independent Medical Evaluation rendered by Dr. H.S., D.O.
is no evidence that the Veteran's NSAID use was excessive or otherwise significantly deviated from the standard of care. The VA examiner stated that the Veteran's March 2024 examination demonstrated elevated blood pressure which is well controlled on three antihypertensive medications, which falls within the projected natural history of the condition and does not represent aggravation beyond its natural progression. The VA examiner therefore opined that it is less likely than not that the Veteran's hypertension is proximately due to or the result of, or aggravated beyond its natural progression by, the Veteran's service-connected tension headaches or related NSAID use.

The Veteran was afforded another VA Hypertension examination in Octobre 2024. The VA examiner confirmed the Veteran's diagnosis of hypertension. The Veteran reported onset of his condition in 1980 as a result of having elevated blood pressure readings. The Veteran is treated with medication and is under the care of his primary physician for this condition. The Veteran reported current symptoms of occasional headaches and occasional dizziness. No medical opinion was rendered as to the Veteran's hypertension at this time.

Given the positive and negative opinions of record, the Board finds that evidence of record is in approximate balance as to whether the Veteran's hypertension is the result of his military service, to include as secondary to his service-connected wrist, ankle, and foot conditions. Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's hypertension is caused by NSAID use for treatment of his service-connected wrist, ankle, and foot conditions. Therefore, service connection for hypertension on a secondary basis is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, 21 F.4th 776 (Fed. Cir. 2021).

10. Entitlement to service connection for left lower extremity varicose veins is granted.

11. Entitlement to service connection for right lower extremity varicose veins is granted.

The Veteran contends that his left and right lower extremity varicose veins are the result of his military service. August 2022 VA Form 21-526EZ.

In the rating decision on appeal, the AOJ conceded that the Veteran has current diagnoses of left and right lower extremity varicose veins. See 38 C.F.R. § 3.104(c). The Board thus finds that the current disability element of service connection has been established. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. § 3.303(a); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009).

The Veteran was first afforded a VA Artery and Vein Conditions examination in September 2022. The VA examiner confirmed the Veteran's diagnosis of varicose veins. The Veteran reported onset of his condition in 1978 during his active duty service, with symptoms of intermittent pain with extended ambulation. The Veteran wears compression stockings to treat his condition. The Board acknowledges that the September 2022 VA examiner rendered a positive nexus opinion regarding the Veteran's claimed varicose veins and a service-connected condition of "arthritis due to trauma." The Board notes, however, that at the time of this opinion, the Veteran was only service connected for tinnitus and was not service connected for any arthritis condition. As such, this positive nexus opinion is based on an inaccurate factual premise and is therefore inadequate for adjudication purposes. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012).

In an August
compression stockings to treat his condition. The Board acknowledges that the September 2022 VA examiner rendered a positive nexus opinion regarding the Veteran's claimed varicose veins and a service-connected condition of "arthritis due to trauma." The Board notes, however, that at the time of this opinion, the Veteran was only service connected for tinnitus and was not service connected for any arthritis condition. As such, this positive nexus opinion is based on an inaccurate factual premise and is therefore inadequate for adjudication purposes. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012).

In an August 2023 VA Form 21-4138, the Veteran stated that he firmly believed that the straining from climbing hills, prolonged periods of standing without breaks, and running during his military service contributed to the development of his varicose veins. The Veteran recalled experiencing ache and pain in his legs during these activities but pushed through and completed basic training. The Veteran stated that from basic training to the present time, he self-treated his varicose veins using over-the-counter medications and Epsom salt soaks, but the condition has persisted and the symptoms have a significant impact on his daily life and well-being.

The Veteran was afforded a second VA Artery and Vein Conditions examination in October 2024. The VA examiner confirmed the Veteran's diagnosis of varicose veins. The Veteran reported onset of his condition in 1979, with symptoms of pain, fatigue, swelling, and torturous veins in his lower extremities. The Veteran reported current symptoms of pain, fatigue, swelling, and torturous veins. The Veteran uses compression stockings to treat his condition. In rendering a negative nexus opinion, the VA examiner stated that the Veteran's STRs are silent for left and right varicose vein complaints and therefore a nexus cannot be established.

Given the positive and negative opinions of record, the Board finds that evidence of record is in approximate balance as to whether the Veteran's left and right lower extremity varicose veins are the result of his military service, to include as secondary to his service-connected wrist, ankle, and foot conditions. Therefore, resolving all reasonable doubt in the Veteran's favor, the Board finds that the Veteran's left and right lower extremity varicose veins are caused by NSAID use for treatment of his service-connected wrist, ankle, and foot conditions. Therefore, service connection for left and right lower extremity varicose veins on a secondary basis are warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, 21 F.4th 776 (Fed. Cir. 2021).

REASONS FOR REMAND

1. Entitlement to service connection for left knee degenerative arthritis is remanded.

2. Entitlement to service connection for right knee degenerative arthritis with gout is remanded.

The Veteran contends that his left knee degenerative arthritis and right knee degenerative arthritis with gout are the result of his military service. August 2022 VA Form 21-526EZ.

In the rating decision on appeal, the AOJ conceded that the Veteran has current diagnoses of left knee degenerative arthritis and right knee degenerative arthritis with gout. See 38 C.F.R. § 3.104(c).

The Veteran was first afforded a VA Knee and Lower Leg examination in September 2022. The VA examiner confirmed the Veteran's diagnoses of bilateral knee joint osteoarthritis and bilateral gout. The Veteran reported onset of his symptoms in 1984, stating that he experienced bilateral knee pain during active service, which he self-managed at the time. The Veteran reported that he was diagnosed with gout in 1984 and prescribed allopurinol and colchicine for treatment. The Veteran reported current symptoms of pain and cramps occurring intermittently, including while sleeping. In rendering a negative nexus opinion as to direct service connection, the VA examiner stated that the Veteran's STRs and medical records are silent for bilateral knee arthritis chronicity or continuation of treatment while the Veteran was in service and within a compensable period after service. Therefore, the Veteran's bilateral knee arthritis was less likely than not incurred in or caused by his military service.

The Board acknowledges that the September 2022 VA examiner rendered a positive nexus opinion regarding the Veteran's claimed bilateral knee arthritis and a service-connected condition of "arthritis due to trauma." The Board notes, however, that at the time of this opinion, the Veteran was only service connected for tinnitus and was not service connected for any arthritis condition. As such, this positive nexus opinion is based on an inaccurate factual premise and is therefore inadequate for adjudication purposes. Reonal v. Brown, 5 Vet. App. 458, 461 (1993); Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012).

The Board acknowledges that the Veteran submitted an October 2024 Independent Medical Evaluation rendered by Dr. H.S., D.O., with regard to the other claimed conditions on appeal. This October 2024 evaluation, however, did not include any evaluation or opinion as to the Veteran's claimed knee conditions.

The Veteran was afforded a second VA Knee and Lower Leg examination in October 2024. The VA examiner confirmed the Veteran's diagnosis of right knee joint osteoarthritis, right knee degenerative arthritis, and gout of the right lower extremity, with no mention of any left knee condition. The Veteran reported onset of right knee pain in 1981. While unable to recall any specific trauma or injury, the Veteran believed his knee pain was secondary to performing military exercises and activities such as repetitive motion, performing push-ups, firing weapons, and heavy lifting. The Veteran reported continued symptoms of right knee pain, which increases
October 2024 evaluation, however, did not include any evaluation or opinion as to the Veteran's claimed knee conditions.

The Veteran was afforded a second VA Knee and Lower Leg examination in October 2024. The VA examiner confirmed the Veteran's diagnosis of right knee joint osteoarthritis, right knee degenerative arthritis, and gout of the right lower extremity, with no mention of any left knee condition. The Veteran reported onset of right knee pain in 1981. While unable to recall any specific trauma or injury, the Veteran believed his knee pain was secondary to performing military exercises and activities such as repetitive motion, performing push-ups, firing weapons, and heavy lifting. The Veteran reported continued symptoms of right knee pain, which increases with activities, and decreased range of motion. The Veteran treats his condition with Tylenol and allopurinol. In rendering a negative nexus opinion, the VA examiner stated that the Veteran's STRs are silent for right knee complaints and therefore a nexus cannot be established.

VA's duty to assist includes conducting a thorough and comprehensive medical examination. 38 U.S.C. § 5103A(d)(2). The Board is required to ensure that medical opinions are made on the basis of sufficient facts or data and the application of reliable medical principles. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302 (2008). A medical opinion is adequate if it is based upon consideration of the Veteran's prior medical history and describes the Veteran's condition in sufficient detail so as to allow the Board to make a fully informed evaluation. Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Ardison v. Brown, 6 Vet. App. 405, 407 (1994). This requires the opinion to "contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008).

The Board must remand a claim to the AOJ to correct pre-decisional duty to assist errors, including when the AOJ fails to make reasonable efforts to obtain VA treatment records or relevant federal or private treatment records; fails to obtain a VA examination; or fails to provide an inadequate VA examination or opinion. 38 C.F.R. § 20.802(a).

The Board finds that the September 2022 and October 2024 VA medical opinions are inadequate for adjudication purposes. First, the chronicity of care, or lack thereof, is neither the correct legal standard for a nexus opinion nor is it a sufficient basis to deny the existence of a nexus between the Veteran's diagnoses and his service. The fact that there is no mention of knee issues in the Veteran's STRs, and no immediate post-service treatment for his knee conditions are not fatal to his claim for service connection. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 496 (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991)).

Additionally, VA regulations do not provide that service connection can only be shown through medical records but rather allow for proof through lay evidence. Smith v. Derwinski, 2 Vet. App. 512, 514-15 (1992). The law specifically provides that service connection may be satisfactorily established by lay evidence without the support of official records. Sheets v. Derwinski, 2 Vet. App. 512, 514-15 (1992). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay testimony is competent to prove that a claimant exhibited certain lay-observable symptoms and the time that those symptoms appeared. Layno v. Brown, 6 Vet. App. 465, 470 (1994). These lay-observable symptoms include pain. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). The Veteran has consistently reported that his bilateral knee symptoms began during his military service and have continued since that time. The Veteran's reports are internally consistent and thus entitled to probative weight. If these reports were discounted, there was no explanation provided by the VA examiner as to why. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (a medical
a claimant exhibited certain lay-observable symptoms and the time that those symptoms appeared. Layno v. Brown, 6 Vet. App. 465, 470 (1994). These lay-observable symptoms include pain. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007). The Veteran has consistently reported that his bilateral knee symptoms began during his military service and have continued since that time. The Veteran's reports are internally consistent and thus entitled to probative weight. If these reports were discounted, there was no explanation provided by the VA examiner as to why. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (a medical opinion is inadequate if it does not take into account the Veteran's reports of symptoms and history).

Therefore, a remand is required to obtain adequate VA medical opinions so that the Veteran's claims may be properly adjudicated.

The matters are REMANDED for the following action:

1. Forward the Veteran's claims file to an appropriate medical professional(s) for addendum opinions addressing the nature and etiology of the Veteran's bilateral knee conditions. The need for another clinical evaluation is left to the discretion of the medical professional offering the addendum opinions. The entire claims file must be made available to, and be reviewed by, the VA examiner(s).

The examiner is asked to provide an opinion as to the following:

(a) Whether the Veteran's left knee degenerative arthritis was incurred in or is otherwise related to the Veteran's active-duty service?

(b) Whether the Veteran's right knee degenerative arthritis with gout was incurred in or is otherwise related to the Veteran's active-duty service?

For the purposes of this remand only and for the limited purpose of conducting the examination and providing the above medical opinion, the examiner should assume that the Veteran's statements are true. If there is a medical reason to doubt their veracity, the examiner should explain why the Veteran's recollection is inconsistent with the principles of medical science or the evidence in this case.

The examiner is reminded that the absence of documented treatment in service or thereafter is not fatal to a service connection claim, and the absence of evidence in the service treatment records is an insufficient basis, by itself, for a negative opinion. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992).

The Board also notes that the absence of documented treatment, in and of itself, is not a basis for discrediting the Veteran's lay statements of continuity. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006).

The examiner is asked to explain the reasons behind any opinions expressed and conclusions rendered. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion cannot be provided without resort to speculation, together with a statement as to whether there is additional evidence that might enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010).

DUSTIN L. WARE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Feely, L.E.

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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