POSTTRAUMATIC STRESS DISORDER (PTSD)

B. D. WATSON · 2026 · Case ID: A26034188

MIXED

Summary

The veteran, who served in the U.S. Army from June 2006 to November 2016, appeals decisions regarding his PTSD, heart condition, and ankle injuries. The Board granted an increased rating for PTSD to 50 percent, finding the veteran's symptoms of anxiety, chronic sleep impairment, disturbances in motivation and mood, and difficulty with social relationships most closely approximated the criteria for that rating. The Board denied a compensable rating for his heart condition (long QT syndrome with heart murmur), concluding that the evidence did not meet the criteria for any compensable rating under either pre- or post-amendment VA regulations, despite the veteran's subjective belief of greater severity. Service connection for bilateral ankle conditions, diagnosed as distal stress fractures, was granted directly. The Board found the veteran's lay testimony credible and consistent with service treatment records showing ankle pain and treatment for ankle injuries during service, establishing the necessary nexus. The claim for an increased rating for right knee patella chondromalacia was remanded due to an inadequate VA examination, which failed to discount the ameliorative effects of medication and provide sufficient rationale for its findings.

Rationale

Symptoms approximated 50% rating criteria; Occupational and social impairment noted; Avoidance, hypervigilance, startle response, sleep issues, motivation/mood disturbances, and interpersonal difficulties identified

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Diagnostic Code

9411

Docket No.

210325-150659

Full Decision Text

Citation Nr: A26034188
Decision Date: 04/14/26 Archive Date: 04/14/26

DOCKET NO. 210325-150659
DATE: April 14, 2026

ORDER

Entitlement to an increased rating of 50 percent, but no higher, for service-connected posttraumatic stress disorder (PTSD) is granted.

Entitlement to a compensable rating for long QT syndrome to include heart murmur is denied.

Entitlement to service connection for a left ankle condition (diagnosed as a distal stress fracture) is granted.

Entitlement to service connection for right ankle condition (diagnosed as a distal stress fracture) is granted.

REMANDED

Entitlement to an increased rating in excess of 10 percent for service-connected right knee patella chondromalacia is remanded.

FINDINGS OF FACT

1. The severity, frequency, and duration of the Veteran's psychiatric symptoms most closely approximate occupational and social impairment with reduced reliability and productivity. Occupational and social impairment with deficiencies in most areas is not indicated at any time.

2. The evidence does not show that the Veteran's long QT syndrome to include heart murmur symptomology resulted in permanent atrial fibrillation (lone atrial fibrillation); or, one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor.

3. From November 14, 2021, the evidence does not show that the Veteran's long QT syndrome to include heart murmur symptomology caused him to experience heart failure symptoms at a workload of 7.1-10.0 METs; or required continuous use of medication for control; or supraventricular tachycardia with one to four treatment interventions per year; or, confirmed by ECG with either continuous use of oral medications to control or use of vagal maneuvers to control.

4. Resolving any reasonable doubt in the Veteran's favor, the evidence establishes that the Veteran's left ankle condition is related to his active-duty service.

5. Resolving any reasonable doubt in the Veteran's favor, the evidence establishes that the Veteran's right ankle condition is related to his active-duty service.

CONCLUSIONS OF LAW

1. The criteria for an increased rating of 50 percent, but no higher, for PTSD have been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.130, Diagnostic Code 9411.

2. The criteria for a compensable rating for long QT syndrome to include heart murmur have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.3, 4.7, 4.100, 4.104, Diagnostic Code 7099-7010.

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

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

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from June 2006 to November 2016.

These matters come before the Board of Veterans' Appeals (Board) on appeal from December 2020 and January 2021 rating decisions issued by a Department of Veterans Affairs (VA) regional office, the agency of original jurisdiction (AOJ).

In the March 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. In September 2024, the Veteran testified before the undersigned Veterans Law Judge at a virtual hearing. A transcript of the hearing has been associated with Veteran's the claims file.

Under the Hearing docket, the Board may only consider the evidence of record at the time of the applicable December 2020 or January 2021 AOJ decision on appeal, as well as any evidence submitted by the Veteran at the hearing or within 90 days following the September 2024 hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the applicable rating decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300,
hearing has been associated with Veteran's the claims file.

However, because the Board is remanding the claim for an increased rating for the Veteran's service-connected right knee patella chondromalacia, any evidence the Board could not consider will be considered by the AOJ in the adjudication of that claim on remand. 38 C.F.R. § 3.103(c)(2)(ii).

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.

Increased Rating Criteria

Disability evaluations (ratings) are determined by evaluating the extent to which a veteran's service-connected disability adversely affects his ability to function under the ordinary conditions of daily life, including employment, by comparing the symptomatology with the criteria set forth in the Schedule for Rating Disabilities (Rating Schedule). 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.2, 4.10.

In evaluating a disability, the Board considers the current examination reports in light of the whole recorded history to ensure that the current rating accurately reflects the severity of the condition. The Board has a duty to acknowledge and consider all regulations that are potentially applicable. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). 38 C.F.R. §§ 4.1, 4.2, 4.10.

Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in the veteran's favor. 38 C.F.R. § 4.3.

Where entitlement to compensation has already been established and an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. See Francisco v. Brown, 7 Vet. App. 55, 58 (1994). Separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Fenderson v. West, 12 Vet. App. 119 (1999).

1. Entitlement to an increased rating of 50 percent, but no higher, for service-connected PTSD is granted.

The Veteran contends that his PTSD is more severe than currently rated.

As background, an August 2017 rating decision granted service connection for PTSD and assigned a 30 percent rating effective November 4, 2016. The Veteran submitted a claim for an increased rating on July 15, 2020. The December 2020 rating decision on appeal continued the 30 percent rating. See Rating Decision -Narrative, December 2020.

The period on appeal before the Board begins on July 15, 2020, the date VA received the Veteran's claim for an increased rating, plus the one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010).

The Veteran's PTSD is evaluated under Diagnostic Code 9411, which assigns ratings based upon the General Rating Formula for Mental Disorders (General Rating Formula). 38 C.F.R. § 4.130. As the Veteran seeks a rating in excess of 30 percent, the Board will only discuss those rating criteria at and above his current criteria.

A 30 percent rating when the evidence shows occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior,
increased rating, plus the one-year look-back period. Gaston v. Shinseki, 605 F.3d 979, 982 (Fed. Cir. 2010).

A 30 percent rating when the evidence shows occupational and social impairment with an occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as: depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, mild memory loss (such as forgetting names, directions, recent events). Id.

A 50 percent evaluation is warranted where there is occupational and social impairment with reduced reliability and productivity due to symptoms as: flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks more than once a week; difficulty in understanding complex commands; impairment of short and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. Id.

A 70 percent rating is warranted when there is occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to suicidal ideation; obsessional rituals which interfere with routine activities, speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately, or effectively; impaired impulse control, such as unprovoked irritability with periods of violence; spatial disorientation, neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances, including work or a work-like setting; and the inability to establish and maintain effective relationships. Id.

A maximum 100 percent rating is warranted when there is total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene; disorientation to time and place; memory loss for names of close relatives, own occupation, or own name. Id.

The symptoms associated with each evaluation under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate evaluation of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. Rather, VA must consider all symptoms of a claimant's condition that affect his or her occupational and social impairment. Id. at 443.

If the evidence demonstrates that the claimant's psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating in the General Rating Formula, then the appropriate, equivalent rating will be assigned. Id. In that regard, the Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran's capacity for adjustment during periods of remission. 38 C.F.R. § 4.126; Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013).

In sum, there are two elements that must be met to assign a particular rating under the General Rating Formula: (1) symptoms equivalent in severity, frequency, and duration to the symptoms corresponding to a given rating, and (2) a level of occupational and social impairment corresponding to that rating that results from those symptoms.

Turning to the evidence, a PHQ-2 depression screen conducted in September 2019 was negative for depression. See CAPRI, Primary Care Outpatient Note, received August 21, 2020.

The Veteran denied depressive symptoms and suicidal ideation during a VA primary care visit in March 2020. See CAPRI, Primary Care Outpatient Note, received August 21, 2020.

The Veteran underwent a VA examination in December 2020. The examiner documented the Veteran's pre-military, military, and post-military history and noted the Veteran's current psychiatric diagnosis as PTSD.

As to his relevant social history, the Veteran reported that he has been in a significant relationship for five years, he has

Turning to the evidence, a PHQ-2 depression screen conducted in September 2019 was negative for depression. See CAPRI, Primary Care Outpatient Note, received August 21, 2020.

The Veteran denied depressive symptoms and suicidal ideation during a VA primary care visit in March 2020. See CAPRI, Primary Care Outpatient Note, received August 21, 2020.

As to his relevant social history, the Veteran reported that he has been in a significant relationship for five years, he has two children from a previous marriage, and his children visit regularly. The Veteran reported drinking more than he should and that he was trying to cut back because his girlfriend suggested that he cut back.

Occupationally, the Veteran reported taking classes "here and there" in management studies; he worked as a warehouse manager for Tenex in 2017; he left the job because his knees would swell, he was not interested in doing what they wanted him to do, he would not show up on time and received writeups that stated, "it seems like you are not interested." The Veteran indicated that he had not been employed since that time.

When asked to describe his anxiety the Veteran responded, "I avoid triggers. I can't get it together. My girlfriend told me I need to get reevaluated. My anxiety is so bad I feel like I'm always on edge, I get angry so fast, and I was a relaxed person. It's mostly with driving, the trigger could be a helicopter. When I hear helicopter noise, I feel like it's bringing me back there. I avoid driving and let my girlfriend or anybody else drive. Any little thing, it seems, sets me off. Like I drive tentative." When asked about other examples of triggers he replied, "I don't know what the other trigger is." The Veteran reported the onset of these problems was two years ago. He also reported that he sleeps 4 hours per night, he has vivid service-related dreams, and he is not prescribed medication to address his symptoms.

As to behavioral observations, the examiner stated that the Veteran was polite and cooperative throughout the evaluation; he was dressed casually, neatly, and appropriate for the weather; there was no evidence of psychomotor agitation or retardation; no impairment in communication was present; the Veteran's affect was appropriate to the situation and to the content of the conversation; his insight and judgment were good. The examiner determined that the Veteran was capable of managing his financial affairs.

The examiner noted a diagnosis of PTSD and PTSD diagnostic criteria including the following: avoidance or efforts to avoid external reminders (people, places, conversations, activities, objects, situations) that arouse distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s); a persistent negative emotional state; feelings of detachment or estrangement from others; hypervigilance; and an exaggerated startle response. The examiner checked a box indicating that "The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning."

The examiner noted the symptoms that apply to the Veteran's PTSD diagnosis as anxiety, chronic sleep impairment, and disturbances of motivation and mood. Based on the articulated symptomatology, the VA examiner concluded that the Veteran's symptoms resulted in occupational and social impairment best summarized as a mental condition has been formally diagnosed, but the symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. See Review PTSD DBQ, December 2020.

The Veteran testified to the following during his September 2024 Board hearing: he worked at a warehouse job for about a year and a half, but he couldn't blend in; he was used to the military standard and didn't feel accepted in the civilian workforce; he felt like he was starting over; after a while he just couldn't do it; it was rough waking up in the morning; he couldn't sleep at night and was only sleeping four hours; it was hard conforming and getting motivated; he felt depressed and withdrawn; he didn't really work after that, and just did odd jobs like Uber or jobs where he didn't really have to interact much with the public; he recently starting bartending part-time and was trying to see if he could do more and better control his anxiety; sleep is still and issue and the doctor thinks it might be sleep apnea but his "brain is constantly on" and he can only sleep for a couple of hours; he doesn't want to deal with people, he has made himself "a loner," and he has one good friend; he's trying to be more social, that's why he's trying the bartending job; he
four hours; it was hard conforming and getting motivated; he felt depressed and withdrawn; he didn't really work after that, and just did odd jobs like Uber or jobs where he didn't really have to interact much with the public; he recently starting bartending part-time and was trying to see if he could do more and better control his anxiety; sleep is still and issue and the doctor thinks it might be sleep apnea but his "brain is constantly on" and he can only sleep for a couple of hours; he doesn't want to deal with people, he has made himself "a loner," and he has one good friend; he's trying to be more social, that's why he's trying the bartending job; he currently goes to school part time; and he just can't connect with people the way he did when he was in the military. See Hearing Transcript, pages 19-23, September 2024.

After careful review of the evidence, the Board finds the severity, frequency, and duration of the Veteran's psychiatric symptoms most closely approximate occupational and social impairment with reduced reliability and productivity. Thus, an increased 50 percent rating is warranted.

As chronicled above, the Veteran's psychiatric disability was manifested by symptoms associated with a 30 percent rating (depressed mood, anxiety, and chronic sleep impairment); and a 50 percent rating (disturbances of motivation and mood and difficulty in establishing and maintaining effective work and social relationships).

The Veteran also has symptoms that are not listed with a specific rating, including avoidance, hypervigilance, an exaggerated startle response, vivid service-related dreams, a persistent negative emotional state, and detachment from others. The Board finds that the Veteran's avoidance, hypervigilance, exaggerated startle response, and vivid service-related dreams are similar to the severity, frequency, and duration of anxiety, suspiciousness, and chronic sleep impairment contemplated by the 30 percent rating. The Veteran's persistent negative emotional state and detachment from others are similar to the severity, frequency, and duration of disturbances in motivation and mood and difficulty in establishing and maintaining effective work and social relationships contemplated by the 50 percent rating.

While the schedular rating criteria provide examples of the types of symptoms associated with specific ratings for psychiatric disability, to warrant a specific rating the evidence must show that symptoms of the disability result in the contemplated level of functional impairment associated with the rating. Vazquez-Claudio v. Shinseki, 713 F.3d 112 (Fed. Cir. 2013).

As to occupational impairment, the Veteran reported that he left his warehouse job, in part, because his knees would swell and he was not interested in doing what they wanted him to do. However, he also reported difficulties fitting into the civilian workforce, difficulty conforming and being accepted by others, difficulty waking up in the morning and lack of motivation. The Veteran then worked odd jobs like Uber so that he did not have to interact much with the public. The Veteran has been taking classes in management studies and more recently started parttime work as a bartender with no reported issues. Taken as a whole, the Board finds that the Veteran's anxiety, chronic sleep impairment, lack of motivation, poor mood, and struggles with interpersonal relationships decreased his overall reliability and productivity as an employee, as contemplated by a 50 percent rating.

As to social impairment, the Veteran has been in a long-term relationship and his two children from a previous marriage visit regularly. The Veteran reported challenges connecting with people the way he did when he was in the military and not wanting to "deal with people." The Veteran tended to isolate himself and became a self-described "loner." However, the Veteran also reported having one close friend and trying to be more social, to include parttime work as a bartender. Taken as a whole, this evidence supports a finding that the Veteran's symptoms most closely approximate difficulty establishing and maintaining effective relationships, which is consistent with a 50 percent rating, as opposed to an inability to do so, which is consistent with a 70 percent rating.

The Board finds the Veteran's symptoms and resultant occupational and social impairment do not more closely approximate a rating in excess of 50 percent at any time during the period on appeal. The Veteran's symptoms are not of the severity, frequency, and duration to warrant a 70 percent rating.

To this point, there is no evidence of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood with symptoms such as suicidal ideation; obsessional rituals that interfere with routine activities; intermittently illogical speech; near continuous panic or depression affecting his ability to function independently, appropriately, or effectively; impaired impulse control; spatial disorientation, neglect of personal appearance or hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or an inability to establish and maintain effective relationships
rating in excess of 50 percent at any time during the period on appeal. The Veteran's symptoms are not of the severity, frequency, and duration to warrant a 70 percent rating.

To this point, there is no evidence of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking or mood with symptoms such as suicidal ideation; obsessional rituals that interfere with routine activities; intermittently illogical speech; near continuous panic or depression affecting his ability to function independently, appropriately, or effectively; impaired impulse control; spatial disorientation, neglect of personal appearance or hygiene; difficulty in adapting to stressful circumstances (including work or a work-like setting); or an inability to establish and maintain effective relationships. The Veteran has not been shown engage in grossly inappropriate behavior or exhibit any other symptom that rises to the level of impairment contemplated by a 70 percent or higher rating.

Thus, while the record demonstrates that the Veteran does have some social and occupational impairment which adversely impact his quality of life, the greater weight of evidence demonstrates that it is to a degree contemplated by a rating less than 70 percent. Furthermore, even resolving any reasonable doubt in the Veteran's favor, the Board finds that he does not meet the requirements for an evaluation greater than the 50 percent schedular rating. The totality of the Veteran's symptoms and impairment most closely approximate a disability picture that is contemplated by a 50 percent disability rating.

In reaching this determination, the Board acknowledges that the VA examiner selected the "severity statement" associated with a noncompensable (0 percent) rating. However, aside from checking a box, the VA examiner did not provide any rationale in support of this finding. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Thus, it is unclear how the VA examiner arrived at the conclusion that the Veteran's symptoms were "not severe enough to interfere with occupational and social functioning or to require continuous medication."

Additionally, the VA examiner noted in the examination report that "The PTSD symptoms described above cause clinically significant distress or impairment in social, occupational, or other important areas of functioning." This finding contradicts the VA examiner's conclusion regarding the severity of the Veteran's PTSD and the examiner provided no explanation resolving this clear contradiction.

Accordingly, the Board affords no probative value to VA examiner's assessment of the Veteran's occupational and social impairment.

In sum, after conducting a holistic review of the Veteran's PTSD symptoms and resultant occupational and social impairment, the Board finds that an increased rating of 50 percent, but no higher, is warranted.

2. Entitlement to a compensable rating for long QT syndrome to include heart murmur is denied.

The Veteran contends that his long QT syndrome to include heart murmur ("heart condition") is more severe than currently rated.

The Board finds that an increased, compensable rating is not warranted for the reasons set forth below.

As background, a January 2018 rating decision granted service connection for the Veteran's heart condition and assigned a noncompensable (zero percent) percent rating under Diagnostic Code 7099-7010 effective November 4, 2016. The Veteran submitted a claim for an increased rating on July 15, 2020. The December 2020 rating decision on appeal continued the noncompensable rating. See Rating Decision - Narrative, December 2020.

The Veteran's specific heart condition is not listed on the rating schedule, and therefore the AOJ rated the Veteran's condition under Diagnostic Code 7099-7010 pursuant to 38 C.F.R. § 4.27, which provides that unlisted disabilities requiring rating by analogy will be coded as the first two numbers of the most closely related body part and "99." The Veteran's condition was then rated under the most closely analogous code, Diagnostic Code 7010 for supraventricular arrhythmias. 38 C.F.R. § 4.104. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31.

Under Diagnostic Code 7010, a 10 percent rating is warranted for permanent atrial fibrillation (lone atrial fibrillation), or; one to four episodes per year of paroxysmal atrial fibrillation or
two numbers of the most closely related body part and "99." The Veteran's condition was then rated under the most closely analogous code, Diagnostic Code 7010 for supraventricular arrhythmias. 38 C.F.R. § 4.104. In every instance where the schedule does not provide a zero percent evaluation for a diagnostic code, a zero percent evaluation shall be assigned when the requirements for a compensable evaluation are not met. See 38 C.F.R. § 4.31.

Under Diagnostic Code 7010, a 10 percent rating is warranted for permanent atrial fibrillation (lone atrial fibrillation), or; one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor. A maximum 30 percent rating is warranted for paroxysmal atrial fibrillation or other supraventricular tachycardia, with more than four episodes per year documented by ECG or Holter monitor.

The Board notes that, effective November 14, 2021, VA amended the rating criteria for the cardiovascular system. This amended regulation applies to all applications for benefits received by VA or that are pending before the agency of original jurisdiction on or after November 14, 2021. Claims pending prior to the effective date will be considered under both the pre- and post-amendment rating criteria, and whichever is more favorable to the Veteran will be applied. However, the Board may not apply the post-amendment rating criteria to a period prior to its effective date, unless the regulation explicitly provides otherwise. Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003). Conversely, the Board is not precluded from applying the pre-amendment rating criteria to a period on or after the effective date of the post-amendment rating criteria so long as it was in effect during the pendency of the appeal.

The new rating criteria effective November 14, 2021 created a General Rating Formula for Diseases of the Heart (General Rating Formula) under which it must be ascertained in all cases whether or not cardiac hypertrophy or dilatation (documented by ECG, echocardiogram, or x-ray) is present and whether or not there is a need for continuous medication. METs testing is required in all cases except: (1) when there is a medical contraindication; (2) when a 100 percent evaluation can be assigned on another basis. 38 C.F.R. § 4.100.

The General Rating Formula is as follows. A 10 percent rating is warranted where a workload of 7.1-10.0 METs results in heart failure symptoms, or continuous medication is required for control. A 30 percent rating is warranted where a workload of 5.1-7.0 METs results in heart failure symptoms, or where there is cardiac hypertrophy or dilatation confirmed by echocardiogram or equivalent (e.g., multi-gated acquisition scan or magnetic resonance imaging). A 60 percent rating is warranted where a workload of 3.1-5.0 METs results in heart failure symptoms. A 100 percent rating is warranted where a workload of 3.0 METs or less results in heart failure symptoms.

Under the post-amendment rating criteria, one MET is the energy cost of standing quietly at rest and represents an oxygen uptake of 3.5 milliliters per kilogram of body weight per minute. 38 C.F.R. § 4.104, Note (2). When the level of METs at which breathlessness, fatigue, angina, dizziness, or syncope develops is required for evaluation, and a laboratory determination of METs by exercise testing cannot be done for medical reasons, an estimation by a medical examiner of the level of activity (expressed in METs and supported by specific examples, such as slow stair climbing or shoveling snow) that results in those symptoms may be used. Id.

Under the new rating criteria, Diagnostic Code 7010 evaluates supraventricular tachycardia and provides that a 10 percent disability rating is warranted for supraventricular tachycardia confirmed by ECG, with one or more treatment interventions per year, or confirmed by ECG with either continuous use of oral medications to control or use of vagal maneuvers to control. A maximum 30 percent disability rating is warranted for supraventricular tachycardia confirmed by ECG, with five or more treatment interventions per year. 38 C.F.R. § 4.104, DC 7010 (effective November 14, 2021).

Two additional notes were added to the rating criteria. The first note provides that examples of
7010 evaluates supraventricular tachycardia and provides that a 10 percent disability rating is warranted for supraventricular tachycardia confirmed by ECG, with one or more treatment interventions per year, or confirmed by ECG with either continuous use of oral medications to control or use of vagal maneuvers to control. A maximum 30 percent disability rating is warranted for supraventricular tachycardia confirmed by ECG, with five or more treatment interventions per year. 38 C.F.R. § 4.104, DC 7010 (effective November 14, 2021).

Two additional notes were added to the rating criteria. The first note provides that examples of supraventricular tachycardia include, but are not limited to: atrial fibrillation, atrial flutter, sinus tachycardia, sinoatrial nodal reentrant tachycardia, atrioventricular nodal reentrant tachycardia, atrioventricular reentrant tachycardia, atrial tachycardia, junctional tachycardia, and multifocal atrial tachycardia. Id. at Note 1. The second note indicates that for purposes of this diagnostic code, a treatment intervention occurs whenever a symptomatic patient requires intravenous pharmacologic adjustment, cardioversion, and/or ablation for symptom relief. Id. at Note 2.

Turning to the evidence, a February 2020 VA primary care note states "regular heart sounds, no gallop, no murmur." See CAPRI, received July 2020.

The Veteran underwent a VA heart conditions examination in October 2020. The Veteran reported that his heart condition was diagnosed in 2011 after he had shortness of breath, difficulty breathing, and underwent an EKG.

The examiner noted the following findings in the examination report: the Veteran's heart condition does not qualify within the generally accepted definition of ischemic heart disease; continuous medication was not required for control of the Veteran's heart condition; the Veteran has not had a myocardial infarction, congestive heart failure, atrial fibrillation, a heart valve condition, an infectious heart condition, pericardial adhesion, surgical or non-surgical procedures, or hospitalizations for the treatment of his heart condition; the Veteran's long QT syndrome resulted in intermittent (paroxysmal) arrhythmia with no episodes in the past 12 months; on examination, the Veteran's heart rate was 78, heart rhythm was regular, heart sounds were normal, lungs were clear, peripheral pulses were normal, and there was no indication of peripheral edema; the results of a November 6, 2020 EKG and chest X-ray was normal; an interview-based METs test of less than 7-10 METs resulted in dyspnea and fatigue (the 7-10 METs level has been found to be consistent with activities such as climbing stairs quickly, moderate bicycling, sawing wood, jogging (6mph); there was no change in the VA established diagnosis of long QT syndrome to include heart murmur; and the Veteran's heart condition results in functional impact in that the Veteran has shortness of breath and fatigue with exertion. See C&P Exam, Heart Conditions DBQ, received November 24, 2020; see also EKG Study Report, received November 24, 2020.

The Veteran testified to the following during his September 2024 Board hearing: he always had an issue running no matter how good of a shape he was in; he had an EKG and that's when his condition was explained to him; it feels like his heart either slows down or beats very fast; his blood pressure has been "weird" and his doctor is still trying to figure out how to control that; he has to sit down, drink some water, or use his inhaler when he feels his heart is beating differently; and his VA primary care doctor is trying to figure out the irregular heartbeat sensation that he keeps having. See Hearing Transcript, pages 16-19, September 2024.

VA treatment records were submitted during the 90-day evidentiary window following the September 2024 Board hearing. Of note, a January 2024 primary care note states "regular heart sounds, no gallop, no murmur." See Medical Treatment Record, Non-Government Facility, received November 14, 2024.

Upon review of the evidence, lay and medical, the Board finds that the criteria for a compensable rating is not warranted at any time during the period on appeal.

The Board finds the October 2020 VA medical examination competent, as it was completed by an appropriately qualified medical professional. The Board finds the examination findings credible and consistent with the evidence of record. Thus,
-19, September 2024.

Upon review of the evidence, lay and medical, the Board finds that the criteria for a compensable rating is not warranted at any time during the period on appeal.

The probative and persuasive evidence demonstrates that the Veteran's heart condition has not resulted in permanent atrial fibrillation (lone atrial fibrillation); or, one to four episodes per year of paroxysmal atrial fibrillation or other supraventricular tachycardia documented by ECG or Holter monitor at any time. Therefore, a compensable rating under the pre-amended Diagnostic Code 7010 is not warranted at any point during the period on appeal. 38 C.F.R. § 4.104.

The Board has also considered the General Rating Formula and amended Diagnostic Code 7010 criteria given that the Veteran provided his Board testimony after November 14, 2021. Additionally, a VA treatment record was submitted within the 90-day window following the Board hearing. However, this evidence fails to show that the Veteran's heart condition results in heart failure symptoms at a workload of 7.1-10.0 METs; requires continuous medication for control; has resulted in supraventricular tachycardia with one to four treatment interventions per year; or, confirmed by ECG with either continuous use of oral medications to control or use of vagal maneuvers to control. Therefore, a compensable rating is also not warranted under the General Rating Formula or amended Diagnostic Code 7010 criteria.

The Board has also considered a rating under other diagnostic codes. However, the evidence does not indicate that the Veteran has any other diagnosed heart condition such that a rating under another diagnostic code would be warranted. As noted above, there was no ischemic heart disease, no myocardial infarction, no congestive heart failure, no heart valve condition, no infectious cardiac condition, no peripheral edema, no pericardial adhesions, and no surgical procedures or hospitalizations.

The Board acknowledges the Veteran's belief that his heart condition is more severe than as reflected by the currently assigned disability rating. In this regard, the Board must consider the entire evidence of record when analyzing the criteria laid out in the rating schedule. While the Board recognizes that the Veteran is competent to describe certain symptoms, he is not competent to provide an opinion regarding the severity of his symptomatology in accordance with the rating criteria. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). Ultimately, the Board finds the medical findings provided by the VA examiner to be more persuasive than the Veteran's own beliefs regarding the severity of his heart condition.

In reaching such determination, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, the probative evidence is not in approximate balance and weighs against the Veteran's claim. Thus, the benefit-of-the-doubt doctrine is not applicable in such regard, and the increased rating claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7.

Finally, the Board has considered whether an inferred claim of entitlement to a total disability rating based on individual unemployability (TDIU) has been raised in conjunction with the increased rating claims adjudicated above. The Board notes that at no point has the evidence supported, nor has the Veteran contended, that his service-connected disabilities render him unable to secure and follow gainful employment. Accordingly, the matter of entitlement to a TDIU is not raised by the record. See Rice v. Shinseki 22 Vet. App. 447, 453-54 (2009).

Service Connection Criteria

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.
TDIU is not raised by the record. See Rice v. Shinseki 22 Vet. App. 447, 453-54 (2009).

Service Connection Criteria

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may also 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 on a secondary basis requires competent and credible evidence demonstrating (1) the existence of a current disability; (2) a service-connected disability; and (3) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. See 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead held a "but for" causation or aggravation is enough to show entitlement to secondary service connection).

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, 999 F. 3rd 1391 (2021).

3. Entitlement to service connection for a left ankle condition (diagnosed as a distal stress fracture) is granted.

4. Entitlement to service connection for right ankle condition (diagnosed as a distal stress fracture) is granted.

The Veteran seeks service connection for left and right ("bilateral") ankle conditions, contending that such are directly related to his active service or secondary to a service-connected disability. See VA 21-526EZ, Fully Developed Claim (Compensation).

The Board finds that service connection for bilateral ankle conditions is warranted on a direct basis for the reasons set forth below.

The record reflects current diagnoses of left and right distal stress fractures. See C&P Exam, Ankle Conditions DBQ, January 2021. Thus, the first element of service connection, a current disability, has been met.

The AOJ made favorable findings in the January 2021 rating decision that the evidence shows that a qualifying event, injury, or disease had its onset during the Veteran's service; specifically, service treatment records (STRs) dated April 29, 2010 show treatment for ankle joint pain. The Board highlights that the AOJ made this favorable finding for both (left and right) claimed ankle conditions. The Board is bound by these favorable findings absent clear and unmistakable error which is not present here. See 38 U.S.C. § 5104A; 38 C.F.R. § 3.104(c).

Additionally, the Veteran's STRs show treatment for left ankle pain in March 2007 after the Veteran reported that he rolled his ankle during combatives training. The treatment record notes swelling and pain radiating from the left part of the ankle to the left shin. An assessment of "ankle sprain" is noted. See STR, received May 2017.

STRs dated April 2010 and May 2010 reflect reported joint pain in both ankles, with increasing pain with active movement and with weight bearing. The Veteran was prescribed Motin (800 mg.). Follow-on encounter notes reflect a past medical history of bilateral ankle stress fractures. See STR, received May 2017.

STRs in 2012, 2013, and 2014 note a history of bilateral ankle joint pain. See STR, received May 2017.

The AOJ's favorable finding and above-mentioned STRs satisfy the second element of service connection, an in-service incurrence of bilateral ankle injuries.

The remaining determination for the
sprain" is noted. See STR, received May 2017.

STRs in 2012, 2013, and 2014 note a history of bilateral ankle joint pain. See STR, received May 2017.

The AOJ's favorable finding and above-mentioned STRs satisfy the second element of service connection, an in-service incurrence of bilateral ankle injuries.

The remaining determination for the Board is whether a nexus (i.e., link) exists between the Veteran's current bilateral ankle conditions and the in-service bilateral ankle injuries.

A VA examiner provided a nexus opinion in January 2021. However, the opinion only addressed secondary service connection; a medical opinion for direct service connection was not provided. See C&P Exam, Medical Opinion DBQ, January 2021.

The Veteran testified to the following during his September 2024 Board hearing: his ankle problems started during his military service; he was young at the time and didn't want to go to sick call; when he did get medical care he was told to take a break, but he was trying to get promoted and needed to take PT tests; he probably should have rested them more, but he kept going; after a while his ankles became a repetitive problem; he would back off when they started to hurt and the pain would go away; he used Ace bandages during service; the ankles problems he experienced during service, including discomfort and pain, have persisted until today; his ankles swell up more as he has gotten older; he has to stay off of them, use ice, and an ankle brace (neoprene-type sleeve); and if one ankle starts hurting he compensates with the other. See Hearing Transcript, pages 8-11, September 2024.

Upon review, the Board finds that a nexus has been established even though there are no medical opinions of record addressing direct service connection.

The Veteran has competently and credibly reported experiencing bilateral ankle pain in and since his separation from active service. The Veteran is competent to report that he experienced pain and discomfort since service. Moreover, his statements are credible and entitled to probative weight, as they are internally consistent and consistent with the overall medical evidence of record reflecting ongoing bilateral ankle issues throughout the Veteran's service. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (a veteran is competent to testify regarding continuous pain since service, and lay evidence, when credible, is competent to establish the presence of continuous symptoms for a claimed disability during and since separation from military service); Buchanan v. Nicholson, 451 F.3d 1331, 1337 (holding lay evidence concerning continuity of symptoms after service, if credible, is ultimately competent, regardless of the lack of contemporaneous medical evidence).

To the extent that a grant of service connection in this matter is based primarily on lay evidence, "nothing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself." Id. at 1335.

The Board could remand the claim for a nexus opinion. However, the Board will resolve any reasonable doubt in the Veteran's favor and find that the third element of service connection has been established. Moreover, the Board will not prolong this appeal and remand to potentially develop negative evidence. See Mariano v. Principi, 17 Vet. App. 305, 312 (2003); Andrews v. McDonough, 34 Vet. App. 216, 225 (2021) ("Remand is inappropriate where the predominant purpose is not to allow the Board to make a fully informed decision unencumbered by error but to allow VA to obtain more evidence so that it can properly deny the claim"). A remand for a VA medical opinion is not necessary because the evidence of record is sufficient to grant the Veteran's claim.

In sum, all three elements of service connection have been met for the Veteran's left and right ankle conditions (diagnosed as distal stress fractures). Accordingly, the claims are granted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

REASONS FOR REMAND

1. Entitlement to an increased rating in excess of 10 percent for service-connected right knee patella chondromal
can properly deny the claim"). A remand for a VA medical opinion is not necessary because the evidence of record is sufficient to grant the Veteran's claim.

REASONS FOR REMAND

1. Entitlement to an increased rating in excess of 10 percent for service-connected right knee patella chondromalacia is remanded.

The Veteran contends that his right knee patella chondromalacia is more severe than currently rated.

As discussed below, the Board finds that there is a pre-decisional duty to assist error, and an addendum VA medical opinion is required on remand to cure the error. 38 C.F.R. § 20.802(a).

As background, a November 2017 rating decision granted service connection for right knee patella chondromalacia and assigned a 10 percent rating under Diagnostic Code 5260 effective November 4, 2016. The Veteran submitted a claim for an increased rating on July 15, 2020. The December 2020 rating decision on appeal continued the 10 percent rating. See Rating Decision - Narrative, December 2020.

Turning to the evidence, a September 2019 VA primary care note documents the Veteran's report of ongoing bilateral knee pain, his right knee pain has worsened over the last six months, and the Veteran uses ibuprofen. See CAPRI, received July 16, 2020

A March 2020 VA treatment record documents the results of recent knee X-rays. Physical therapy and the use of over-the-counter medications such as Tylenol and/or ibuprofen were recommended as treatment. See CAPRI, received July 16, 2020.

The Veteran was provided a VA knee conditions examination in October 2020. The Veteran was noted to have right knee flare ups, described as "moderate," occurring 3-4 times per week, lasting hours, precipitated by overuse, and alleviated by rest and NSAIDs. Upon examination, right knee range of motion testing was determined to be "abnormal or outside of normal range." Pain was noted as causing additional loss of function and range of motion after repeated use over time and during flare-ups. See C&P Exam, Knee and Lower Leg Conditions DBQ, pages 3-6, received November 24, 2020.

In evaluating the severity of a disability, VA may not consider the ameliorative effects of medication on that disability unless the use of medication is specifically contemplated by the rating criteria. See Jones v. Shinseki, 26 Vet. App. 56, 63 (2012). This includes musculoskeletal disabilities in which the use of medications is not specifically contemplated by the rating criteria. see also Ingram v. Collins, 23 Vet. App. 1798. (2025) (holding that the Board is to take due consideration that the beneficial effects of medication are discounted in assessing musculoskeletal ratings as such effects are not contemplated therein and, therefore, taking medication may make a veteran appear less disabled than in reality).

The Board notes that Diagnostic Code 5260 does not contemplate the ameliorative effects of medication. Thus, in evaluating the Veteran's right knee disability, the Board must discount the benefits of medication, to include additional functional impairment as due to flare-ups and repeated use over time. See Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017).

VA has a duty to assist Veterans in developing their claims for benefits. 38 C.F.R. § 3.159. The duty to assist includes providing a medical examination when necessary to decide a claim. 38 C.F.R. § 3.159 (c)(4). When VA undertakes to provide a VA examination it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007).

In this case, the VA examiner in rendering findings, did not note or indicate consideration and discount of any ameliorative effects of the Veteran's documented use of NSAIDS when describing functional limitations in all worst-case scenarios (e.g., during flare ups, on repetitive motion, due to lack of endurance, lack of coordination, etc.). This deficiency renders the examination inadequate. The failure of the AOJ to obtain a proper examination prior to issuing the December 2020 rating decision is a pre-decisional duty to assist error. See 38 C.F.R. § 20.802(a).

While the Board regrets the additional delay, the claim must be remanded in order to obtain the information necessary to properly adjudicate the claim.

The matter is REMANDED for the following action:

1. Schedule the Veteran for a new VA examination to determine the severity of his service-connected right knee patella chondromalacia absent the ameliorative effects of medication. The entire claims file and a copy of this remand must be made available to the examiner for review. All tests deemed necessary should be conducted and the results reported in detail.

If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, they should clearly explain why that is so.

The full range of motion testing must be performed in both active and passive motion, in weightbearing and non-weightbearing with range of motion measurements of the opposite undamaged joint. The examiner should address in detail the additional functional impairment and range of motion loss due to factors such as pain, weakened movement, excess fatigability, incoordination, and flare-ups.

The examiner should estimate any additional loss of motion to the best of their ability. The examiner must specifically evaluate the severity of the Veteran's right knee patella chondromalacia, including during flare-ups, and speak to the severity of his symptoms absent the ameliorative effects of any medication that would alleviate his symptoms, including both prescription and over-the-counter medications.

If it is not possible to provide a specific measurement without speculation, the examiner should state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training).

All opinions should be accompanied by adequate reasons and bases. All opinions should include a discussion of the Veteran's lay statements.

If the examiner cannot provide the requested opinion without resorting to mere speculation, they should provide a complete explanation stating why this is so.

In so doing, the examiner should explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that they have exhausted the limits of current medical knowledge in providing an answer to that particular question.

B. D. WATSON

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board P. S. Rubin, 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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