FLATFOOT BILATERAL ACQUIRED

Summary

The veteran appeals the denial of service connection for bilateral flatfoot (pes planus), left and right knee disabilities, a psychiatric disability (generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder), and erectile dysfunction. The Board found that the veteran's bilateral flatfoot was at least as likely as not the result of an in-service disease or injury, citing treatment for foot swelling during initial entry training and a favorable, albeit imperfect, VA examination opinion. Despite some ambiguity in the VA examiner's opinion and a subsequent negative opinion that did not fully address all factors, the Board resolved reasonable doubt in the veteran's favor, granting service connection for bilateral flatfoot. Based on this, the Board also granted service connection for the left and right knee disabilities as secondary to the service-connected flatfoot, citing a favorable secondary opinion. For the psychiatric disability, the Board found it was at least as likely as not the result of service, specifically noting the multifactorial nature of the diagnoses and the veteran's consistent, credible statements, despite some unverified treatment details. Service connection for erectile dysfunction was granted as secondary to the service-connected psychiatric disability, supported by a favorable secondary opinion. All claims were granted.

Rationale

Current diagnosis of bilateral flatfoot (pes planus) conceded.; In-service disease/injury conceded based on August 2013 treatment for foot swelling during ACDUTRA.; Nexus found based on favorable February 2024 VA opinion and resolution of reasonable doubt.

Full Decision Text

Citation Nr: A26035117
Decision Date: 04/15/26	Archive Date: 04/15/26

DOCKET NO. 250409-536622
DATE: April 15, 2026

ORDER

Entitlement to service connection for bilateral flatfoot (pes planus) is granted.

Entitlement to service connection for a left knee disability is granted.

Entitlement to service connection for a right knee disability is granted.

Entitlement to service connection for a psychiatric disability, to include generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder, is granted.

Entitlement to service connection for erectile dysfunction is granted.

FINDINGS OF FACT

1. The Veteran's current bilateral flatfoot (pes planus) is at least as likely as not the result of an in-service disease or injury.

2. The Veteran's current left knee disability is at least as likely as not the result of his bilateral flatfoot (pes planus).

3. The Veteran's current right knee disability is at least as likely as not the result of his bilateral flatfoot (pes planus).

4. The Veteran's current psychiatric disability, to include generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder, is at least as likely as not the result of his active service.

5. The Veteran's current erectile dysfunction is at least as likely as not the result of his service-connected psychiatric disability.

CONCLUSIONS OF LAW

1. The criteria for service connection for bilateral flatfoot (pes planus) have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

2. The criteria for service connection for a left knee disability have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

3. The criteria for service connection for a right knee disability have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

4. The criteria for service connection for a psychiatric disability, to include generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder, have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304.

5. The criteria for service connection for erectile dysfunction have been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

These matters come before the Board of Veterans' Appeals (Board) on appeal from March 2025 and April 2025 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO).

In April 2025, the Veteran submitted a timely notice of disagreement (VA Form 10182) and requested direct review of his service connection claims for bilateral flatfoot (pes planus), a left knee disability, a right knee disability, a psychiatric disability, and erectile dysfunction by a Veterans Law Judge.  The Board acknowledges the Veteran's April 2025 VA Form 10182 incorrectly identifies the March 2025 rating decision on appeal as the basis for his appeal of the issues of service connection for a psychiatric disorder and erectile dysfunction, when these issues were actually deferred at the time of the March 2025 rating decision; however, since the April 2025 rating decision that actually addressed the merits of the claims was issued prior to the submission of the Veteran's April 2025 VA Form 10182, the Board will construe it as a timely notice of disagreement for that decision in accordance with the paternalistic nature of the VA adjudication system.

Applicable Evidentiary Window

In accordance with provisions of the Appeals Modernization Act (AMA), the Board's review in this case is limited to evidence considered by the AOJ in the respective decision on appeal.  See 38 C.F.R. § 20.301.  If evidence was associated with the claims file outside of the applicable evidentiary window, the Board has not considered it in its decision.  See 38 C.F.R. § 20.300.  The Veteran is advised of the supplemental claim option if he desires consideration of any evidence not received prior to the closure of the evidentiary record for a specific issue on appeal.  See 38 C.F.R. §
 VA adjudication system.

Applicable Evidentiary Window

In accordance with provisions of the Appeals Modernization Act (AMA), the Board's review in this case is limited to evidence considered by the AOJ in the respective decision on appeal.  See 38 C.F.R. § 20.301.  If evidence was associated with the claims file outside of the applicable evidentiary window, the Board has not considered it in its decision.  See 38 C.F.R. § 20.300.  The Veteran is advised of the supplemental claim option if he desires consideration of any evidence not received prior to the closure of the evidentiary record for a specific issue on appeal.  See 38 C.F.R. § 3.2501; see also Cook v. McDonough, 36 Vet. App. 175 (2023).

Analysis

Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303.

Service connection may also be granted for disability resulting from disease or injury incurred in or aggravated while performing active duty for training (ACDUTRA) or injury incurred or aggravated by inactive duty for training (INACDUTRA).  38 U.S.C. §§ 101(24), 106, 1110.  In the case of a member of the National Guard, ACDUTRA means full-time duty for training purposes or field exercises under section 316, 502, 503, 504, or 505 of title 32 of the United States Code.  38 U.S.C. § 101(22).  INACDUTRA means duty (other than full-time) duty performed by a member of the National Guard under section 316, 502, 503, 504, or 505 of title 32 of the United States Code.  38 U.S.C. § 101(23).

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

In accordance with these principles, service connection may be granted when a claimed disability is found to be caused by or the result of a service-connected disability, or when any increase in severity (aggravation) of a nonservice-connected disease or injury is found to be due to or the result of a service-connected disability.  38 C.F.R. § 3.310.

When there is an approximate balance of positive and negative evidence regarding any material issue, reasonable doubt will be resolved in favor of the claimant.  See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (holding evidence is not in approximate balance, or nearly equal, when the evidence "persuasively favors one side or the other").

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

Initially, the Board notes the March 2025 rating decision on appeal appears to have applied a higher evidentiary standard than necessary regarding the Veteran's bilateral flatfoot (pes planus) service connection claim - expressly stating revision of the previous decision regarding the claim on the basis of clear and unmistakable error is not warranted.  The Board notes the Veteran requested a higher-level review after the March 2024 rating decision that initially denied his bilateral flatfoot (pes planus) claim, which eventually led to the May 2025 rating decision on appeal, via the supplemental review lane, after a duty-to-assist error was identified in the initial decision.  As a result, the Veteran has continuously pursued his claim within the meaning of the AMA, requiring application of the "at least as likely as not" standard in his case, as opposed to the much higher evidentiary burden required for revision on the basis of clear and unmistakable error.

Regarding the merits of the claim, the AOJ has conceded the presence of a current disability based on a diagnosis of bilateral flatfoot (pes planus) confirmed on examination.  The AOJ also conceded the in-service disease or injury element of the claim based on service treatment records that reflect treatment of bilateral feet swelling on August 5, 2013, during the Veteran's verified period of ACDUTRA from July 2013 to December 2013 for initial entry training.  The only material issue in dispute is the nexus
 AMA, requiring application of the "at least as likely as not" standard in his case, as opposed to the much higher evidentiary burden required for revision on the basis of clear and unmistakable error.

Regarding the merits of the claim, the AOJ has conceded the presence of a current disability based on a diagnosis of bilateral flatfoot (pes planus) confirmed on examination.  The AOJ also conceded the in-service disease or injury element of the claim based on service treatment records that reflect treatment of bilateral feet swelling on August 5, 2013, during the Veteran's verified period of ACDUTRA from July 2013 to December 2013 for initial entry training.  The only material issue in dispute is the nexus element of the claim.

The Board notes the Veteran's initial February 2024 VA examiner provided what appears to be a favorable nexus opinion regarding the claim, noting the "condition of pes planus, or flat feet, is more likely to have contributed to the swelling of the feet during [the Veteran's] service.  The examiner cited medical literature noting pes planus "among athletes and military personnel [is] associated with increased foot pain and injuries" to support her conclusion regarding the Veteran's claim; however, the examiner checked the box of the applicable disability benefits questionnaire that supports a negative nexus opinion.  Yet, it is clear the February 2024 examiner intended to provide a favorable opinion regarding bilateral flatfoot (pes planus) because the accompanying knee opinion, which will be discussed in more detail below, indicates the "[c]urrent severity of the service connected flatfoot, bilateral warrants by proximity, association of the bilateral knees", evidencing the examiner's belief that a favorable nexus conclusion regarding bilateral flatfoot (pes planus) is warranted in the Veteran's case.

The Board acknowledges the AOJ requested a second opinion regarding the Veteran's claim in November 2024, but the rationale provided to support the negative nexus conclusion in this opinion is limited to a lack of diagnosis of bilateral flatfoot (pes planus) during service or in treatment records immediately thereafter, which cannot be the sole basis for a negative nexus conclusion standing alone.  Further, the November 2024 examiner did not address documentation of bilateral foot swelling during the Veteran's initial entry training or his lay reports regarding his symptoms both during and after service.  Accordingly, the November 2024 opinion is not more persuasive than the previously obtained February 2024 opinion, which accounts for these factors.  As result, there is at least an approximate balance of positive and negative evidence regarding the Veteran's claim.  Resolving reasonable doubt in the Veteran's favor, the Board finds service connection for bilateral flatfoot (pes planus) is warranted.  See Wise v. Shinseki, 26 Vet. App. 517, 531 (2014) ("By requiring only an 'approximate balance of positive and negative evidence' the Nation, 'in recognition of our debt to our veterans,' has 'taken upon itself the risk of error' in awarding . . . benefits.").

2. Entitlement to service connection for a left knee disability is granted.

3. Entitlement to service connection for a right knee disability is granted.

As previously noted, the Veteran's initial February 2024 examiner provided a favorable secondary service connection opinion regarding his claim for left and right knee disabilities based on causation under 38 C.F.R. § 3.310(a), explaining the change in biomechanics due to the severity of his bilateral flatfoot has resulted in a bilateral knee disability.  There is no other secondary service connection opinion to weigh against this favorable opinion.  The Board finds service connection for bilateral flatfoot is warranted when reasonable doubt is resolved in the Veteran's favor; therefore, it follows that service connection is also warranted for left and right knee disabilities on a secondary basis in accordance with 38 C.F.R. § 3.310.  See Wise, supra.

4. Entitlement to service connection for a psychiatric disability, to include generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder, is granted.

The April 2025 rating decision on appeal conceded all three elements of the Veteran's service connection claim for an acquired psychiatric disorder.  The decision included binding favorable findings regarding a current disability (generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder), an in-service disease or injury (exposure to dead bodies during hurricane relief efforts in the U.S. Virgin Islands), and a nexus to service.  Yet, the AOJ still denied the Veteran's claim based on a finding that "the treatment by others" noted in a March 2025 opinion regarding the claim could not be verified from service records.

By way of history, an initial June 2024 VA examiner provided a favorable, but general, opinion regarding the Veteran's claim indicating his diagnoses of generalized anxiety disorder
 all three elements of the Veteran's service connection claim for an acquired psychiatric disorder.  The decision included binding favorable findings regarding a current disability (generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder), an in-service disease or injury (exposure to dead bodies during hurricane relief efforts in the U.S. Virgin Islands), and a nexus to service.  Yet, the AOJ still denied the Veteran's claim based on a finding that "the treatment by others" noted in a March 2025 opinion regarding the claim could not be verified from service records.

By way of history, an initial June 2024 VA examiner provided a favorable, but general, opinion regarding the Veteran's claim indicating his diagnoses of generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder are at least as likely as not the result of his military service, to include a deployment to the U.S. Virgin Islands in 2017 for hurricane relief efforts, as claimed by the Veteran; however, the June 2024 VA examiner commented on how difficulty complying with military height-and-weight standards led to the development of body-image issues in the Veteran's case and played a role in the onset of his psychiatric disability.  Thereafter, the AOJ requested a new opinion regarding the Veteran's claim, based on a finding that the initial opinion "was too broad and not specific to the deployment to the Virgin Islands."  In March 2025, the Veteran's initial June 2024 VA examiner provided a new opinion regarding the Veteran's claim, noting it is "difficult to drill down" to an "exact cause" of his disability given the nature of the diagnoses.  The examiner explained the Veteran does not experience symptoms typically associated with trauma, making it unlikely that his experience in the U.S. Virgin Islands caused his psychiatric disability, standing alone, while noting "these experiences contributed to or exacerbated anxiety symptoms" in his case.  The examiner further explained that the Veteran's perception of "treatment by others" due to difficulty complying with height-and-weight standards, to include as early as his initial entry training, and the associated onset of anxiety and body-image issues, which have persisted since then, are a more likely causative factor for his current disability, which was then aggravated during his deployment to the U.S. Virgin Islands.

The Board finds the Veteran's currently diagnosed psychiatric disability, to include generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder, is at least as likely as not the result of his active service.  It is clear the expert asked to opine on the nexus element of the Veteran's claim believes there is an association between such service and the claimed disability, although acknowledging the multifactorial nature of the Veteran's diagnoses makes it difficult to identify an exact cause.  The Board recognizes the AOJ's concerns that the "treatment by others" noted in the most recently obtained opinion has not been verified, but VA regulation contemplates situations in which certain aspects of military service may not be documented in service records, to include, but not limited to, situations in which a claimant's behavior changes may support a psychiatric claim based on undocumented events.  The Veteran has maintained a consistent account of his symptoms and the factual basis of his claim throughout the claim process despite being asked to report for multiple examinations.  There is no evidence that directly rebuts his otherwise consistent and credible statements.  He is also competent to report his symptoms and history.  Based on this evidence, an expert has attributed his current disability to events in service.  There is no expert opinion weighing against the claim.  Resolving reasonable doubt in the Veteran's favor, the Board finds service connection for generalized anxiety disorder, social anxiety disorder, and other specified feeding and eating disorder is warranted.  See Wise, supra.

5. Entitlement to service connection for erectile dysfunction is granted.

Much like the Veteran's bilateral knee service connection claims, the award of service connection for the primary disability, i.e., a psychiatric disability, controls with respect to the secondary claimed disability, i.e., erectile dysfunction.  A May 2024 examiner provided a favorable secondary service connection opinion based on causation that attributes the Veteran's claimed erectile dysfunction to the severity of his diagnosed psychiatric disability, explaining in detail how the Veteran's specific psychiatric disorders affect the physiological processes involved in achieving and maintaining an erection.  There is no other secondary service connection opinion to weigh against the persuasive value of the November 2024 opinion.  As a result, service connection for erectile dysfunction is warranted in accordance with 38 C.F.R. § 3.310(a).

 

 

M. HYLAND

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	L. S. Kyle, 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
 attributes the Veteran's claimed erectile dysfunction to the severity of his diagnosed psychiatric disability, explaining in detail how the Veteran's specific psychiatric disorders affect the physiological processes involved in achieving and maintaining an erection.  There is no other secondary service connection opinion to weigh against the persuasive value of the November 2024 opinion.  As a result, service connection for erectile dysfunction is warranted in accordance with 38 C.F.R. § 3.310(a).

 

 

M. HYLAND

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	L. S. Kyle, 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.