Citation Nr: 23024695 Decision Date: 04/28/23 Archive Date: 04/28/23 DOCKET NO. 19-26 218A DATE: April 28, 2023 ORDER New and material evidence having been received, the claim for service connection for a right hip condition to include arthritis is reopened. Subject to the laws and regulations governing the award of VA monetary benefits, a 20 percent rating, but no more, for left lower extremity (LLE) radiculopathy with compromised L4 nerve sleeve from December 30, 2016, is granted. Subject to the laws and regulations governing the award of VA monetary benefits, a 20 percent rating, but no more, for right lower extremity (RLE) radiculopathy from December 30, 2016, is granted. Service connection for degenerative arthritis of the spine with spinal stenosis (claimed as neck condition and cervical) is denied. Service connection for left upper extremity (LUE) radiculopathy is denied. Service connection for right upper extremity (RUE) radiculopathy is denied. REMANDED Entitlement to a rating in excess of 20 percent for chronic ankle sprain, left, from January 31, 2018, is remanded. Entitlement to service connection for bilateral pes planus is remanded. Entitlement to service connection for plantar fasciitis is remanded. Entitlement to service connection for right ankle condition with edema to include as secondary to plantar fasciitis is remanded. Entitlement to service connection for a right hip condition to include arthritis as secondary to service-connected disabilities is remanded. Entitlement to service connection for a left hip condition to include arthritis as secondary to service-connected disabilities is remanded. FINDINGS OF FACT 1. In an August 2015 rating decision, service connection for a right hip condition was denied; the Veteran did not timely appeal or submit new and material evidence within a year of the decision. 2. Evidence added to claims file since the August 2015 rating decision, specifically to include VA examinations and treatment records, lay statements, and hearing testimony, relates to unestablished facts necessary to support the Veteran's claim for service connection for a right hip condition. 3. Throughout the entire appeal period, the Veteran's LLE and RLE radiculopathy has resulted in moderate involvement of the sciatic nerve. 4. The persuasive evidence of record is against a finding that the Veteran's claimed cervical spine disability is the result of his active service, including his presumed Gulf War exposures. 5. The persuasive evidence of record is against a finding that the Veteran's claimed LUE and RUE radiculopathy is the result of his active service, including his presumed Gulf War exposures, or secondary to a service-connected disability. CONCLUSIONS OF LAW 1. The August 2015 rating decision that denied service connection for a right hip condition is final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. 2. New and material evidence having been received, the claim for entitlement to service connection for a right hip condition to include arthritis is reopened. 38 U.S.C. § 5108; 38 C.F.R. § 3.156(c)(i). 3. The criteria for a 20 percent rating, but no more, for LLE radiculopathy with compromised L4 nerve sleeve from December 30, 2016, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, Diagnostic Code (DC) 8520. 4. The criteria for a 20 percent rating, but no more, for RLE radiculopathy from December 30, 2016, have been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.321, 4.1, 4.2, 4.3, 4.7, 4.10, 4.124a, DC 8520. 5. The criteria for service connection for degenerative arthritis of the spine with spinal stenosis (claimed as neck condition and cervical) have not been met. 38 U.S.C. § §§ 1110, 1117, 1131, 1154(a), 1168, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.317. 6. The criteria for service connection for LUE radiculopathy have not been met. 38 U.S.C. § §§ 1110, 1117, 1131, 1154(a), 1168, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317. 7. The criteria for service connection for RUE radiculopathy have not been met. 38 U.S.C. § §§ 1110, 1117, 1131, 1154(a), 1168, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1987 to June 1992, to include service in the Southwest Asia theater of operations. These matters come before the Board of Veterans Appeals (Board) on appeal from May 2017, January 2018, and September 2018 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at an October 2021 hearing before the undersigned Veterans Law Judge. A transcript of the proceeding has been associated with the claims file. The Board has limited the discussion below to the relevant evidence required to support its finding of facts 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). New and Material Evidence Generally, a claim which has been denied in an unappealed RO or Board decision may not thereafter be reopened and allowed. 38 U.S.C. §§ 7104(b), 7105(c). An exception to this rule is 38 U.S.C. § 5108, which provides that if new and material evidence is presented or secured with respect to a claim which has been disallowed, the VA Secretary shall reopen the claim and review the former disposition of the claim. 38 U.S.C. § 5108. New evidence means evidence not previously submitted. Material evidence means existing evidence that by itself or when considered with previous evidence relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last final decision and must raise a reasonable possibility of substantiating the claim. 38 C.F.R. § 3.156(a). If the evidence is new, but not material, the inquiry ends, and the claim cannot be reopened. See Smith v. West, 12 Vet. App. 312, 314 (1999). In Shade v. Shinseki, 24 Vet. App. 110 (2010), the Court of Appeals for Veterans Claims (Court) interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold, and viewed the phrase "raises a reasonable possibility of substantiating the claim" as "enabling rather than precluding reopening." The Court emphasized that the regulation is designed to be consistent with 38 C.F.R. § 3.159(c)(4), which "does not require new and material evidence as to each previously unproven element of a claim." The Court further held that the determination of whether newly submitted evidence raises a reasonable possibility of substantiating the claim should be considered a component of the question of what is new and material evidence, rather than a separate determination to be made after the Board has found that evidence is new and material. Id. For the purpose of establishing whether new and material evidence has been submitted, the credibility of the evidence, although not its weight, is to be presumed. Justus v. Principi, 3 Vet. App. 510, 513 (1992). The Veteran initially sought service connection for a right hip disability in April 2015. The RO denied service connection in an August 2015 rating decision, finding that there was no clear pathology in the right hip to warrant service connection as secondary to a service-connected back disability. Evidence considered in the August 2015 decision included the Veteran's service treatment records (STRs), VA treatment records, and a VA examination. The STRs included a March 1988 bone scan which found there was increased uptake located within the acetabula of both hips, compatible with stress phenomena. Following a back injury in March 1991, clinicians stated that there was some edema of the left hip and pain in the LLE. No complaints were noted regarding the right hip. At an August 1991 examination, it was noted that the Veteran's RLE was normal. At a September 1991 medical evaluation board (MEB) examination, the March 1991 back injury was reviewed, noting that it resulted in lumbosacral pain and pain and numbness down the LLE. The pain occurred in the left lumbosacral paraspinal region and radiated to the left buttock down the left posterior thigh and leg. Gait was fairly brisk with a slight limp involving the LLE. No symptomology regarding the right hip was noted. There was no muscle atrophy in the RLE and range of motion was full. Post-service, a November 2005 VA treatment record demonstrated normal range of motion in the right hip. The Veteran started physical therapy for his back disability with radiculopathy which included extensive flexibility work for his hips. An August 2012 treatment record noted chronic back pain and hip pain. In April 2013, the Veteran reported having hip issues. An x-ray conducted in August 2015 demonstrated mild degenerative change with joint space narrowing, osteophyte formation subchondral sclerosis. At the August 2015 VA examination, the Veteran reported that his right leg would go numb on him, affecting the way he walked. His hip hurt all the time at about 7 out of 10, sometimes increased to an 8 or 9 out of 10 in severity. When his pain was worse, he would pop his hip back into place. The examiner determined that the claimed right hip condition was less likely than not proximately due to or the result of the Veteran's service-connected back disability. In support, he stated that the Veteran had hip arthritis based on x-ray, but the cause of this was unclear as he did not have complaints of pain or problems with the hip joint itself. The Veteran pointed to the sacroiliac (SI) joints as the areas that hurt. This was not part of the hip joint but part of the back. He had reduced range of motion in the hip because of the SI joint pain but did not have hip joint pathology. The hip had reduced range of motion but that could not be explained on the basis of a hip condition and might be related to pain behaviors. Because no diagnosis could be found on examination or on review of the medical records to explain the hip complaints, no relationship of a hip condition could be made to the Veteran's lumbar spine disability. The Veteran did not appeal the decision or submit new and material evidence within the subsequent one-year appeal period. Accordingly, the decision is final. 38 U.S.C. § 7105; 38 C.F.R. §§ 3.156(b), 20.1103; see also Pickett v. McDonough, U.S. Court of Appeals for Vet. Claims, No. 2022-1057, (April 6, 2023). VA treatment records in constructive possession of VA within the one-year appeal period also did not demonstrate new and material evidence regarding the service connection claim. See Lang v. Wilkie, 971 F.3d 1348 (Fed. Cir. 2020). In December 2016, the Veteran sought to reopen the claim. In a May 2017 rating decision, the RO found that new and material evidence had been submitted sufficient to reopen the claim but continued to deny the claim, finding that the evidence continued to show that the condition was not related to his service-connected back disability. The Veteran timely appealed. Evidence added to the record after the August 2015 rating decision included a private Disability Benefits Questionnaire (DBQ), VA treatment records, a VA examination, and lay statements. The October 2016 DBQ diagnosed osteoarthritis (OA), trochanteris pain syndrome, and femoral acetabular impingement of the left hip, but no conditions of the right hip. The examiner did indicate that the Veteran had lumbosacral subluxation affecting both sides, causing neurological impingement in both lower extremities. A lumbar spine x-ray conducted in November 2016 noted moderate degenerative change at both hips and that the prominence of acetabulum may contribute to Cam-type impingement. In a December 2016 treatment record, the Veteran reported that he had chronic pain in his neck, back, hips, ankles, and feet since the 1980s. In a December 2016 statement, the Veteran claimed that his right hip disability was the result of pes planus. In January 2017, he told VA treating clinicians that he had been having more problems with his feet, resulting in more limping. This limping caused pain in his hips, including pain in the "ball and socket area" of the right hip. A March 2017 VA examination diagnosed asymptomatic right hip OA and degenerative joint disease (DJD). The Veteran identified his discomfort as localized to the SI joint area which was not consistent with a hip condition. Although he had OA/DJD in the right hip, he did not have associated hip discomfort attributable to OA/DJD. He did have SI joint dysfunction with associated SI joint tenderness and localized SI joint discomfort that increased with lumbar active range of motion and hip range of motion. As such, the asymptomatic right hip OA/DJD was less likely than not the result of the Veteran's service-connected back disability. The asymptomatic right hip OA/DJD was more likely than not the result of the normal aging process. Scientific literature did not support the premise that individuals with chronic low back pain and lumbar DJD/degenerative disc disease (DDD) with associated lumbar radiculopathy are at increased risk of developing hip OA/DJD. As noted above, the Veteran appealed the May 2017 rating decision denying the claim. Evidence added to the record since that decision included VA treatment records, private treatment records, a VA examination, and hearing testimony. VA treatment records demonstrated ongoing physical therapy for a multitude of physical disabilities. Range of motion in the bilateral hips was noted to be limited due to pain. At an August 2019 VA examination, mild bilateral DJD of the hips was diagnosed. The examiner determined that the condition was asymptomatic and was less likely the result of his active service, including the abnormal bone scan findings in March 1988. The examiner also determined that it was less likely than not that the asymptomatic hip condition was a result of or aggravated by his service-connected back disability. In support, the examiner stated that the STRs were negative for any evidence of chronic right hip complaints/pain. The bone scan showed an incidental finding of increased uptake in the acetabular bilaterally. Based on the imaging findings, the radiologist speculated about a possible stress injury. However, clinically, there was no evidence of any hip symptoms. Stress reactions such as that seen on the bone scan usually resolved without permanent disability. Subsequent in-service examinations were negative for any right hip condition. Since leaving service, the examiner stated that VA treatment records were negative for any treatment of a specific right hip condition. The Veteran reported constant back pain, including pain radiating into both legs. Based on his testimony, as well as the physical examination, the examiner stated that he was unable to attribute any of his symptoms to his hips. His current symptoms were consistent with his service-connected back disability and radiculopathy. The Veteran's bilateral radiculopathy caused painful symptoms in both legs including hips, knees, ankles, and feet. When the Veteran was lying down, range of motion testing of the knees and hips produced pain in his back including pain localized to the SI joint. He specifically indicated that pain was in the SI joint. The examiner determined that the symptoms in the hips were the result of the back disability. Although the Veteran was able to provide accurate testimony regarding his symptoms, it was difficult for any patient to determine the diagnosis or source of pain in the hips versus SI dysfunction versus the back disability. The mild x-ray findings of symmetrical hip DJD were consistent with his age of 50. In a January 2020 VA musculoskeletal review, SI joint tenderness, iliac crest tenderness, and greater trochanteric tenderness were observed. The Veteran had limited range of motion in the hips with pain on motion. The treating clinician stated that the Veteran's primary pain generator appeared to be sensory-only lumbar radiculopathy and flexion-based pain. Hip x-rays were ordered but subsequent records reflected that he did not undergo any imaging. At the October 2021 VA hearing, the Veteran testified that the injury in service to his back also injured his right hip. He stated that he was on bedrest for the injury in service. 1. New and material evidence having been received, the claim for service connection for a right hip condition to include arthritis is reopened. Subsequent to the final August 2015 rating decision, additional evidence was added to the claims file which relates to unestablished facts necessary to support the Veteran's claim for service connection for a right hip condition. Particularly, VA examinations and treatment records reflected additional diagnoses and lay statements included reports of ongoing symptomology. Accordingly, the Board finds that the Veteran's claim of entitlement to service connection for a right hip condition to include arthritis is reopened. The claim is granted to this extent only. Increased Ratings Disability evaluations are determined by the application of the facts presented to VA's Schedule for Rating Disabilities (Rating Schedule) at 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and the residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. In evaluating the severity of a particular disability, it is essential to consider its history. 38 C.F.R. § 4.1; Peyton v. Derwinski, 1 Vet. App. 282 (1991); Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Whether the issue is one of an initial rating or an increased rating, separate ratings can be assigned for separate periods of time based on the facts found, a practice known as "staged" ratings. See Hart v. Mansfield, 21 Vet. App. 505 (2007). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of his symptoms. Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). Any reasonable doubt regarding the degree of disability should be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that evaluation. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Additionally, the evaluation of the same disability under several Diagnostic Codes, known as pyramiding, must be avoided. See 38 C.F.R. § 4.14. Separate ratings may be assigned for distinct disabilities resulting from the same injury only where the symptomatology for one condition is not duplicative or overlapping with the symptomatology of the other condition. See Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). 1. Radiculopathy Service connection for the Veteran's LLE radiculopathy was granted in a January 2006 rating decision, effective November 14, 2005. LLE radiculopathy was rated at 10 percent under 38 C.F.R. § 4.124a, DC 8520, pertaining to involvement of the sciatic nerve. The Veteran submitted a claim for an increased rating for LLE radiculopathy and service connection for RLE radiculopathy in September 2014. In a February 2015 rating decision, 10 percent for LLE radiculopathy was continued. Service connection for RLE radiculopathy was granted, effective September 3, 2014, at 10 percent disabling under DC 8520. On December 30, 2016, the Veteran submitted a claim for increase for both disabilities. In a May 2017 rating decision, the RO continued the 10 percent ratings. The Veteran timely appealed. Accordingly, the Board will consider entitlement to a rating in excess of 10 percent for LLE radiculopathy and a rating in excess of 10 percent for RLE radiculopathy from December 30, 2016, to include whether there was a factually ascertainable increase in disability during the one-year look-back period preceding the claim. See 38 C.F.R. § 3.400(o). Under DC 8520, complete paralysis where the foot dangles and drops, there is no active movement possible of muscles below the knee, and flexion of the knee is weakened or (very rarely) lost is rated 80 percent. Severe incomplete paralysis with marked muscular atrophy is rated 60 percent; moderately severe incomplete paralysis is rated 40 percent; moderate incomplete paralysis is rated 20 percent; and mild incomplete paralysis is rated 10 percent. The term "incomplete paralysis" with peripheral nerve injuries indicates a degree of loss or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to the varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for mild, or at most, the moderate degree. See Note at "Diseases of the Peripheral Nerves" in 38 C.F.R. § 4.124(a). Descriptive words such as "mild," "moderate," "moderately severe" and "severe" are not defined in the Rating Schedule. Rather than applying a mechanical formula, the Board must evaluate all of the evidence to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. According to Merriam Webster's Collegiate Dictionary 999 (11th Ed. 2007), "mild" means gentle in nature or temperate. "Moderate" means limited in scope or effect or average in amount, intensity, quality, or degree. The term "moderately severe" includes impairment that is considered more than "moderate" but not to the extent as to be considered "severe." Webster's New World Dictionary (2nd ed. 1999), 1012. "Severe" means very painful or harmful or of a great degree. Although a medical examiner's use of descriptive terminology such as "mild" is an element of evidence to be considered by the Board, it is not dispositive of an issue. The Board must evaluate all evidence in arriving at a decision regarding an increased rating. 38 C.F.R. §§ 4.2, 4.6. Turning to the relevant evidence of record, prior to the period on appeal, the Veteran underwent electromyography (EMG) testing which demonstrated chronic/mild ongoing neurogenic changes in the L5-S1 vertebra nerve distribution bilaterally consistent with chronic mild radiculopathy. The Veteran submitted a back conditions DBQ in October 2016. The examiner indicated that sensation was decreased in the LLE at the upper anterior thigh, thigh/knee, lower leg/ankle, and foot/toes. Constant pain in the LLE was noted to be severe and both paresthesias/dysesthesias and numbness were checked to be both moderate and severe in the LLE. The examiner concluded that there was involvement of the sciatic and femoral nerves in the LLE that was marked to be both moderate and severe. There were no other neurologic abnormalities. A lumbar x-ray conducted in November 2016 demonstrated mild to moderate degenerative changes with no acute process. A December 2016 MRI revealed disc and facet degenerative changes in the lower lumbar spine, stable compared to prior imaging. No critical spinal stenosis was noted. In a January 2017 VA treatment record, the Veteran reported that he had been experiencing more pain and numbness in his legs, getting a cold and wet sensation and shooting pain from his thighs down his legs. He also described a "prickly feeling" in his bilateral feet. He denied muscle weakness and any numbness or tingling. Pain ranged from a 4 to a 9 out of 10 in severity. In a January 2017, the Veteran stated that he was experiencing a cold, wet feeling throughout his legs and he wore extra clothing and used warmers to improve the condition. The Veteran underwent a VA back examination in March 2017. Normal muscle strength and deep tendon reflexes (DTRs) were demonstrated in the bilateral lower extremities. Sensory examinations using monofilament, position sensation, and cold sensation all yielded normal results. Vibratory sensation in the bilateral lower extremities was decreased. The examiner indicated that the Veteran had bilateral radiculopathy with no constant pain but mild intermittent pain, paresthesias, dysesthesias, and numbness bilaterally. The examiner concluded that the radiculopathy was mild in severity and involved the sciatic nerve. The Veteran had no other signs or symptoms of radiculopathy and no other neurologic abnormalities. VA clinicians administered a facet injection to the Veteran's lumbar spine in July 2017. He stated that his radicular symptoms improved but later returned to baseline after a month. Another VA back examination was conducted in December 2017. The Veteran had normal muscle strength and DTRs in the bilateral lower extremities. A sensory examination yielded normal results but there was decreased vibratory sensation in the bilateral toes. The Veteran's radiculopathy resulted in no constant pain; mild intermittent pain, paresthesias, and dysesthesias; and moderate numbness bilaterally. The examiner determined that his radiculopathy was mild in severity and involved the sciatic nerve. There were no other signs and symptoms of radiculopathy or other neurologic abnormalities. In February 2018, the Veteran told treating VA clinicians that his radiculopathy symptoms seemed to be progressing with a mild increase in right thigh weakness over the last 2 to 3 years. There was no muscle atrophy and light sensation was intact upon observation. Another facet injection was administered with resolution of pain. A lumbar MRI was conducted which demonstrated mild DDD at L4-L5 and L5-S1, not significantly changed; moderate to severe L5-S1 facet arthropathy, mildly worsened from 2016; mild facet arthropathy at L3-L4 and L4-L5; mild bilateral L4-L5 and L5-S1 neural foraminal narrowing, unchanged; and no significant spinal canal narrowing. A private chiropractor treated the Veteran in May 2019 with complaints of SI joint discomfort radiating to the posterior aspect of the legs to the calves, left greater than right. He also stated that he experienced a cold water-like sensation down his legs. Sensory examination of vibration, sharp, and dull sensation of the lower dermatomes was altered with greater sensation in the RLE than in the LLE. Patellar and Achilles' reflexes were 1+ and symmetrical bilaterally. He was unable to perform additional testing after a straight leg test caused severe muscle spasms in his back. He thereafter underwent chiropractic care and reported "fair" improvement of symptoms in July 2019. A VA peripheral nerves examination was conducted in August 2019. The Veteran continued to report numbness and dysesthesias in the legs. He also described intermittent pain in his calf. He was prescribed Gabapentin for his bilateral upper and lower extremity radiculopathy. There was no constant pain; mild intermittent pain, paresthesias, and dysesthesias; and moderate numbness in the bilateral lower extremities. Muscle strength testing was normal with no atrophy. DTRs were normal in the bilateral knees but hypoactive in the bilateral ankles. Sensation testing for light touch was normal in the upper anterior thighs and thighs/knees but decreased in the lower leg/ankle and foot/toes. There were no trophic changes. The examiner determined that the Veteran's radiculopathy resulted in mild incomplete paralysis of both lower extremities involving the sciatic nerve. There was no functional impact from the disabilities. The Veteran underwent another VA back examination in December 2019. He described chronic, constant numbness and tingling, radiating down both legs to the level of the calf muscles. Muscle strength testing was normal without atrophy in both extremities. DTRs were normal. Light touch testing yielded normal results bilaterally except in the left lower leg/ankle. Radiculopathy resulted in moderate intermittent pain but no constant pain, paresthesias/dysesthesias, or numbness in either extremity. The involvement of the sciatic nerve was determined to be moderate bilaterally. There were no other signs or symptoms of radiculopathy or other neurologic abnormalities. In an April 2020 VA treatment record, it was noted that the Veteran had continuing low back pain with paresthesias in the lower extremities. He denied new numbness or progressive weakness. In May 2020, his back pain and radiculopathy were aggravated by a recent back strain. At the October 2021 hearing, the Veteran stated that he experienced a cold, wet feeling in his legs and they had gotten weaker. He continued to take Gabapentin for radiculopathy. A. A 20 percent rating, but no more, for LLE radiculopathy with compromised L4 nerve sleeve from December 30, 2016, is granted. B. A 20 percent rating, but no more, for RLE radiculopathy from December 30, 2016, is granted. Based on the foregoing, the Board finds that a 20 percent rating for LLE radiculopathy and a 20 percent rating for RLE radiculopathy are warranted throughout the entire appeal period. The severity of the Veteran's radiculopathy varied during the claim, but consistently manifested in mild to moderate pain, paresthesias/dysesthesias, and numbness. The Veteran described a cold, wet feeling in his lower extremities and a prickly feeling in his feet. Degenerative changes in the lumbar spine mildly worsened over the appeal period as demonstrated on imaging. The Board finds that this largely subjective symptomology most closely approximates moderate (or limited in scope or effect or average in amount, intensity, quality, or degree) involvement of the sciatic nerve. No additional physical symptomology (trophic changes, loss of reflexes, muscle atrophy) approximating a more severe level of disability were demonstrated upon examination or described by the Veteran. The Board notes that the October 2016 DBQ indicated some symptomology as both moderate and severe in the LLE. However, this evaluation appears to be an outlier in the Veteran's medical history. The clinician stated that both the sciatic and femoral nerve were involved, which has not been demonstrated on EMG or imaging, and found no symptomology in the RLE. Given the internally inconsistent and divergent information on the DBQ, the Board affords it little probative value. Further, there is no other evidence of record in the one-year look-back period suggesting a factually ascertainable increase in disability in the LLE or RLE. The Board also acknowledges that the Veteran indicated at the hearing that his bilateral lower extremity radiculopathy was worse than currently rated. However, VA treatment records continued to demonstrate ongoing moderate (or limited in scope or effect or average in amount, intensity, quality, or degree) symptomology of pain, paresthesias, and a cold/wet feeling in the bilateral lower extremities, treated by Gabapentin and occasional facet injections, without appreciable worsening. Accordingly, the Board finds that, based on the totality of the evidence, no additional VA examination is needed. Accordingly, 20 percent ratings are warranted for the Veteran's LLE radiculopathy with comprised L4 nerve sleeve and RLE radiculopathy, respectively, from the December 30, 2016, date of claim. Service Connection Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing direct service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. 38 C.F.R. § 3.303. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology can be applied only in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, No. 2022-1239 (Fed. Cir. March 8, 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). Further, special service connection rules exist for Gulf War Veterans. 38 U.S.C. § § 1117; 38 C.F.R. § 3.317. The Southwest Asia theater of operations includes Iraq, Kuwait, Saudi Arabia, the neutral zone between Iraq and Saudi Arabia, Bahrain, Qatar, the United Arab Emirates, Oman, the Gulf of Aden, the Gulf of Oman, the Persian Gulf, the Arabian Sea, the Red Sea, and the airspace above these locations. 38 C.F.R. § 3.317(e)(2). Under that section, service connection may be warranted for a Gulf War veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Gulf War. For disability due to undiagnosed illness and medically unexplained chronic multi-symptom illness, the disability must have been manifest either during active military service in the Southwest Asia theater of operations or to a degree of 10 percent or more not later than December 31, 2026. See 38 C.F.R. § 3.317(a)(1). For purposes of 38 C.F.R. § 3.317, aside from disabilities that the Secretary has deemed as per-se presumptive with Southwest Asia service, there are two types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a diagnosed medically unexplained chronic multi-symptom illness (MUCMI) that is defined by a cluster of signs or symptoms such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding gastrointestinal diseases). With regard to "functional gastrointestinal disorders," this would include, but are not limited to: IBS, functional dyspepsia, functional vomiting, functional constipation, functional bloating, functional abdominal pain syndrome, and functional dysphagia. 38 C.F.R. § 3.317(a)(2)(i)(B). An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § § 1117 and 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317(a)(5); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). On the other hand, the term "MUCMI" refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic MUCMIs of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered "medically unexplained." Id. For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4). Notwithstanding the foregoing presumption provisions, a claimant is not precluded from establishing service connection for a disability due to Gulf War exposures with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); Ramey v. Brown, 9 Vet. App. 40, 44 (1996), aff'd sub nom, Ramey v. Gober, 120 F.3d 1239 (Fed. Cir. 1997), cert. denied, 118 S. Ct. 1171 (1998). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular 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 at 1376-77. In rendering this decision, the Board has reviewed all evidence of record whether discussed in detail. See Newhouse v. Nicholson, 497 F.3d 1298, 1302 (Fed. Cir. 2007) (holding the Board must only discuss the evidence which is relevant to the issues on appeal). A veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal," and does not require that the evidence be in exact equipoise. Evidence is in approximate balance when the evidence in favor of and opposing the veteran's claim is found to be almost exactly or nearly equal. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). 1. Cervical Spine and Radiculopathy The Veteran has contended that an injury to his cervical spine occurred in service which has continued to the present and caused associated bilateral upper extremity radiculopathy. At service entrance in February 1986, no cervical spine conditions were noted on examination or reported by the Veteran. In November 1987, the STRs indicated that the Veteran was hit on the left side of the head by a shovel handle that bounced. An x-ray of the skull was conducted with no abnormalities detected. He was diagnosed with a closed head injury. Nothing regarding the cervical spine was noted. In March 1991, the Veteran injured his lumbar spine when he was lifting water boxes and one of them fell on his back. No injuries to the neck were reported. In August 1991, the Veteran had good active range of motion of the neck with no visible or palpable abnormalities. There was no muscle atrophy of the bilateral upper extremities. A neurology clinic noted in September 1991 that there was good active range of motion in the neck without abnormalities or pain on palpation. At the September 1991 MEB examination, the March 1991 back injury was reviewed. The evaluator noted that the injury resulted in pain in the lumbosacral spine and LLE. Nothing regarding the cervical spine was mentioned. An examination of the neck demonstrated good active range of motion without pain, no visual or palpable abnormalities of the neck, and no pain on palpation of the neck. The bilateral upper extremities were normal. Post-service, in a June 2001 VA treatment record, the Veteran reported neck tension associated with migraine headaches. He stated he would start seeing a masseuse. In June 2011, the Veteran stated to VA clinicians that he had two pinched nerves in his neck that had been bothersome. In July 2011, he underwent a cervical spine evaluation and reported that he had had no neck problems prior to the onset of current symptoms 5 years previously. The Veteran underwent an EMG in October 2013. It demonstrated electrodiagnostic evidence of acute on chronic neurogenic changes in the left C5-C6 nerve root distribution consistent with acute on chronic C5-C6 radiculopathy. There was no evidence of median (carpal tunnel syndrome) or ulnar neuropathy in the upper extremities. A cervical MRI was conducted in November 2013. It demonstrated cervical myelomalacia at C3-C4, secondary to broad-based posterior disc protrusion/endplate osteophytes complex on top of congenital canal stenosis; and mild left ventral cord deformity with no cord contact at C5-C6, secondary to left central and subarticular disc protrusion and endplate osteophytes. The Veteran was referred for chiropractic care in October 2014 and acupuncture treatment in December 2015 for his cervical spine and lumbar spine disabilities. In notes for the acupuncture treatment, it was stated that he experienced back and neck pain "service related." However, no rationale or reasoning for this comment was provided. Cervical MRIs conducted in May 2015 and April 2016 demonstrated degenerative changes superimposed on a congenitally narrow spinal canal, more pronounced at C3-C4, with marked canal stenosis, cord deformity, and myelomalacia being stable. In a May 2016 VA treatment record, the Veteran reported that his neck pain onset in the 1990s during Army training. In September 2016, based on his cervical spine pain and upper extremity radiculopathy, VA treating clinicians suggested a surgical intervention due to cervical stenosis and cervical myelopathy. The Veteran claimed to VA clinicians that his chronic pain in his neck, hips, ankles, and feet began in the 1980s. A VA neck examination was conducted in November 2017. The Veteran stated that his neck pain started when he injured his back in 1991 when boxes fell on his back and neck in service. He was initially treated for neck pain in 2013. Prior to that, he reported that he dealt with his neck pain without any medical intervention. The examiner determined that the Veteran's claimed neck disability was not the result of service. In support, she stated that the STRs detailing the 1991 injury showed treatment for the back but no injury to the neck. A physical examination conducted in September 1991 reported no neck pain and the examination was within normal limits. There were no records to indicate any active treatment for the claimed condition until 2013 when EMG and MRI scans reported multilevel DJD and congenital narrowing of the central canal at C3-C4. Medical records demonstrated treatment including physical therapy for his left shoulder tendinitis in 2003 contained no mention of any neck condition, pain, or injury. His current neck pain and arm pain were more likely related to persistent cervical radiculopathy from DJD and congenital canal stenosis which were not service-connected. The Veteran received another round of chiropractic care for neck and back pain in May 2019. In February 2021, the Veteran underwent a C3-C4 anterior cervical discectomy and fusion. At the October 2021 hearing, the Veteran contended that his current neck condition was the result of the same in-service incident where he injured his back; another incident where he was hit on the head with a shovel; and normal wear and tear of service. He stated he had neck pain since service with periodic treatment. A. Service connection for degenerative arthritis of the spine with spinal stenosis (claimed as neck condition and cervical) is denied. Based on the foregoing, the Board finds that service connection for a cervical spine disability is not warranted. At the outset, the Board notes that the Veteran has established Persian Gulf service. However, his neck disability has been clearly diagnosed by radiographic imaging. As such, it is not an undiagnosed disability. Further, there is no evidence it is a MUCMI - a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs. The neck disability clearly has established pathophysiology demonstrated by x-ray and MRI, delineating the mechanical nature of the condition. Additionally, on August 10, 2022, a statute known as "the PACT Act" was signed into law expanding the scope of presumed in-service toxic exposures. See Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act), Pub. L. 117-168 (August 10, 2022). However, although under this legislation his Persian Gulf service establishes presumptive exposure to burn pit and other toxins (BPOT), cervical myelopathy, congenital cervical stenosis, and degenerative changes of the cervical spine are not presumptive conditions for which BPOT exposure is warranted. The PACT Act also established standards for Veterans exposed to toxic exposure risk activities (TERA). Based on his Persian Gulf service, he is presumed to have toxic exposures. However, because the current disability is based on physical trauma and mechanics of the cervical spine which has not been determined to have a positive association with Gulf War environmental exposures and no credible evidence has been submitted contending an association with such exposures, the standard for a TERA examination does not apply. See 38 U.S.C. § 1168(a). Accordingly, service connection based on the Veteran's Persian Gulf service is not warranted. Further, the Board finds that service connection is not warranted on a direct basis or as a chronic condition. Although the Veteran has since contended that his neck was injured in the 1987 shovel handle incident or 1991 back injury, there is no contemporaneous evidence of any injury to the neck at those times or subsequently in service. Treating clinicians detailed the incidents but no clinical testing at the time demonstrated any cervical involvement. Subsequent evaluations, including a very detailed MEB evaluation, found no complaints, symptoms, treatment, or diagnosis of any neck condition. The Board attaches more probative value to these contemporaneous records of treatment and evaluation than the Veteran's post-service statements made in connection with a claim for VA monetary benefits. The Veteran has also asserted that he had neck pain since service but just dealt with it without getting treatment. However, extensive medical records are in the claims file documenting his complaints, symptoms, treatment, and diagnosis of many other medical conditions after service, including a left shoulder condition, which contained no mention of any symptomology in the cervical spine. The Veteran specifically told treating clinicians that his neck symptoms began in approximately 2006, 14 years after separation. The Board attaches more credibility to his statements made to clinicians for the purposes of medical treatment than to subsequent statements made in connection with a VA monetary benefits claim. Finally, the Board attaches significant probative weight to the VA examiner's opinion as it is well-reasoned, detailed, consistent with other evidence of record, and included consideration of the Veteran's pertinent medical history and lay statements. Accordingly, the Board finds that the persuasive evidence of record is against a finding that the Veteran's claimed cervical spine disability is the result of his active service. B. Service connection for LUE radiculopathy is denied. C. Service connection for RUE radiculopathy is denied. There is no evidence of upper extremity radiculopathy in service or for many years thereafter. Accordingly, service connection on a direct or chronic basis are not warranted. Further, as noted above, the October 2013 EMG demonstrated neurogenic changes in the left C5-C6 nerve root distribution consistent with acute on chronic C5-C6 radiculopathy with no other evidence of neuropathy in the upper extremities. As such, the claimed condition is diagnosed and has a demonstrated pathophysiology. It is not a BPOT presumptive condition and no evidence has been submitted attributing the claimed disabilities with toxic exposures warranting a TERA evaluation. As such, service connection based on Persian Gulf service is not merited. Finally, the November 2017 VA examiner attributed the Veteran's bilateral upper extremity radiculopathy to his cervical spine disability. As service connection is not established for the cervical spine disability, secondary service connection for LUE/RUE radiculopathy is not available. Therefore, service connection for LUE and RUE radiculopathy is denied. REASONS FOR REMAND 1. Entitlement to a rating in excess of 20 percent for chronic ankle sprain, left, from January 31, 2018, is remanded. The Veteran most recently underwent a VA examination in connection with his service-connected left ankle disability in August 2019. The examiner determined that he did not have ankylosis in the left ankle. At the October 2021 hearing, the Veteran testified that his ankle frequently locked and was "frozen in place" at times. The Board finds that to comply with the requirements of Chavis v. McDonough, 34 Vet. App. 1 (2021), a determination as to whether this reported symptomology is the "functional equivalent" of ankylosis is needed. Further, subsequent VA treatment records reflected that the Veteran has had to undergo additional physical therapy for his left ankle disability since the last VA examination. As this may suggest a worsening of symptom severity, a new VA examination is needed to ascertain the current extent and severity of the condition. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). 2. Entitlement to service connection for bilateral pes planus is remanded. 3. Entitlement to service connection for plantar fasciitis is remanded. The Veteran's service entrance examination noted that he had mild pes planus, not disabling. Accordingly, the condition clearly and unmistakably preexisted service. Right foot plantar fasciitis was diagnosed in July 1999 and bilateral foot plantar fasciitis was diagnosed in July 2012. Several VA examinations and opinions have been obtained in connection with the Veteran's claims. Most recently, in August 2019, a VA examiner reviewed the record and determined that pes planus was not permanently aggravated beyond normal progression in service and that plantar fasciitis was less likely related to service. However, the examiner did not discuss several pertinent pieces of evidence and incorrectly found some symptomology to have occurred much later in time than demonstrated in the claims file. As such, to ensure a medical opinion based on an accurate factual premise, remand is needed. See Swann v. Brown, 5 Vet. App. 229, 233 (1993). Additionally, it appears as though some medical practitioners have identified increased symptomology in the bilateral feet due to conditions in the bilateral ankles. The August 2019 VA examiner noted the service-connected chronic left ankle sprain but did not provide an opinion as to whether there was any etiological association to the documented bilateral foot symptomology. As such, a new opinion addressing a secondary theory of entitlement is needed. See Allen v. Brown, 7 Vet. App. at 448; see also Spicer v. McDonough, No. 2022-1239 (Fed. Cir. March 8, 2023). 4. Entitlement to service connection for right ankle condition with edema to include as secondary to plantar fasciitis is remanded. The Board has contended that he had multiple right ankle injuries in service which have resulted in a current condition. The STRs included an April 1990 complaint of pain in the right Achilles tendon for 4 days. The condition caused an inability to flex without causing discomfort and the ankle went out from time to time. In September 1991, decreased light touch sensation in the right ankle was noted. An August 2012 VA treatment record noted the Veteran's report that he had "rolled both ankles in military training 30 years ago" without treatment. He described pain and swelling in the right ankle with standing and walking. An August 2017 x-ray demonstrated minimal/mild DJD in the right ankle. The Veteran underwent a VA examination in March 2018. Osteoarthritis was diagnosed in the right ankle. The examiner determined that the Veteran's right ankle mild DJD was less likely than not proximately due to or aggravated beyond normal progression by the service-connected left ankle disability or the claimed bilateral plantar fasciitis. In support, he stated that it was more likely a result of the normal aging process and it was diagnosed approximately 25 years after separation. In August 2019, a VA examiner found that it was less likely that the claimed right ankle condition was permanently aggravated by his service-connected left ankle disability. The Board finds that a new VA examination and opinion are needed before a decision may be rendered on the claim. Neither examiner addressed the relevant notations in the STRs and whether they were related to the current DJD/OA of the right ankle. Further, although an alternative cause (the normal aging process) was provided for the current condition, no actual rationale was provided as to why it was not caused or aggravated by the service-connected left ankle disability, to include as due to overcompensation as the Veteran has contended to treating clinicians. Finally, the August 2019 examiner used an incorrect standard as secondary service connection does not require permanent aggravation. 5. Entitlement to service connection for a right hip condition to include arthritis as secondary to service-connected disabilities is remanded. The Veteran has contended, including in a December 2016 statement, that his right hip disability was the result of pes planus. In January 2017, he told VA treating clinicians that he had been having more problems with his feet, resulting in more limping. This limping caused pain in his hips, including pain in the "ball and socket area" of the right hip. VA examiners determined in August 2015, March 2017, and August 2019 that the Veteran's right hip OA/DJD was less likely than not a result of his active service or his service-connected back condition, finding that the condition was asymptomatic and his pain and other symptoms were referred SI pain rather than an actual hip condition. However, as the claims for service connection for bilateral pes planus/plantar fasciitis are being remanded herein and the Veteran has contended a worsening of right hip symptoms with increased foot pain/limping, the Board finds that any decision regarding the right hip condition would be premature at this time. As such, the Board finds that the issues are inextricably intertwined and remand is needed. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). 6. Entitlement to service connection for a left hip condition to include arthritis as secondary to service-connected disabilities is remanded. The Veteran testified at the October 2021 hearing that he was not claiming service connection for a left hip condition on a direct basis, noting instead that he believed it was secondary to his service-connected back disability or to overcompensating for his right hip condition. As noted above, the STRs included a March 1988 bone scan which found there was increased uptake located within the acetabula of both hips, compatible with stress phenomena. Following the March 1991 back injury, some edema of the left hip was noted by treating clinicians. The Veteran described injuring his back and his entire LLE at the time. Post-service, an October 2016 DBQ diagnosed OA, trochanteris pain syndrome, and femoral acetabular impingement of the left hip. A lumbar spine x-ray conducted in November 2016 noted moderate degenerative change and that the prominence of acetabulum may contribute to Cam-type impingement in the left hip. VA examiners determined in March 2017 and August 2019 that the Veteran's left hip OA/DJD was less likely than not a result of his active service or his service-connected back condition, finding that the condition was asymptomatic and his pain and other symptoms were referred SI pain rather than an actual hip condition. The post-service diagnoses of femoral acetabular impingement in the left hip were not discussed. As such, the Board finds that a VA opinion regarding a direct theory of entitlement are needed before a decision may be rendered on the claim which considers the in-service notations and post-service diagnoses other than OA/DJD. Additionally, as noted above, in a December 2016 statement, the Veteran contended that his left hip disability was the result of pes planus and at the October 2021 hearing, he contended it was a result of his right hip condition. As entitlement to his claimed bilateral foot disabilities and right hip condition are being remanded herein, the claim is therefore inexplicably intertwined and also remanded. Id. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate clinician to determine the current extent and severity of his chronic left ankle sprain. The claims folder should be made available to and be reviewed by the examiner. All indicated tests and studies should be performed. (a.) The examination should record the results of range of motion testing on both active and passive motion and in weight-bearing and nonweight-bearing. (b.) The examiner should also express an opinion concerning whether there would be additional functional impairment on repeated use or during flare-ups throughout the entire appeal period. (c.) In regard to flare-ups, if he is not currently experiencing a flare-up, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding her flare-ups, the examiner is requested to provide an estimate of the functional loss due to flare-ups expressed in terms of the degree of additional range of motion lost, or to explain why the examiner cannot do so. (d.) If the Veteran does not have ankylosis of the left ankle, the examiner should determine whether he has functional ankylosis, given his testimony regarding the ankle locking up and freezing in place. (e.) The examiner should fully describe any and all functional deficits associated with the disability and discuss any occupational impact. All opinions provided should be fully explained. If any requested opinion cannot be provided without resort to speculation, the examiner should so state and explain why an opinion cannot be provided without resort to speculation. 2. Schedule the Veteran for a TERA examination to consider the synergistic, combined effect of each of the substances, chemicals, and airborne hazards identified in 38 U.S.C. § 1119(b)(2) to which he was exposed during his Gulf War service and determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that his claimed pes planus, plantar fasciitis, right ankle condition, right hip condition, or left hip condition are the result of the toxic exposure risk activity. 3. Schedule the Veteran for a VA examination to determine the nature and etiology of his bilateral foot disabilities, to include pes planus and plantar fasciitis. Following a review of the claims file and any clinical testing deemed necessary, the examiner is asked to address the following: (a.) Determine whether the Veteran's reported symptomology in his bilateral feet is the result of an "undiagnosed illness" or a diagnosed MUCMI. The term "MUCMI" refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic MUCMIs of partially understood etiology and pathophysiology will not be considered "medically unexplained." (b.) Determine whether the mild pes planus, not disabling, noted at service entrance in February 1986 was aggravated by service or whether the evidence clearly and unmistakably demonstrates that either there was no increase in the disability in service or that any increase in disability was the result of the natural process of the condition. (c.) Determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that plantar fasciitis is etiologically related to his active service. (d.) If the examiner finds that pes planus was not aggravated by service, determine whether, post-service, it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that pes planus was aggravated beyond natural progression by any service-connected disability or treatment therefor, specifically to include chronic left ankle strain and/or right ankle condition with edema (specifically, would the pes planus have been less severe but for the service-connected disability, either because there is an etiological link or because the service-connected disability resulted in the inability to treat the condition). (e.) If the examiner finds that pes planus was aggravated by service, determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that plantar fasciitis 1) was caused by any service-connected disability or treatment therefor, specifically to include pes planus, chronic left ankle sprain, and/or right ankle condition with edema; or 2) was aggravated beyond natural progression by any service-connected disability or treatment therefor, specifically to include pes planus, chronic left ankle sprain, and/or right ankle condition with edema (specifically, would plantar fasciitis have been less severe but for the service-connected disability, either because there is an etiological link or because the service-connected disability resulted in the inability to treat the condition). (f.) The examiner is specifically advised of the following evidence: 1. February 1986 entrance examination noting mild pes planus, not disabling; 2. February 1986 entrance report of medical history denying foot trouble; 3. December 1987 treatment record with a complaint of a swollen left foot for 3 weeks, leading to a diagnosis of possible tendonitis in the left ankle; 4. January 1988 treatment records reflecting a swollen left foot for a month, later noted to be edema at ankle; 5. January 1988 treatment record noting a 4-week history of idiopathic onset of right pedal edema; 6. March 1988 bone scan which demonstrated slightly increased uptake in the plantar surfaces of both calcanea compatible with stress and/or trauma; 7. June 1989 treatment records reflecting pain and swelling in the right big toe, resulting in a profile; 8. July 1989 right big toe x-ray demonstrating the toe was within normal limits; 9. April 1990 record noting bilateral pes planus with full active range of motion, slight right Achilles tendon tenderness to palpation, prescription of arch supports, and physical therapy; 10. June 1991 examination noting pes planus, mild asymptomatic; 11. June 1991 report of medical history denying foot trouble; 12. August 1991 neurology report of slight edema of the left foot and slight discomfort in the left dorsum of the foot at metatarsals 2-3 on passive range of motion and decreased light touch sensation in the right lateral ankle and foot; 13. September 1991 neurology report of decreased light touch sensation in the right lateral ankle and foot; 14. September 1991 MEB evaluation describing light touch sensation decreased in the right lateral ankle and foot; 15. October 1991 examination noting pes planus, mildly symptomatic; 16. October 1991 report of medical history denying foot trouble; 17. May 1999 VA treatment record reflecting right foot pain and a notation that he might benefit from an evaluation for foot wear; 18. July 1999 VA referral for inserts for bilateral pes planus and new right calcaneal pain that might be due to a heel spur; 19. July 1999 x-ray negative for heel spurs, right plantar fasciitis suspected and night splint ordered for fasciitis; 20. July 2001 pes plano valgus deformity of the left foot with significant tenderness along the posterior tibial tendon; 21. May 2003 VA examination noting a pes plano valgus appearance to the feet, pain with movement, limited range of motion, and no significant midfoot or hindfoot degenerative changes; and 22. July 2012 diagnosis of bilateral plantar fasciitis. (g.) The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports should be acknowledged and considered in formulating any opinion. (h.) If medical literature is relied upon, the examiner should identify and specifically cite each reference material used. (i.) All opinions should be accompanied by supporting rationale explaining how the examiner arrived at the conclusions expressed. (j.) If the examiner determines that s/he cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, s/he should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. 4. Schedule the Veteran for a VA examination to determine the nature and etiology of his current right ankle condition. Following a review of the claims file and any clinical testing deemed necessary, the examiner is asked to address the following: (a.) Determine whether the Veteran's reported symptomology in his right ankle is the result of an "undiagnosed illness" or a diagnosed MUCMI. The term "MUCMI" refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic MUCMIs of partially understood etiology and pathophysiology will not be considered "medically unexplained." (b.) Determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any right ankle condition is etiologically related to his active service, specifically to include the April 1990 and September 1991 notations in the STRs. (c.) Determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any right ankle condition 1) was caused by any service-connected disability or treatment therefor, specifically to include chronic left ankle strain; or 2) was aggravated beyond natural progression by any service-connected disability or treatment therefor, specifically to include chronic left ankle strain (specifically, would the right ankle condition have been less severe but for the service-connected disability, either because there is an etiological link or because the service-connected disability resulted in the inability to treat the condition). (d.) If it is found that either the Veteran's bilateral pes planus or plantar fasciitis is the result of service, determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any right ankle condition 1) was caused by pes planus/plantar fasciitis or treatment therefor; or 2) was aggravated beyond natural progression by pes planus/plantar fasciitis (specifically, would the right ankle condition have been less severe but for the service-connected disability, either because there is an etiological link or because the pes planus/plantar fasciitis resulted in the inability to treat the condition). (e.) In considering any lay statements of record, the examiner should note that the Veteran is competent to attest to matters of which she had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (f.) If medical literature is relied upon, the examiner should identify and specifically cite each reference material used and discuss how it relates to the Veteran's particular medical history. The examiner should specifically discuss any contradictory evidence in the claims file and reconcile that evidence with their findings. (g.) All opinions should be accompanied by supporting rationale explaining how the examiner arrived at the conclusions expressed. (h.) If the examiner determines that s/he cannot provide an opinion without resorting to speculation, the examiner should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, s/he should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. 5. Obtain an addendum opinion from an appropriate VA clinician regarding the Veteran's claimed right hip condition. Following a review of the claims file, the clinician is asked to address the following: (a.) Determine whether the Veteran's reported symptomology in his right hip is the result of an "undiagnosed illness" or a diagnosed MUCMI. The term "MUCMI" refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic MUCMIs of partially understood etiology and pathophysiology will not be considered "medically unexplained." (b.) If it is found that either the Veteran's bilateral pes planus or plantar fasciitis is the result of service, determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any right hip condition 1) was caused by bilateral pes planus/plantar fasciitis or treatment therefor; or 2) was aggravated beyond natural progression by bilateral pes planus/plantar fasciitis (specifically, would the right hip condition have been less severe but for the service-connected disability, either because there is an etiological link or because the pes planus/plantar fasciitis resulted in the inability to treat the condition). (c.) In considering any lay statements of record, the clinician should note that the Veteran is competent to attest to matters of which she had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the clinician should provide a fully reasoned explanation. (d.) If medical literature is relied upon, the clinician should identify and specifically cite each reference material used and discuss how it relates to the Veteran's particular medical history. The clinician should specifically discuss any contradictory evidence in the claims file and reconcile that evidence with their findings. (e.) All opinions should be accompanied by supporting rationale explaining how the clinician arrived at the conclusions expressed. (f.) If the clinician determines that s/he cannot provide an opinion without resorting to speculation, s/he should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, s/he should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. 6. Obtain an addendum opinion from an appropriate VA clinician regarding the Veteran's claimed left hip condition. Following a review of the claims file, the clinician is asked to address the following: (a.) Determine whether the Veteran's reported symptomology in his left hip is the result of an "undiagnosed illness" or a diagnosed MUCMI. The term "MUCMI" refers to a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic MUCMIs of partially understood etiology and pathophysiology will not be considered "medically unexplained." (b.) Determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any left hip condition is etiologically related to his active service. The clinician is specifically asked to address: 1. March 1988 bone scan finding increased uptake located within the acetabula of the hip, compatible with stress phenomena; 2. March 1991 back injury follow-up noting some edema of the left hip; 3. October 2016 diagnosis of femoral acetabular impingement of the left hip; 4. November 2016 lumbar spine x-ray noting that the prominence of acetabulum may contribute to Cam-type impingement in the left hip; 5. March 2017 and August 2019 VA examinations finding that OA/DJD were asymptomatic and reported hip symptoms were referred back/SI/radiculopathy pain. (c.) If it is found that bilateral pes planus or plantar fasciitis is the result of service, determine whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any left hip condition 1) was caused by pes planus/plantar fasciitis or treatment therefor; or 2) was aggravated beyond natural progression by pes planus/plantar fasciitis (specifically, would the left hip condition have been less severe but for the service-connected disability, either because there is an etiological link or because the pes planus/plantar fasciitis resulted in the inability to treat the condition). (d.) In considering any lay statements of record, the clinician should note that the Veteran is competent to attest to matters of which she had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the clinician should provide a fully reasoned explanation. (e.) If medical literature is relied upon, the clinician should identify and specifically cite each reference material used and discuss how it relates to the Veteran's particular medical history. The clinician should specifically discuss any contradictory evidence in the claims file and reconcile that evidence with their findings. (f.) All opinions should be accompanied by supporting rationale explaining how the clinician arrived at the conclusions expressed. (Continued on the next page) ? (g.) If the clinician determines that s/he cannot provide an opinion without resorting to speculation, s/he should explain the inability to provide an opinion, identifying precisely what facts could not be determined. In particular, s/he should comment on whether an opinion could not be provided because the limits of medical knowledge have been exhausted or whether additional testing or information could be obtained that would lead to a conclusive opinion. 7. After completing the above, and any additionally indicated development, readjudicate the claims. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Rachel E. Jensen, 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.