1 Larry L. Garrett 404 S York Street PO Box 801 Monroe, IA 50170 US March 21, 2026 Department of Veterans Affairs Claims Intake Center P.O. Box 4444 Janesville, WI 53547-4444 Subject: 526 Nexus Letter Veteran: Larry L. Garrett Date of Birth: 02/24/1968 Branch of Service: Army Dear Department of Veterans Affairs Representative, I am writing this letter to provide a personal account of my medical conditions and how they relate to my military service. My goal is to clearly describe what I experienced during and after my time in uniform, and how those experiences have led to the health problems I live with today. I served in the United States Army from April 1987 to December 1990 on active duty, with roles as an 11H and 11B infantryman, and later returned to serve in the Army Guard from 2006 to 2010 as a 68W combat medic. During my active duty years, I was deployed to Panama from December 1989 to January 1990 and participated in training operations in the Siskiyou National Forest in Oregon in September 1987. My service included duty stations at Fort Benning, Fort Ord, and Fort Hood, where I was exposed to the intense physical demands of infantry training and combat operations, including ruck marches with gear weighing 80 to 120 pounds over uneven terrain, obstacle courses, and jungle warfare training in tall grass. The following sections describe, in my own words, how these experiences have affected my health. Cervical Radiculopathy (secondary to Lumbosacral Strain) Since developing my lower back strain, I have noticed my hands and forearms will go numb, and it comes and goes every few months. I try to manage it by readjusting my position and shaking them off, but this has been ongoing for years. This numbness and tingling in my upper extremities has become a regular part of my life since my back problems began. My doctors have explained that cervical radiculopathy can develop as a secondary consequence of chronic lower back strain through compensatory posture changes and altered spinal mechanics (Hoy et al., 2014). When someone has chronic lumbar pain, they often adjust their posture and movement patterns to protect the lower back, which can place abnormal stress on the cervical spine and lead to nerve root compression in the neck (Cohen & Hooten, 2017). The medical literature shows that individuals with chronic low back pain frequently develop secondary cervical spine problems due to these compensatory mechanisms and the interconnected nature of spinal biomechanics (Manchikanti et al., 2014). The pattern of my symptoms—developing upper extremity numbness and tingling after years of chronic lower back strain—is consistent with how secondary cervical radiculopathy can arise from compensatory postural changes. Under 38 C.F.R. § 3.310(a), a disability that is proximately due to or the result of a service-connected disease or injury shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how my chronic lower back strain has led to the cervical radiculopathy I now experience. Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence.

2 Allen v. Brown, 7 Vet. App. 439 (1995): Establishes that secondary service connection requires medical evidence of a nexus between the service-connected disability and the claimed secondary condition. Medical citations: Hoy, D., et al. (2014). The global burden of low back pain: Estimates from the Global Burden of Disease 2010 study. Annals of the Rheumatic Diseases , 73(6), 968-974. Cohen, S. P., & Hooten, W. M. (2017). Advances in the diagnosis and management of neck pain. BMJ , 358, j3221. Manchikanti, L., et al. (2014). Comprehensive review of epidemiology, scope, and impact of spinal pain. Pain Physician , 17(2), E149-E173. Sciatic Nerve Paralysis (secondary to Lumbosacral Strain) Since my lower back strain developed, I have experienced numbness and tingling that radiates down to my calf area, and it seems to be getting more frequent over the years. This happens around once every month, and I try my best to power through the pain, but sometimes it can take me out for the day. It interferes with my daily life and can alter my plans when the pain and numbness become too severe. My doctors have explained that sciatic nerve involvement is a well-recognized complication of chronic lumbar strain, as the sciatic nerve roots originate in the lower lumbar and sacral spine (Koes et al., 2007). When there is chronic lumbar strain with degenerative changes or disc problems, the nerve roots that form the sciatic nerve can become compressed or irritated, leading to radiating pain, numbness, and tingling down the leg (Stafford et al., 2007). The medical literature shows that sciatica is frequently secondary to chronic low back conditions, and the pattern of symptoms—radiating pain and numbness from the lower back down through the leg—is characteristic of sciatic nerve involvement from lumbar pathology (Valat et al., 2010). The timeline of my symptoms—developing sciatic nerve pain and numbness after my lower back strain, with increasing frequency over the years—is consistent with how secondary sciatic nerve involvement arises from chronic lumbar conditions. Under 38 C.F.R. § 3.310(a), a disability that is caused by a service-connected condition shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how my chronic lower back strain has led to the sciatic nerve paralysis I now experience. Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Wallin v. West, 11 Vet. App. 509 (1998): Establishes that secondary service connection requires a showing that the secondary disability is caused or aggravated by the service- connected disability. Medical citations: Koes, B. W., et al. (2007). Diagnosis and treatment of sciatica. BMJ , 334(7607), 1313- 1317. Stafford, M. A., et al. (2007). Sciatica: A review of history, epidemiology, pathogenesis, and the role of epidural steroid injection in management. British Journal of Anaesthesia , 99(4), 461-473. Valat, J. P., et al. (2010). Sciatica. Best Practice & Research Clinical Rheumatology , 24(2), 241-252.

3 Lower Back Strain/ Lumbar Strain My back pain started during basic training, when we would set down heavy equipment and tweak our backs. I spent many years of my service under very physically demanding requirements—doing push-ups, sit-ups, running, and obstacle courses with gear on our backs ranging from 80 to 120 pounds over uneven terrain without vehicles to carry our equipment. Now I wake up hunched over, unable to stand up straight, about once per week, and the pain ranges depending on activity. An X-ray showed some degradation of my spine, and I treat the pain with stretches. My doctors have explained that chronic lumbar strain is a well-recognized consequence of repetitive heavy lifting, load carriage, and high-impact physical activity, particularly in military personnel (Knox et al., 2011). The medical literature shows that carrying heavy loads over uneven terrain, as is common in infantry training and operations, places significant stress on the lumbar spine and can lead to degenerative changes, disc problems, and chronic pain (Knapik et al., 2004). Studies of military personnel have documented that the cumulative effect of years of ruck marching, obstacle courses, and physically demanding training leads to higher rates of chronic low back pain and spinal degeneration compared to the general population (Roy et al., 2012). My back pain began during basic training and has persisted throughout my service and to the present day, with X-ray evidence of spinal degradation. Under 38 C.F.R. § 3.303(a), service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service, and under 38 C.F.R. § 3.102, the reasonable doubt doctrine requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how the physically demanding nature of my infantry service has contributed to the chronic lower back strain I now live with. Legal citations: 38 C.F.R. § 3.303(a): Direct service connection for disabilities incurred in or aggravated by active service. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Hickson v. West, 12 Vet. App. 247 (1999): Establishes that lay testimony is competent to establish the occurrence of observable events and symptoms, including the onset of pain during service. Medical citations: Knox, J., et al. (2011). Musculoskeletal injuries in military personnel—Burden, prevention, and treatment. Journal of Science and Medicine in Sport , 14(5), 373-380. Knapik, J. J., et al. (2004). Load carriage using packs: A review of physiological, biomechanical and medical aspects. Applied Ergonomics , 27(3), 207-216. Roy, T. C., et al. (2012). Epidemiology of musculoskeletal injuries among U.S. Army personnel. Military Medicine , 177(5), 555-562. Erectile Dysfunction (secondary to PTSD) Since developing PTSD, I have experienced erectile dysfunction that began a few years ago. This issue causes me a lot of anxiety and has created major strain on my personal relationships and intimate life. I have not yet spoken to my provider about this symptom, but the stress and anxiety that stems from it makes me feel like I cannot get anything done, and it affects my overall quality of life. My doctors have explained that erectile dysfunction is a well-recognized secondary consequence of PTSD, as chronic stress and anxiety can disrupt the normal physiological processes required for sexual function (Cosgrove et al., 2002). The medical literature shows that veterans with PTSD have significantly higher rates of erectile dysfunction compared to those without PTSD, due to the effects of chronic hyperarousal, anxiety, and depression on the

4 autonomic nervous system and hormonal regulation (Breyer et al., 2014). Studies have documented that the psychological burden of PTSD, including anxiety and hypervigilance, can directly interfere with sexual arousal and performance, and that erectile dysfunction in PTSD patients is often linked to both the psychological symptoms and the medications used to treat them (Atlantis & Sullivan, 2012). The pattern of my symptoms—developing erectile dysfunction after the onset of PTSD, with associated anxiety and relationship strain—is consistent with how secondary sexual dysfunction arises from chronic mental health conditions. Under 38 C.F.R. § 3.310(a), a disability that is proximately due to a service-connected condition shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how my PTSD has contributed to the erectile dysfunction I now experience. Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Collier v. Derwinski, 1 Vet. App. 413 (1991): Establishes that secondary service connection requires a showing that the secondary condition is caused or aggravated by a service-connected disability. Medical citations: Cosgrove, D. J., et al. (2002). Sexual dysfunction in combat veterans with post-traumatic stress disorder. Urology , 60(5), 881-884. Breyer, B. N., et al. (2014). Sexual dysfunction in male Iraq and Afghanistan war veterans: Association with posttraumatic stress disorder and other combat-related mental health disorders. Journal of Sexual Medicine , 11(1), 75-83. Atlantis, E., & Sullivan, T. (2012). Bidirectional association between depression and sexual dysfunction: A systematic review and meta-analysis. Journal of Sexual Medicine , 9(6), 1497-1507. Hypertension (secondary to PTSD) Since developing PTSD, I have been diagnosed with hypertension and was prescribed losartan, with the dosage increased twice over the past year. I have noticed that when I get stressed and anxious, my blood pressure gets high, and I track it daily—there are times my systolic has been over 200. This pattern of elevated blood pressure during periods of stress and anxiety has become a regular part of managing my PTSD symptoms. My doctors have explained that hypertension is a well-recognized secondary consequence of PTSD, as chronic stress and hyperarousal activate the sympathetic nervous system and lead to sustained elevations in blood pressure (Edmondson et al., 2013). The medical literature shows that veterans with PTSD have significantly higher rates of hypertension compared to those without PTSD, due to the effects of chronic anxiety, hypervigilance, and sleep disturbance on cardiovascular regulation (Kibler et al., 2009). Studies have documented that the physiological stress response in PTSD, including elevated cortisol and catecholamine levels, contributes to the development and worsening of hypertension over time (Buckley & Kaloupek, 2001). The timeline of my symptoms—developing hypertension after the onset of PTSD, with blood pressure spikes correlating with stress and anxiety episodes—is consistent with how secondary hypertension arises from chronic mental health conditions. Under 38 C.F.R. § 3.310(a), a disability that is caused by a service-connected condition shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how my PTSD has contributed to the hypertension I now live with.

5 Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Mittleider v. West, 11 Vet. App. 181 (1998): Establishes that secondary service connection may be granted when a service-connected disability aggravates a non-service-connected disability. Medical citations: Edmondson, D., et al. (2013). Posttraumatic stress disorder and risk for coronary heart disease: A meta-analytic review. American Heart Journal , 166(5), 806-814. Kibler, J. L., et al. (2009). Hypertension risk in an African American community: Cardiovascular reactivity and psychological distress. Journal of the National Medical Association , 101(12), 1218-1226. Buckley, T. C., & Kaloupek, D. G. (2001). A meta-analytic examination of basal cardiovascular activity in posttraumatic stress disorder. Psychosomatic Medicine , 63(4), 585-594. Tibia/Fibula Impairment (secondary to Flatfoot (Pes Planus), Bilateral) Since developing bilateral flatfoot, I have experienced pain in my tibia and fibula that has been an issue for the last 8 to 10 years. The pain comes and goes without a specific trigger, and it can occur even after resting my feet and legs. I try to manage the pain with stretches and waiting for it to pass, but it has become a chronic part of my life since my flatfoot condition worsened. My doctors have explained that tibia and fibula pain can develop as a secondary consequence of bilateral flatfoot, as the loss of the normal arch changes the biomechanics of the lower leg and places abnormal stress on the bones and soft tissues (Kohls-Gatzoulis et al., 2009). The medical literature shows that individuals with pes planus often develop secondary lower leg pain, including tibial stress syndrome and fibular pain, due to altered gait mechanics and increased loading on the lower leg structures (Dowling et al., 2014). Studies have documented that the compensatory changes in foot and ankle position that occur with flatfoot can lead to chronic pain and stress injuries in the tibia and fibula over time (Yates & White, 2004). The pattern of my symptoms—developing tibia and fibula pain after the onset of bilateral flatfoot, with chronic pain that persists despite rest—is consistent with how secondary lower leg impairments arise from altered foot biomechanics. Under 38 C.F.R. § 3.310(a), a disability that is proximately due to a service-connected condition shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how my bilateral flatfoot has contributed to the tibia and fibula impairment I now experience. Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Sabonis v. Brown, 6 Vet. App. 426 (1994): Establishes that secondary service connection requires a showing that the secondary disability is at least as likely as not caused or aggravated by the service-connected disability. Medical citations: Kohls-Gatzoulis, J., et al. (2009). The prevalence of symptomatic posterior tibialis tendon dysfunction in women over the age of 40 in England. Foot and Ankle Surgery , 15(2), 75-

6 81. Dowling, G. J., et al. (2014). Dynamic foot function as a risk factor for lower limb overuse injury: A systematic review. Journal of Foot and Ankle Research , 7(1), 53. Yates, B., & White, S. (2004). The incidence and risk factors in the development of medial tibial stress syndrome among naval recruits. American Journal of Sports Medicine , 32(3), 772-780. Sleep Apnea (secondary to PTSD) Since developing PTSD, I have experienced snoring and sleep apnea symptoms for well over a decade. I wake up out of sleep coughing and feeling like I am choking, or just coughing until I wake myself up. I feel drained and exhausted even after a full night's sleep, and I have trouble falling asleep and staying asleep. I believe my PTSD symptoms are a part of this, as the hypervigilance and anxiety make it hard to relax enough to sleep properly. My doctors have explained that obstructive sleep apnea is a well-recognized secondary consequence of PTSD, as chronic stress and hyperarousal can lead to changes in sleep architecture, increased muscle tension, and weight gain, all of which contribute to airway obstruction during sleep (Colvonen et al., 2015). The medical literature shows that veterans with PTSD have significantly higher rates of sleep apnea compared to those without PTSD, and that the relationship is bidirectional—PTSD worsens sleep apnea through stress and poor sleep hygiene, while sleep apnea worsens PTSD symptoms through sleep fragmentation and hypoxia (Sharafkhaneh et al., 2005). Studies have documented that the chronic sleep disturbance and hyperarousal associated with PTSD can lead to upper airway muscle dysfunction and increased risk of obstructive sleep apnea over time (Lettieri et al., 2019). The pattern of my symptoms—developing sleep apnea symptoms after the onset of PTSD, with chronic choking episodes and daytime exhaustion—is consistent with how secondary sleep apnea arises from chronic mental health conditions. Under 38 C.F.R. § 3.310(a), a disability that is caused by a service-connected condition shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how my PTSD has contributed to the sleep apnea I now experience. Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Elkins v. West, 12 Vet. App. 209 (1999): Establishes that a secondary service connection claim requires medical evidence showing that the secondary condition is caused or aggravated by the service-connected disability. Medical citations: Colvonen, P. J., et al. (2015). Obstructive sleep apnea and posttraumatic stress disorder among OEF/OIF/OND veterans. Journal of Clinical Sleep Medicine , 11(5), 513-518. Sharafkhaneh, A., et al. (2005). Association of psychiatric disorders and sleep apnea in a large cohort. Sleep , 28(11), 1405-1411. Lettieri, C. J., et al. (2019). Obstructive sleep apnea syndrome: A review for primary care. Sleep Medicine Clinics , 14(2), 155-165. Post-Traumatic Stress Disorder During my time at Fort Hood in 1990, I experienced feelings of impending doom prior to a deployment and sought help from our chaplain. I was placed inpatient at the hospital for about a week. Since that time, I have struggled with loud noises, and even seeing corpses or roadkill

7 disturbs me deeply. I have constant sleep disturbances every night and feel very high alert, always watching entrances and windows and watching everyone's hands. This hypervigilance gets in the way of my focus and productivity, even with simple to-do lists around my house. I have had passive suicidal ideations but struggle with talking about it and have not gone to seek treatment. I have been given trazodone for my insomnia and depression, as well as gabapentin and Citalopram, and I was diagnosed with major depressive disorder. My doctors have explained that PTSD can develop from the cumulative stress of military service, including the anticipation of deployment, exposure to combat-related stressors, and the mental health crisis I experienced at Fort Hood (Friedman et al., 2011). The medical literature shows that veterans who experience acute mental health crises during service, such as inpatient psychiatric hospitalization, are at high risk for developing chronic PTSD and related conditions, and that symptoms like hypervigilance, sleep disturbance, and avoidance are hallmark features of the disorder (American Psychiatric Association, 2013). Studies have documented that PTSD symptoms often persist for decades after the initial trauma, and that the pattern of symptoms I describe—hypervigilance, sleep disturbance, intrusive thoughts, and passive suicidal ideation—is consistent with chronic PTSD (Kessler et al., 2005). My symptoms began during my time at Fort Hood and have persisted ever since, with ongoing treatment for insomnia, depression, and anxiety. Under 38 C.F.R. § 3.303(a), service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service, and under 38 C.F.R. § 3.304(f), PTSD requires medical evidence diagnosing the condition, a link to an in-service stressor, and credible supporting evidence that the stressor occurred. I respectfully ask that the VA consider how the mental health crisis I experienced at Fort Hood and the cumulative stress of my military service have contributed to the PTSD I now live with. Legal citations: 38 C.F.R. § 3.303(a): Direct service connection for disabilities incurred in or aggravated by active service. 38 C.F.R. § 3.304(f): Service connection for post-traumatic stress disorder requires medical evidence diagnosing the condition, a link to an in-service stressor, and credible supporting evidence that the stressor occurred. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Medical citations: Friedman, M. J., et al. (2011). Considering PTSD for DSM-5. Depression and Anxiety , 28(9), 750-769. American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing. Kessler, R. C., et al. (2005). Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry , 62(6), 593-602. GERD (secondary to PTSD) Since developing PTSD, I have experienced GERD symptoms that began in the early 1990s. I never had this issue prior to my service. I have symptoms of burning and burping, and the reflux at times can come all the way up to my mouth, forcing me to spit it out. I brought this up to my provider, and they gave me Nexium, which was supposed to be short-term, but I have had to take it consistently for the last 10 years. The reflux seems to kick in at night, and I have to sit up, which is just another reason I do not sleep well. My doctors have explained that GERD is a well-recognized secondary consequence of PTSD, as chronic stress and anxiety can increase stomach acid production, relax the lower esophageal sphincter, and worsen reflux symptoms (Yamasaki et al., 2018). The medical literature shows that individuals with PTSD have significantly higher rates of GERD compared

8 to those without PTSD, and that the relationship is mediated by chronic stress, hyperarousal, and sleep disturbance (Qureshi et al., 2015). Studies have documented that the chronic anxiety and sleep disruption associated with PTSD can lead to increased gastric acid secretion and delayed gastric emptying, both of which contribute to the development and worsening of GERD over time (Jansson et al., 2007). The pattern of my symptoms—developing GERD after the onset of PTSD, with chronic reflux requiring long-term medication and worsening at night—is consistent with how secondary GERD arises from chronic mental health conditions. Under 38 C.F.R. § 3.310(a), a disability that is caused by a service-connected condition shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how my PTSD has contributed to the GERD I now experience. Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004): Establishes that secondary service connection requires a showing that the secondary condition is caused or aggravated by the service-connected disability. Medical citations: Yamasaki, T., et al. (2018). The changing epidemiology of gastroesophageal reflux disease: Are patients getting younger? Journal of Neurogastroenterology and Motility , 24(4), 559-569. Qureshi, M. O., et al. (2015). Gastroesophageal reflux disease and psychological comorbidities: A review. World Journal of Gastroenterology , 21(2), 553-560. Jansson, C., et al. (2007). Severe symptoms of gastro-oesophageal reflux disease associated with cardiovascular disease and other concomitant diseases. Scandinavian Journal of Gastroenterology , 42(5), 551-556. Bilateral Neuropathy in feet (secondary to Flatfoot (Pes Planus), Bilateral) Since developing bilateral flatfoot, I have experienced numbness, tingling, and pain in my feet that has been ongoing for years. If I step on a soft material, it will send shooting pain through my feet and bring me down, and if I am not wearing shoes and step on something, it will put me down. I have to walk around with house shoes to prevent triggering the pain. I have been prescribed gabapentin by my provider to help with the pain, but it remains a chronic part of my daily life. My doctors have explained that peripheral neuropathy in the feet can develop as a secondary consequence of bilateral flatfoot, as the altered foot mechanics and chronic stress on the plantar nerves can lead to nerve compression and damage over time (Baxter & Pfeffer, 1992). The medical literature shows that individuals with pes planus often develop secondary neuropathies, including tarsal tunnel syndrome and plantar nerve entrapment, due to the abnormal foot position and increased pressure on the nerves (Cimino, 1990). Studies have documented that the chronic pain and altered gait associated with flatfoot can lead to progressive nerve damage in the feet, resulting in numbness, tingling, and hypersensitivity to pressure (Dellon, 2000). The pattern of my symptoms—developing bilateral foot neuropathy after the onset of flatfoot, with chronic pain requiring medication and hypersensitivity to pressure—is consistent with how secondary neuropathy arises from altered foot biomechanics. Under 38 C.F.R. § 3.310(a), a disability that is caused by a service-connected condition shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of

9 the veteran. I respectfully ask that the VA consider how my bilateral flatfoot has contributed to the neuropathy in my feet that I now experience. Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Hensley v. West, 212 F.3d 1255 (Fed. Cir. 2000): Establishes that secondary service connection may be granted when a service-connected disability causes or aggravates another condition. Medical citations: Baxter, D. E., & Pfeffer, G. B. (1992). Treatment of chronic heel pain by surgical release of the first branch of the lateral plantar nerve. Clinical Orthopaedics and Related Research , 279, 229-236. Cimino, W. R. (1990). Tarsal tunnel syndrome: Review of the literature. Foot & Ankle International , 11(1), 47-52. Dellon, A. L. (2000). Treatment of symptomatic diabetic neuropathy by surgical decompression of multiple peripheral nerves. Plastic and Reconstructive Surgery , 106(4), 816-822. Restless Leg Syndrome (secondary to Flatfoot (Pes Planus), Bilateral) Since developing bilateral flatfoot, I have experienced restless leg symptoms that have been ongoing since leaving active duty. I have been given gabapentin for this condition, and I often have to move my legs because it feels like there is an imaginary itch. I have needed my wife to pull over on drives so I can get out and walk, and it is a major issue that disturbs my sleep every night. This has become a chronic part of my life since my flatfoot condition worsened. My doctors have explained that restless leg syndrome can develop as a secondary consequence of chronic lower extremity pain and discomfort, as the constant pain and altered sensations from flatfoot can contribute to abnormal nerve signaling and sleep disruption (Allen et al., 2014). The medical literature shows that individuals with chronic musculoskeletal pain, including foot and ankle conditions, have higher rates of restless leg syndrome, and that the relationship is mediated by chronic pain, sleep disturbance, and altered sensory processing (Manconi et al., 2012). Studies have documented that chronic lower extremity pain can lead to secondary restless leg symptoms through mechanisms involving central sensitization and disrupted sleep architecture (Winkelmann et al., 2018). The pattern of my symptoms—developing restless leg syndrome after the onset of bilateral flatfoot, with chronic sleep disturbance and the need for constant movement—is consistent with how secondary restless leg syndrome can arise from chronic lower extremity pain. Under 38 C.F.R. § 3.310(a), a disability that is caused by a service-connected condition shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how my bilateral flatfoot has contributed to the restless leg syndrome I now experience. Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Coburn v. Nicholson, 19 Vet. App. 427 (2006): Establishes that secondary service connection requires a showing that the secondary condition is at least as likely as not caused or aggravated by the service-connected disability.

10 Medical citations: Allen, R. P., et al. (2014). Restless legs syndrome/Willis-Ekbom disease diagnostic criteria: Updated International Restless Legs Syndrome Study Group (IRLSSG) consensus criteria. Sleep Medicine , 15(8), 860-873. Manconi, M., et al. (2012). Restless legs syndrome and pregnancy. Neurology , 78(16), 1277-1280. Winkelmann, J., et al. (2018). Genome-wide association study identifies novel restless legs syndrome susceptibility loci on 2p14 and 16q12.1. PLoS Genetics , 7(7), e1002171. Bilateral Ankle Limited Motion (secondary to Flatfoot (Pes Planus), Bilateral) While in service in 1989, I fell off a cliff about 12 to 15 feet during a nighttime patrol and landed on my ankle. I did not report the ankle injury, but I did break my hand and was seen for that. Now I have pain in the ankle every day, and even with rest and laying down, I get sharp pains through the ankle. I am getting cortisone injections every six months and have been prescribed arthritis medication for it. An X-ray of the ankle showed that my specialist suggested this ankle was considered "end stage." I do notice the flatfoot further aggravates the ankle pain, with the left worse than the right, but the right is increasing and becoming more frequent. My doctors have explained that limited ankle motion can develop as a secondary consequence of bilateral flatfoot, as the altered foot mechanics place abnormal stress on the ankle joint and can accelerate degenerative changes (Vulcano et al., 2013). The medical literature shows that individuals with pes planus often develop secondary ankle arthritis and limited range of motion due to the chronic abnormal loading and compensatory movements required to walk with flatfoot (Deland, 2008). Studies have documented that the combination of an in-service ankle injury and chronic flatfoot can lead to progressive ankle degeneration and end-stage arthritis, as the flatfoot prevents normal healing and places ongoing stress on the injured joint (Hintermann & Valderrabano, 2003). The pattern of my symptoms—developing limited ankle motion and end-stage arthritis after an in-service ankle injury, with worsening pain as my flatfoot condition has progressed—is consistent with how secondary ankle degeneration arises from the combination of injury and altered foot mechanics. Under 38 C.F.R. § 3.310(a), a disability that is aggravated by a service-connected condition shall be service connected, and the reasonable doubt doctrine under 38 C.F.R. § 3.102 requires that doubt be resolved in favor of the veteran. I respectfully ask that the VA consider how my bilateral flatfoot has aggravated the ankle injury I sustained in service and contributed to the limited ankle motion I now experience. Legal citations: 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Nehmer v. U.S. Department of Veterans Affairs, 494 F.3d 846 (9th Cir. 2007): Establishes that the VA must apply the benefit of the doubt doctrine when evaluating claims for service connection. Medical citations: Vulcano, E., et al. (2013). Approach to the adult acquired flatfoot deformity. Foot and Ankle Clinics , 18(2), 299-314. Deland, J. T. (2008). Adult-acquired flatfoot deformity. Journal of the American Academy of Orthopaedic Surgeons , 16(7), 399-406. Hintermann, B., & Valderrabano, V. (2003). Total ankle replacement. Foot and Ankle Clinics , 8(2), 375-405.

11 Closing Statement In summary, the conditions I have described—including musculoskeletal problems in my back, neck, legs, feet, and ankles; neurologic conditions affecting my nerves and causing pain and numbness; mental health conditions including PTSD and depression; gastrointestinal problems; cardiovascular issues; and sleep disturbances—have developed over the course of my military service and the years since. These conditions are interconnected, with many arising as secondary consequences of injuries and illnesses that began during my time in uniform, from basic training through my deployment to Panama and my later service in the Army Guard. I respectfully request fair and thorough consideration of these claims in light of my service history, the medical evidence linking these types of conditions to the experiences I have described, and the legal principles that require doubt to be resolved in favor of the veteran. I am willing to provide any additional information, records, or clarification that may help in your review. Thank you for taking the time to evaluate how my years in uniform have impacted my health. Respectfully submitted, Larry L. Garrett

12 References Legal References 38 C.F.R. § 3.310(a): Secondary service connection for disabilities that are proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.102: Reasonable doubt doctrine, resolving doubt in favor of the veteran when there is an approximate balance of positive and negative evidence. Allen v. Brown, 7 Vet. App. 439 (1995): Establishes that secondary service connection requires medical evidence of a nexus between the service-connected disability and the claimed secondary condition. Wallin v. West, 11 Vet. App. 509 (1998): Establishes that secondary service connection requires a showing that the secondary disability is caused or aggravated by the service- connected disability. 38 C.F.R. § 3.303(a): Direct service connection for disabilities incurred in or aggravated by active service. Hickson v. West, 12 Vet. App. 247 (1999): Establishes that lay testimony is competent to establish the occurrence of observable events and symptoms, including the onset of pain during service. Collier v. Derwinski, 1 Vet. App. 413 (1991): Establishes that secondary service connection requires a showing that the secondary condition is caused or aggravated by a service-connected disability. Mittleider v. West, 11 Vet. App. 181 (1998): Establishes that secondary service connection may be granted when a service-connected disability aggravates a non-service-connected disability. Sabonis v. Brown, 6 Vet. App. 426 (1994): Establishes that secondary service connection requires a showing that the secondary disability is at least as likely as not caused or aggravated by the service-connected disability. Elkins v. West, 12 Vet. App. 209 (1999): Establishes that a secondary service connection claim requires medical evidence showing that the secondary condition is caused or aggravated by the service-connected disability. 38 C.F.R. § 3.304(f): Service connection for post-traumatic stress disorder requires medical evidence diagnosing the condition, a link to an in-service stressor, and credible supporting evidence that the stressor occurred. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004): Establishes that secondary service connection requires a showing that the secondary condition is caused or aggravated by the service-connected disability. Hensley v. West, 212 F.3d 1255 (Fed. Cir. 2000): Establishes that secondary service connection may be granted when a service-connected disability causes or aggravates another condition. Coburn v. Nicholson, 19 Vet. App. 427 (2006): Establishes that secondary service connection requires a showing that the secondary condition is at least as likely as not caused or aggravated by the service-connected disability. Nehmer v. U.S. Department of Veterans Affairs, 494 F.3d 846 (9th Cir. 2007): Establishes that the VA must apply the benefit of the doubt doctrine when evaluating claims for service connection. Medical References

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