Citation Nr: 1217841 Decision Date: 05/18/12 Archive Date: 05/31/12 DOCKET NO. 09-09 387 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Denver, Colorado THE ISSUES 1. Entitlement to service connection for a right shoulder disability. 2. Entitlement to service connection for bilateral plantar fasciitis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Van Wambeke, Counsel INTRODUCTION The Veteran served on active duty from August 2001 to January 2002 and from February 2003 to May 2004. She had an unverified period of service with a reserve unit prior to both periods of active duty and following her second period of active duty. The Veteran served in Kuwait from May 2003 to June 2003 and from March 2004 to April 2004; she had service in Iraq from June 2003 until March 2004. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Denver, Colorado, which denied the claims. FINDINGS OF FACT 1. The Veteran sustained an injury to her right shoulder during a drill weekend and is currently diagnosed with right rhomboid muscle strain. 2. The Board resolves reasonable doubt in the Veteran's favor by finding that bilateral plantar fasciitis is etiologically related to her second period of active duty. CONCLUSIONS OF LAW 1. The criteria for service connection for a right shoulder disorder have been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). 2. The criteria for service connection for bilateral plantar fasciitis have been met. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.102, 3.303 (2011). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS In this decision, the Board grants entitlement to service connection for a right shoulder disorder and bilateral plantar fasciitis, which represents a complete grant of the benefits sought on appeal. See Barrera v. Gober, 122 F.3d 1030 (Fed. Cir. 1997); Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Thus, there is no need to discuss whether VA has complied with its duties to notify and assist found at 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. § 3.159. Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Active service includes any period of active duty for training during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty and any period of inactive duty for training during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. See 38 U.S.C.A. § 101 (24). Thus, in the case of inactive duty training, only if the individual suffered an "injury" during such service can disability resulting from such service provide a basis of eligibility for disability compensation. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. In order to prevail on the issue of service connection there must be competent evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Service connection may also be established by chronicity and continuity of symptomatology. See 38 C.F.R. § 3.303(b) (2011). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007) (citing Savage v. Gober, 10 Vet. App. 488, 495-96 (1997)). "[S]ymptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage, 10 Vet. App. at 496. In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). Service connection may also be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran seeks service connection for a right shoulder disability, which she contends is the result of an injury that occurred during a drill weekend in December 2004 while playing basketball. She reports that she has had constant right shoulder problems since that time. The Veteran also seeks service connection for bilateral plantar fasciitis. She reports that while stationed in Iraq, she was seen at least once for problems with her feet and was told to stay off them. The Veteran acknowledges that she was not diagnosed with bilateral plantar fasciitis until she was seen at the Portland VAMC but contends that her current disorder is related to her complaints in service. See July 2008 VA Form 21-4138. The Veteran's service treatment records from her second period of active duty are not available. See May 2008 memorandum. However, she has submitted copies of records she had in her possession. An April 2004 report of medical assessment reveals that the Veteran reported a problem with her right foot (may have fallen arch) with onset of pain in September 2003. And in December 2004, it was noted that she had injured her right shoulder while playing basketball in physical training during a drill weekend. See medical record. An April 2005 DA Form 2807-1 also documented the right shoulder injury noting occasional right scapular discomfort. Post-service medical evidence of record reveals that the Veteran has received VA treatment for bilateral plantar fasciitis and right subscapular bursitis. See April 2006 primary care outpatient note. In June 2007, she was assessed with chronic levator/rhomboid strain from old probable basketball injury. See physical therapy outpatient consult. The Veteran underwent a VA examination in May 2008, at which time her claims folder was reviewed. In pertinent part, she reported developing pain in the heels of both feet while on patrol in 2003. It was not severe enough to warrant medical evaluation or treatment and the symptoms waxed and waned and eventually went away, but recurrent symptoms of bilateral heel pain returned in 2005 while she was working in a pizza parlor. The Veteran also reported that she collided with another player while playing basketball and struck her right shoulder. She was evaluated by a medical provider without diagnostic testing and was treated with ibuprofen. The condition improved but she had residual discomfort in the right rhomboid muscle (not the shoulder joint) while carrying a heavy pack during service. Following physical examination and diagnostic testing in the form of x-rays, the Veteran was diagnosed with bilateral plantar fasciitis and right rhomboid muscle strain. The examiner noted that shoulder joint examination and x-ray were normal and there was insufficient clinical evidence to warrant a diagnosis of a right shoulder condition or residuals thereof. The examiner addressed the RO's question as to whether the current bilateral foot condition was related to the Veteran's complaint of fallen right foot arch in service. The examiner noted that she could find no supporting documentation of bilateral foot symptoms while in service, but the Veteran did provide a plausible history with symptoms of bilateral plantar fasciitis while on patrol with extensive walking on uneven ground during service. The examiner noted that the Veteran's arches were normal but that her current symptoms and physical findings were diagnostically consistent with plantar fasciitis and it was her opinion that the condition is related to overuse activity, (which the Veteran described as occurring during service) and less likely as not due to a "fallen arch." The examiner also provided an opinion that the rhomboid muscle strain of the right shoulder is the same condition that the Veteran complained of, and received treatment for, while in service. The Veteran's assertions that she began having problems with her feet while stationed in Iraq in 2003 are both competent and credible. Layno v. Brown, 6 Vet. App. 465, 471 (1994). As such, she has one of the elements required to substantiate a claim for service connection, namely evidence of an in-service injury. The Veteran also has another element required to substantiate a claim for service connection since the post-service medical evidence of record documents a current diagnosis of bilateral plantar fasciitis. Lastly, the VA examiner provided the third element required to substantiate the claim for service connection when she provided an opinion that the condition is related to overuse activity, which the Veteran described as occurring during service. The examiner also noted that the Veteran provided a plausible history with symptoms of bilateral plantar fasciitis while on patrol with extensive walking on uneven ground during service. Given the foregoing, the Board resolves reasonable doubt in the Veteran's favor by finding that service connection for bilateral plantar fasciitis is warranted as etiologically related to her second period of active duty. 38 C.F.R. § 3.303. The Veteran clearly sustained an injury to her right shoulder in December 2004 and the associated record of treatment clearly indicates that this happened during a drill weekend while she was serving in a reserve unit. As it is immaterial whether this incident occurred during a period of active or inactive duty training, the Veteran has one of the elements required to substantiate a claim for service connection, namely evidence of an in-service injury. See 38 U.S.C.A. § 101 (24). The Veteran also has another element required to substantiate a claim for service connection since the post-service medical evidence of record documents a current diagnosis of right rhomboid muscle strain. Lastly, the VA examiner provided the third element required to substantiate the claim for service connection when she provided an opinion that the rhomboid muscle strain of the right shoulder is the same condition that the Veteran complained of, and received treatment for, while in service. Given the foregoing, the Board finds that service connection for a right shoulder disorder is warranted. 38 C.F.R. § 3.303. ORDER Service connection for a right shoulder disorder is granted. Service connection for bilateral plantar fasciitis is granted. ____________________________________________ RONALD W. SCHOLZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs