Citation Nr: 1325211 Decision Date: 08/08/13 Archive Date: 08/13/13 DOCKET NO. 05-02 360 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for a variously diagnosed bilateral foot disability, to include pes cavus, claimed as secondary to service-connected cervical, low back and bilateral hip disabilities. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD James R. Siegel, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from November 1983 to March 1997, and had four months of prior active service. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2003 rating decision of the Regional Office (RO). This case was previously before the Board in November 2009, June 2010 and again in March 2012, at which times it was remanded for additional development and/or to ensure due process. In June 2013, the Board requested a medical advisory opinion in the matter from the Veterans Health Administration (VHA). Such opinion was received in July 2013. FINDINGS OF FACT 1. The Veteran is shown to have bilateral pes cavus. 2. The Veteran's service connected disabilities include lumbar spine degenerative disc disease (DDD), with bilateral lower extremity radiculopathy. 3. Competent evidence establishes that the Veteran's bilateral pes cavus was caused (or aggravated) by his service connected lumbar DDD with radiculopathy to the lower extremities. CONCLUSION OF LAW Service connection for bilateral pes cavus as secondary to service-connected lumbar DDD with lower extremity radiculopathy is warranted. 38 U.S.C.A. § 5107 (West 2002); 38 C.F.R. § 3.310 (a) (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) Under the VCAA VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). The VCAA applies in this case. However, as the benefits sought are being granted, there is no need to belabor the impact of the VCAA on this claim as any VCAA-mandated notice or duty to assist omission is harmless. Factual background, legal criteria and analysis The Board has reviewed all the evidence in the appellant's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that each item of evidence received be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the record shows, or does not show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). The Veteran's service treatment records are silent for complaints or findings pertaining to a foot disability. The report of a physical evaluation board in October 1996 contains no mention of a foot disorder. VA outpatient treatment records show that in February 2000 the Veteran was seen for follow-up of right foot pain at the lateral malleolus and metatarsals. The assessments were suspicion of tendonitis and pain in the limb secondary to equinus/pes anterior cavus. The Veteran was seen by a private podiatrist in August 2000 for bilateral foot pain associated with ambulation. The assessment was to rule out degenerative joint disease versus radiation versus neurotrophic changes of the feet. The examiner stated the Veteran's gait pattern might be part of an antalgic gait pattern. He added the Veteran understood that his bilateral foot symptoms might be exacerbated by degenerative joint disease of the cervical spine and lower back. On February 2001 VA joints examination, the examiner indicated that he reviewed the Veteran's VA clinic records which demonstrated the feet were entirely normal, to include a normal arch. He added he could not make a diagnosis of pes cavus. VA outpatient treatment records show the Veteran was seen in February 2002 and reported he had been seen in the podiatry clinic in February 2000 for heel pain. He related the burning across the top of his feet had decreased in frequency and intensity and the pain in his heels had subsided after he began wearing inserts and losing weight. The assessments were flexible pes plano valgus deformity, heel spur syndrome/plantar fasciitis, asymptomatic at present, and first metatarsal cuneiform joint exostosis. The examiner stated the latter problem was the most likely explanation for the shooting/burning pain across the dorsum of the feet. He also indicated that old spine injuries might be responsible for the heel spur syndrome. On March 2003 VA examination the examiner noted he had reviewed the claims folder. He found no evidence of pes cavus. He opined the pes cavus was unrelated to service, and that it was unlikely that any of the Veteran's service-connected disabilities resulted in pes cavus. On April 2004 VA examination the examiner found that the Veteran had no indication of a pes cavus deformity, and did not have pes planus. She stated he had a relatively rectus foot type, and evidence of peroneal muscle weakness. On August 2010 VA examination the examiner summarized some of the medical evidence in the record. The Veteran related he had been provided orthotics which relieved his pain. He reported he was advised by physicians that pes cavus was caused by his spine and hip problems. The examiner noted that electromyograms of the lower extremities in 2002 showed some bilateral L5, S1 radiculopathy with no evidence of peroneal nerve entrapment. There was no evidence of neuropathy or myopathy or peripheral neuropathy. He stated this meant that a neurologic cause was less likely. He commented that the Veteran's statement that pes cavus was related to the spine and hip problems was not supported by medical literature. Thus, it would be presumed to be less likely than not that it was related to injuries sustained in service. In a January 2011 addendum to the August 2010 examination report the examiner stated that he had reviewed the entire claims folder, including service treatment records, VA examinations, radiology reports, and VA and private medical records. On April 2012 VA examination the examiner stated she reviewed the claims folder, and concluded the Veteran had a bilateral pes cavus deformity, but that it was not likely from service. She noted he had an abducted stance position, apparently coming from his hips, and that it was not clear if it was related to service. She could not say whether the Veteran's pes cavus deformity was from his cervical spine injury or his low back pain. She also stated it was as likely as not that the Veteran's stance position was from a bilateral hip disability because external rotation of the hips can result from degenerative joint disease of the hip. In a January 2013 addendum, the April 2012 VA examiner opined the Veteran's pes cavus, which is an osseous deformity of the foot, was not aggravated by hi's cervical spine, low back pain or bilateral hip pain. As was noted above, the Board found the medical opinions in the record inadequate and sought an advisory medical opinion in the matter from a VHA expert. In July 2013 an attending orthopedic surgeon who reviewed the record concluded the Veteran has a pes cavus deformity of both feet, which was caused or aggravated by his service-connected lumbar radiculopathy. He cited to supporting factual data (including that the Veteran has weakness of peroneal musculature, 4/5 of both legs, that he has documented lumbar radiculopathy, that physical examination found a longitudinal arch that did not diminish with weight bearing, and that the evidence suggested the pes cavus was progressive and most likely neurogenic in origin). He indicated that pes cavus was not due to bony abnormalities of the feet. The Veteran's service connected disabilities include lumbar DDD with lumbar radiculopathy to both lower extremities. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection is also warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. The elements of a successful secondary service connection claim are: Evidence of a disability for which service connection is sought; a disability that is already service connected; and competent evidence that the service connected disability caused or aggravated the disability for which service connection is sought. Here, the record shows that the Veteran has bilateral pes cavus (while March 2003 and April 2004 examiners did not find pes cavus, subsequent VA examination confirmed he has such disability). The Veteran has service-connected lumbar DDD with bilateral lower extremity radiculopathy. And a VHA consulting expert, citing to findings/diagnostic studies that indicated that the cause of the pes cavus was neurogenic, not orthopedic, opined that the service-connected lumbar radiculopathy of the lower extremities is a cause of the pes cavus. The Board finds the VHA expert's opinion to be the most probative evidence regarding a nexus between the pes cavus and the service connected lumbar DDD with bilateral lower extremity radiculopathy. By virtue of training and experience (as an orthopedic surgeon), he is eminently qualified to offer the opinion, and provides a clear explanation of rationale, with citation to supporting factual data. The prior VA examiners' opinions to the contrary are unaccompanied by adequate explanation of rationale (they do not discuss the supporting factual data cited by the VHA expert), and therefore are lacking in probative value. As the record shows that the Veteran has bilateral pes cavus, that he has service connected lumbar DDD with lower extremity radiculopathy, and that the lumbar DDD with radiculopathy was an etiological factor in the development of his pes cavus, all of the requirements for establishing secondary service connection are met. Service connection for bilateral pes cavus as secondary to service connected lumbar DDD with lower extremity radiculopathy is warranted. ORDER Service connection for bilateral pes cavus is granted. ____________________________________________ GEORGE R. SENYK Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs