Citation Nr: 1604414 Decision Date: 02/05/16 Archive Date: 02/11/16 DOCKET NO. 10-08 306 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a right foot disability. REPRESENTATION Appellant represented by: Robert W. Gillikin, II, Attorney WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Jonathan Tracy, Associate Counsel INTRODUCTION The Veteran served on active duty from March 1963 to March 1966. This appeal comes before the Board of Veterans Appeals (Board) from an October 2008 rating decision by the Roanoke, Virginia Regional Office (RO) of the United States Department of Veterans Affairs (VA). In June 2011, the Veteran had a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript has been associated with the claims file. This matter was previously remanded in July 2011. The Board finds substantial compliance with the requested development. Stegall v. West, 11 Vet. App. 268 (1998). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2015). 38 U.S.C.A. § 7107(a)(2) (West 2014). FINDING OF FACT The preponderance of evidence reflects that there is no current right foot condition that was incurred in or aggravated by service. CONCLUSION OF LAW Service connection for a right foot condition is not warranted. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf 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 evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). I. Duties to Notify and Assist 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). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; (3) and that the claimant is expected to provide. Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004); see 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). In this case, notice fulfilling the requirements of 38 C.F.R. § 3.159(b) was furnished to the Veteran in a letter dated in January 2008. The issues were most recently adjudicated by the RO in March 2015. The Veteran also received notice regarding the disability-rating and effective-date elements of the claim in that letter. See Dingess/Hartman v. Nicholson, 19 Vet. App. 473 2006). VA is also required to make reasonable efforts to help a claimant obtain evidence necessary to substantiate a claim. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c), (d). This "duty to assist" contemplates that VA will help a claimant obtain records relevant to a claim, whether or not the records are in Federal custody. The claims file includes service treatment records, VA treatment records, and lay statements in support of the claim. The Veteran has asserted that he receives disability compensation from the Social Security Administration (SSA). However, he has indicated, which is supported by VA treatment records, that the Veteran receives disability compensation for a heart condition and knee problems. The Veteran has never identified these records as relevant to the issue being appealed and the Board has no reason to believe that they contain information pertinent to the issue being adjudicated. Thus, the Board finds no basis for remand. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (VA has an obligation to secure SSA records only if there is a reasonable possibility that the records would help to substantiate the Veteran's claim). The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claim for which VA has a duty to obtain. After the July 2011 remand, the Veteran was afforded a VA examination in October 2011 and an addendum opinion was provided in January 2013. The examination and the medical opinions are adequate to allow proper adjudication of the issue on appeal. The examiner conducted a complete examination, recorded all findings considered relevant under the applicable law and regulations, and offered well supported opinions based on consideration of the full history of the disabilities. Moreover, the examiner offered clear conclusions with supporting data as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Hence, no further notice or assistance to the appellant is required. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). II. Service Connection Criteria 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. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet. App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a). Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C.A. § 5107(b). III. Analysis The Veteran claims that he has a right foot condition that is related to service. Service treatment records (STR) show complaints and treatment of a right foot condition. The Veteran claimed at the examination in 2011 that he injured his right foot while unloading a truck and a "tailgate landed on [the] top right of the foot." STR records from January 1965 document the accident. X-rays were taken and were negative for any fracture. The Veteran complained of pain in the foot again in April 1965 through May 1965. However, no further diagnosis is provided. The note indicates that no further treatment was recommended with the "hope that symptoms subside." Radiographic testing was conducted again in May 1965 and no abnormalities were found. Following that May 1965 entry there are no further treatment notes discussing the right foot. The Veteran underwent a separation examination in February 1966. Clinical evaluation of the feet showed normal results. The Veteran checked "yes" to history of foot trouble on the Report of Medical History at that time and referenced the treatment he received in January 1965. However, there was no indication from the examination report that the Veteran continued to experience any symptoms related to his right foot. The Veteran entered the reserves from 1975 to 1995 and there are STRs dated during that period. For example, there is an examination in November 1984 that indicates a normal clinical evaluation of the feet. On the Report of Medical history he indicated not having a foot condition. Earlier, in February 1982, the Veteran did mark yes to past foot trouble. However, clinical evaluation of the feet showed normal results at that time. There is also an examination from December 1993 that shows normal results to clinical evaluation of the feet. The Veteran underwent a VA examination in October 2011. The examiner noted that there is pain when the Veteran walks. The Veteran claimed that cold weather makes his right foot "feel like it is in a vise." Upon examination, the examiner reported that there is no painful motion, welling, tenderness, instability, weakness, or abnormal weight bearing. X-ray testing showed arthritis in the midfoot and calcaneal spurs. After reviewing the claims file and examining the Veteran, the examiner opined that the right foot condition was less likely than not incurred in or caused by the claimed in-service injury. The examiner's rationale was unclear. Therefore, an addendum opinion was provided in January 2013. The examiner provided the following: a STR noted "dated 29 April 1965...reveals speculation for causes for right foot pain but no definitive diagnosis. In fact, [the] author documents plain radiograph was negative for fracture or arthritis. No sequelae [was] noted. In addition, separation physical examination reveals no supporting evidence for claimed foot condition... Additional views of both feet for comparison acquired on 28 May 1965 which demonstrate right foot normal and left foot (not associated with this claim) demonstrated a congenital area of interest... VA medical records provide no supporting evidence for Veteran seeking care or treatment for [the] claimed foot condition." The examiner also explained that the arthritis and calcaneal spurs shown in 2011, which were shown 46 years after the claimed foot problem, is "associated with the natural aging process" and is not related to any in-service event or injury. There are extensive post-service treatment records. Many are related to diabetes, obesity, hypertension, knee problems, and mental health treatment. There are no records that offer evidence of a current right foot problem being related to any incident in service. He was treated for an ingrown toenail in 2004. He was treated for foot pain and requested prosthetics for his feet in 2006. He also complained of a toe lesion in 2007. Since his diagnosis of diabetes he has undergone "diabetic feet examinations" and was advised on proper treatment of his feet. He was treated for painful and elongated nails in February 2008. He also complained of foot pain in February 2008. Significantly, none of the post-service treatment records provide any basis to find that any right foot condition is related to service or the 1965 accident. The only other relevant evidence in the record concerning the etiology of the Veteran's right foot is the Veteran's own statements. Lay persons are competent to provide opinions on some medical issues. Kahana v. Shinseki, 24 Vet. App. 428 (2011). However, the right foot condition at issue in this case could have multiple possible causes and thus, falls outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 429 F.3d 1372 (Fed. Cir. 2007). In deciding this claim, the Board notes that there are treatment records for a right foot condition after an accident in January 1965. There are records of treatment from January to May 1965. Repeated radiologic testing showed normal results at that time. The separation examination indicated normal results upon clinical evaluation of the feet. The VA examiner concluded that the current right foot condition is not related to service or the treatment the Veteran received in service. Moreover, there are no post-service treatment records linking current right foot problems to service. Thus, the VA examiner could not find a connection between the current right foot condition and service. There is no competent, credible, or probative medical evidence or medical opinion in the claims file to weigh against the VA opinion, and the Board finds the opinion to be persuasive in finding against the claim for service connection. Accordingly, the Board must conclude that the preponderance of the evidence is against the claim and it is denied. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for a right foot disability is denied. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs