Citation Nr: 18142073 Decision Date: 10/16/18 Archive Date: 10/12/18 DOCKET NO. 13-03 165A DATE: October 16, 2018 ORDER Entitlement to service connection for plantar fasciitis of the left foot as related to the service-connected left ankle sprain is granted. Entitlement to service connection for pes planus, including as due to the service-connected left ankle sprain, is denied. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran’s currently diagnosed plantar fasciitis of the left foot is caused or aggravated by his service-connected left ankle sprain. 2. The Veteran’s currently diagnosed left foot pes planus is not etiologically related to his service or his service-connected left ankle sprain. CONCLUSIONS OF LAW 1. Resolving all reasonable doubt in the Veteran’s favor, the criteria for entitlement to service connection for plantar fasciitis of the left foot, as related to the service-connected left ankle sprain, have been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2017). 2. The criteria for entitlement to service connection for left foot pes planus have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran, who is the appellant in this case, served on active duty from July 1982 to July 1986. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision dated April 2011 of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. In September 2015, April 2017, and January 2018, the Board remanded the claim for further development. Preliminary Matter The Board has limited the discussion below to the relevant evidence required to support its findings of fact 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); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016). Service Connection Service Connection – Pertinent Laws and Regulations Under the relevant laws and regulations, service connection will be granted for a disability that was caused or aggravated by a disease or injury in active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection requires evidence of (1) an in-service disease or injury; (2) a current disease or disability; and (3) a nexus between the in-service event and the current disease or disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Further, service connection may be granted for any disease 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). The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997). Service connection may alternatively be established on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.310(b); Allen v. Brown, 8 Vet. App. 374 (1995). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The United States Court of Appeals for the Federal Circuit (Federal Circuit) has clarified that lay evidence can be competent and sufficient to establish a diagnosis or etiology when (1) a lay person is competent to identify a medical condition; (2) the lay person 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 (Fed. Cir. 2009). Generally, the degree of probative value which may be attributed to a medical opinion issued by a VA or private treatment provider takes into account such factors as its thoroughness and degree of detail, and whether there was review of the claims file. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Also significant is whether the examining medical provider had a sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). The Court has held that a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Entitlement to service connection for left foot disability, to include as due to the service-connected left ankle sprain. The Veteran asserts that his left foot was injured during service when he stepped out of a helicopter and turned his ankle. See June 2017 VA examination report dated June 13, 2017; VA neurosurgery consultation notes dated July 2, 2012 and August 8, 2012. The Board initially notes that the Veteran has a current diagnosis of bilateral pes planus and bilateral plantar fasciitis. See e.g., VA examination report dated June 13, 2017; VA outpatient treatment record dated April 25, 2011. The Board will focus on the left foot disability, as claimed by the Veteran. The Veteran’s service treatment records (STRs) reflect that the Veteran’s feet were normal at enlistment. The STRs reflect that the Veteran complained of minor injuries to his feet during service. See STRs dated February 16, 1983, February 5, 1986, and May 2, 1986. At separation in June 1986, the Veteran endorsed “foot trouble.” On examination, however, the Veteran’s feet were found to be normal, with the examiner noting a left ankle problem as well as tinea pedis and a superficial abcess. Post-service VA treatment records reflect that the Veteran consistently reported left foot pain, with other symptoms that include intermittent numbness, tingling, and weakness that he attributes to an in-service injury exiting a helicopter. See e.g. VA outpatient treatment records dated October 13, 2010, April 26, 2012, July 2, 2012, August 8, 2012, and January 9, 2014. The Veteran underwent VA examinations in March 2011 and July 2016. The Board previously found these examinations to be inadequate for VA purposes. See Board remands dated September 4, 2015 and April 28, 2017. Therefore, in its April 2017 remand, the Board requested that the Veteran be afforded a new VA examination, which was provided in June 2017. The June 2017 examiner diagnosed bilateral pes planus and bilateral plantar fasciitis, acknowledged the in-service foot problems noted in the STRs, and opined that the Veteran’s left foot disabilities were less likely than not related to service. The examiner explained that the foot problems shown in the STRs are not among the risk factors for plantar fasciitis, which include obesity, diabetes mellitus, extended periods of standing, significant increase in physical activity, aging, and pes planus/pes cavus. Additionally, the examiner indicated that the in-service foot problems are not risk factors for pes planus, which include obesity, diabetes mellitus, rheumatoid arthritis, foot or ankle injury, and increasing age. Notably, the examiner stated that the Veteran was not diagnosed with pes planus prior to 2017, and that the most likely risk factor for the Veteran’s pes planus is aging. See VA examination report dated June 13, 2017. In a November 2017 letter, the Veteran asserted that his left foot pain was a direct result of his service-connected left ankle injury. Finding that an additional medical opinion was necessary to address the theory of service connection on a secondary basis, raised by the Veteran’s letter, the Board again remanded the claim in January 2018, requesting a medical opinion to address whether the Veteran’s left foot disabilities were caused or aggravated by his service-connected left ankle sprain. In March 2018, a VA examiner confirmed diagnoses of bilateral pes planus and bilateral plantar fasciitis, and opined that both disabilities were not caused or aggravated by his service-connected ankle disability. With regard to the pes planus disability, the examiner noted that the disability was very mild with no pronation, and that the fact that it was bilateral, suggests that it was not due to the left ankle disability. Regarding bilateral plantar fasciitis, the examiner acknowledged that review of medical literature shows that the nature of the disability is unclear; however, the examiner indicated that known risk factors include obesity, prolonged standing or jumping, flat feet, and reduced ankle dorsiflexion and referenced supportive medical literature. Plantar Fasciitis On review, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s currently diagnosed left foot plantar fasciitis was caused or aggravated by his service-connected left ankle disability. A careful review of the evidence shows that, during an October 2012 VA outpatient visit to the Durham VA Medical Center, the Veteran was found to have decreased dorsiflexion of the left ankle. See VA Physical Therapy Evaluation dated October 16, 2012. It was noted that left ankle dorsiflexion was to 10 degrees. While the March 2018 VA examiner did not address this evidence, the examiner’s opinion clearly supports the conclusion that the Veteran’s service-connected left ankle disability, especially reduced dorsiflexion of the ankle, is a known risk factor for the development of his plantar fasciitis. Further development could be undertaken to obtain yet another medical opinion to clarify the etiology. Nonetheless, the Board will resolve any reasonable doubt in the Veteran’s favor, and find that his plantar fasciitis of the left foot was caused by his service-connected left ankle sprain. Accordingly, entitlement to service connection for plantar fasciitis of the left foot, to include as due to the Veteran’s service-connected left ankle sprain, is granted. See 38 C.F.R. § 3.310(b); Allen, supra. Pes Planus Regarding the diagnosis of pes planus, the Board finds that the preponderance of the evidence weighs against the claim for service connection. There is no evidence of pes planus in the Veteran’s STRs and the June 2017 VA examiner determined that the foot problems noted in the Veteran’s STRs are not risk factors for pes planus. Moreover, the examiner stated that the Veteran was not diagnosed with pes planus prior to 2017, which is decades after service, and opined that the most likely risk factor for the Veteran’s pes planus is aging, and not his military service. See VA examination report dated June 13, 2017. Additionally, the March 2018 VA examiner concluded that the Veteran’s pes planus was very mild in nature with no pronation, inferring that the disability would have been more severe decades after service, if related to it. Lastly, the examiner indicated that the fact that the pes planus is in both feet (bilateral) suggests that it was not etiologically related to the left ankle disability. In this case, the Veteran has not submitted competent evidence of a nexus between his current pes planus and service or his service-connected left ankle disability. Although he is competent to report observable symptoms of his pes planus, he, as a layperson, is not able to render a competent opinion regarding the etiology of the disability. As the preponderance of the evidence weighs against a finding that the Veteran’s pes planus is related to service or his service-connected left ankle disability, the   doctrine is not for application here. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As such, service connection for left foot pes planus is not warranted. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Brad Farrell, Associate Counsel