Citation Nr: 18153803 Decision Date: 11/28/18 Archive Date: 11/28/18 DOCKET NO. 10-41 345 DATE: November 28, 2018 ORDER Entitlement to service connection for bilateral plantar fasciitis and foot sprain are granted. Entitlement to service connection for irritable bowel syndrome (IBS) is granted. REMANDED Entitlement to service connection for a GI disability, other than IBS, but to include gastroesophageal reflux disease (GERD), is remanded. Entitlement to an initial compensable disability rating for left foot hallux valgus and left great toe metatarsophalangeal (MTP) degenerative joint disease (DJD) is remanded. FINDINGS OF FACT 1. The Veteran’s bilateral plantar fasciitis and foot sprains were incurred in-service. 2. The Veteran’s IBS was incurred in-service. CONCLUSIONS OF LAW 1. The criteria for service connection for the bilateral foot disabilities of plantar fasciitis and foot sprain are met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). 2. The criteria for service connection for IBS are met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1989 to August 2009. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2009 rating decision by the Salt Lake City, Utah, Regional Office (RO) of the Department of Veterans Affairs (VA). In June 2013, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A copy of the transcript of that hearing is of record. This matter was remanded in May 2016 for further development. For clarity, the Board has combined the Veteran’s foot disability claims for entitlement to service connection for a bilateral foot disability requiring arch supports and a right foot disability into one claim. The record establishes that these claims are the result of diagnosed bilateral plantar fasciitis and foot sprain, both of which are granted herein. Similarly, the claim for a GI disability has been expanded to include IBS and GERD to better reflect the assertions and medical findings of record. See June 2016 VA Examination Report and July 2016 Supplemental Statement of the Case; see also Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service, even if the disability was initially diagnosed after service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). 1. Entitlement to service connection for bilateral foot disabilities The Veteran seeks service connection for bilateral foot disabilities. During the pendency of the claim, he was diagnosed with bilateral foot sprain and bilateral plantar fasciitis. See May 2009 and July 2015 VA Examination Reports and July 2013 Scott & White Treatment Records. From the outset, the Board acknowledges that examiners have provided varying dates as to the onset of the Veteran’s foot symptomatology. Nevertheless, these dates still fall within the Veteran’s periods of service such as to warrant service connection. As to foot sprain, during in-service May 2009 VA compensation and pension examination, an examiner noted the onset of the Veteran’s bilateral foot symptomatology was 2006. The examiner indicated that symptoms started gradually on walking and persisted when at rest. The examiner noted the Veteran was already prescribed orthotic inserts for both feet and motrin. Final examination diagnosis was bilateral foot sprain. Given the condition was diagnosed and treated in-service and present at the time of claim, service connection is warranted. Acknowledgement is given to the RO’s initial denial of service connection being predicated on the VA examination report lacking “objective findings to support the examiner’s diagnosis.” The Board does not agree with this determination. The examination report documents the examiner’s consideration of the physical examination results, as well as, the Veteran’s claims file and medical records prior to diagnosis. The Board finds it likely that notwithstanding normal in-person examination results, the examiner still found the Veteran’s clinically noted symptomatology sufficient to warrant diagnosis. To that end, contemporaneous treatment records reflected a foot condition so severe as to require on-going dual treatment of specialized orthotics and motrin for pain. Service connection is warranted. As to diagnosed plantar fasciitis, service treatment records (STR) are positive for repeat diagnosis of plantar fasciitis in September 1993 and January 1994. STRs for the remainder of service reflect consistent reports of recurrent foot pain. In addition, the Veteran has a current diagnosis of plantar fasciitis from both private and VA physicians. See Scott & White 2013 Treatment Records and July 2015 VA Examination Report. What remains for consideration is a nexus between in-service diagnosis and current disability. The Board finds sufficient evidence to grant. In July 2015, a VA examiner diagnosed plantar fasciitis. The examiner indicated that the onset of the condition occurred while the Veteran was in-service. This determination was predicated on careful physical examination and consideration of the Veteran’s credible reports of worsening bilateral foot pain on the bottom of his feet since service. This reported foot pain appears to mirror symptoms recorded at the time of in-service diagnosed plantar fasciitis. There is no competent opinion to the contrary addressing etiology of plantar fasciitis. In sum, the record establishes in-service incurrence of the Veteran’s currently diagnosed bilateral foot sprains and plantar fasciitis. Entitlement to service connection for both conditions is granted. 2. Entitlement to service connection for IBS The record establishes that the Veteran initially sought service connection for gastroenteritis and colitis shortly before service separation in April 2009. At the time of in-service VA compensation examination, in May 2009, he was diagnosed with IBS. The examiner noted that the Veteran reported problems with gastroenteritis and colitis beginning in 2005. The examiner also noted that the veteran suffered from flatulence, constipation, diarrhea, and had blood in his stool the week prior to examination. Based on this reported symptomatology, record review, and in-person examination the examiner diagnosed IBS. Given the condition was diagnosed in-service and present at the time of claim, service connection is warranted. Again, acknowledgement is given to the RO’s initial denial of service connection being predicated on the VA examination report lacking “objective findings to support the examiner’s diagnosis.” Nevertheless, the Board finds it likely that notwithstanding normal in-person examination results, the examiner still found the Veteran’s lay reports and clinically noted symptomatology sufficient to warrant diagnosis. Contemporaneous STRs supported the Veteran reports as they noted repeat treatment for an array of GI conditions including, but not limited to: abdominal cramping, bloating, gastroenteritis, bloody stool, flatulence, constipation, and a condition noted as “other and unspecified noninfectious gastroenteritis and colitis.” See generally, STRs from November 2001- November 2008. Such records, when paired with the Veteran’s on-going reports are sufficient to support the presence and examiner diagnosis of the GI condition of IBS. This diagnosis has not been competently contradicted. In sum, the record establishes in-service incurrence of the Veteran’s currently diagnosed IBS, therefore entitlement to service connection is granted. REMANDED ISSUE 1. Entitlement to service connection for a GI condition, other than IBS is remanded. The Veteran asserts that his GI condition is also manifested by GERD, which has been present since service. See June 2016 VA Examination Report. VA and private records document diagnosed GERD. See Id. and Scott & White Treatment Records. Additionally, although not diagnosed with GERD in-service, as stated above, the Veteran suffered from an array of GI symptoms. Further, on November 2008 Report of Medical History, a physician documented the Veteran’s reports of suffering from frequent mild heartburn and indigestion. What remains is a nexus. In June 2016, a VA examiner opined that the Veteran’s current GERD was less likely than not incurred in or caused by service. The opinion was essentially predicated on the record lacking diagnostic evidence or indication of GERD prior to January 2011. The Board finds the opinion is contradictory and inadequate. Although, the examiner opined that the record lacked sufficient evidence of GERD prior to 2011 diagnosis, she did not address whether the Veteran’s combined symptoms of uncontrolled belching, epigastric distress, heartburn, and indigestion throughout service were sufficient to established GERD manifestation. Additionally, the examiner did not address the significance of her own previous statements documenting a GI condition in December 2010. Notably, on December 2010 VA Examination Report, the same examiner indicated the Veteran was already prescribed Prilosec to treat a GI condition manifested by indigestion and heartburn. Discussion of this notation is significant as it predates the January 2011 records, denotes symptomatology identical to that reported in-service, and notes active use of Prilosec, which was prescribed solely to treat the Veteran’s GERD. See VAMC Treatment Records. Given the above, a remand for a new opinion is required. An opinion should also be obtained addressing the relationship, if any, between the Veteran’s diagnosed IBS and other diagnosed GI disabilities including GERD. 2. Entitlement to an initial compensable disability rating for left foot hallux valgus and left great toe MTP DJD is remanded. The claim for an initial compensable rating for left foot hallux valgus and left great toe MTP DJD is inextricably intertwined with the claim of entitlement to service connection for left foot disabilities, which the Board has granted herein. Specifically, there is potential for overlapping in pain symptomatology and functional impairment. As a result, the Board will defer consideration of the increased rating claim to allow the AOJ to assign a rating for these awards. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). Finally, the Veteran, by way of his Representative, has asserted that his most recent July 2015 VA examination is inadequate in evaluating the functional impairments present on “active and passive motion with weight bearing” solely due to his left toe and hallux valgus conditions. See October 2018 Informal Hearing Presentation. To that point, review of the 2015 examination is unclear whether the Veteran’s currently rated conditions, without regarding to his now service-connection left foot plantar fasciitis and sprain, cause functional impairment. The matter is REMANDED for the following action: 1. Schedule the Veteran for an appropriate VA examination, with an examiner other than the June 2016 VA examiner, to address the nature and etiology of the Veteran’s claimed gastrointestinal disabilities, other than IBS, but to include GERD. The claims folder, including a copy of this remand, should be provided to the examiner for review of the pertinent documents. Any additional studies should be performed. After the foregoing has been completed, the examiner shall provide an opinion on the following: (a.) Diagnose any disability of the GI system, other than IBS, but to include GERD, which presently exists or has existed during the pendency of this claim (since 2009). (b.) Is it at least as likely as not (i.e. a probability of 50 percent or greater) that any diagnosed GI disability, other than IBS, but to include GERD (i) had its onset during active service, or (ii) is related to any in-service disease, event, or injury, to include the Veteran’s reported in-service GI difficulty (stomach pain/epigastric distress/ heartburn/indigestion), or caused or aggravated by the Veteran’s now service-connected IBS. 2. In rendering the requested opinions, the examiner should specifically consider and address: (a.) the Veteran’s hearing testimony and examination reports that he began having GI symptoms during service and has suffered from symptoms since then. Note, the Veteran is deemed competent and credible to report experiencing heartburn and indigestion in and since service; (b.) the Veteran’s service treatment records including: diagnosed flatulence in November 2001(note the Veteran reported that his symptomatology of uncontrolled belching, stomach cramps, and bloating had been occurring four times a week for a year prior to diagnosis despite regularly taking over the counter medication); May 2002 records reflecting continued stomach pain; Diagnosed gastroenteritis in May 2004; August 2008 hospitalization for diagnosed acute abdominal pains and noted mild epigastric pain treated by a “GI cocktail”; and November 2008 Report of Medical History of frequent indigestion and heartburn thereafter. Note, the examiner must address whether the Veteran’s complete disability picture in-service supports in-service GERD or a GI condition other than IBS. In rendering this opinion, the examiner must discuss clinical symptoms associated with GERD and other GI conditions and distinguish those from the symptoms repeatedly manifested by the Veteran in-service. (c.) the Veteran’s medical history. Note, the Board considers treatment for GERD to have occurred prior to January 2011 as in December 2010 a VA examiner indicated that the Veteran suffered from GI symptomatology of heartburn and indigestion and already had a prescription for Prilosec. VA treatment medical records indicate Prilosec was used solely to treat the Veteran’s GERD. (d.) the 2016 examiner did not address whether the Veteran’s GERD could have resolved or at least decreased in severity during the pendency of the appeal. Such an opinion is necessary as the examiner essentially opined that the Veteran’s GERD symptomatology was not chronic as he at times was noncompliant with his medication. Rationales for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In doing so, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer. 3. Schedule the Veteran for a VA examination to ascertain and evaluate the current level of severity of his service-connected left foot hallux valgus and left great toe MTP DJD. The claims file should be made available to the examiner. The examiner should report the extent of the Veteran’s disability in accordance with VA rating criteria. Any indicated studies should be performed. The joints involved should be tested for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with the range of the opposite undamaged joint. The examiner should review the July 2015 VA examination and determine functional impairment associated solely with the left foot hallux valgus and big toe MTP DJD. Additionally, opine whether active and passive motion impairment solely due to MTP DJD can be determined. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD J. L. Burroughs, Associate Counsel