Citation Nr: 18156747 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 16-31 977 DATE: December 11, 2018 ORDER Entitlement to an increased rating in excess of 10 percent for cervical spine degenerative disc and joint disease with sprain is dismissed. Entitlement to an increased rating for right knee chondromalacia patella, status post retinacular release with degenerative joint disease (now with right medial meniscus tear status post arthroscopy with partial meniscectomy and chondroplasty), is dismissed. Entitlement to an increased rating for right knee subluxation, evaluated as 30 percent disabling from July 2, 2015 to November 4, 2015, is dismissed. Entitlement to service connection for a left shoulder condition is denied. Entitlement to service connection for hypertension, claimed as high blood pressure, is denied. Entitlement to service connection for cysts on the liver and kidneys, claimed as pain in the abdomen, is denied. REMANDED Entitlement to service connection for residuals of right great toe surgery including hallux valgus and arthritis in the first metatarsophalangeal arthrosis, is remanded. Entitlement to an increased rating in excess of 10 percent for Morton’s neuroma right foot status post excision with arthroplasty, syndactyl, and metatarsalgia, is remanded. Entitlement to a temporary total evaluation for right great toe surgery is remanded. FINDINGS OF FACT 1. On September 4, 2018, prior to the promulgation of a decision in the appeal, the Board received notification from the Veteran that he was satisfied with the ratings assigned for all issues except the right foot and right wrist. 2. The Veteran is not shown to have a fractured left clavicle. 3. The diagnosed left shoulder condition is not shown to be causally or etiologically related to any disease, injury, or incident during service. 4. Hypertension is not shown to be causally or etiologically related to any disease, injury, or incident during service, and did not manifest within one year of discharge from service. 5. Cysts on the liver and kidneys were not present in service and are not shown to be causally or etiologically related to any disease, injury, or incident during service, and did not manifest within one year of discharge from service. CONCLUSIONS OF LAW 1. The criteria for withdrawal of the appeal of entitlement to an increased rating in excess of 10 percent for cervical spine degenerative disc and joint disease with sprain are met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 2. The criteria for withdrawal of the appeal of entitlement to an increased rating for right knee chondromalacia patella, status post retinacular release with degenerative joint disease, are met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 3. The criteria for withdrawal of the appeal of entitlement to an increased rating in excess of 30 percent from July 2, 2015 to November 4, 2015for right knee subluxation are met. 38 U.S.C. § 7105(b)(2), (d)(5) (2012); 38 C.F.R. § 20.204 (2017). 4. The criteria for service connection for a left shoulder condition are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303 (2017). 5. The criteria for service connection for a high blood pressure condition are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2017). 6. The criteria for service connection for cysts of the liver and kidneys are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. § 3.303, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service in the United States Army from October 1977 to June 1995. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran submitted a notice of disagreement (NOD) in February 2014. A statement of the case (SOC) was issued in June 2016. The Veteran perfected a timely substantive appeal via VA Form 9 in July 2016. A supplemental SOC was issued in July 2018. The record reflects that additional evidence, including VA treatment records, was added to the claims file following the July 2018 supplemental SOC. However, the additional evidence is not relevant to the claims decided herein, as it relates to the current nature of the Veteran’s disabilities, but does not address the critical element of a nexus between his service and his claimed conditions. The Board finds that adjudication of the service connection claims may proceed without prejudice to the Veteran. 38 C.F.R. § 20.1304 (2017). The Board acknowledges the Veteran’s contentions regarding clear and unmistakable error in regard to the denial of entitlement to service connection for residuals of right great toe surgery including hallux valgus and arthritis. However, as the January 2014 rating decision which denied the original claim is not final, it cannot be subject to a claim of clear and unmistakable error. See 38 U.S.C. §§ 5109A, 7104 (2012); 38 C.F.R. § 3.105(a) (2017). The Board also acknowledges the Veteran’s contentions regarding his claim of entitlement to an increased rating for his service-connected right wrist condition. This claim was considered in a June 2018 rating decision and a timely NOD was received in September 2018. The matter is referred to the RO for appropriate action. Withdrawal of Appeals The Board may dismiss any appeal which fails to allege specific error of fact or law in the determination being appealed. 38 U.S.C. § 7105. An appeal may be withdrawn as to any or all issues involved in the appeal at any time before the Board promulgates a decision. 38 C.F.R. § 20.204. Withdrawal may be made by the appellant or by his or her authorized representative. 38 C.F.R. § 20.204. In the present case, the Veteran has withdrawn the appeals of increased ratings for the right knee and cervical spine disabilities. In written correspondence dated September 4, 2018, he stated that he accepted “all issues rated except right foot and right wrist.” As noted above, an appeal in regard entitlement to an increased rating for the right wrist is not currently before the Board. In regard to the claims of entitlement for increased ratings for the right knee and cervical spine disabilities, there remain no allegations of errors of fact or law for appellate consideration. Accordingly, the Board does not have jurisdiction to review the claims of entitlement for increased ratings for the right knee and cervical spine disabilities and those appeals are dismissed. Service Connection The Board has reviewed all of the evidence in the Veteran’s claims file, with an emphasis on the evidence relevant to this appeal. The Board will summarize the relevant evidence and focus specifically on what the evidence shows or fails to show as to the claims. See, e.g., Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) When there is an approximate balance of evidence regarding an issue material to the determination of a matter, the benefit of the doubt in resolving the issue shall be given to the claimant. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 4.3 (2017); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service connection may be granted for a disability resulting from injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In addition, 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). In order to prevail on the issue of entitlement to service connection, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be granted for certain chronic diseases if manifested to a degree of 10 percent or more within one year of separation from active service. 38 U.S.C. §§ 1112, 1113 (2012); 38 C.F.R. §§ 3.307, 3.309. If there is no evidence of a chronic condition during service or the applicable presumptive period, then a showing of continuity of symptomatology after service may serve as an alternative method of establishing the second and/or third element of a service connection claim. See 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet. App. 488 (1997). Cardiovascular-renal diseases, including hypertension, are included in the list of chronic diseases under 38 C.F.R. § 3.309(a). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. 1. Entitlement to service connection for a left shoulder condition. The Veteran contends that service connection is warranted for a left shoulder condition incurred in service. After thorough review of the evidence, the Board finds that while he has a current diagnosis of thoracic outlet syndrome (TOS), and his record reflects treatment for neck and shoulder issues during service, the preponderance of the evidence weighs against finding that the currently-diagnosed condition began during service or is otherwise related to his service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). As an initial matter, the Board notes that the Veteran originally claimed entitlement to service connection for a left shoulder fracture. A July 2009 MRI report included an impression of a probable non-displaced fracture at the mid aspect of the left clavicle based on a very subtle irregularity. The MRI impression was suggested to be correlated clinically, but there are no further medical records reflecting a diagnosis of a left clavicle fracture. MRI results alone without clinical correlations are not a confirmed diagnosis. The medical evidence from the period on appeal reflects a diagnosis of TOS, based upon complaints of pain and tingling and as confirmed in the December 2015 VA examination report, discussed further below. During an October 2015 informal conference with the Decision Review Officer, the Veteran described a motor vehicle accident in service. He felt that he had sustained a left shoulder fracture in service that was missed by radiological testing. Review of the claims file reveals that the Veteran was treated for a cervical spine sprain following a motor vehicle accident in 1981. Later, in 1987, he was assessed with a left shoulder strain after a wrestling injury. Upon separation from service in 1995, he reported shoulder trouble, but no shoulder defects were noted in the Report of Medical Examination. The Veteran underwent VA examination in conjunction with his claim in December 2015. The examiner noted complaints of left shoulder pain radiating to the left upper extremity. He reviewed the service treatment records (STRs), which revealed that the Veteran was seen in October 1981 after an accident and given a diagnosis of a cervical spine sprain. The examiner noted an x-ray of the cervical spine was within normal limits at that time. Also documented in the STRs was an assessment of left shoulder strain in 1987. More recently, the examiner noted a diagnosis of TOS. After a thorough explanation of TOS signs and symptoms, he stated that an acute sprain/strain is a time-limited condition and would be expected to resolve in a few weeks to few months. He found no evidence of diagnosis or treatment for intermittent or chronic left shoulder pain in the STRs. Ultimately, he concluded that the Veteran’s current left shoulder condition was less likely than not incurred in or caused by the head injury or injury to the trapezius during service. After careful consideration of the evidence of record, the Board finds that service connection is not warranted due to a lack of nexus between the currently-diagnosed TOS and the Veteran’s service. The Veteran is competent to report symptoms he has experienced, such as shoulder pain, because this requires only personal knowledge, not medical expertise. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, he is not competent to opine on the etiology of a condition like TOS, as the issue is medically complex and requires interpretation of complicated diagnostic medical testing. See Jandreau v. Nicholson, 492 F. 3d 1372, 1376 (2007). In a case such as this, where the condition has multiple potential etiologies, lay testimony is insufficient to establish causation. See, e.g., Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Given the complexity of the medical issues at hand, the examiner’s opinion is given significant weight on the nexus between the current diagnoses and the documented in-service shoulder problems. The examiner’s opinion is considered probative, as it is uncontroverted by any evidence, apart from the Veteran’s own implied assertions. See Black v. Brown, 10 Vet. App. 279, 284 (1997) (in determining the weight assigned to this evidence, the Board looks at factors such as the provider’s knowledge and skill in analyzing the medical data). Absent countervailing medical evidence, the Board itself is prohibited from exercising its own independent judgment in the Veteran’s favor. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991) (holding that the Board may not exercise its own independent judgment to resolve medical questions). While the Board has carefully reviewed the record in depth, it has been unable to identify a basis upon which service connection may be granted for a left shoulder condition. The Board has weighed the evidence of record, and finds that the preponderance of the evidence is against a finding that the currently-diagnosed TOS is related to service. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 2. Entitlement to service connection for hypertension. The Veteran contends that his hypertension is related to his period of service. Specifically, he alleged in his initial claim that he was treated for high blood pressure in service after he thought he was having a heart attack in 1988. He stated that he was on medication for high blood pressure on and off since that time. After thorough review of the evidence, the Board concludes that the preponderance of the evidence weighs against entitlement to service connection for hypertension. Post-service VA treatment records reflect a current diagnosis of hypertension. Thus, the Board’s inquiry turns to the demonstration of an in-service event or diagnosis related to high blood pressure. STRs reflect multiple blood pressure readings during service. Although elevated upon occasion, no work-up or diagnosis for hypertension is reflected. Upon separation examination in January 1995, the Veteran’s blood pressure reading was 114/82. No diagnosis of hypertension was given at that time. Thus, the inquiry turns to whether a nexus exists between the currently diagnosed hypertension and the in-service incidents of elevated blood pressure. In this regard, the Board finds that the Veteran is not competent as to the etiology of his hypertension. He is competent to attest to factual matters of which he has first-hand knowledge, such as experiencing elevated blood pressure in service. See Layno, 6 Vet. App. at 469; Washington, 19 Vet. App. at 368. However, he is not competent to opine on the complex medical question of etiology of hypertension. See Woehlaert, 21 Vet. App. 456; Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); see also Jandreau, 492 F.3d at 1377. The question of causation of a condition such as hypertension involves medical subjects concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In a case such as this, where the condition has multiple potential etiologies, lay testimony is insufficient to establish causation. Additionally, as the Veteran has asserted various differing dates of onset, as well as stating that it has been so many years that he cannot recall the exact onset of the hypertension, his conflicting statements are afforded little weight. Thus, the Board assigns no probative value to the Veteran’s assertions regarding etiology. Instead, the Board finds the objective medical evidence, including the December 2015 VA examination report, to be highly probative as to the issue of a nexus. The Board notes that the probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, his or her knowledge and skill in analyzing the data, and the medical conclusion. As is true with any piece of evidence, the credibility and weight to be attached to these opinions are within the province of the adjudicator. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for the medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379 (1998). Here, the December 2015 VA examiner reviewed the claims file and prepared a medical opinion addressing whether the Veteran’s current hypertension is related to increased blood pressure readings during service. Ultimately, he opined that it was less likely than not that the hypertension was incurred in or caused by service. The examiner noted multiple normal blood pressure readings during service, including during the separation examination in January 1995. He stated that the Veteran was not diagnosed with hypertension and did not receive treatment for the condition while in service. The examiner explained that the pathogenesis of primary hypertension is not well understood but is most likely the result of numerous genetic and environmental factors that have multiple compounding effects. Numerous risk factors for developing hypertension have been identified, including age, race, a family history of hypertension, sodium intake, alcohol intake, weight, and physical inactivity. The Board notes that the Veteran underwent VA examination in March 1996. His blood pressure was measured as 138/94. VA treatment records contain readings of 156/88 (January 1999) and 131/85 (March 1999). In June 2001, his blood pressure was reported as 129/77. Hypercholesterolemia was noted, but not hypertension. In July 2008, private treatment records reflect a reading of 140/90. No blood pressure medication was documented. In October 2011, private treatment records reflect a history of hypertension. Medications include Metoprolol, started in July 2011. Thus, while the evidence reflects elevated blood pressure readings on occasion, treatment for high blood pressure did not begin until 2011, over 10 years following the Veteran’s service. Although not dispositive, the passage of many years between discharge from active service and the continuity of symptomatology or medical documentation of a disability are factors that tend to weigh against a claim for service connection. Mense v. Derwinski, 1 Vet. App. 354, 356 (1991); Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). Notably, there is no medical evidence of record which provides a positive nexus opinion connecting the condition on appeal to the Veteran’s service. Absent countervailing medical evidence, the Board itself is prohibited from exercising its own independent judgment in the Veteran’s favor. See Colvin, 1 Vet. App. at 175. The Board also notes that the Veteran’s hypertension cannot be service connected on a presumptive basis as a chronic disease or based on continuity of symptomatology. 38 C.F.R. §§ 3.307, 3.309. There was no diagnosis of hypertension in service. Additionally, the record does not contain a diagnosis of hypertension or characteristic manifestations of the disease within a year of separation or evidence weighing in favor of continuity of symptomatology. To the extent the Veteran has implied entitlement due to a chronic disease, such a contention would be inconsistent with the competent and probative evidence of record. Accordingly, service connection is not warranted on a presumptive or continuity of symptomatology basis. Based upon the evidence of record, the Board concludes that entitlement to service connection for hypertension cannot be granted. The competent, probative evidence does not reflect a nexus between the in-service incidents of elevated blood pressure and the Veteran’s current hypertension. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 55. 3. Entitlement to service connection for cysts on the liver and kidneys. The Veteran contends that service connection is warranted for blisters on the liver and kidney. Specifically, he asserts that he was struck by lighting while in service, resulting in pain in his abdomen due to blisters on the liver and kidney. As an initial matter, VA treatment records reflect that a December 2015 CT scan indicated the presence of cysts on the Veteran’s kidneys. A July 2009 CT scan showed the presence of cysts on the kidneys and liver. When a veteran claims service connection, he or she is not claiming service connection for a specific diagnosis but for his or her symptoms regardless of the diagnosis, and the claim encompasses the underlying condition, regardless of diagnosis. Clemons v. Shinseki, 23 Vet. App. 1, 4-6 (2009). Thus, while the Veteran described the condition as blisters, the Board has recharacterized the issue as reflected on the title page of this decision. After thorough review of the evidence, the Board concludes that the preponderance of the evidence weighs against entitlement to service connection for liver and kidney cysts. STRs do not contain any indication that the Veteran was struck by lightning, resulting in cysts or pain in the abdomen. Upon separation from the service, he denied any cysts and stomach or liver trouble in the January 1995 Report of Medical History. He provided a detailed list of injuries, but no mention was made of being struck by lightning. No relevant conditions were noted in the accompanying Report of Medical Examination. The only evidence suggesting that liver and kidney cysts had their onset in service is the Veteran’s statements. While the Board acknowledges that the Veteran is competent to report being struck by lightning, this contention is in conflict with the objective medical evidence of record. See Layno, 6 Vet. App. at 469. In weighing credibility, the Board may consider interest bias, inconsistent statements, bad character, internal inconsistency, facial plausibility, self-interest, consistency with other evidence of record, malingering, desires for monetary gain, and demeanor of the witness. Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Furthermore, statements made for the purpose of diagnosis or treatment “are regarded as inherently reliable because of the recognition that one seeking medical treatment is keenly aware of the necessity for being truthful in order to secure proper care.” Williams v. Gov. of Virgin Islands, 271 F.Supp.2d 696, 702 (V.I. 2003); see Fed. R. Evid. 803(4) and accompanying Notes (noting statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth); Rucker, 10 Vet. App. at 73 (providing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate). Because the Veteran’s current statements regarding cysts, made in connection with a pending claim for VA benefits, are inconsistent with statements made earlier in his STRs for the purposes of obtaining medical care, the Board finds that his lay statements concerning the onset and continuity of symptoms cannot be deemed credible. Consequently, the Board assigns them little probative value. Notably, the medical evidence of record suggests that the cysts are unrelated to the Veteran’s service. Following an August 2016 CT scan, VA treatment notes indicate that treatment provider felt they are related to proteinaceous and/or hemorrhagic content. Finally, to the extent they may be considered “calculi of the kidney,” the Veteran’s kidney cysts cannot be service connected on a presumptive basis as a chronic disease in this case. 38 C.F.R. §§ 3.307, 3.309. The presumption for chronic diseases deals with three situations: 1) a chronic diagnosis in service linked to the same chronic diagnosis after service; 2) a chronic diagnosis or symptoms thereof within a year of separation; or 3) continuity of symptomatology. As described above, there was no diagnosis of cysts in service and the Veteran’s separation examination and report of medical history are silent to any relevant issues. Additionally, the record does not contain a diagnosis of cysts within a year of separation. Furthermore, the evidence weighs against a finding of continuity of symptomatology. It was not until over 10 years following his service that the record indicates the presence of cysts. Thus, to the extent that the Veteran has implied entitlement due to a chronic disease, such a contention would be inconsistent with the probative evidence of record. Accordingly, service connection is not warranted on a presumptive basis. Accordingly, the Board concludes that most competent and credible evidence of record weighs against a finding that cysts of the liver or kidneys are causally or etiologically related to the Veteran’s service. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53. REASONS FOR REMAND 1. Entitlement to service connection for residuals of right great toe surgery, to include hallux valgus and arthritis in the first metatarsal, is remanded. The Veteran contends that service connection is warranted for his right great toe, in addition to the existing grant of service connection for right foot Morton’s neuroma involving the little toe. In support of this claim, the Veteran has advanced several theories of entitlement, including direct service connection due to in-service foot injuries and secondary service connection due to the existing service-connected right foot condition. Multiple medical opinions have been obtained regarding the present claim. In January 2014, a VA examiner opined that it is less likely than not that the surgery of the right great toe is due to the service connected little toe. No nexus was found between syndactyly/arthroplasty of fifth toe and subsequent development of hallux valgus. In March 2015, an addendum opinion reported that it is less likely than not that the service-connected fifth toe aggravated the right great toe hallux valgus, as there is no causal relationship between the conditions. The examiner also opined that it is less likely than not that the current great right toe condition is related to the in-service treatment of the feet and toes. In December 2015, another VA examination report was prepared. Metatarsalgia of the right foot was reported to be at least as likely as not incurred in or caused by the claimed in-service injuries. This condition was subsequently included in the right foot rating with the existing Morton’s neuroma of the little toe. Additionally, the examiner opined that the right foot hallux valgus and bunion deformity is less likely than not incurred in or caused by or aggravated by his service connected condition of Morton’s neuroma of right foot with arthroplasty syndactyly little toe. Most recently, in February 2018, a VA examination report included diagnoses of right foot Morton’s neuroma, metatarsalgia, hallux valgus, degenerative arthritis, status post arthroplasty with middle hemi-phalangectomy, fifth toe. The examiner stated that the degenerative joint disease was secondary to the first metatarso-phalangeal joint. While the record contains multiple detailed medical opinions, the nature and etiology of the right foot degenerative arthritis by the Veteran’s service-connected Morton’s neuroma of right foot with arthroplasty syndactyly little toe has not been fully addressed. Accordingly, remand is warranted for an addendum opinion on this issue. 2. Entitlement to an increased rating in excess of 10 percent for right foot Morton’s neuroma, status post excision with arthroplasty and syndactyl little toe is remanded. In a January 2018 statement, the Veteran indicated that he had previously submitted photographs depicting discoloration of his right foot. He alleged that the photographs reflect internal bruising as the result of toe fusion surgery and neuromas. These photographs are not included in the claims file. Upon remand, the photographs of the Veteran’s right foot should be requested and associated with the claims file. If the photographs are located or received from the Veteran, an addendum medical opinion should be obtained to address the severity of the service-connected right foot condition, including discussion of the photographic evidence. 3. Entitlement to a temporary total rating following right toe surgery is remanded. A temporary total rating can only be assigned for service-connected disabilities (“a service-connected disability has required hospital treatment...”). 38 C.F.R. §§ 4.29, 4.30 (2017). Thus, the issue of entitlement to a temporary total rating following surgery on the right great toe is inextricably intertwined with the claim for service connection for the right great toe. The appropriate action is to defer consideration of the temporary total rating claim until a decision is reached on the service connection claim. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that where a decision on one issue would have a “significant impact” upon another, and that impact in turn could render any appellate review on the other claim meaningless and a waste of judicial resources, the two claims are inextricably intertwined). The matters are REMANDED for the following action: 1. Undertake appropriate action to locate and associate the right foot photographs with the claims file, to include requesting from the Veteran if needed. 2. If the right foot photographs are located or received from the Veteran, an addendum medical opinion should be obtained to address the current severity of the service-connected right foot Morton’s neuroma, status post excision with arthroplasty and syndactyl little toe, including discussion of the photographic evidence. 3. Obtain an addendum opinion from an appropriate clinician to determine the nature and etiology of the diagnosed right foot arthritis. The examiner should review the claims folder and this fact should be noted in the accompanying medical report. (a.) The examiner must opine whether the right foot degenerative arthritis is at least as likely as not related to an in-service injury, event, or disease. (b.) The examiner must opine whether the right foot degenerative arthritis is at least as likely as not (1) proximately due to the service-connected right foot Morton’s neuroma, status post excision with arthroplasty and syndactyl little toe, or (2) aggravated beyond its natural progression by the service-connected right foot Morton’s neuroma, status post excision with arthroplasty and syndactyl little toe. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Jamison, Elizabeth G.