Citation Nr: 18157843 Decision Date: 12/13/18 Archive Date: 12/13/18 DOCKET NO. 16-53 216 DATE: December 13, 2018 REMANDED Entitlement to service connection for disabilities of the great toe of the Veteran’s left foot, including hallux valgus, hallux limitus, and onychomycosis, is remanded. Entitlement to service connection for a bilateral foot disability, including heel spurs, plantar fasciitis, bilateral hallux valgus, and onychomycosis, is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1977 through October 1983. The case comes before the Board of Veterans’ Appeals (Board) from a December 2013 rating decision and a February 2015 rating decision. The December 2013 rating decision denied service connection for the Veteran’s currently diagnosed hallux valgus, hallux limitus, and onychomycosis because there was no nexus between the disabilities and the Veteran’s service. The February 2015 rating decision denied service connection for a bilateral heel spur disability because the Veteran’s disability was not connected to any in-service injury. The issues on appeal have been recharacterized as noted above for clarity and to better reflect the Veteran’s assertions. 1. Entitlement to service connection for disabilities of the great toe of the Veteran’s left foot, including hallux valgus, hallux limitus, and onychomycosis, is remanded. The Veteran asserts that her current disabilities of the great toe of her left foot are the result of ill-fitting military boots worn while on active duty. The Veteran’s service treatment records (STRs) indicate that the Veteran underwent treatment for a painful great toe nail in July 1980. Additionally, it appears that the Veteran may have had mild inflammation of the hallux, left greater than right, although the handwritten podiatry entry is difficult to discern. The Veteran was afforded a VA examination in December 2013. The examiner noted the Veteran’s treatment for an injury to the great toenail of her left foot while in service, but explained that no additional complaints or foot abnormalities were documented within the Veteran’s STRs throughout her military career. This being the case, the examiner concluded that the Veteran’s current disabilities are not related to her in-service treatment. However, the examiner did not address the Veteran’s assertion that her problems are the result of wearing ill-fitting boots during active duty. While the examiner noted the assertion, the examiner did not opine as to whether the boots could have caused the disabilities currently plaguing the great toe of the Veteran’s left foot. Similarly, the examiner noted that the Veteran was being treated for hallux valgus, hallux limitus, and onychomycosis; however, the examiner did not opine as to whether any of these conditions had their onset during service. Following this examination, additional STRs were submitted, and appear to show reports of painful toes in March 1977 (although the handwriting on the note is nearly illegible). It appears that new foot wear was issued as a result. A December 2008 VA foot x-ray report notes early bunion formation with minimal hallux valgus deformity and moderate calcaneal spur of the right foot. An October 2013 VA podiatry note shows that the Veteran was assessed with bilateral plantar keratosis, plantar flexed 5th metatarsal, hallux limitus, hallux valgus, and onychomycosis. The plan was to order custom orthotics with deep heel seats, semi-rigid base with calcaneal spur padding soft growth to toes with a reverse Morton’s extension. The custom orthotics evaluation noted that the left foot was more problematic than the right. She had callus formations on both heels, and on the first and 5th metatarsal heads. The left toe was very sensitive. A March 2014 VA podiatry note reveals that the Veteran had multiple foot keratotic lesions. Another March 2014 podiatry note reveals diagnoses of bilateral bunion deformities. In July 2014, the Veteran was seen by her primary care physician at a VAMC. The physician found that the Veteran’s foot problems were caused by her military boots. However, the physician did not explain what exact problems are caused by the boots. Specifically, the physician did not explain which of the disabilities plaguing the Veteran’s great toe of her left foot are likely caused by the boots worn during active duty and which disabilities likely have other causes. At a March 2015 VA podiatry appointment, the Veteran reported that she had significant heel pain which appeared to be worsening. She reported that she had the condition previously during active duty and it appears to have returned. She described burning pain that radiated up the back of the legs with standing and walking for extended periods. The Veteran’s primary care physician again stated in July 2015 that the Veteran’s foot problems are caused by her military boots, but again did not address which particular problems are caused by the ill-fitting boots. The Veteran has multiple current disabilities that relate to her feet and thus it is necessary to have a medical opinion that reviews the Veteran’s current disabilities and determines which are likely to have been caused by her military boots and which have another cause. Moreover, at the time of the 2013 VA examination, the record did not yet include the Veteran’s credible and competent evidence regarding her observable symptoms since service. See October 2016 and March 2017 VA Form 9s. Accordingly, this case is remand for an additional examination that addresses which disabilities are the result of the Veteran’s ill-fitting military boots. 2. Entitlement to service connection for a bilateral foot disability to include heel spurs, plantar fasciitis, bilateral hallux valgus, and onychomycosis, is remanded. The Veteran asserts that her bilateral heel spurs are the result of the ill-fitting military boots she worn while on active duty. There is no indication in the Veteran’s STRs that she was ever treated for a problem regarding either of her heels. The Veteran was not afforded a VA examination that specifically evaluated her claim for service connection for heel spurs. The general foot examination conducted in December 2013 was used by the regional office in evaluating her claim for heel spurs, even though the examiner did not specifically address the Veteran’s claim for compensation regarding her bilateral heel spurs. For service connection claims, VA is obliged to provide an examination or obtain a medical opinion in a claim when (1) the record contains competent evidence that the claimant has a current disability, (2) the record indicates that the disability or signs and symptoms of disability may be associated with active service, and (3) the record does not contain sufficient information to decide the claim. See 38 U.S.C. § 5103A (d) (2012); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). The threshold for finding a potential link between current disability and service is low. Locklear v. Nicholson, 20 Vet. App. 410 (2006); McLendon, 20 Vet. App. at 83. Here, in both July 2014 and July 2015 the Veteran’s primary care physician concluded the Veteran’s foot disabilities are caused by ill-fitting military boots worn during service. However, as noted above, the physician did not specially explain which of the numerous disabilities are the result of the boots and which, if any, resulted from something other than the Veteran’s active duty military service. Thus, the Board does not have the requisite information to make a fully informed decision as to whether the Veteran’s bilateral heel spurs are the result of the boots worn during active duty. Accordingly, the claim is remanded for a further examination to determine which disabilities, if any, are the result of wearing ill-fitting military boots. The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 2. Schedule the Veteran for a VA examination with an appropriate examiner to determine the etiology of any foot disability currently plaguing the Veteran. Specifically, the examiner should opine whether it is as least as likely as not (50 percent probability or more) that the Veteran’s bilateral heel spurs, hallux valgus, hallux limitus, and/or onychomycosis are the result of the Veteran wearing ill-fitting military boots while on active duty and/or whether the origin of the Veteran’s current foot problems began during service considering that no foot problems were noted prior to service, and the Veteran was treated for foot problems during service. In offering any opinion, the examiner must consider the full record, to include the STRs, the Veteran’s credible lay statements regarding in-service incurrence and observable symptoms since service, and the notations in 2014 and 2015 from the Veteran’s VA primary care physician and podiatrist as to the etiology of the foot disabilities. The opinion should reflect such consideration. A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records. The examiner should consider the Veteran's self-reported history regarding onset and observable symptoms. If the examiner is unable to reach an opinion without resort to speculation, he or she should explain the reasons for this inability. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Shelton, Law Clerk