Citation Nr: 18158030 Decision Date: 12/14/18 Archive Date: 12/14/18 DOCKET NO. 16-40 539A DATE: December 14, 2018 REMANDED Entitlement to service connection for left foot plantar fasciitis is remanded. Entitlement to service connection for a right foot disorder, to include plantar fasciitis, is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to an evaluation higher than 10 percent for chondromalacia of the right knee is remanded. Entitlement to an initial compensable evaluation for left foot plantar fibromatosis is remanded. REASONS FOR REMAND The Veteran served honorably in the Air Force from May 1985 to December 1994. This case comes before the Board of Veterans’ Appeals (Board) on appeal from May 2015 and August 2015 rating decisions of the Department of Veteran Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. The Veteran was initially denied entitlement to service connection for a left knee disorder in an October 2014 rating decision. August 2014 private treatment records were added to the file, thus keeping that rating decision pending. See 38 C.F.R. § 3.156(b). Accordingly, reopening is not required. 1. Service Connection - Left Foot Plantar Fasciitis Remand is required to secure an adequate VA examination for left plantar fasciitis. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Where the Veteran has provided lay testimony of an in-service injury, an examiner cannot ignore that lay evidence and base his or her opinion that there is no relationship to service on the absence of in-service corroborating medical records. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). Generally, a medical opinion should address the appropriate theories of entitlement. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007). The Veteran received a VA examination in August 2015. The examiner opined that the plantar fasciitis was not incurred in or cause by service. Additionally, the examiner opined that the plantar fasciitis was less likely than not proximately due to or the result of his left foot plantar fibromatosis. The examiner based this opinion on the finding that the Veteran was never diagnosed with plantar fasciitis in-service. During a May 2015 VA treatment, the Veteran alleged left foot pain since service. The examiner failed to address: 1) the Veteran’s lay statements of pain since service, 2) complaints of left foot and heel pain in the Veteran’s service treatment records (STRs), and 3) a diagnosis of left foot periostitis in in the Veteran’s STRs. Additionally, the examiner did not address whether the service-connected left foot plantar fibromatosis aggravated a current left foot disorder. Accordingly, remand is required to adequately address the evidence and the Veteran’s lay statements. 2. Service Connection - Right Foot Disorder Remand is required to secure an adequate VA examination for a right foot disorder. Generally, a medical opinion should address the appropriate theories of entitlement. Stefl, 21 Vet. App. at 123-24. In the August 2016 substantive appeal, the Veteran suggested his bilateral foot disorder was secondary to his service-contented bilateral dupuytren’s contracture. The Veteran received a VA examination for the feet in August 2015. The examiner found no right foot disorder but noted pain on use of both feet. A May 2015 VA treatment record showed small painful lesions on the right foot with an assessment of plantar and palmar fibromatosis with plantar fasciitis. Additionally, the VA examiner failed to provide an opinion for direct service connection or secondary service connection. Accordingly, remand is required. 3. Service Connection - Left Knee Disorder Remand is required to secure an adequate VA examination for the left knee disorder. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). The Veteran received a VA examination in August 2014. The examiner opined it was less likely than not the left knee disorder is proximately due to or the result of the service connected right knee disorder, explaining that the medical literature does not support the Veteran’s claim. This rationale does not provide an explanation of why, and does not address that the examiner found that the residual signs and/or symptoms of several right knee meniscus repairs and chondroplasty included pain in both knees. Additionally, a September 2014 VA treatment record indicated the Veteran’s left knee problems were likely due to some increased wear and tear secondary to placing more stress on the left knee because of problems with the right knee. Accordingly, remand is required to address the inconsistencies in the record. 4. Increased Evaluation - Right Knee Remand is required to adequately assess the severity of the Veteran’s service connected right knee. In increased evaluation claims, VA examinations for musculoskeletal conditions must include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 38 C.F.R. § 4.59 (2018); Correia v. McDonald, 28 Vet. App. 158 (2016). In increased evaluation claims, a VA examination report is not adequate without an explanation for an examiner’s failure to evaluate the functional effects of a flare-up. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board may accept a VA examiner’s statement that he or she cannot offer an opinion in that regard without resorting to speculation, but only after determining that this is not based on the absence of procurable information or on a particular examiner’s shortcomings or general aversion to offering an opinion on issues not directly observed. Although not binding on VA examiners, the VA Clinician’s Guide instructs examiners when evaluating certain musculoskeletal conditions to obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves. Sharp, 29 Vet. App. at 34-35, citing VA CLINICIAN’S GUIDE, ch. 11. For example, a VA examination report is not adequate when the VA examiner failed to elicit relevant information as to the veteran’s flares or ask him to describe the additional functional loss, if any, he suffered during flares and then estimate the veteran’s functional loss due to flares based on all the evidence of record- including the veteran’s lay information-or explain why she or he could not do so. Sharp, 29 Vet. App. at 34-35. The Veteran received a VA examination in August 2014. In September 2014, the Veteran had right knee surgery. The Veteran received an additional VA examination in August 2015. The Veteran endorsed pain with weight bearing, pain with repeated use over time, and pain during flare-ups. The examiner noted no pain with weight bearing. The examiner noted the examination was not being conducted during a flare-up. The examiner opined that the examination was neither medically consistent or inconsistent with the Veteran’s statements describing functional loss during flare-ups. And that he or she could not offer an opinion on functional effects of flare-ups based solely on no observation. Accordingly, remand is required for Sharp and Correia compliance.   5. Compensable Evaluation - Left Foot Lastly, remand is required because the evaluation of the left foot is inextricably intertwined with the claim for entitlement to service connection for left plantar fasciitis. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (holding that issues are inextricably intertwined and must be considered together when a decision concerning one could have a significant impact on the other). The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his left foot plantar fasciitis. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the left foot plantar fasciitis and any other left foot disorder had onset in, or is otherwise related to, active military service. Second, the examiner must provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the left foot plantar fasciitis and any other left foot disorder is caused or aggravated by the service-connected left foot fibromatosis. Third, the examiner must provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the left foot plantar fasciitis or any other left foot disorder is caused or aggravated by the service-connected bilateral dupuytren’s contracture (palmer fibromatosis).   The examiner must specifically address the following: 1) the Veteran’s statements of pain since service; 2) complaints of left foot and heel pain in the STRs; and 3) a diagnosis of left foot periostitis in the STRs. 4. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his right foot disorder, to include right foot plantar fasciitis. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each right foot disorder had onset in, or is otherwise related to, active military service. Second, the examiner must provide an opinion whether it is at least as likely as not (50 percent or greater probability) that each right foot disorder is caused or aggravated by the service-connected bilateral dupuytren’s contracture (palmer fibromatosis). The examiner must specifically address VA treatment for painful lesions on the right foot with an assessment of plantar and palmar fibromatosis with plantar fasciitis. 5. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his left knee disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. First, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the left knee disorder had onset in, or is otherwise related to, active military service. Second, the examiner must provide an opinion whether it is at least as likely as not (50 percent or greater probability) that the left knee disorder is caused or aggravated by the service-connected right knee chondromalacia. The examiner must specifically address a September 2014 VA treatment record that indicated the Veteran’s left knee problems were likely due to some increased wear and tear secondary to placing more stress on the left knee because of problems with the right knee. 6. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected right knee chondromalacia. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must utilize the appropriate Disability Benefits Questionnaire. The examiner is also asked to indicate the point during range of motion testing that motion is limited by pain. The examiner must test the range of motion and pain of the right knee in active motion, passive motion, weight-bearing, and non-weight-bearing. Describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. Additional limitation of motion during flare-ups and following repetitive use due to limited motion, excess motion, fatigability, weakened motion, incoordination, or painful motion must also be noted. If the Veteran describes flare-ups of pain, the examiner must offer an opinion as to whether there would be additional limits on functional ability during flare-ups. All losses of function due to problems such as pain should be equated to additional degrees of limitation of flexion and extension beyond that shown clinically. Should the examiner state that he or she is unable to offer such an opinion without resorting to speculation based on the fact that the examination was not performed during a flare, the examiner is directed to do all that reasonably can be done to become informed before such a conclusion, to include ascertaining adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding his flares by alternative means. 7. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the severity of the service-connected left foot plantar fibromatosis. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized. 7. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claims, and that the consequences for failure to report for a VA examination without good cause may include denial of the claims. 38 C.F.R. §§ 3.158, 3.655 (2017). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. Bruton, Associate Counsel