Citation Nr: 18158891 Decision Date: 12/18/18 Archive Date: 12/18/18 DOCKET NO. 16-46 539 DATE: December 18, 2018 REMANDED Entitlement to service connection for bilateral trochanteric bursitis is remanded. Entitlement to service connection for bilateral knee strain is remanded. Entitlement to service connection for left foot tendonitis is remanded. Entitlement to service connection for right foot tendonitis is remanded. Entitlement to a rating in excess of 30 percent for asthma is remanded. REASONS FOR REMAND These matters reach the Board of Veterans’ Appeals (Board) on appeal of July 2011 and September 2013 decisions of a Department of Veterans Affairs (VA) regional office (RO). 1. Entitlement to service connection for bilateral trochanteric bursitis is remanded. 2. Entitlement to service connection for bilateral knee strain is remanded. The Veteran served on active duty from March 1992 to June 1995. In February 2011, she sought service connection for joint pain in her bilateral hips and lower extremities. In May 2011, she underwent VA examination for joints, including the hips and knees. The examiner noted that radiology showed no degenerative changes in either the hips or the knees. She provided diagnoses of bilateral trochanteric bursitis in the hips and bilateral knee strain. Although she noted that the Veteran’s service treatment records (STRs) showed multiple in-service complaints of hip and knee pain, she also noted that the May 2011 examination was taking place 16 years after the Veteran’s 1995 discharge, and explained that because there was no continuity of care documented during that interval, she could not offer an opinion concerning service connection for those disorders without resorting to speculation. The examiner noted that she had reviewed the Veteran’s claims file and VA medical records, but also noted that certain of the Veteran’s VA medical records from a New York medical center were not available for review at the time of the examination. The Board notes that these would have included records from April and June 1996, now associated with the Veteran’s claims file, reflecting post-service orthopedic visits in which she complained of hip and knee pain. The Board also notes the presence of a February 2000 VA medical record in which the Veteran complains of knee and hip pain since service. A thorough medical examination is one that takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board notes that the May 2011 VA joints examination did not include a review of all of the relevant medical records, and thus is inadequate. Further, the examiner did not offer a medical opinion evaluating service connection for the Veteran’s hips and knees. VA must provide a claimant a medical examination or obtain a medical opinion when such an examination or opinion is necessary to make a decision on a claim for compensation. 38 U.S.C. § 5103(d)(1) (2012); 38 C.F.R. § 3.159(c)(4) (2018). Accordingly, the Board will remand for new examinations and opinions for the Veteran’s knee and hip claims. 3. Entitlement to service connection for left foot tendonitis is remanded. 4. Entitlement to service connection for right foot tendonitis is remanded. In February 2012, VA provided the Veteran with an examination for her feet. The examiner diagnosed two disorders of the feet: mild bilateral flatfoot and mild degenerative joint disease (DJD) in the left foot. The examiner stated that the only record of foot problems in service was the pre-discharge examination, showing left foot problems with no diagnosis. The examiner opined that it was less likely as not that the Veteran’s left foot condition was related to service, because there was no in-service record of flatfoot or treatment for any other foot problems, and no post-service record of foot issues until 2011. The Board notes, however, that the Veteran’s examination at entry into service specifically diagnosed mild, bilateral asymptomatic flatfoot as a pre-existing condition. In May 1994 she sought treatment for pain in the soles of both feet, on walking or standing, of one week’s duration. Her pre-discharge examination cited an eight-month history of left-foot pain associated with running, with a diagnosis of sprain, as well as tenderness between the first and second toes on palpation. Thus, the February 2012 examination was based on an inaccurate factual premise, which is not probative. See Reonal v. Brown, 5 Vet. App. 458 (1993). Where, as here, a pre-existing medical condition is noted specifically on the entrance physical examination, service connection requires a showing that the condition was aggravated beyond its natural progression during the Veteran’s service. 38 U.S.C. §§ 1111, 1153 (2012); 38 C.F.R. § 3.306 (2018). The February 2012 examiner failed to offer an opinion whether such aggravation occurred in the Veteran’s pre-existing flatfoot condition. The examiner further offered no opinion on whether the Veteran’s left foot DJD was causally or etiologically related to service, and offered no explicit opinion concerning the Veteran’s right foot claim. As a result, the February 2012 examination is inadequate for rating purposes. The RO provided the Veteran with another VA foot examination in March 2016. The examiner noted diagnoses of two disorders of the feet: flatfoot and DJD. The examiner noted the diagnosis of mild, asymptomatic flatfoot on the Veteran’s entrance examination. He noted two in-service complaints of foot problems: in May 1994, which noted pain to the bottoms of both feet while walking and standing, with a diagnosis of overuse, and in June 1995, noting left foot pain between the first and second digits, with an assessment of foot sprain. He observed that there were no further complaints of foot problems in either the STRs or the post-service medical records. He opined that there was no objective evidence of aggravation in the Veteran’s pre-existing flatfoot condition during service. The Board notes, however, that the cited June 1995 incident appears to be a notation in the Veteran’s exit examination, with the diagnosis of sprain pertaining to an eight-month history of foot pain related to running, not considered in the examiner’s medical opinion. The examiner’s failure to address this issue undermines the validity of his opinion concerning in-service aggravation of the Veteran’s pre-existing flatfoot. Further, the examiner’s opinion that the Veteran’s 2016 diagnosis of bilateral foot DJD could not be related to her flatfoot did not consider the Veteran’s 2011 diagnosis of left foot DJD, or whether the Veteran’s bilateral foot DJD was related to her service, independent of her flatfoot condition. A medical opinion is adequate when it is based upon consideration of the Veteran’s prior medical history and examinations and also describes the disability in sufficient detail so that the Board’s “evaluation of the claimed disability will be a fully informed one.” Barr v. Nicholson, 21 Vet. App. 303 (2007). An adequate rationale must be provided for any medical opinion rendered; a conclusory, contradictory or incomplete analysis is not adequate. Stefl v. Nicholson, 21 Vet. App. 120 (2007). As a result of the above defects, however, the Board finds the March 2016 examiner’s opinions inadequate for rating purposes, and will remand for a new bilateral foot examination and medical opinions. 5. Entitlement to a rating in excess of 30 percent for asthma is remanded. In May 2011 the Veteran underwent a VA respiratory examination, including pulmonary function testing. In light of the passage of time since the last examination, and the Veteran’s assertion in her March 2014 notice of disagreement that her asthma had worsened, the Board finds that a new respiratory examination is necessary to evaluate the current severity of the Veteran’s asthma disability. Snuffer v. Gober, 10 Vet. App. 400 (1997). The matters are REMANDED for the following action: 1. Undertake appropriate efforts to obtain any relevant outstanding VA or private medical records, and associate them with the claims file. 2. Thereafter, afford the Veteran a VA examination to determine the nature and etiology of any currently diagnosed disabilities of the feet, to include flatfoot. The examiner must review the Veteran’s entire claims file, including this remand, and must obtain a detailed clinical history from the Veteran. All pertinent pathology found on examination must be noted in the report. Any testing deemed necessary must be performed. The examiner must opine as to the following: (a) For each diagnosed disability of the feet other than flatfoot, the examiner must offer an opinion as to whether it is at least as likely as not (a probability of 50 percent or greater) that the disability began during service, or is causally or etiologically due to service. (b) Did the Veteran’s pre-existing flatfoot increase in severity during her period of military service? If so, the examiner must address whether there is clear and unmistakable evidence that the increase in disability was a result of the natural progress of the disability. (The examiner is advised that the Veteran was diagnosed with mild, asymptomatic flatfoot upon her entry into service.) 3. Afford the Veteran VA examination to determine the nature and etiology of any currently diagnosed disability of the hips and knees. The examiner must review the Veteran’s entire claims file, including this remand, and must obtain a detailed clinical history from the Veteran. All pertinent pathology found on examination must be noted in the report. Any testing deemed necessary must be performed. For each disability of the hips and knees found to be present, the examiner must offer an opinion as to whether it is at least as likely as not (a probability of 50 percent or greater) that the diagnosed disability began during service, or is causally or etiologically due to service. 4. Afford the Veteran a VA examination to evaluate the current severity of her service-connected asthma. The examiner is advised that the Veteran is competent to report history and symptoms and that those reports must be considered in formulating any requested opinion. If the examiner rejects the Veteran’s reports, the examiner must provide a rationale for doing so. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD David S. Katz, Associate Counsel