Citation Nr: 20003896 Decision Date: 01/16/20 Archive Date: 01/15/20 DOCKET NO. 17-62 405A DATE: January 16, 2020 ORDER Service connection for right foot metatarsalgia is denied. Service connection for right foot hallux valgus is denied. FINDINGS OF FACT 1. The preponderance of the competent medical and other evidence of record is against a finding that the Veteran’s current right foot metatarsalgia was incurred in or is otherwise the result of active service. 2. The preponderance of the competent medical and other evidence of record is against a finding that the Veteran’s current right foot hallux valgus was incurred in or is otherwise the result of active service. CONCLUSIONS OF LAW 1. The criteria for an award of service connection for right foot metatarsalgia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for an award of service connection for right foot hallux valgus have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty as a cadet at the United States Air Force Academy from June 1980 to May 1984 and on subsequent active duty in the Air Force from May 1984 to September 1992. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision issued by the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida. This case was previously before the Board in April 2019. The Board granted service connection for hallux rigidus of the right foot and remanded the right foot metatarsalgia and hallux valgus claims for additional development, to include a medical nexus opinion. There has been at least substantial compliance with the Board’s remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for right foot metatarsalgia 2. Entitlement to service connection for right foot hallux valgus Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). In adjudicating the Veteran's claims, the Board observes that nothing of record shows that he has the requisite knowledge, skill, experience, training, or education to render medical opinions. Consequently, his contentions cannot constitute competent medical evidence. 38 C.F.R. § 3.159(a)(1). However, in making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and recurrence of observable symptoms. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). When considering whether lay evidence is competent, the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the benefit of the doubt shall be given to the claimant. 38 U.S.C. § 5107(b). When a reasonable doubt arises regarding service origin, such doubt will be resolved in the favor of the claimant. Reasonable doubt is doubt which exists because of an approximate balance of positive and negative evidence which does not satisfactorily prove or disprove the claim. 38 C.F.R. § 3.102. The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether the preponderance of the evidence is against the claim, in which event the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). In this case, the Veteran has contended that he developed disabilities of the right foot as a result of injuries sustained while playing sports, including lacrosse. The Board notes that the Veteran’s service treatment records do not explicitly note any treatment for right foot injuries from playing sports. However, he is competent as a lay person to describe such injuries. Further, his service treatment records document other sports-related injuries, including to the right thumb and left shoulder. In addition, he was treated in 1989 after dropping a heavy object on his foot. Those facts notwithstanding, the Veteran’s feet were clinically evaluated as normal on service department examinations in 1990 and 1992. He also indicated on concurrent Reports of Medical History that he did not have any foot trouble. In addition, while injuries to the left shoulder and right thumb from playing lacrosse while on active duty were noted on a February 1994 VA general medical examination, there was no mention of a right foot injury. The evaluation of his feet revealed that his big toes showed some tinea unguium infection, and these appeared to be discolored and slightly deformed toenails. However, there were no findings of metatarsalgia and/or hallux valgus of the right foot. In fact, the first competent medical findings of such appears to be several years after his separation from service. The United States Court of Veterans Claims (Court) has indicated that the normal medical findings at the time of separation from service, as well as the absence of any medical records of a diagnosis or treatment for many years after service can be probative evidence against the claim. See Mense v. Derwinski, 1 Vet. App. 354, 356 (1991) (affirming Board where it found that veteran failed to account for the lengthy time period after service for which there was no clinical documentation of low back condition); see also Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (A prolonged period without medical complaint can be considered, along with other factors concerning a claimant's health and medical treatment during and after military service, as evidence of whether an injury or a disease was incurred in service which resulted in any chronic or persistent disability.) For these reasons, the Board finds that the competent medical evidence is required to determine whether the Veteran’s current metatarsalgia and/or hallux valgus is etiologically linked to service. Here, the evidence includes an August 2016 private opinion from J.A., DPM, which provides some support for the Veteran’s claim. Although the record also includes a September 2016 opinion from Dr. P.K., that opinion only addressed hallux rigidus. Opinions resulting from VA examinations conducted in May 2014 and November 2019 weigh against the Veteran’s claim. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See Id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. Most of the probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight, and review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion . . . must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.”). Initially, the Board notes that there is nothing in the record which causes it to question the qualifications of J.A., DPM, the May 2014 VA examiner, and/or the November 2019 VA examiner. However, it is not clear whether the opinion from J.A. was based upon an accurate understanding of the Veteran’s medical history. For example, while J.A. noted the reported sports-related injury to the right foot, and noted multiple records had been reviewed, he did not address the normal evaluations of the feet on the 1990 or 1992 service examinations, or the lack of pertinent findings on the February 1994 VA general medical examination. Conversely, the November 2019 VA examiner explicitly and accurately noted these and other detailed findings regarding the Veteran’s right foot in the service treatment and post-service medical records. The Board further notes that while J.A., DPM, noted metatarsalgia and the fact that the Veteran underwent bunionectomy for hallux valgus deformity, it does not appear the August 2016 opinion was explicitly in regard to those disabilities. J.A.’s opinion also discusses the impairment attributable to hallux rigidus, which is a separately diagnosed and already service-connected disability. Further, while J.A. opined the diagnosed conditions were due to in-service injury related to playing lacrosse, no detailed rationale appears to have been provided in support of that opinion. The May 2014 VA examiner opined that the Veteran’s disabilities of the right foot, to include hallux valgus and metatarsalgia, were less likely than not caused by or related to military service, to include dropping a heavy object on his foot in 1989. The rationale was that the Veteran’s service treatment records were silent for any complaints, diagnosis, or treatment regarding these disabilities. However, as noted in the April 2019 remand, this VA examiner did not explicitly address whether the disabilities were related to the Veteran’s participation in sports. The November 2019 VA examiner, on other hand, explicitly noted both the hallux valgus and metatarsalgia, and provided a detailed description as to the nature of the former. The examiner also referred to both the detailed medical history and nature of hallux valgus as part of the underlying rationale. In light of the foregoing, the Board finds that the August 2016 opinion from J.A., DPM, as well as the May 2014 VA examiner, are entitled to limited probative value, while the November 2019 VA examiner’s opinion is entitled to significant probative value. Consequently, the Board must conclude that the preponderance of the competent medical and other evidence of record is against a finding the Veteran’s current right foot metatarsalgia and/or hallux valgus was incurred in or otherwise the result of active service. As the preponderance of the evidence is against these claims, the benefit of the doubt doctrine is not for application. See generally Gilbert, supra; see also Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001). No other basis for establishing service connection for the claimed disabilities is otherwise demonstrated by the evidence of record, to include the presumptive provisions of 38 C.F.R. §§ 3.307 and 3.309 or as secondary to a service-connected disability pursuant to 38 C.F.R. § 3.310.  For these reasons, the Board finds that the claims for service connection for right foot metatarsalgia and hallux valgus must be denied. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board John Kitlas, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.