Citation Nr: 20009919 Decision Date: 02/06/20 Archive Date: 02/05/20 DOCKET NO. 13-00 597 DATE: February 6, 2020 ORDER Service connection for right leg shin splints is denied. Service connection for left leg shin splints is denied. An initial rating in excess of 10 percent for bilateral pes planus with plantar fasciitis and hallux valgus with right bunionectomy is denied. REMANDED The issue of service connection for a lumbar strain is remanded. FINDINGS OF FACT 1. A right leg shin splint disability did not begin during active service and is not otherwise related to an in-service injury or disease, including the documented complaints of right leg shin pain experienced in September and October 1982. 2. A left leg shin splint disability did not begin during active service and is not otherwise related to an in-service injury or disease. 3. Since service connection was established, bilateral pes planus with plantar fasciitis and hallux valgus status post right bunionectomy has been manifested at worst by pain on use accentuated with symptoms improved by use of arch supports or orthotics; x-ray evidence of mild flattening of the arches of both feet on weight-bearing views; mild to moderate bilateral hallux valgus with clinical and x-ray evidence of right foot bunionectomy; and tenderness to palpation of the plantar calcanei and fascia, which resolved. CONCLUSIONS OF LAW 1. The criteria for service connection for right leg shin splints are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for left leg shin splints are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for an initial rating in excess of 10 percent for bilateral pes planus with plantar fasciitis and hallux valgus with right bunionectomy have not been met. 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1, 4.71a, Diagnostic Code 5280-5276. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1982 to April 1984. This matter comes before the Board of Veterans’ Appeals (Board) from an April 2010 rating decision. In October 2016, the Veteran testified at a Board hearing; a transcript of the hearing is associated with the claims file. In April 2017, the Board remanded the appeal to the agency of original jurisdiction (AOJ) for additional development. 1. Service connection for right leg shin splints 2. Service connection for left leg shin splints Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. In addition, service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To establish direct service connection, there must be: the existence of a present disability; in-service incurrence or aggravation of a disease or injury; and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). The Veteran’s service treatment records show she presented to an Army clinic in October 1982 with complaints of right leg pain since basic training and forced road marches one month earlier. The assessment was anterior compartment syndrome/shin splints. The plan included a 15-day physical profile with no physical training, followed by a 15-day profile of self-paced activity. She was also referred to the physical therapy clinic. During a physical therapy consultation the same day, she again complained of right anterior shin pain for the past month that began while running. The assessment was “right tibialis muscle strain (poss[ible] shin splints).” The plan included toe-raises and moist heat as needed. Later in October 1982, she was discharged from the physical therapy clinic with instructions to continue her exercises two to three times daily and to continue the light profile, followed by the self-paced profile. She was instructed to return if complications recur. A March 1984 separation report of medical history reflects the Veteran denied having cramps in her legs; on separation examination the same day, her lower extremities were reported as normal. In August 2002, the Veteran presented for an initial evaluation by a private podiatrist, Roberta Giudice-Teller, D.P.M., for complaints regarding her feet. She did not report any problems with her legs or shin splints. Reported examination findings of the vascular, dermatological, neurological, and musculoskeletal systems did not include any shin splints or disorder of the lower legs. The assessment was foot pain. A follow-up note from August 2002 was silent for complaints, diagnosis, or treatment related to shin splints. An August 2005 record indicates the Veteran failed to appear for her scheduled appointment. Private treatment records from a women’s health center dated from May 2000 to July 2009 reflect the Veteran consistently denied musculoskeletal problems during a review of systems and general physical examination of the musculoskeletal system was reported as normal. In March 2010, the Veteran was afforded a VA examination. She reported developing pain in both shins while running during military service and continuing to have similar pain after service with prolonged standing or walking, with episodes occurring every one to two months and alleviated by rest and medication. On examination, there was tenderness to palpation at the anterior tibia midshaft bilaterally. The diagnosis was bilateral shin splints. The examiner opined it was less likely as not that the Veteran’s shin splints are due to the in-service complaints. In support of the conclusion, the examiner explained the Veteran was “treated for the right leg pain on only one occasion during service. Thus, there is no indication that this is a chronic or ongoing problem. There is no documentation at all of shin splints in the left lower extremity.” An August 2010 treatment record from Dr. Giudice-Teller documents that the Veteran returned since last being seen in 2005. She complained of ongoing foot pain that “progressed into shin splints in the last two months.” On examination, the “right and left lower extremity is seen intact.” The assessment was shin splints, bilaterally, anterior portion of her leg. The following month, the Veteran reported her shin splints had improved but not resolved by changing her shoes, icing, and stretching. Dr. Giudice-Teller indicated she reviewed some records the Veteran brought from 1983 [sic] that showed she did toe raises, moist heat, ice. Dr. Giudice-Teller stated, “The first time I had seen her was in 2002 with a similar situation. So, at this time, I did feel that the shin splints has [sic] been a problem throughout her stay in the service, aggravated and begun with the time she was in the service; this is truly service connected.” The assessment was “shin splints secondary to pes planus foot structure aggravated by military service.” After establishing VA medical care in September 2010, the Veteran often reported having shin splints during podiatry clinic visits, with the last documented report of shin splints in March 2012 (among treatment records dating to September 2017). A January 2011 x-ray report of the bilateral tibia and fibula noted a clinical history of pain in the mid-legs. The report documented there was no fracture, dislocation, or bony abnormality. During the October 2016 hearing, the Veteran affirmed she did not mention problems with shin splints on separation examination, but her complaints and treatment, which was “just resting and pain medicine,” were documented in her service treatment records. She testified she did not seek any treatment for shin splints after service until she started getting treated by VA. She testified that after service while she was working, she was in pain, but not “excruciating pain ‘til I got older.” She stated that according to her VA podiatrist, treatment for shin splints involves resting and icing. She also testified that her podiatrist told her that “shin splints don’t just go away . . . . Once they’re there, they are always there.” The Veteran was afforded another VA examination in May 2017. She described being evaluated for shin splints three or four times during military service, but stated she had no current ongoing issues and had no other evaluation or treatment for shin splints after a January 2011 x-ray examination of her lower legs. Examination of the right and left lower legs was reported as grossly normal with no pain or tenderness on palpation to the shins. The examiner concluded the Veteran did not currently have shin splints involving either leg. The examiner explained that shin splints are a transient condition that resolve without residuals, which was true in this case as confirmed by the January 2011 x-ray study and the Veteran’s current asymptomatic status. Having considered the medical and lay evidence of record, service connection for either right or left leg shin splints is not warranted. Competent medical evidence of record reflects the Veteran does not currently have shin splints in either leg; however, the March 2010 VA examination report indicates she had shin splints in each leg at that time. Thus, the issue is whether either disability is related to her military service. Service connection for left leg shin splints is not warranted because the preponderance of the evidence indicates the Veteran did not experience symptoms of left leg shin splints during military service. Her service treatment records are silent for complaints, diagnosis, or treatment related to left leg shin splints or problems. To the extent she told the March 2010 VA examiner or other medical providers that she had shin splints in her left leg during military service, she is competent to describe such pain. Her statements regarding symptoms of left leg shin splints in service, however, are not credible because she never mentioned left leg shin splints during the three occasions in 1982 when she described right leg shin splints. Rather, service treatment records show that on three separate occasions on two separate days, the Veteran had described symptoms she believed to be shin splints, but consistently identified those symptoms as occurring only in her right leg. If she had experienced symptoms of left leg shin splints during military service concurrently with her right leg shin splint symptoms as claimed, one would expect to see complaints of shin splints in both legs documented in the records. Instead, each service treatment records reflects her complaints of only right leg pain. See Fountain v. McDonald, 27 Vet. App. 258, 272 (2015) (holding that the Board may weigh a claimant’s lay statements against the absence of contemporary medical evidence after establishing a proper foundation for drawing inferences against a claimant from an absence of documentation). Moreover, she denied having cramps in her legs at separation examination, and her lower extremities were normal at separation examination. In the absence of competent and credible evidence of in-service symptoms or diagnosis of left leg shin splints, the criteria for service connection for left leg shin splints are not met. Regarding service connection for right leg shin splints, the Veteran’s service treatment records support the conclusion that her symptoms resolved after seeking treatment, resting while on a 15-day restricted profile, and resuming activity at her own pace during a 15-day limited profile. When she was discharged from physical therapy in October 1982, she was instructed to return if her symptoms recurred. Her remaining service treatment records reflect that while she sought treatment for other medical problems during the last year and a half of service, she did not report any recurrence of right leg shin splints symptoms; at separation examination, she denied leg cramps and her lower extremities were normal on examination. Considering a medical connection or nexus between the right and left leg shin splints shown on VA examination in March 2010 and military service, the opinion of the March 2010 VA examiner is probative and persuasive in weighing against the claims because it was based on a review of the claims file and supported by an articulated medical explanation that is consistent with the remaining records. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). The examiner accurately observed that there was no documentation of shin splints in the left lower extremity among the Veteran’s service treatment records. The examiner supported the conclusion that the right leg shin splint disability was not related to the complaints in service, noting that the Veteran was treated on one occasion (in October 1982 after a period of basic training with road marches) with no documentation that the right leg symptoms were chronic. The March 2010 medical opinion regarding the acute and transitory nature of the right leg shin splint symptoms documented in October 1982 is consistent with the service treatment records described above and with post-service private treatment records that show the Veteran denied musculoskeletal complaints and had normal findings on musculoskeletal examination during annual visits between May 2000 and July 2007. Although the absence of evidence does not by itself warrant a negative inference, here given the many years during which the Veteran sought treatment for many medical disorders, a notation or reference to right leg shin splint symptoms would be expected in these records if the Veteran were experiencing ongoing symptoms of shin splints since military service as she reported. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that “the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded”); see also Kahana v. Shinseki, 24 Vet. App. 428, 438-41 (2011) (Lance, J., concurring) (discussing the distinction between cases in which there is a complete absence of any evidence to corroborate or contradict the testimony, as opposed to cases in which there is evidence that is relevant either because it speaks directly to the issue or allows the Board, as factfinder, to draw a reasonable inference). As such, these records support the findings of the May 2010 VA examiner and weigh against any finding of in-service incurrence of a chronic problem with right leg shin splints, any continuity of right leg shin splint symptomatology since service, or any medical relationship between the two-month period of right leg shin pain experienced during service in September and October 1982 and the current right (and left) leg shin splints diagnosed on VA examination in May 2010, more than 26 years after separation from service. The opinion of the May 2017 VA examiner is also persuasive and weighs against the service connection claim for right leg shin splints. The examiner explained that shin splints are a transient condition that resolve without residuals. The Veteran herself testified about her knowledge that shin splints resolve with rest and pain medicine. Her service treatment records indicate her right leg shin splint symptoms followed this pattern of resolving after resting and reducing her activity, performing toe-raising exercises, and taking pain medications. In comparison, the Board affords no probative value to the medical opinion of Dr. Giudice-Teller. Again, Dr. Giudice-Teller opined in September 2010 that the Veteran had current shin splints that began during military service, reasoning that the Veteran had had similar problems during her first visit in 2002. Because treatment records authored by Dr. Giudice-Teller in 2002 are entirely silent for complaints or findings related to shin splints and contain no mention of the Veteran’s military service, the medical opinion offered eight years later is inconsistent with and unsupported by the previous records. Instead, Dr. Giudice-Teller’s opinion regarding the onset and etiology of the Veteran’s shin splints appears to be based on the Veteran’s subjective reports after her claim was denied of experiencing ongoing shin splints since military service. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (an opinion based on an inaccurate factual premise has no probative value). The preponderance of the evidence is against the Veteran’s claims for right and left leg shin splints. Therefore, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. 3. An initial rating in excess of 10 percent for bilateral pes planus with plantar fasciitis and hallux valgus with right bunionectomy The Veteran contends that a higher initial rating is warranted for her service-connected bilateral pes planus with plantar fasciitis and hallux valgus with right bunionectomy disability. The Veteran’s bilateral foot disability is rated under 38 C.F.R. § 4.71a, Diagnostic Code 5280-5276. Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the rating assigned. The additional code is shown after a hyphen. 38 C.F.R. § 4.27. In this case, Diagnostic Code 5280 pertains to unilateral hallux valgus, and 5276 refers to acquired flatfoot. 38 C.F.R. § 4.71a, Diagnostic Codes 5276, 5280. Under Diagnostic Code 5280, a 10 percent rating is assigned for severe unilateral hallux valgus if equivalent to amputation of the great toe or for unilateral hallux valgus operated with resection of the metatarsal head. Id., Diagnostic Code 5280. Under Diagnostic Code 5276, a noncompensable, zero percent rating is assigned for mild acquired flatfoot (pes planus) with symptoms relieved by built-up shoes or arch support. A 10 percent rating is assigned for moderate flatfoot where there is weight-bearing line over or medial to the great toe, inward bowing of the tendo achillis, pain on manipulation and use of the feet, bilateral or unilateral. For severe symptomatology, objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, characteristic callosities is rated 20 percent for one foot and 30 percent for both feet. Finally, for pronounced symptomatology shown by marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement and severe spasm of the tendo achillis on manipulation, not improved by orthopedic shoes or appliances, a rating of 30 percent for one foot or 50 percent for both feet is assigned. Id., Diagnostic Code 5276. Words such as “mild,” “moderate,” “moderately severe,” and “severe” are not defined in the Rating Schedule or in the regulations. Consequently, the Board must evaluate all the evidence to ensure that its decisions are “equitable and just as contemplated by the requirements of the law.” 38 C.F.R. § 4.6. The intent of the Rating Schedule is to recognize actually painful, unstable or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint, even in the absence of arthritis, to include in situations where the disability at issue is not evaluated based on range of motion measurements. 38 C.F.R. § 4.59; Burton v. Shinseki, 25 Vet. App. 1, 5 (2011); Southall-Norman v. McDonald, 28 Vet. App. 346 (2016). In October 2009, VA received the Veteran’s service connection claim for “bilateral injury to foot arches.” Service treatment records documented bilateral foot pain, treatment with arch supports, and diagnosis of bilateral flat foot or pes planus. During a March 2010 VA examination, the Veteran described her history of bilateral foot pain during active duty service and reported having ongoing problems after service, including undergoing a right bunionectomy in 1997 and being diagnosed with plantar fasciitis. Regarding current symptoms, she reported typically having high level pain when first getting out of bed and towards the end of a busy day, daily pain with weight-bearing activities, fatigability and stiffness, and moderate to severe flare-ups occurring once every two months precipitated by weightbearing and alleviated by rest and over-the-counter medication. She stated that bilateral arch supports and taking ibuprofen as needed was helpful in managing her symptoms. She denied any weakness, heat, or redness. Reported examination findings included the following: normal gait pattern; abnormal shoe wear pattern bilaterally; evidence of prior surgery to the right great toe; moderate bilateral pes planus and bilateral hallux valgus with no overlap of the first and second does; tenderness to palpation at the plantar surface of the calcaneus and along the plantar fascia bilaterally; tenderness with manipulation of the Achilles tendon bilaterally; normal alignment of the Achilles and midfoot bilaterally; and no evidence of edema, effusion, instability, heat, or redness. Range-of-motion testing of both ankles revealed full range of motion bilaterally with pain at the end range of dorsiflexion bilaterally and no pain with plantar flexion. The examiner opined that the Veteran’s complications of plantar fasciitis and hallux valgus were most likely related to her history of flatfeet in service. Regarding the effects of her bilateral foot disability, the Veteran indicated she worked an office job as a construction management administrator but was required to go on site sometimes. She stated her feet did “not hinder her job much” because she has adapted to her foot pain and “will take a break and sit down at the site if she needs to.” She stated that walking for exercise was limited and she was unable to tolerate 30 minutes on a treadmill. She stated she could not go shopping for as long as she would like sometimes. A private podiatry treatment record from Dr. Giudice-Teller reflects the Veteran returned in August 2010 after last being seen in 2005. She reported ongoing pain due to flat feet, having worn orthotics, and reproducible pain in the medial longitudinal arch bilaterally with walking. On examination, she had “pes planus foot structure with normal appearance of the foot and short first metatarsal bilaterally.” In September 2010, the Veteran established VA medical care, reporting a history of flatfoot, plantar fasciitis, and bunion removal, and requesting anti-inflammatory medication for plantar fasciitis and a referral to podiatry. During an October 2010 podiatry consultation, she described being unable to run, stand or walk for prolonged periods, or walk barefoot due to foot pain. She reported that one brand of orthotics she tried was uncomfortable, but another brand had felt very comfortable. Examination findings included collapsed arches on weight-bearing and tenderness of the arches. The podiatrist dispensed Spenco shoe inserts and non-slip hospital socks. Subsequent records show similar complaints and findings with some relief of symptoms after receiving Bio-Fit shoe orthotics. The impression of a January 2011 x-ray study of both feet was post right great toe bunionectomy; otherwise normal bilateral feet. During a March 2012 podiatry visit, the Veteran reported she stopped going to the gym due to foot pain and shin splints. Examination revealed pronation of her feet with mid heel to medial wear on her shoes bilaterally and normal gait. An August 2012 podiatry note reflects her report of getting a sharp pain in the bottom of her heels at times. She reported that her arch supports help, but they fall apart when she washes them. On examination, she had a normal gait with no swelling or skin discoloration of the feet. She received new arch supports and plantar fascial air splints to wear at night. In February 2013, the Veteran was afforded another VA examination to evaluate her feet. She reported constant use of bilateral custom shoe inserts for flatfoot and plantar fasciitis and stated she continued to work as a county capital projects construction manager. On examination, she had mild to moderate hallux valgus bilaterally with history of bunionectomy in 1997; the hallux valgus symptoms were not severe enough to be equivalent to amputation of the great toe in either foot. Physical examination also showed pain on manipulation and use of the feet accentuated bilaterally with no objective evidence of marked deformity of either foot, no indication of swelling on use, and no characteristic (or any) callosities on either foot. There was extreme tenderness on the plantar surfaces of the feet bilaterally, which was improved by orthotic shoes or appliances. Bilaterally, there was no inward bowing of the Achilles tendon; the weight-bearing line did not fall over or medial to the great toe; and there was no marked inward displacement and severe spasms of the tendo achillis on manipulation. The report of an x-ray examination of both feet described mild hallux valgus involving the left foot; mild bilateral soft tissue swelling; mild flattening of the arch of the feet on weight-bearing view; and wire suture noted on the medial aspect of the proximal phalanx of the right great toe. In August 2013, the Veteran sought urgent VA medical care for a rash. Reported examination findings included gait grossly intact, comfortable appearance, in no acute distress. An April 2014 VA podiatry note documents the Veteran’s request for new Bio-Fit orthotics and renewal of Naproxen. Objective findings included normal gait with no edema, collapsed arches on weight-bearing, and tenderness of arches. During the October 2016 hearing, the Veteran testified that her bilateral foot pain had worsened since the February 2013 VA examination. She stated she was always in pain but standing for 30 minutes to an hour increased her pain level to 8 or 9/10 in severity and caused her to limit her activities. During an October 2016 VA primary care visit, the Veteran’s only complaint was continued bilateral foot pain on the plantar surfaces of her feet. On examination, she appeared in no acute distress and her gait was grossly intact. She received a referral for physical therapy. From October 2016 to January 2017, the Veteran participated in VA physical therapy, including a home exercise program, for bilateral plantar foot pain. During the October 2016 consultation, she described pain in her arches with prolonged walking, alleviated by use of nonsteroidal anti-inflammatory drugs (NSAIDs) and use of shoe inserts. She indicated she was an avid bowler. (Other VA treatment records reflect she sought medical care on several occasions related to various musculoskeletal pains that began while bowling). During a December 2016 physical therapy session, she reported she had reduced her pain medication to one Tylenol when bowling. The January 2017 physical therapy discharge note documents her report that her symptoms had continued to improve. Objectively, she had improved her tolerance to activity, was independent with her home exercise program, and no longer needed formal physical therapy. A March 2017 follow-up VA podiatry note indicates the Veteran had tried physical therapy, NSAIDs, and custom and off-the-shelf arch supports, but nothing relieved her foot pain and she had to curtail her physical activities as a result. No physical examination findings were reported. Instead, the podiatrist included the report of bilateral foot x-rays from the February 2013 VA examination in the treatment record. The assessment was “chronic foot pain, pes planus, painful flat feet; Tylenol helps.” The podiatrist dispensed new arch supports. In May 2017, the Veteran was afforded a VA examination. She described bilateral foot pain in her arches with prolonged standing, adding that her feet are okay if she can sit for a little bit every 30 minutes. She reported wearing wide-front shoes or tennis shoes with regular use of insoles issued by her VA podiatrist and stated that her left foot “bunion was not an issue.” She did not report any flare-ups that impact the function of her feet. Physical examination revealed pain on use accentuated bilaterally and decreased longitudinal arch height of both feet. There was no pain on manipulation of the feet; no characteristic callouses; no extreme tenderness of the plantar surfaces of one or both feet; no marked deformity; no weight-bearing line falling over or medial to the great toe; no inward bowing of the Achilles tendon; and no marked inward displacement and severe spasm of the Achilles tendon on manipulation of either foot. The use of arch supports or orthotics reportedly relieved symptoms to some degree, but the Veteran’s feet remained symptomatic. Other examination findings included no current symptoms due to hallux valgus. The examiner commented there was nothing suggestive of current residuals of plantar fasciitis of the right or left foot either by history or examination, reiterating that examination revealed the Veteran’s bilateral plantar fasciitis had resolved with no evidence of chronic residuals. Although not requested, the examiner opined that the left hallux valgus and right hallux valgus status post bunionectomy were not incurred in or related to service, and that the current bilateral pes planus disability was “most consistent with 30 [pounds] weight gain over the years.” Because bilateral pes planus was manifested during active duty service, and because service connection has already been established for bilateral pes planus and hallus valgus, the May 2017 opinion regarding the etiology of the Veteran’s bilateral foot disability has no bearing on the analysis regarding the current severity and proper rating of her disability. Since service connection was established effective in October 2009, the Veteran’s bilateral pes planus with plantar fasciitis and hallux valgus status post right bunionectomy has been manifested at worst by pain on use accentuated with symptoms improved by use of arch supports or orthotics; x-ray evidence of mild flattening of the arches of both feet on weight-bearing views; mild to moderate bilateral hallux valgus with clinical and x-ray evidence of right foot bunionectomy; and tenderness to palpation of the plantar calcanei and fascia, which resolved. These findings are consistent with the 10 percent rating assigned for the Veteran’s bilateral foot disability. A separate, 10 percent rating is not warranted for the Veteran’s left foot hallux valgus disability under Diagnostic Code 5280 because physical and x-ray examination findings have described her left foot hallux valgus as mild or moderate, VA examination revealed her left foot hallux valgus was not equivalent to amputation of the great toe, and she has not had a left hallux valgus operation with resection of the metatarsal head. A higher, 20 (unilateral) or 30 (bilateral) percent rating based on severe symptomatology under Diagnostic Code 5276 is not warranted at any time during the appeal for the Veteran’s bilateral foot disability because repeated examinations demonstrated no objective evidence of marked deformity, no indication of swelling on use, and no characteristic callosities of either foot. Moreover, a 30 (unilateral) or 50 (bilateral) percent rating based on pronounced symptomatology is not warranted because physical and/or x-ray examinations documented she did not have marked pronation or marked inward displacement and severe spasm of the tendo achillis on manipulation of either foot. Although the February 2013 VA examination documented pain on manipulation accentuated (a criterion for a 20 or 30 percent rating) and extreme tenderness of the plantar surfaces of the feet (a criterion for a 30 or 50 percent rating), those findings were not replicated in other contemporaneous treatment records or other VA examination reports. Similarly, the finding of extreme tenderness on the plantar surfaces of the feet appears to be inconsistent with contemporaneous and subsequent treatment records, which document the Veteran’s gait as being grossly intact and non-antalgic. Finally, with respect to the February 2013 finding of extreme tenderness of the plantar surfaces of the feet, a higher, 30 (unilateral) or 50 (bilateral) percent rating is not warranted because the evidence of record demonstrates the Veteran’s symptoms are improved by orthopedic appliances such as arch supports and orthotics. Lastly, a higher or separate rating based on other potentially applicate rating criteria is not warranted because the medical evidence of record demonstrates the Veteran does not have bilateral weak foot, acquired claw foot (pes cavus), anterior metatarsalgia, severe hallux rigidus, hammer toe, malunion or nonunion of the tarsal or metatarsal bones, or other foot injuries. 38 C.F.R. § 4.71a, Diagnostic Codes 5277, 5278, 5279, 5281, 5282, 5283, 5284. As the preponderance of the evidence is against the Veteran’s claim for a higher rating than that assigned for her bilateral foot disability, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Service connection for a lumbar strain. The claim of service connection for a low back disability must be remanded to attempt to obtain outstanding private treatment records and to obtain an addendum medical opinion regarding the etiology of dextroscoliosis demonstrated on a May 2017 x-ray examination. The Veteran contends she has a current low back disability that began during military service. Her service treatment records document her spine was normal on enlistment examination in November 1981. In November 1982, she presented to the clinic with complaints of back pain in the “lumbar sacrum region” since she hurt her back moving bunks during a GI party nine days earlier. The assessment was paraspinal muscle spasms versus muscle strain. The plan included a 14-day physical profile with no physical training. She was instructed to return to the clinic if her symptoms worsened or persisted more than seven days. A December 1983 service treatment record reflects the Veteran’s complaint of back pain for the past four days since tripping over a tent rope and falling on her back. Physical examination showed parathoracic muscle spasm at the right, mid-thoracic area. The assessment was back strain. The plan included a seven-day physical profile. The examiner instructed the Veteran to return to the clinic if there was no improvement. In January 1984, the Veteran learned she was pregnant. In a March 1984 separation report of medical history, she denied having recurrent back pain. On examination the same day, her spine was reported as normal on clinical evaluation. The examiner noted she was three and a half months pregnant and recorded her weight as 131 pounds, representing a 13-pound gain since enlistment. The Veteran had a VA examination in March 2010. The diagnosis was lumbar strain. The examiner opined that the lumbar strain was less likely than not related to her complaints of back pain during service. The examiner explained that the vast majority of cases of acute low back pain resolve without any long-term sequelae, emphasized that service treatment records contained no indication of a chronic back disorder or serious injury to the lumbar spine, and observed there was no documentation of treatment of a lumbar strain since service. After the Veteran’s service connection claim for a back disorder was denied, she established VA medical care in September 2010. During her initial visit, she reported a past medical history of chronic back pain due to a traumatic injury during service. The assessment included back pain. At a follow-up appointment the same month, she indicated she had previously seen a chiropractor with good results and wanted to continue therapy. The plan included fee-basis chiropractor visits for back pain. In October 2010, the Veteran began fee-basis chiropractic treatment at Access Chiropractic Center. She complained of low back, neck, and upper back pain being a long-term problem, stating it “has come on after military acc[ident] where I tripped over tent line.” She reported receiving previous chiropractic care from Dr. Chance. In October 2016, the Veteran testified that her back pain began when she tripped over a tent rope and fell on her back. She stated she did not report any back pain at separation examination or seek treatment shortly after service because she was “pregnant at the time so back pain was back pain. I thought it associated more with the pregnancy.” She also testified that approximately 15 years earlier she entered the construction management field, working as a project manager for a construction company. She stated that her job involved going out to job sites, climbing ladders, and getting on roofs. She added, “That’s when I started noticing I was having back pain.” She indicated she still did not seek treatment at that time because she “just thought it was hard doing that type of work, and then when looking back, I realized it was from when the back injury started in the military.” She testified she was first diagnosed with a back disorder during the October 2010 VA examination and first received back treatment in 2010 by a private chiropractor, Dr. Chance, and by a fee-basis chiropractor at Access Chiropractic Center. In October 2016, VA received a September 2010 “corrected” letter from C. Chance, D.C., which was addressed to the Veteran’s VA primary care physician. Dr. Chance reported he first treated the Veteran in August 2010 when she presented for complaints of back pain between the lower back and mid-back region, which she believed was “related to accident in 1983 when she fell over tent spikes.” He indicated that x-rays taken during the initial visit in August 2010 “showed anterior instability of both L4 and L5 with small anterior spurs which is indicative of some type of hyperextension injury.” In June 2017, the Veteran indicated she had checked out x-rays from Dr. Chance on December 28, 2010, and provided them to Access Chiropractic Center; however, the chiropractor she had seen retired in 2015 and Access Chiropractic Center did not have any x-rays on file for the Veteran. VA treatment records document the Veteran received fee-basis chiropractic care from October 2010 to August 2011 and explain how to access the images of those records. The Veteran herself provided treatment records dated from October 2010 to August 2011 from Access Chiropractic Center. Regarding an x-ray report from her initial visit, the chiropractor documented “available at later date.” The AOJ should print all fee-basis treatment records from Access Chiropractic Center and upload them to the Veteran’s claims file. The AOJ should also give another opportunity to provide treatment records from Dr. Chance. The Veteran was afforded another VA examination in May 2016. The diagnosis was lumbosacral strain. The examiner indicated the lumbar strain was a transient condition, which had resolved with no objective evidence of chronic residuals. The impression of a lumbar spine x-ray study was mild dextroscoliosis. The examiner detailed that service treatment records showed the Veteran’s two back injuries in service were appropriately treated and resolved with no evidence of chronic residuals. The examiner emphasized that the March 1984 separation examination showed no chronic residuals because the Veteran reported she did not have ongoing back issues and examination of her back was normal. Regarding the mild dextroscoliosis, the examiner opined it was “an incidental finding, not of unclear clinical significance in this case since her back exam is [within normal limits]. The weight of peer-reviewed medical literature is against a relationship.” The AOJ should obtain an addendum medical opinion regarding the etiology of the Veteran’s mild dextroscoliosis because the May 2017 opinion did not provide an adequate opinion or rationale as to whether dextroscoliosis is related to the back injuries documented during military service. The matter is REMANDED for the following action: 1. With any necessary assistance from the Veteran, obtain the following records: a) Any ongoing treatment records from the Gainesville VA Medical Center dating since September 2017. b) All fee-basis chiropractic treatment records from Access Chiropractic Center dated from October 2010 to August 2011, including the reports of any x-ray studies. VA treatment records list the dates of service for these chiropractic visits and explain, “To see this image, open Imaging located on Tools menu and select this image from the palette.” c) All treatment records and reports of x-ray studies from C. Chance, D.C., dating since August 2010. Provide the Veteran’s electronic claims file and a complete copy of this Remand to the May 2017 VA examiner or another clinician to obtain an addendum medical opinion. Following a review of the claims file, provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the mild dextroscoliosis documented on x-ray examination in May 2017 had its onset in service or is otherwise medically related to the Veteran’s military service, including the documented back injuries in November 1982 and December 1983. A detailed medical explanation must be provided for all opinions expressed. JAMES L. MARCH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laura Kirscher Strauss 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.