Citation Nr: 20037541 Decision Date: 06/02/20 Archive Date: 06/02/20 DOCKET NO. 15-32 571 DATE: June 2, 2020 REMANDED The issue of service connection for a right foot disorder is remanded. The issue of service connection for a left foot disorder is remanded. The issue of service connection for a right knee disorder, to include as secondary to the claimed right foot disorder, is remanded. The issue of service connection for a left knee disorder, to include as secondary to the left foot disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1989 to December 1993. This matter comes before the Board of Veterans’ Appeals (Board) from a February 2014 rating decision. In November 2018, the Board denied service connection for right and left foot disabilities and right and left knee disabilities, among other issues decided. The Veteran appealed the Board’s decision regarding the foot and knee issues to the United States Court of Appeals for Veterans Claims (Court). In a January 2020 Order, the Court granted a Joint Motion for Partial Remand (Joint Motion), vacating that part of the Board’s decision that denied service connection for right and left foot disabilities and right and left knee disabilities and remanding for additional proceedings. 1. Service connection for a right foot disorder is remanded. 2. Service connection for a left foot disorder is remanded. The Veteran contends he has a bilateral foot disorder caused by long hours performing extremely strenuous duties as a boatswain mate during military service. The parties to the Joint Remand agreed that although the November 2018 “Board decision determined that there was ‘no indication that pes planus noted upon enlistment examination underwent any increase in severity during active service,’” the Board did not “provide an adequate statement of reasons or bases discussing the application of aggravation.” A November 1989 enlistment report of medical history reflects the Veteran’s report that he did not currently or ever have foot trouble. On enlistment examination the same day, the examiner noted the Veteran had moderate, asymptomatic pes planus of his feet. In April 1991, the Veteran presented for evaluation of left ankle pain after twisting his ankle two weeks earlier while playing basketball. Reported examination findings of his left foot included no redness, swelling, discoloration, deformity, or crepitus; he had full range of motion with equal and good strength. His right foot was reported as within normal limits. The assessment was unresolved inversion to left ankle. The Veteran first complained of foot pain in November 1991. The record indicates he was “educated on bonyins [sic],” which he reported having for about three years. He reported pain after exercise and general every-day activity. He was instructed to soak his feet in warm water and rest as much as possible. In September 1992, he stated he had had a “knot” on the side of his left great toe for two years that began to hurt one week earlier. He described constant, sharp left foot pain that increased with walking and mild numbness. He denied any trauma or any history of foot problems. On examination he had a slight limp to the left leg, his left foot had a slight deviation laterally to the great toe, the head of the first metatarsal phalangeal joint had edema and erythema, and he had increased tenderness with pressure applied to the foot. A left foot x-ray examination was reported as normal. The assessment was left foot pain. Finally, in March 1993, the Veteran complained of right heel pain after stepping on a sea urchin while snorkeling. Examination revealed small black dots in the right heel where the Veteran had contact with the sea urchin. There was no erythema or edema and his gait was normal upon ambulation. The assessment was status post sea urchin bite. On separation examination in December 1993, the Veteran denied having foot trouble or swollen or painful joints. He did endorse having back pain; a physician’s summary detailed that he had mild intermittent low back pain that did not interfere with his duties, adding that he “plays basketball.” The Veteran was afforded a VA examination in December 2013. X-rays of both feet revealed bunions with mild degenerative changes of the first metatarsal phalangeal joint and hallux valgus; the right foot also had a posterior calcaneal spur. The examiner’s opinion that the Veteran did not have a right or left foot disability related to service was based on an inaccurate factual history because she concluded the Veteran was not treated for right or left foot problems during military service when, in fact, he was treated for foot problems. Another VA clinician provided an addendum medical opinion in September 2015, which addressed the current right heel spur and current left foot bunion or hallux valgus deformity with mild degenerative changes. The reviewing examiner explained that hallux valgus is due to abnormal forces of pronation over time and observed that the Veteran’s complaints of foot pain in November 1991 and September 1992 were both “likely overuse symptoms.” The opinion did not appear to consider the Veteran’s contention that his current foot symptoms were caused by long hours performing strenuous duties as a boatswain mate. Also, although the December 2013 examiner observed that moderate, asymptomatic pes planus was noted on entrance examination, neither examiner addressed any current pes planus. Remand is necessary in this case to provide the Veteran an adequate VA examination and to obtain medical opinions as to whether a preexisting pes planus (flat foot) disability was aggravated during military service or whether any other current right of left foot disability is related to his military service. The AOJ should arrange for a VA examination of the Veteran’s feet. 3. Service connection for a right knee disorder, to include as secondary to the claimed right foot disorder, is remanded. 4. Service connection for a left knee disorder, to include as secondary to the left foot disorder, is remanded. The Veteran contends he has a bilateral knee disability caused by long hours performing extremely strenuous duties as a boatswain mate during military service. In October 2018 correspondence, the Veteran’s former representative argued on his behalf that the “progressive deterioration of [his] bilateral foot condition has negatively impacted and caused his bilateral knee condition.” The representative pointed out a service treatment record that documented the Veteran’s limp and suggested that over time the “continuous limping and alteration of his gait would affect his knees.” The contention that the Veteran has been limping since military service is unsupported by the evidence of record. Although he was observed to have a “slight limp” to his left leg in September 1992 when he sought treatment for a “knot” to the side of his left great toe, subsequent records demonstrated he did not have a chronic, continuing limp. For example, after stepping on a sea urchin in March 1993 and experiencing increasing right heel pain, his gait was observed as stable on ambulation. Post-service VA treatment records as recent as June 2018 also document the Veteran’s normal gait. Nevertheless, additional development is required to decide the Veteran’s claim for right and left knee disabilities. A July 2013 VA primary care note reflects the Veteran’s complaint of bilateral knee pain, right worse than left. He denied any twisting injury or recent knee injuries but stated he had had knee pain since playing basketball in the Navy. The assessment was knee pain. The physician ordered knee x-rays; an addendum note indicates “his knee x-ray was normal.” The VA treatment records associated with the claims file do not appear to include imaging studies referenced within the records. For example, a June 2016 primary care note indicates that weight-bearing x-rays of the Veteran’s feet were completed; however, those x-ray reports also are not included in the treatment records. The AOJ should add all VA imaging studies of the Veteran’s feet and knees to the claims file and obtain any ongoing VA treatment records dating since September 2019. Finally, the AOJ should arrange for a VA examination to determine whether any current right or left knee disability is related to the Veteran’s military service or to the claimed right and left foot disabilities. The matters are REMANDED for the following action: 1. Obtain any ongoing treatment records from the Kansas City VA Medical Center dating since September 2019 and all imaging studies of the Veteran’s feet and knees since he first established VA medical care in July 2004. 2. Schedule the Veteran for a VA examination of his feet with an appropriate clinician. Provide the Veteran’s entire electronic claims file, including a complete copy of this Remand, to the designated examiner for review. The reports of any indicated tests or studies must be associated with the examination report. Following a review of the claims file and examination, the examiner should address the following opinion requests: a) If the Veteran has a current right or left foot pes planus disability, was the moderate, asymptomatic pes planus noted on entrance examination in November 1989 clearly and unmistakably NOT aggravated (permanently worsened beyond its natural progression) by active service? b) Considering the Veteran’s November 1991 complaint of foot pain and being educated on bunions and his September 1992 complaint of a painful “knot” on the side of his left great toe, is it at least as likely as not (a 50 percent or greater probability) that any current right or left foot hallux valgus deformities or bunions began during military service or are otherwise related to military service, including his report of performing strenuous duties as a boatswain mate and/or playing basketball? c) Is it at least as likely as not (a 50 percent or greater probability) that the mild degenerative changes of the first metatarsal phalangeal joint of each foot (1 had its onset during active duty service, (2) manifested to a compensable degree within one year of separation from service, or (3) is otherwise related to the Veteran’s military service, including his report of performing strenuous duties as a boatswain mate and/or playing basketball? A detailed medical explanation must be provided for all opinions expressed. 3. Schedule the Veteran for a VA examination of his knees with an appropriate clinician. Provide the Veteran’s entire electronic claims file to the designated examiner for review. The reports of any indicated tests or studies must be associated with the examination report. Following a review of the claims file and examination, the examiner should provide opinions as to whether any current right and left knee disabilities (a) had their onset during military service; (b) whether any right or left knee arthritis manifested to a compensable degree within one year of separation from service; (c) whether any right or left knee disability is otherwise related to the Veteran’s military service, including performing strenuous physical duties as a boatswain mate and/or playing basketball; or (d) if a right or left foot disability is determined to be related to service, whether any right or left knee disability was caused OR is, or has been, aggravated by a right or left foot disability. 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.