Citation Nr: 21001640 Decision Date: 01/11/21 Archive Date: 01/11/21 DOCKET NO. 15-03 920A DATE: January 11, 2021 REMANDED 1. Entitlement to service connection for a right foot disorder, to include plantar fasciitis, fasciitis is remanded. 2. Entitlement to service connection for chronic sinusitis is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1975 to September 1977, January 1980 to January 1982, and September 1982 to April 1998. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2010 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in a February 2018 hearing. These issues were previously before the Board in September 2018 when they were remanded for further development. That development was completed, and the case returned to the Board in July 2020 when the issues were remanded for further development.   1. Entitlement to service connection for a right foot disorder, to include plantar fasciitis, remanded. 2. Entitlement to service connection for chronic sinusitis is remanded. Remand is required for substantial compliance with the July 2020 Board remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The July 2020 Board remand instructed the RO to verify the Veteran’s representative’s address, and to obtain addendum VA medical opinions. An October 2020 memorandum indicates that the Veteran’s representative’s address was verified. The RO obtained addendum VA medical opinions in November 2020. First, remand is required for an addendum VA medical opinion for the right foot plantar fasciitis claim. 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). A medical opinion based upon an inaccurate factual premise has no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). 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). When a Veteran has provided competent lay statements of an in-service injury, the examiner must consider and address them when developing his rationale. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007) (holding that when 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). The RO obtained a new VA medical opinion in November 2020. The examiner provided a negative nexus opinion, stating that although the Veteran was treated for overuse syndrome in 1991, imaging found no bony abnormality and the medical examination did not describe findings consistent with plantar fasciitis. The examiner explained that according to medical literature, overuse syndrome is related to strain, and when treated appropriately, it should resolve within six to eight weeks. Further, the examiner noted that during examinations in June 1992 and June 1997, the Veteran denied any feet problems, and endorsed his feet as normal. The examiner explained that this is consistent with objective evidence in literature that the overuse syndrome had resolved, and that plantar fasciitis was not diagnosed until many years after separation from active duty. The July 2020 Board remand instructed the examiner to address the February 2018 Naval Hospital opinion. The examiner stated that the February 2018 opinion erroneously stated that the Veteran was first seen for plantar fasciitis in September 1991 while on active duty, while September 1991 STRs actually diagnosed the Veteran’s right foot pain as overuse syndrome, and not plantar fasciitis. Further, the examiner explained that current medical literature indicates that the 1991 note is inconsistent with pain noted in plantar fasciitis. The examiner stated that while the February 2018 Naval Hospital opinion highlighted October 2003 and May 2017 visits for foot pain, they neglected to add that these visits were for left foot pain, and there was no mention of any right foot pain. However, a careful review of the record finds a June 2003 Naval Hospital record featuring complaints of right foot pain for over ten years. Further, the October 2003 and May 2017 records the examiner references do not appear to be in the Veteran’s claims file, as well as July 2003, November 2003, July 2004, April 2017, February 2018, and August 2018 records the examiner references in the medical record review. This matter will be discussed further below. The July 2020 Board remand also instructed the examiner to address the January 2020 VA medical opinion, which the examiner failed to do. Further, while the examiner noted in the medical record review the Veteran’s mention of the in-service overuse syndrome during his February 2018 Board hearing, they failed to actually address it, along with the Veteran’s lay testimony regarding working on the flight deck without proper support, during their opinion. In fact, this issue was partially remanded in September 2018 because the February 2015 VA medical opinion also failed to address the Veteran’s lay testimony regarding working on the flight deck. Accordingly, remand is required for a new addendum VA medical opinion. Second, remand is required to obtain missing military hospital records. VA has a duty to assist claimants to obtain evidence needed to substantiate a claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2019). This includes making reasonable efforts to obtain relevant private medical records. 38 C.F.R. § 3.159(c)(1). As noted above, numerous Naval Hospital treatment records were referenced in the November 2020 VA addendum opinion for the plantar fasciitis claim that are not in the Veteran’s claims file. Although some records from the Naval Hospital in Jacksonville, Florida are in the Veteran’s claims file, they appear to be largely incomplete. Accordingly, remand is required to obtain missing Naval Hospital records. The matters are REMANDED for the following action: 1. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records, to include Naval Hospital in Jacksonville, Florida. 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. 2. After any additional records are associated with the claims file, obtain an addendum opinion regarding the etiology of the right foot disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the right foot disorder had onset in, or is otherwise related to, active service. (b) The examiner must address the following: 1) the February 2018 medical opinion, found on the final page of records from the Jacksonville Naval Hospital added to the claims folder February 28, 2018; 2) the February 2015 VA medical examination; 3) the January 2020 VA examination; 4) the November 2020 addendum VA medical opinion; 5) the Veteran’s February 2018 Board hearing testimony, including his assertions that his right foot disorder is due to his time spent on the flight deck without proper foot support; and 6) the June 2003 Naval Hospital records noting complaints of right foot pain for 10 years. 3. After any additional records are associated with the claims file, if, and only if, deemed necessary based on these additional records, obtain an addendum opinion regarding the etiology of the sinus disorder from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. (a) The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the sinus disorder had onset in, or is otherwise related to, active service. (b) The examiner must address the following: 1) the Veteran’s February 2018 Board hearing testimony; 2) the February 2018 Naval Hospital medical opinion; 3) the June 2010 and February 2015 VA examinations; 4) the Veteran’s lay statements; and 5) the Veteran’s STRs noting sinus related complaints in October 1997, January 1990, and January 1992. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Rogos 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.