Citation Nr: 21003182 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 16-44 407 DATE: January 19, 2021 ORDER Service connection for prominent posterior plantar and retrocalcaneal spurs of the left foot as secondary to service-connected left knee patellofemoral syndrome is granted. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran’s service-connected patellofemoral syndrome of the left knee aggravated the Veteran’s current prominent posterior plantar and retrocalcaneal spurs. CONCLUSION OF LAW The criteria for service connection for prominent posterior plantar and retrocalcaneal spurs of the left foot is secondary to service-connected left knee patellofemoral syndrome are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from January 2008 to May 2008 and from February 2009 to February 2010. This case is before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 Regional Office (RO) rating decision. In that rating decision, the RO continued the denial of entitlement to service connection for a left foot condition because the evidence submits was not new and material. The Veteran’s notice of disagreement (NOD) was received in April 2016. The RO issued a statement of the case (SOC) in August 2016. The Veteran’s VA Form 9, substantive appeal to the Board, was received in September 2016. In July 2019, the Veteran testified at a travel Board hearing before the undersigned Veterans Law Judge. A transcript of the testimony is associated with the claims file. In December 2019, the Board granted the request to reopen the service connection claim for a left foot disorder and remanded the underlying claim to the RO for further development and adjudicative action. Entitlement to service connection for a left foot disorder to include as secondary to service-connected disability. The Veteran contends that that he has a current left foot disorder is due to his service-connected right ankle disability. Specifically, he asserts that his service-connected disabilities result in him having an altered gait that has caused pain in his left foot. Because the Veteran has not raised, and the record does not otherwise show, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of or is aggravated beyond its natural progress by service-connected disability. The Board concludes that the Veteran has a current disability of prominent posterior plantar and retrocalcaneal spurs of the left foot that are aggravated beyond its natural progression by service-connected patellofemoral syndrome of the left knee. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). A September 2020 VA examiner diagnosed the Veteran with prominent posterior plantar and retrocalcaneal spurs of the left foot. Thus, the Veteran has a current diagnosis of a left foot disorder. With respect to the issue of whether the Veteran’s current prominent posterior plantar and retrocalcaneal spurs of the left foot are secondary to service-connected patellofemoral syndrome of the left knee, the claims file contains conflicting medical opinions. In this regard, the September 2020 VA examiner determined that the Veteran’s left foot disorder was less likely than not proximately due to or the results of the Veteran’s service-connected patellofemoral syndrome of the left knee. The examiner explained that there is no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have a significant impact on another or opposite joint or limb, unless the injury results in a major muscle or nerve damage causing partial or complete paralysis, or shortening of the injured limb resulting in length discrepancy so that the individual gait pattern has been altered. The examiner noted that this level of severity is not supported based on record, review, history or exam. However, later in the opinion, in the section regarding aggravation, the examiner stated that the Veteran’s left foot disorder is related to left knee patellofemoral syndrome. The examiner explained that the gait is affected by the kinetic chain. A kinetic chain is the notion that joints, and segments have an effect on one another during movement. Dysfunction within the kinetic chain where a muscle is recruited improperly relative to optimal firing patterns within the kinetic chain result in potential overuse of the specified muscle(s), inhibition of the muscles antagonist, poor motor control, and improver functional movement patterns. A study showed a significant correlation between adjacent segments for the knee-hip and hip-pelvis pairs. For the ankle-knee pair, a significant correlation was found only for initial contact, opposite toe off and heel rise. These correlations are subject to changes at the knee joint. The foot can become overused and subject to numerous localized injuries. Injuries or bio-mechanical problems more proximally up the leg can have a subsequent, indirect effect on the foot mechanics. The Board notes that the examiner appears to have provided conflicting opinions with respect to whether the Veteran’s current prominent posterior plantar and retrocalcaneal spurs of the left foot is caused by or related to the Veteran’s service-connected patellofemoral syndrome of the left knee. However, a remand to obtain a clarifying opinion is not necessary as the examiner also provided the opinion Veteran’s current prominent posterior plantar and retrocalcaneal spurs of the left foot are at least as likely as not aggravated beyond its natural progression by the service-connected patellofemoral syndrome of the left knee. The examiner’s medical opinion with respect to aggravation is probative as persuasive as to this issue as she provided a clear explanation in support of her opinion based on the evidence of record, medical knowledge, and a medical study that reflects injuries or bio-mechanical problems more proximally up the leg can have a subsequent, indirect effect on the foot mechanics. The RO sought clarification with respect to aggravation as the September 2020 examiner’s rationale addressed the issue whether the Veteran’s left foot disability was directly related to active military service and did not support an opinion with respect to aggravation by his service-connected right ankle disabilities, right knee patellofemoral syndrome, trochanteric bursitis of the bilateral hip, and right sacroiliac joint dysfunction. A clarification opinion was provided by a different nurse practitioner in October 2020. The nurse practitioner stated that the conditions are not medically related and there is no credible evidence to suggest that injury or disease of one/both extremity (service-connected metatarsalgia, right ankle condition, sciatic right leg, bilateral patellofemoral syndrome, or trochanteric bursitis of the bilateral hips) would have any significant impact on another lower extremity. Her explanation appears to copy the September 2009 examiner’s opinion with respect to whether the Veteran’s left foot disorder was caused by a service-connected disability. The nurse practitioner specifically noted that she was unable to review the Veteran’s claims file. However, in her rationale she noted that per the claims file, the Veteran’s gait pattern was not significantly altered. Thus, the Board finds that this opinion is of low probative value as the nurse practitioner did not evaluate the Veteran or review the claims file. The nurse practitioner also did not address the positive opinion with respect to whether the Veteran’s prominent posterior plantar and retrocalcaneal spurs of the left foot are caused by or aggravated beyond its natural progression by service-connected left knee patellofemoral causation in the September 2020 VA opinion. In light of the foregoing, there is no reason to accord more weight to the negative medical opinion over the positive medical opinion. Thus, the evidence is at least in equipoise with respect to whether prominent posterior plantar and retrocalcaneal spurs of the left foot is aggravated beyond its natural progression by service-connected left knee patellofemoral and the Board resolves any reasonable doubt in favor of the Veteran. Accordingly, entitlement to service connection for prominent posterior plantar and retrocalcaneal spurs of the left foot is warranted. L. B. CRYAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Berry, 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.