Citation Nr: 21062403 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 17-01 421 DATE: October 7, 2021 ORDER Entitlement to service connection for bilateral pes planus is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his bilateral pes planus was noted on entry and was aggravated beyond its natural progression by his active duty service. CONCLUSION OF LAW The criteria for entitlement to service connection for bilateral pes planus have been met. 38 U.S.C. §§ 1131, 1153, 5107; 38 C.F.R. § 3.303, 3.304, 3.306. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from November 1983 to March 1984, September 1999 to March 2000, and August 2006 to January 2008. This matter comes to the Board of Veteran's Appeals (Board) on appeal from a January 2014 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in September 2019 to the agency of original jurisdiction (AOJ) for further development. The Board's remand directives have been substantially completed. See Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for bilateral pes planus The Veteran has been diagnosed with bilateral pes planus that causes functional loss and impairment. See December 2019 VA examination. For the reasons that follow, resolving all reasonable doubt in favor of the Veteran, the Board finds that service connection for bilateral pes planus is warranted. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131. Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden element is through a demonstration of continuity of symptomatology if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). As an initial matter, the Board notes that bilateral pes planus was "noted" as asymptomatic on the Veteran's August 1983 service entrance examination. Thus, this demonstrates bilateral pes planus on entry to military service. As the Veteran's bilateral pes planus was "noted" at entrance into service, the presumption of sound condition does not attach at service entrance with regard to such disability. See 38 U.S.C. § 1111. Consequently, service connection may be granted only if it is shown that the Veteran's bilateral pes planus increased in severity (was aggravated) during service and, if so, such was not clearly and unmistakably due to the natural progression of such disorder. 38 U.S.C. § 1153; 38 C.F.R. § 3.306. With regard to the 'aggravation prong', the Board finds that the evidence shows that the Veteran's pre-existing pes planus was aggravated during military service beyond its natural progression. In this regard, the Veteran's service treatment records (STRs) do not show complaints or treatment for bilateral pes planus. However, a swollen right ankle was noted on the separation examination in December 2007. A March 2008 radiographic study of the Veteran's right ankle showed evidence of multiple bony fragments in the medial malleolus, suggesting an old fracture. See March 2008 VA treatment record. An October 2013 private treatment record shows a diagnosis of flat feet, right greater than left with an old medial malleolus fracture. Radiographic studies taken at that time revealed an old right ankle fracture (fracture of medial malleolus), compounded with the Veteran's flat feet. A March 2014 private treatment record showed an assessment relating the Veteran's bilateral flat feet to his military service, weight-bearing, prolonged walking, and carrying weight. The evidence of record also includes a private March 2019 Disability Benefits Questionnaire (DBQ). The private examiner diagnosed the Veteran with a right flat foot (pes planus) and opined that his condition is secondary to his service-connected residuals of right ankle fracture. The private examiner noted that the Veteran's right ankle condition is chronic and progressive in nature, and he has been prescribed an ankle boot and a brace. The private examiner also noted that it would be difficult for the Veteran to sustain any employment that would require prolonged standing or walking. Pursuant to September 2019 Board's remand directives, the Veteran underwent a VA examination for his bilateral pes planus in December 2019. At that time, the Veteran reported that his bilateral foot condition was discovered during his military entrance examination in 1983, it was aggravated by his service and became worse over time. The Veteran reported experiencing throbbing foot pain, aching and tenderness. The examiner diagnosed the Veteran with bilateral pes planus and noted that his condition causes functional impairment, to include difficulty with prolonged standing or walking. The examiner opined that the Veteran's bilateral pes planus, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner based this opinion on the fact that daily marching, running and physical training during service exacerbates pes planus. The examiner noted that the Veteran constantly uses insoles bilaterally for added arch support. The AOJ found the December 2019 VA opinion insufficient for rating purposes and requested an addendum opinion. In a July 2020 VA addendum opinion, the examiner again opined that it is at least as likely as not that the Veteran's pre-existing bilateral pes planus was aggravated beyond natural progression by active duty service. In the rationale the VA examiner noted post-military treatment records reflecting complaints and treatment of the Veteran's bilateral pes planus resulting from his active duty service. The AOJ again found the July 2020 VA opinion insufficient for rating purposes and requested another addendum opinion. In an August 2020 VA addendum opinion, the examiner yet again opined that the Veteran's bilateral pes planus, which clearly and unmistakably existed prior to service, was aggravated beyond its natural progression by an in-service injury, event, or illness. The examiner explained that pes planus is asymptomatic in majority of cases, unless physical activity permanently increases the discomfort from pes planus, thereby aggravating the disability. The examiner added that secondary changes may occur in surrounding bones and soft tissues where the condition has existed for some time. The examiner further opined that the Veteran's service-connected right ankle condition, aggravated his pre-existing pes planus. The examiner based this opinion on the fact that the ankle condition forced the Veteran to change his gait to avoid pain and protect his ankle. This repetitive use of his foot with changed gait triggered pain and enhanced flare-ups. The examiner added that this is a chronic problem because sustained imbalance between flexion and extension involves intrinsic and extrinsic tendons of the foot, causing more pain and increasing deformity. The Board accords great probative weight to the August 2020 VA addendum opinion. The examiner considered all of the pertinent evidence of record, to include the Veteran's statements, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiner offered a clear conclusion with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra. The objective evidence of record is also consistent with the examiner's conclusion. Based on the foregoing, the Board finds that there is competent and credible evidence of a worsening of the Veteran's bilateral pes planus during service. His pes planus was asymptomatic on entrance examination in August 1983. However, it became symptomatic as a result of in-service aggravation. There is also no clear and unmistakable evidence of record showing that the increase in disability was due to the natural progress of the disease. In sum, the Board finds that after resolving the benefit of the doubt in favor of the Veteran, service connection for bilateral pes planus is warranted. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Thus, the appeal is granted. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Kuzniar, Associate 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.