Citation Nr: 21065239 Decision Date: 10/25/21 Archive Date: 10/25/21 DOCKET NO. 09-12 000 DATE: October 25, 2021 REMANDED Entitlement to service connection for a right foot disability, to include as secondary to a service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1992 to December 1999. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, the Board remanded the issues of service connection for a right foot disability and service connection for a left knee disability for additional development. Regarding the previously remanded claim of entitlement to service connection for right foot disability, the Board finds that another remand is required for the reasons set forth below. During remand status, the RO granted service connection for left knee patellofemoral pain syndrome in an April 2021 rating decision. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997) (noting that a grant of service connection extinguishes appeals before the Board). Therefore, this issue is not before the Board. Entitlement to service connection for a right foot disability, to include as secondary to a service-connected disability. As an initial matter, the Veteran has been diagnosed with right foot pes planus, callouses, hallux valgus, and plantar fasciitis at various times during the appeal period. The Veteran contends that her right foot disabilities are related to her active service and that she has had right foot pain "ever since leaving the service." See December 2007 VA Form 21-4138. In the alternative, the Veteran contends that her "current foot disability is related to her [service-connected] disabilities." See September 2021 Appellate Brief. See also March 2008 VA Form 21-4138 (stating that low back pain caused problems with her feet). For the reasons that follow, the Board finds that another remand is necessary for an adequate medical opinion that addresses an additional theory raised by her representative. The Veteran was diagnosed with mild pes planus and calluses on the January 1991 Entrance Examination and Enlistment Report. Thus, the presumption of soundness is rebutted, and the question is whether her preexisting pes planus and calluses clearly and unmistakably did not undergo a permanent worsening beyond normal progression during active service. Although the April 2021 examiner addressed aggravation of the Veteran's preexisting right foot pes planus, he did not apply the correct legal standard, nor did he acknowledge the preexisting calluses. Moreover, it is unclear whether the Veteran's other foot diagnoses besides pes planus, including plantar fasciitis, are related to the preexisting pes planus, as opposed to separate conditions. In this case, following the most recent Board remand, an April 2021 VA opinion stated that medical literature supports that plantar fasciitis of the right foot is caused by pes planus. An addendum opinion was obtained in May 2021, which stated that plantar fasciitis, hallux valgus, and callouses were more likely than not normal progressions of preexisting pes planus, which was not aggravated during service. The clinician reasoned that the diagnosed plantar fasciitis, hallux valgus, and callouses were natural progressions of preexisting pes planus as there was "no documented alteration in gait due to the L foot which would impact the R foot." See C&P Exam (May 2021). The VA examiner provided a negative nexus opinion based on an incomplete or inaccurate medical history and is supported by inadequate reasoning. An adequate medical opinion must be based on an accurate factual premise and consideration of a veteran's prior medical history. Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In addition, the opinion "must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"). Specifically, a report of VA examination in May 2011 shows that the clinician noted unusual wear pattern upon examination of the feet. See VA Examination at 4 (May 2011). Additionally, findings from VA's Veteran Readiness and Employment (VR&E) (formerly known as Vocational Rehabilitation and Employment) program included that the Veteran was "challenged in ambulation," due to right foot pain. An October 2015 VA treatment record indicates that the Veteran's gait was "slightly antalgic." To the extent such evidence was considered, the opinion provides no reasoning why such evidence does not indicate an alteration in gait. The clinician also reasoned that, regarding hallux valgus, the April 2008 findings were not related to service as the findings were "9 years after service with no previous evidence of a R foot bunion." See C&P Exam (May 2021). The clinician noted that hallux valgus is related to footwear and foot mechanics, but provided inadequate reasoning why the military footwear worn by the Veteran over seven years of service, and the foot mechanic findings discussed above, were less likely than not related to diagnosed hallux valgus. Further, the May 2021 addendum opinion addressed secondary service connection, but it indicates that the only service-connected disability considered was the Veteran's left foot residuals of fracture with calcaneal bone spur and plantar fasciitis. Notably, the Board's January 2021 remand directed the clinician to consider whether a right foot disability is "proximately due to or aggravated beyond its normal course by any service-connected disability." See BVA Decision (January 2021) (emphasis added). Although the Veteran was also service-connected for bilateral hip, thoracolumbar spine, left ankle, left knee, and bilateral lower extremity neuropathy disabilities at the time of the May 2021 opinion, the opinion provides no indication that such service-connected disabilities were considered as directed. In addition, the Veteran's representative has recently raised obesity as a theory of entitlement. See September 2021 Brief. Although obesity is not a condition for which service connection may be granted, obesity may qualify as an "intermediate step" between a service-connected disability and another current disability." See VAOPGCPREC 1-2017; see also Garner v. Tran, No. 18-5865, 2021 U.S. App. Vet. Claims LEXIS 81, at *16 (Vet. App. Jan. 26, 2021). Accordingly, the matter is REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician other than the one who provided the April 2021 (with May 2021 addendum) on the nature and etiology of the Veteran's right foot (1) pes planus, (2) plantar fasciitis, (3) hallux valgus, and (4) callouses. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. The clinician must respond to the following: a) Assume that the Veteran's pes planus and calluses clearly and unmistakably preexisted her service. Then opine as to whether there is clear and unmistakable (undebatable from a medical perspective) evidence that the Veteran's preexisting pes planus and calluses were not aggravated by service. The clinician should address the September 1999 separation examination report of medical history, which notes the use of arch supports. Note: The term "aggravated" in this context means a permanent worsening beyond the natural progression of the disease or a temporary flare-up. (b) As to each right foot condition that did not clearly and unmistakably preexist service, is it at least as likely as not incurred in, or is otherwise related to, her active service? The clinician should address the Veteran's allegation attributing current foot symptoms to marching and walking in combat boots for several hours per day during active service. The clinician should also address the September 1999 separation examination report of medical history, which contains a diagnosis of plantar fasciitis. An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. c) As to each right foot condition that is not related to the Veteran's active service, is it at least as likely as not caused or aggravated by any of her service-connected disabilities, to include the bilateral hips, back, left knee, and left foot as well as obesity as an intermediary step? The clinician should address the June 2011 VA opinion linking the Veteran's callosities of the plantar skin on the right foot to the service-connected left foot disability. The clinician should consider the contention that the Veteran's service-connected disabilities (alone or in combination) cause an altered gait, which causes or aggravates her right foot conditions. Please address the May 2011 VA examination (noting unusual wear pattern upon examination of the feet); February 2018 VR&E (noting that Veteran was "challenged in ambulation" due to right foot pain); and October 2015 VA treatment record (describing Veteran's gait as "slightly antalgic"). The examiner should address whether obesity was an "intermediate step" between a service-connected disability in causing or contributing to any degree to each right foot condition that is not related to the Veteran's active service. Note: The term "aggravated" in this context means any increase in severity beyond the natural progress of the disease. d) If pes planus is opined to be at least as likely as not etiologically related to service, the examiner should determine whether it is at least as likely as not that plantar fasciitis, hallux valgus, and callouses are proximately due to or aggravated by the pes planus. A complete rationale for all opinions should be included. Separate opinions for causation and aggravation are required. If any findings are not possible without resort to mere speculation, please explain why. 2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. If the benefit sought is not granted to the Veteran's satisfaction, send the Veteran and her representative a Supplemental Statement of the Case and return the case to the Board for further appellate review. Rebecca N. Poulson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Thaddaeus J. Cox, 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.