Citation Nr: 21065843 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 14-31 043A DATE: October 27, 2021 ORDER Entitlement to service connection for amputation of the fourth toe, right foot, to include as secondary to service-connected congenital flat feet, is denied. FINDING OF FACT The Veteran's amputation of the fourth toe, right foot, was not caused or aggravated by his service-connected flat feet. CONCLUSION OF LAW The criteria for service connection for amputation of the fourth toe, right foot due service-connected flat feet are not met. 38 U.S.C. §§ 1110, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.310 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the United States Army from July 1982 to June 1984. This matter was previously before the Board in June 2021 but was remanded to the Agency of Original Jurisdiction (AOJ) for further development. Specifically, the AOJ was directed to obtain an addendum medical opinion regarding whether the Veteran's claimed disability was aggravated by his service-connected flat feet. The required opinion was obtained and associated with the claims file in July 2021. The VA opinion is adequate because it is based on a complete review of the claims file and the examiner provided a well-reasoned explanation for his opinion. The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a three-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303, 308 (2007). The third step of this inquiry requires the Board to weigh the probative value of the evidence in light of the entirety of the record. Neither the Veteran nor his representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). 1. Entitlement to service connection for amputation of the fourth toe, right foot, to include as secondary to service-connected flat feet Service connection may be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Veteran claims entitlement to service connection for amputation of his fourth toe, right foot, to include as secondary to his service-connected bilateral flat feet. He contends that his fourth toe amputation, right foot, was caused or aggravated by his flat feet. The Veteran is service connected for flat feet, effective February 25, 2011. However, as discussed blow, the probative medical evidence of record does not establish that the Veteran's amputation of the fourth toe, right foot, was caused or aggravated by his service-connected flat feet. In August 2014, following an in-person examination and review of the Veteran's medical records, a VA examiner opined it was less likely than not that the Veteran's amputation of the fourth toe, right foot, was caused by his service-connected flat feet. The examiner reasoned that the Veteran's amputation was caused by his chronic, uncontrolled diabetes, not a flat feet deformity. The Board notes that the Veteran is not service-connected for diabetes. An additional opinion was obtained in September 2019 stating: [The Veteran's] right below the knee amputation (BKA) was caused by methicillin resistant staph infection (MRSA), the same infection that caused amputation of his toe. He did not have an amputation leg or toe in the service. The toe amputation was caused by MRSA and this same MRSA caused the BKA - all this was related to his diabetes and occurred after service. In April 2021, and additional VA medical opinion concluded: The [V]eteran had an amputation of his right 4th toe in 2011from a non-healing toe infection most likely because of his diabetes. The following year he had a right BKA amputation because of a MRSA infection. This toe amputation and later the BKA amputation is not related to anything from the service. It is related to his diabetes. His amputations are also not related to his flat feet, it is impossible for a flat foot condition to lead to his amputations. In its June 2021 remand, the Board found this opinion inadequate with regard to aggravation. It is clear from the record that the cause of the amputation from a MRSA infection brought on by nonservice-connected diabetes. Multiple opinions explain how the nonservice-connected diabetes caused a MRSA infection, which then resulted in amputation of the toe, and then a below the knee amputation later. Although the opinions were inadequate regarding aggravation, and therefore will be afforded no probative weight regarding aggravation, they are adequate regarding causation because they clearly explain the reason for the amputation. They are highly probative evidence against a finding that flat feet caused the amputation. Finally, a July 2021 medical opinion concluded that it was less likely than not that the Veteran's amputation of the fourth toe, right foot was aggravated by his service-connected flat feet. The examiner reasoned that the Veteran developed an acute MRSA infection as a result of his diabetes eventually resulting in the amputation of his fourth toe, right foot, and eventual BKA. The examiner opined that the infection and subsequent infection "had nothing to do with the Veteran's service-connected flat feet." The Board finds that the July 2021 examiner's chosen phrase, "had nothing to do with" is highly probative against a finding that the flat feet aggravated the MRSA infection that caused his toe amputation. This is an extremely broad term. "Nothing" means "not at all" or "in no degree." Merriam-Webster's Collegiate Dictionary 848 (11th ed. 2012). This phrase encompasses aggravation, and expressly rules out aggravation. This opinion is highly probative evidence the Veteran's claim. The Board finds the above discussed medical opinions to be competent and well-reasoned. These opinions are highly probative evidence against the Veteran's claim for secondary service connection. At present, the probative evidence of record does not contain a medical opinion or other medical evidence establishing that the Veteran's amputation of the fourth toe, right foot was caused or aggravated by his service-connected flat feet. The Board acknowledges the Veteran's contention that his amputation of the fourth toe, right foot, was caused or aggravated by his service-connected flat feet. However, making this determination requires medical inquiry into the Veteran's anatomical and physiological functioning. With regard to the specific issue in this case, whether his amputation of the fourth toe, right foot, was caused or aggravated by his service-connected flat feet, falls outside the realm of knowledge of the Veteran in this case. See Jandreau, 492 F.3d at 1377 n.4. Such internal processes are not readily observable and are not within the competence of the Veteran in this case, who has not been shown by the evidence of record to have medical training or skills. As a result, the probative value of his lay assertions is low. The above-discussed medical opinions are of significantly more probative value. The Board concludes that the preponderance of the evidence is against the claim for service connection for the Veteran's amputation of the fourth toe, right foot. The benefit of the doubt rule therefore does not apply, and service connection for this disability is not warranted. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Riordan, 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.