Citation Nr: 21066974 Decision Date: 11/03/21 Archive Date: 11/03/21 DOCKET NO. 13-29 539 DATE: November 3, 2021 ORDER Entitlement to service connection for a psychiatric disability, claimed as depressive disorder, including as secondary to service-connected bilateral foot disability, is granted. Entitlement to service connection for cervical muscle spasms, including as secondary to service-connected bilateral foot disability, is granted. Entitlement to service connection for lumbar myositis, minimal spondylosis, including as secondary to service-connected bilateral foot disability, is granted. Entitlement to a 30 percent rating for residuals of a stress fracture of the calcaneum of the left foot, with plantar fasciitis and plantar and dorsal calcaneal spurs (left foot disability), is granted. Entitlement to a 30 percent rating for residuals of a stress fracture of the calcaneum of the right foot, with plantar fasciitis and plantar and dorsal calcaneal spurs (right foot disability), is granted. REMANDED Entitlement to service connection for left knee disability, including as secondary to service-connected disability is remanded. Entitlement to service connection for a right knee disability, including as secondary to service-connected disability is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. FINDINGS OF FACT 1. Resolving reasonable doubt in the Veteran's favor, his diagnosed depressive disorder is proximately due to his service-connected bilateral foot disability. 2. Resolving reasonable doubt in the Veteran's favor, neck/cervical muscle spasms disorder is proximately due to his service-connected bilateral foot disability. 3. Resolving reasonable doubt in the Veteran's favor, lumbar myositis, minimal spondylosis disorder is proximately due to his service-connected bilateral foot disability. 4. The Veteran's left foot disability is manifested by severe symptoms. 5. The Veteran's right foot disability is manifested by severe symptoms. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a psychiatric disability, claimed as depressive disorder, including as secondary to service-connected bilateral foot disability have been met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for cervical muscle spasms, including as secondary to service-connected bilateral foot disability have been met. 38 U.S.C. §§ 1131, 1137, 5107(b); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 3. The criteria for entitlement to service connection for lumbar myositis, minimal spondylosis, including as secondary to service-connected bilateral foot disability have been met. 38 U.S.C. §§ 1131, 1137, 5107(b); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. 4. The criteria for entitlement to a 30 percent rating for left foot disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (Code) 5284. 5. The criteria for entitlement to a 30 percent rating for right foot disability have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.7, 4.40, 4.45, 4.59, 4.71a, Code 5284. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from May 1985 to January 1986. These matters were last before the Board of Veterans' Appeals (Board) in June 2020 and remanded to a Department of Veterans Affairs (VA) Regional Office (RO) for additional development. SERVICE CONNECTION Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. § 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). Certain chronic diseases (to include arthritis) may be service-connected on a presumptive basis if manifested to a compensable degree within a specified period of time post-service (one year for arthritis). 38 U.S.C. § 1137; 38 C.F.R. §§ 3.307, 3.309. Nexus of a chronic disease to service may be established by showing continuity of symptomatology following service. Walker v. Shinseki, 708 F.3d 1331, 1338-40 (Fed. Cir. 2013). Disability which is proximately due to or the result of a service-connected disease or injury shall also be service connected. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists; and (2) that the current disability was either (a) caused or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448 (1995). 1. Entitlement to service connection for a psychiatric disability, claimed as depressive disorder, including as secondary to a service-connected disability The Veteran asserts entitlement to service connection for a depressive disorder as secondary to his service-connected bilateral foot disability. Based on the evidence that follows, the Board finds that service connection for depressive disorder secondary to service-connected bilateral foot disability is warranted. In May 2011 the Veteran was seen for a private psychiatric evaluation with Dr. JAA, psychiatrist. Dr. JAA noted that the Veteran sought treatment with him because his physical condition was affecting his performance at work and he developed depression, anxiety, insomnia, irritability and problems with his companion. Following mental status evaluation, Dr. JAA rendered an Axis I diagnosis of moderate major depression. Dr. JAA opined that the Veteran's depression is secondary to his service-connected bilateral foot disability. Dr. JAA's rationale was that the Veteran's physical problem causes him problems in his daily work responsibilities, which causes the depression. In an August 2012 medical statement the Veteran's private physician, Dr. NAOV proffered an opinion that the Veteran's nervous problem is at least as likely as not secondary to his musculoskeletal problems. Dr. NAOV reasoned that the Veteran's musculoskeletal problems have caused restrictions of his daily activities and social functioning. He is no longer able to tolerate strong physical activity, and he is not involved in any household tasks. As a consequence, he presents decreased interest and pleasure in most of his usual activities. His pain has been causing him frequent episodes of mood changes and improvement has been minimal. On May 2014 VA mental disorders examination, the examiner noted the Veteran was referred for a secondary service connection evaluation. He is claiming secondary service connection for depressive disorder secondary to service-connected bilateral foot disability. The examiner noted review of the claims file and interviewed the Veteran in person. The Veteran reported symptoms of depressed mood and chronic sleep impairment. The diagnosis was unspecified depressive disorder. The examiner opined that the Veteran's claimed psychiatric disorder is less likely than not proximately due to or the result of his service-connected bilateral foot disability. The rationale for the opinion is the pathophysiology of depressive disorder and bilateral foot disability are different and do not share any common receptor or pathophysiological mechanism. It is also worth mentioning that there is no evidence in the medical literature of a direct physiological consequence between the claimed depressive disorder and the bilateral foot disability. The preponderance of longitudinal medical evidence in the record and current mental disorders examination shows no functional or social impairment. The Veteran has been able to work after suffering from the injury during service. Regarding Dr. JAA's opinion, the examiner noted that the opinion lacks medical reference, longitudinal association, and the temporal relationship between mental and physical conditions. On September 2020 VA mental disorders examination, the Veteran reported that psychiatric medication has been prescribed by his primary provider. He stated he was receiving treatment from a private psychiatric doctor, Dr. JAA, but he closed the practice several years ago. The examiner noted that no medical evidence of psychiatric follow-up intervention, emotional crisis intervention, or inpatient psychiatric treatment was found. He has current symptoms of depressed mood, chronic sleep impairment, mild memory loss, and disturbances of motivation and mood. The diagnosis was unspecified depressive disorder. It was noted that a mental condition has been formally diagnosed, but symptoms are not severe enough either to interfere with occupational and social functioning or to require continuous medication. The Veteran reported that he is employed full-time as a postal carrier and is currently on medical leave for recovery time due to shoulder surgery performed in September 2020. The examiner opined that the Veteran's claimed psychiatric disorder is less likely than not proximately due to or the result of the Veteran's service-connected bilateral foot disability. The rationale for the opinion is that there is no evidence in the literature of a direct physiological consequence between the Veteran's service-connected bilateral foot disability (to include altered gait resulting therefrom) and a depressive disorder. Review of the record reveals there is no evidence of psychiatric complaints, findings or treatment prior to or during military service. The Veteran received psychiatric treatment with a private psychiatrist as per a letter signed by the private psychiatrist Dr. JAA dated in 2010, but last documented psychiatric follow-up note is in May 2011. There is no medical evidence of any psychiatric follow-up treatment intervention afterwards. It is noted in the March 2009, August 2010 and January 2016 VA compensation examinations that despite the Veteran's bilateral foot disability he is able to ambulate and perform activities of daily living and self-care activities and there is no functional loss. The longitudinal medical evidence does not show any temporal relation between the Veteran's depressive condition and his bilateral foot disabilities. There is no medical evidence of any aggravation beyond the baseline of the Veteran's depressive disorder. There is no medical evidence of any current psychiatric follow-up intervention, or emotional crisis intervention, or inpatient psychiatric treatment. The examiner concluded that based on the above findings a link between the Veteran's neuropsychiatric established condition and his bilateral foot disability cannot be made. Here, the medical nexus opinions addressing secondary service connection for the Veteran's claimed psychiatric disorder are in conflict. The Board finds the positive nexus opinions of the Veteran's private psychiatrist, Dr. JAA and his private physician, Dr. NAOV are probative and persuasive for addressing the matter of the connection between the Veteran's diagnosed depressive disorder and his service-connected bilateral foot disability. Likewise, the Board finds the negative nexus opinions of the VA examiners to be equally probative and persuasive. As this puts the evidence in relative equipoise as to whether the Veteran's diagnosed depressive disorder is proximately due to his service-connected bilateral foot disorder, it is resolved in the Veteran's favor. Resolving reasonable doubt in the Veteran's favor, his current diagnosis of depressive disorder is proximately due to his service-connected bilateral foot disability. 2. Entitlement to service connection for cervical muscle spasms, including as secondary to a shoulder disorder and service-connected bilateral foot disability 3. Entitlement to service connection for lumbar myositis, minimal spondylosis, including as secondary to a shoulder disorder and service-connected bilateral foot disability The Veteran asserts that service connection is warranted for neck/cervical and back/lumbar spine disorders as associated with his service-connected bilateral foot disability. The evidence shows that in August 2012 the Veteran's private physician, Dr. NAOV proffers an opinion that it is more likely than not that the Veteran's original bilateral foot injury caused his neck and back conditions. Dr. NAOV reasons that the Veteran's back and neck problems developed after his bilateral foot injury in service and afterwards he developed constant pain. She stated that it is recognized in medical literature and in her personal experience that a leg injury that causes an alteration of a person's gait often progresses to issues with the person's back. From the time of the original injury to the present, there has been no other injury that accounts for the Veteran's condition. He has weight-bearing problems, bad posture, loss of correct alignment and loss of curvature of cervical, thoracic and lumbar lordosis, and problems of radiculopathy may arise. Dr. NAOV concludes that it is reasonable to assume that it is more likely than not that the Veteran's original foot injury has caused his neck and back conditions. On December 2012 VA neck/cervical spine conditions examination, the Veteran reported that he feels a tensional pain since several years ago. He denied trauma. The pain was non-irradiating. He had numbness and cramps in both arms. X-rays show mild straightening of the cervical lordosis, which could be the basis of muscle spasm versus positioning. The diagnosis was cervical muscle spasms. Regarding functional impact, the Veteran stated that the pain limits his neck movement, and he drives a postal service vehicle. The examiner opined that the Veteran's neck/cervical spine disorder is less likely than not proximately due to or the result of the Veteran's service-connected bilateral foot disability. The rationale for the opinion is that the current cervical myositis is less likely to be secondary to the calcaneal stress fracture due to no anatomic or neurologic connection. The cervical myositis is most likely related to cumulative microtrauma. The radiologic examination shows no evidence of discogenic disease and no evidence of radiculopathy. On December 2012 VA back conditions examination, the Veteran reported having constant low back pain without irradiation. He has a burning sensation to the right leg. He stated that the pain started about 4 or 5 years ago without traumas. X-rays revealed paravertebral muscle spasm and minimal spondylosis of the lower lumbar spine. The diagnoses were lumbar myositis and minimal spondylosis. Regarding functional impact, the Veteran stated he works as a mailman and has applied to stay in the vehicle instead of walking due to back pain. The examiner opined that the Veteran's claimed low back disorder is less likely than not proximately due to or the result of his service-connected bilateral foot disability. The rationale for the opinion is that the current minimal spondylosis is more likely related to the natural aging process and not related to the calcaneal stress fractures. The Veteran failed to provide evidence of treatment for his service connected disability through the years after he was discharged. He is a mailman in the postal service and he needs to walk in his previous job and now in the new duties needs to drive long distances. This is a risk factor to develop lower back pain with muscles spasms and less likely to be related to the calcaneal stress fractures and plantar fasciitis. July 2013 MRI of the lumbar spine shows discogenic disc disease, central disc protrusion producing mild to moderate impression upon the thecal sac, no central spinal canal stenosis, no narrowing of the neural foramina, and mild posterior facet joint degenerative changes. July 2013 MRI of the cervical spine shows early discogenic disc disease, no herniated, no bulging disc seen, no spinal canal stenosis and no narrowing of neural foramina seen. In a September 2013 private medical report, Dr. LEFC noted that he initially saw the Veteran in December 2009. At that time the Veteran related the history of the inservice accident involving bilateral foot calcaneal bone fractures. Dr. LEFC provided the initial impressions of cervical spine and intravertebral disc disease, cervical nerve root compromise and lumbar spinal nerve root compromise and subsequent to physical examination he diagnosed bilateral calcaneal bone fractures, degenerative intravertebral disc disease L2-L3, L3-L4, L4-L5, and L5-S1, herniations at L2-L3, L3-L4, L4-L5, bilateral central lumbar 5 sacral, polyradiculopathy, chronic, and right C5, C6 and C7, polyradiculopathy. Dr. LEFC established a causal relationship with the Veteran's lumbar and cervical spine disorders and the Veteran's service-connected bilateral foot disability. Dr. LEFC opined that it is more probable than not that the additional diagnoses of lumbar and cervical spine disorders developed as a direct result of the severe initial trauma to the Veteran's feet during active military service, which was clearly of such magnitude that he would eventually develop chronic lumbar and cervical spine conditions. Dr. LEFC reasoned that the trauma the Veteran sustained to his feet was significant or severe enough to cause fracture of both calcaneal foot bones. The trauma definitively was of such magnitude, catastrophic in order to cause the calcaneal bones to break apart. That same severe catastrophic severe trauma was transmitted towards and along the lumbar spine up to the cervical levels. In May 2014, VA requested a "record only" medical opinion to address the conflicting medical evidence regarding the claimed cervical and lumbar spine disorders by Dr. LEFC and Dr. NAOV. The VA medical opinion provider agreed with Dr. LEFC that the Veteran has cervical and lumbar degenerative disc disease (DDD). (See April 2008 cervical spine MRI and December 2009 lumbar spine MRI). The VA medical opinion provider related that he does not agree with the opinion given by Dr. LEFC and Dr. NAOV regarding the Veteran's cervical DDD with radiculopathy and lumbar DDD with radiculopathy being related to his service-connected bilateral foot disability. The nexus that Dr. NAOV makes between the service-connected bilateral foot disability and current cervical and lumbar conditions are based on gait and posture taken from experience as a physician and medical literature. Dr. NAOV does not perform a physical examination in her report describing the Veteran's gait or posture. No gait or posture abnormalities were described in Dr. LEFC's report from September 2013. The nexus given by Dr. LEFC has a different approach compared to Dr. NAOV. Dr. LEFC mentions that the trauma to the Veteran's feet was "severe", "catastrophic" that was "transmitted towards and along at the cervical levels". Dr. LEFC begins his reports stating that the Veteran offered the history of the trauma to both feet. He did not have the opportunity to review service treatment records and therefore was unaware of the nature of how the Veteran injured his feet. Also, if the injury was "severe" and "catastrophic" which "transmitted towards and along at the cervical levels," as described by Dr. LEFC but not seen in the service treatment records, it was unclear how there could be no lumbar or cervical complaints with radiculopathy while in service or shortly after. Cervical and lumbar complaints came more than 20 years after discharge from military service. Degenerative disc disease of the cervical and lumbar spine is seen as a normal aging process in individuals who develop it. The VA medical opinion provider noted agreement with the December 2012 VA examiner who opined that the claimed disorders are less likely than not proximately due to or the result of the Veteran's service-connected bilateral foot disability. On April 2021 VA-contract neck/cervical spine conditions examination, the Veteran reported that the onset of his neck disorder was in 2010. He states that for the past years he has had neck pain that has progressively worsened. He has weekly flare-ups of mild localized neck pain that last 1 to 5 hours that result in difficulty with flexion anteriorly. There were imaging studies of the cervical spine performed in conjunction with the examination. The diagnosis was degenerative disc disease of the neck other than intervertebral disc syndrome (IVDS), diagnosed in July 2013. The Veteran states that claimed neck/cervical spine disorder impacts his ability to perform any type of occupational task in that he must avoid lifting or carrying heavy objects. The examiner opined that the Veteran's neck/cervical discogenic disc disease is less likely than not proximately due to or the result of or aggravated beyond its natural progression by the Veteran's service-connected bilateral foot disability to include any altered gait resulting therefrom. The rationale for the opinion was that at the time of the evaluation there was no objective evidence of weight-shifting gait patterns. By definition cervical discogenic disc disease and the diagnosed bilateral foot disability are different disease entities with different pathophysiological and anatomical processes unrelated to each other. In addition, there is no objective evidence that the Veteran's neck/cervical spine disorder has been aggravated beyond its natural progression by the service-connected bilateral foot disability. There is no evidence that the Veteran has been treated with cervical surgery or hospitalizations. On April 2021 VA-contract back conditions examination, the Veteran reported that he has had lower back pain for the past several years that has progressively worsened. Following examination, the examiner diagnosed lumbar spine degenerative arthritis and lumbar spine degenerative disc disease other than IVDS. The examiner opined that the Veteran's lumbar discogenic disc disease, arthritis is less likely than not proximately due to or the result of the Veteran's service-connected bilateral foot disability, to include any altered gait resulting therefrom. The rationale for the opinion was that at the time of the evaluation there was no objective evidence of weight shifting gait patterns. By definition lumbar discogenic disc disease, arthritis, and the diagnosed bilateral foot disability are different disease entities with different pathophysiological and anatomical processes unrelated to each other. In addition, lumbar discogenic disc disease, arthritis was less likely than not aggravated beyond its natural progression by the Veteran's service-connected bilateral foot disability, to include any altered gait resulting therefrom. The rationale for the opinion was that there is no objective evidence that the Veteran's low back disorder has been aggravated beyond its natural progression by his service-connected bilateral foot disability. There is no evidence that the Veteran has been treated with lumbar surgery and/or hospitalizations. In June 2021 Dr. JE of the Forensic Capacity Evaluation Center (FCEC) performed an evaluation of the Veteran's disabilities. Regarding his claimed low back disorder, the Veteran reported that his lumbar disorder resulted from his military service injuries when he slipped on black ice and injured his lumbar spine. Dr. JE conducted examination of the Veteran's cervical and lumbar spine. He noted that facts shown by evidence establish that the Veteran's claimed impairments resulted in disability and were incurred coincident with his military service. His conditions are more likely than not (50 percent or greater probability) that his diagnosed conditions began during his military service. After considering the evidence of record, the Board finds that the evidence of record is in relative equipoise and resolving all doubt in the Veteran's favor, service connection for cervical muscle spasms, and lumbar myositis, minimal spondylosis disorders is warranted. Here, the medical nexus opinions addressing secondary service connection for the Veteran's claimed cervical and lumbar spine disorders are in conflict. The Board finds the positive nexus opinions of the Veteran's private medical providers (Dr. NAOV in August 2012, Dr. LEFC in September 2013 and Dr. JE in June 2021) are probative and persuasive for addressing the matter of the connection between the Veteran's diagnosed cervical and lumbar spine disorders and his service-connected bilateral foot disability. Likewise, the Board finds the negative nexus opinions of the VA examiners (December 2012 VA neck and back examination reports, May 2014 VA medical opinion and April 2021 VA-contract neck and back examination reports) to be equally probative and persuasive. This puts the evidence in relative equipoise as to whether the Veteran's diagnosed cervical and lumbar spine disorders are proximately due to his service-connected bilateral foot disorder, and resolution is in the Veteran's favor. Resolving reasonable doubt in the Veteran's favor, his current diagnoses of cervical and lumbar spine disorders are proximately due to his service-connected bilateral foot disability. INCREASED RATING Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. It is necessary to rate the disability from the point of view of the Veteran working or seeking work. 38 C.F.R. § 4.2. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating; otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Generally, when an increase in the disability rating is at issue, it is the present level of disability that is of primary concern. Francisco v. Brown, 7 Vet. App. 55 (1994). However, consideration also must be given as to whether staged ratings should be assigned to reflect entitlement to a higher rating at any point during the pendency of the claim. Hart v. Mansfield, 21 Vet. App. 505 (2007). Disability of the musculoskeletal system is primarily the inability, due to damage or infection in the parts of the system, to perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance. It is essential that the examination on which ratings are based adequately portray the anatomical damage, and the functional loss, with respect to all these elements. The functional loss may be due to absence of part, or all, of the necessary bones, joints and muscles, or associated structures, or to deformity, adhesions, defective innervation, or other pathology, or it may be due to pain, supported by adequate pathology and evidenced by visible behavior of the claimant undertaking the motion. Weakness is as important as limitation of motion, and a part which becomes painful on use must be regarded as seriously disabled. 38 C.F.R. §§ 4.10, 4.40, 4.45. VA must analyze the evidence of pain, weakened movement, excess fatigability, or incoordination and determine the level of associated functional loss in light of 38 C.F.R. § 4.40, which requires the VA to regard as "seriously disabled" any part of the musculoskeletal system that becomes painful on use. DeLuca v. Brown, 8 Vet. App. 202 (1995). Although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011); Pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance, as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement that affects stability, standing, and weight-bearing. Therefore, in rating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. Consideration must include joint testing for pain on both active and passive motion, in weight bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158 (2016). The intent of the rating schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. It is the intention to recognize actual painful, unstable, or malaligned joints, due to healed injury, as entitled to at least the minimum compensable rating for the joint. 38 C.F.R. § 4.59. 1. Entitlement to a rating higher than 20 percent for residuals of a stress fracture of the calcaneum of the left foot, with plantar fasciitis and plantar and dorsal calcaneal spurs 2. Entitlement to a rating higher than 20 percent for residuals of a stress fracture of the calcaneum of the right foot, with plantar fasciitis and plantar and dorsal calcaneal spurs In May 2010 the Veteran filed a claim for increased ratings for his service-connected left and right foot disabilities. He is currently in receipt of a 20 percent rating for each foot under Code 5284. Under Code 5284, a 20 percent rating is warranted for a moderately severe foot injury. A 30 percent rating is warranted for a severe foot injury. A 40 percent rating may be assigned if there is actual loss of use of the foot. 38 C.F.R. § 4.71a, Code 5284. The words "moderate," "moderately severe," and "severe," as used in the various diagnostic codes are not defined in the VA Schedule for Rating Disabilities. Rather than applying a mechanical formula, the Board must evaluate all of the evidence, to the end that its decisions are "equitable and just." 38 C.F.R. § 4.6. "Loss of use of a foot" is defined as no effective function remaining other than that which would be equally well served by an amputation stump at the site of election below the knee with use of a suitable prosthetic appliance. The determination will be made on the basis of the actual remaining function of balance, propulsion, etc., which could be accomplished equally well by an amputation stump with prosthesis. 38 C.F.R. § 4.63. Examples under 38 C.F.R. § 4.63 that constitute loss of use of a foot include extremely unfavorable ankylosis of the knee, complete ankylosis of two major joints of an extremity, shortening of the lower extremity of 3 1/2 inches or more, or complete paralysis of the external popliteal nerve and consequent foot drop. The Veteran was afforded a VA examination in March 2009. At the examination, he reported that his bilateral calcaneal stress fracture healed within 5 to 6 months, but since that time (1986) he has had bilateral heel pain that occurs with prolonged walking, and the pain is severe in the morning. He described having bilateral foot symptoms while standing and walking. He experiences pain and swelling at the Achilles tendon and calcaneal areas, and heat, fatigability, weakness, and endurance that affect the entire foot. He had flare-ups of foot joint occurring weekly or more often and last more than 2 but less than 7 days precipitated with walking and alleviated with rest. He is unable to walk when flare-ups occur. He is able to stand for 15 to 30 minutes and able to walk a quarter mile. He does not use assistive devices. On physical examination of the bilateral feet, there was no evidence of painful motion, swelling, instability, weakness, or abnormal weight bearing. There was evidence of tenderness of the Achilles tendon and calcaneal areas. There was no bilateral foot muscle atrophy or foot deformity. His gait was a normal pattern. X-rays show plantar and dorsal calcaneal spurs. No fracture or subluxation were present. The diagnoses were bilateral Achilles tendinitis, bilateral diagnostic residuals stress fracture of calcaneum, bilateral plantar and dorsal calcaneal spurs, and bilateral plantar fasciitis. The Veteran's occupational activities were impacted by decreased mobility and pain of the bilateral foot. The effects of his bilateral foot disability on daily activities were severe for shopping, exercise, and sports; moderate for traveling; and none for chores, recreation, feeding, bathing, dressing, toileting, grooming, and driving. The Veteran was employed full-time for more than 20 years as an industrial mechanic. In the last 12-month period he lost 2 weeks from work due to his bilateral foot disability. The examiner noted the Veteran continuously complained of bilateral heel pain even after calcaneal stress fracture treatment was complete. The examiner further noted that the fact that the Veteran had calcaneal stress fracture bilaterally could have contributed to the development of bilateral plantar fasciitis and/or calcaneal spurs conditions. The Veteran underwent a VA general medical examination in January 2011. The examination report revealed the Veteran had bilateral foot pain with flare-ups of foot disease. During flare-ups, the Veteran stated he cannot perform his usual working tasks. On physical examination, he had a normal gait. The diagnoses were residuals stress fracture calcaneus, plantar fasciitis, and plantar and dorsal calcaneal spurs of the right and left feet. At the time of the examination, the Veteran was employed as a postal worker, fulltime. Time lost from work during the past 12-month period was 4 weeks due to pain and swelling of his feet. On a December 2012 VA foot examination, the Veteran report having bilateral calcaneal pain that is worse on the right foot. He stated the pain is constant, and the pain level was 5-6/10. He was under no treatment at the time of the examination. The Veteran used a cane regularly. X-rays revealed mild osteoarthritic changes of the right foot. The examiner diagnosed bilateral calcaneal stress fractures and bilateral plantar fasciitis of moderate to moderately severe severity. Regarding functional impact, the Veteran stated he works at the postal service as a mailman and needed to change from walking to vehicle work. On January 2016 VA foot conditions examination, the Veteran reported worsened pain of his bilateral foot disability since the last compensation examination in December 2012. He describes pain in the bilateral plantar calcaneal area. He did not report flare-ups that impact the function of the feet. He did not have pain on use of the feet, or on manipulation of the feet. There is no indication of swelling on use or characteristic callouses. He does not have extreme tenderness of plantar surfaces of the feet or decreased longitudinal arch height on weight-bearing of either foot. There is no evidence of marked deformity or marked pronation of the feet, and the weight-bearing line does not fall over the medial to the great toe. There is no lower extremity deformity other than pes planus causing alteration of the weight-bearing line, or "inward" bowing of the Achilles tendon, or marked inward displacement and severe spasm of the Achilles tendon on manipulation. Malunion or nonunion of tarsal or metatarsal bones was not indicated. It was noted that the Veteran has residuals stress fracture of calcaneus, plantar fasciitis and plantar and dorsal calcaneal spurs that is moderate on the left and moderately severe on the right. The Veteran has bilateral foot pain that does not contribute to functional loss, as he is able to ambulate and do activities of daily living and self-care activities. There is no functional loss for the bilateral lower extremity. There is no pain, weakness, fatigability, or incoordination that significantly limits functional ability during flare-up or when the feet are used repeatedly over time. No assistive devices are used. Imaging studies of the feet were not performed. The diagnosis was bilateral residuals of stress fracture of calcaneus, plantar fasciitis and plantar and dorsal calcaneal spurs. The Veteran stated that his ability to perform any type of occupational task is impacted by his bilateral foot disability due to limitation in prolonged standing and prolonged ambulation activities. On April 2021 VA-contract foot conditions examination, the Veteran reported he has continued bilateral foot pain using orthotics with partial relief of symptoms. He described bilateral heel/plantar pain. He has weekly episodes of flare-up of symptoms, described as mild sharp bilateral foot pain. He also has poor tolerance in prolonged standing activities. The Veteran has pain on use of both feet and the pain was accentuated on use. He did not have pain on manipulation of the feet, nor was there indication of swelling on use, nor characteristic calluses. He did not have extreme tenderness of the plantar surfaces or decreased longitudinal arch height of his feet on weight-bearing, with marked pronation. The Veteran had poor tolerance in prolonged standing activities bilaterally, due to plantar fasciitis. In addition to the diagnosed bilateral foot disability, the Veteran had moderate tenderness to palpation at the plantar and calcaneal areas, bilaterally. There was bilateral foot pain on physical that contributed to functional loss. The examiner noted that despite pain the Veteran is able to ambulate. Further, the procured evidence suggests bilateral foot pain, fatigability, weakness, lack of endurance, or incoordination which significantly limits functional ability during flare-ups and/or after repeated use over time. There was also evidence of bilateral foot pain on the plantar/heel area with weight-bearing. The Veteran uses orthotics regularly. The diagnoses were bilateral foot residuals stress fracture of calcaneum, plantar fasciitis, and plantar and dorsal calcaneal spur. In June 2021 Dr. JE of the Forensic Capacity Evaluation Center (FCEC) performed an evaluation of the Veteran's disabilities. Dr. JE noted that the Veteran's bilateral foot disability is manifested by objective evidence of marked bilateral pes planus and plantar fasciitis pain on exertion that are not improved by orthopedic shoes or appliances. He further noted that the Veteran presented with pronounced flat feet, bilaterally. The Veteran experiences marked pronation and exquisite tenderness of his plantar surface bilaterally. The Veteran described symptoms of feet tiring out quickly after less than 30 minutes of walking continuously, pain in the areas of the big toes, heels, and longitudinal arches, right area swelling, pain while performing foot movements, plantar fasciitis, calcaneal spurs, deviation of the first toe, and ankle joint pain. The Veteran stated his pes planus worsened beyond its natural progression because of military service. Dr. JE commented that pes planus can increase the risk of secondary injury to the musculoskeletal system. Dr. JE further noted that the Veteran reports that flare-ups are daily and negatively impact his feet function. He has characteristic ankle and feet swelling bilaterally. The Veteran presented with deformed longitudinal arch upon weight-bearing, bilaterally. There is objective evidence of the Veteran's marked feet deformity. There is marked bilateral foot pronation. He has symptoms associated with a hallux valgus deformity condition. He has movement restrictions secondary to ankylosis, limitation or blocking, adhesions, tendon tie-ups, and contracted scars. He has movement weakness and fatigue secondary to muscle injury, disease, or injury of peripheral nerves, divided or lengthened tendons. He has exertional and weight-bearing pain and swelling and deformity of the ankle and toes. He has gait instability and locomotion and sitting and walking limitation secondary to pain. Having carefully considered the evidence of record, the Board finds that the criteria for a disability rating of 30 percent for each foot have been met. As indicated above, under Code 5284, evidence of severe foot disability warrants a 30 percent disability rating. In this regard, Dr. JE in the June 2021 evaluation of the Veteran's bilateral foot disability described symptoms and functional impairment of the Veteran's feet that more nearly approximate the criteria for a 30 percent rating. The Veteran has complained of severe pain throughout the appeal period, and the Board thus finds that the 30 percent evaluations are warranted for the entire appeal period. The Board has considered whether an even higher rating is warranted under alternate diagnostic codes, however, the evidence has consistently demonstrated that there is an absence of bilateral acquired pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo achillis on manipulation, that is not improved by orthopedic shoes or appliances, and bilateral pes cavus. As such, ratings under Codes 5276 and 5278 are not appropriate. The Board also notes that the newly enacted Code 5269 for plantar fasciitis, effective from February 7, 2021, does not allow for a rating in excess of 30 percent. Accordingly, a rating of 30 percent each for left and right foot disabilities, but no higher, is granted. REASONS FOR REMAND 1. and 2. Entitlement to service connection for right and left knee disabilities In the June 2020 Board remand, the Board noted that the January 2016 VA examiner concluded that disabilities of both knees were unrelated to service, and were not secondary to a service-connected disability. In the rationale, the examiner noted that the Veteran did not report knee pain in service, which the Board pointed out was an incorrect finding, as the Veteran's service treatment records show he did seek treatment for right knee pain in service in July 1985. In addition, the Board noted that the examiner incorrectly listed the Veteran's service dates as May 1967 to November 1967, which raised the possibility that the examiner was provided the wrong service treatment records. Moreover, while the VA examination report evaluated both knees the medical opinion associated with the report addressed the right knee only. The Board essentially deemed the January 2016 medical opinion inadequate and remanded the claims for a new opinion to address the question of whether the Veteran's bilateral foot disabilities aggravated his bilateral knee disabilities. While the April 2021 post-remand VA-contract medical opinion provided an opinion on aggravation of the right and left knees, direct service connection was not addressed. Thus, an adequate opinion has not been proffered on the question of direct service connection for both knees, and a remand is necessary to obtain such opinions. 3. Entitlement to TDIU The TDIU claim is inextricably intertwined with the remanded service connection claims as the resolution of these claims may impact adjudication of the claim for a TDIU, and so that claim must be remanded as well. The matters are REMANDED for the following action: Schedule the Veteran for a VA knee examination by an appropriate professional to determine the nature and etiology of any bilateral knee disability. The examiner should review all pertinent records in the Veteran's claims file. All necessary tests and studies should be conducted. The examiner must opine as to whether it is at least as likely as not (at least an approximate balance of positive and negative evidence) that any diagnosed bilateral knee disability had its onset during, or otherwise related to, the Veteran's active duty service. In rendering an opinion, the examiner must consider that the Veteran sought treatment for right knee pain in service in July 1985. A complete rationale must be provided for all opinions expressed and conclusions reached. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Young, 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.