Citation Nr: 21068979 Decision Date: 11/16/21 Archive Date: 11/17/21 DOCKET NO. 16-32 560 DATE: November 17, 2021 REMANDED Service connection for bilateral pes planus based on service aggravation. Service connection for a right foot disorder, other than pes planus. Service connection for a left foot disorder, other than pes planus. REASONS FOR REMAND The Veteran served on active duty from May 1986 to March 1990. The case is on appeal from a December 2014 rating decision. In October 2020, the United States Court of Appeals for Veterans Claims (Court) vacated the July 2019 Board decision denying service connection for bilateral pes planus based on aggravation and remanded the matter for additional development. In June 2021, the Board remanded the case for further development. 1. Service connection for bilateral pes planus based on aggravation. 2. Service connection for a right foot disorder, other than pes planus. 3. Service connection for a left foot disorder, other than pes planus. Pursuant to the Board's June 2021 remand, the Veteran was afforded a VA examination in July 2021. The report of examination reflects bilateral foot conditions to include pes planus, plantar fasciitis, and degenerative changes at the first metatarsophalangeal joint of each foot, resulting in foot pain. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the Court held that "multiple medical diagnoses or diagnoses that differ from the claimed condition do not necessarily represent wholly separate claims," and that because a lay claimant is only competent to report symptoms and not diagnoses, VA must consider the claim for disabilities reasonably raised by the description of the claimant's symptoms. Id. at 6-7. In the context of the record, the Board finds that the record raises service connection for bilateral foot conditions, other than pes planus, that are close in anatomical proximity and relate to the same body system as bilateral pes planus. As such, the Board determines that a right and left foot disorder, other than pes planus, is reasonably encompassed in the claim on appeal. As noted above, the issue with respect to bilateral pes planus is based on service aggravation. See 38 U.S.C. § 1153; 38 C.F.R. § 3.306. For any other foot disorder, the issue is standard service connection. Further, and although the VA examiner provided a negative opinion as to in-service aggravation of preexisting bilateral pes planus based, at least in part, on the absence of treatment for pes planus prior to 2014, June 2014 records note that prior treatment for bilateral pes planus included prescribed insoles and cortisone injections on three occasions. See November 2014 VA treatment records. Further, and although no bilateral foot condition was noted to have been diagnosed until 2014, the examiner also stated that a bilateral foot condition was not diagnosed until "several years after discharge." Based on the foregoing, the examination report is not completely adequate. Thus, the Board finds that remand for a new VA examination is warranted. On remand, an attempt should be made to obtain non-VA treatment records, to include from Fort Wayne Orthopedics in Indiana, including May 2021 records associated with steroid injections in the bilateral feet for foot pain, see July 2021 VA examination report, as well records prior to 2014. In addition, outstanding VA treatment records, including from the VA Northern Indiana Health Care System, since the issuance of the September 2021 Supplemental Statement of the Case (SSOC) should be associated with the claims file. The matters are REMANDED for the following action: 1. Obtain outstanding VA treatment records since September 2021, including from the VA Northern Indiana Health Care System. See September 2021 VA records. 2. Contact the Veteran and invite her to provide all outstanding records of non-VA/private medical treatment she received for bilateral foot disorders, including from Fort Wayne Orthopedics in Indiana prior to 2014 and in May 2021, providing her VA Forms 21-4142, Authorization and Consent to Release Information to the VA, for this purpose. Also advise her that she may submit such records if she so chooses. Allow a reasonable time for reply. If any records sought are unavailable, the Veteran should be notified of such pursuant to 38 C.F.R. § 3.159(e). 3. After completion of the above, schedule the Veteran for a VA examination by a qualified medical professional for an opinion with respect to aggravation of pre-existing bilateral pes planus, and further, the nature and etiology of any other diagnosed foot disorders, including plantar fasciitis. The examiner should identify the Veteran's current bilateral foot disorder(s), to include pes planus and plantar fasciitis. The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's preexisting pes planus increased in severity during service beyond a temporary flare-up. If so, he or she should opine whether it is undebatable from a medical standpoint that the increase in severity was due to the natural progress of the disease. For any other diagnosed foot disorder, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disorder(s) had their onset during, during or within the initial year of separation or are otherwise related to, service. In considering the evidence, the examiner must address the Veteran's report that pes planus worsened during service due to prolonged standing and exercise, and that she currently has constant pain and difficulty standing; medical literature indicating that symptoms of pes planus are often absent or trivial, except during times of exceptional stress, such as military service, see June 2019 Appellate Brief; diagnoses in addition to pes planus and plantar fasciitis, to include bunion/hallux abducto valgus, see November 2014 VA treatment records, tibial tendonitis, see October 2018 VA treatment records, and degenerative changes at the first metatarsophalangeal joint of each foot, see July 2021 VA examination; and any non-VA treatment records associated with the claims file. Rationale for all opinions expressed should be provided. If the reviewing clinician is unable to provide the requested opinions without resort to speculation, it must be so stated, and he or she must provide the reasons why an opinion would require speculation. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Taylor 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.