Citation Nr: 21071104 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 16-21 681 DATE: November 29, 2021 ORDER Entitlement to service connection for right foot pes planus is granted. Entitlement to service connection for left foot pes planus is granted. REMANDED Entitlement to service connection for left shin splints is remanded. Entitlement to service connection for right shin splints is remanded. Entitlement to service connection for left ankle disability is remanded. Entitlement to service connection for left shoulder disability is remanded. FINDINGS OF FACTS 1. Resolving reasonable doubt in the Veteran's favor, his right foot pes planus had its onset in service. 2. Resolving reasonable doubt in the Veteran's favor, his left foot pes planus had its onset in service. CONCLUSIONS OF LAW 1. The criteria for service connection for right foot pes planus are met. 38 U.S.C. §, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for left foot pes planus are met. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1990 to October 1990, from January 1991 to September 1991, from February 1994 to July 1996, and from October 1997 to January 2014. The appeal regarding the claimed bilateral pes planus comes to the Board of Veterans' Appeals (Board) from a September 2014 rating decision. The other claims were appealed from a November 2014 rating decision. The Veteran filed a notice of disagreement in April 2015, with respect to the issues currently on appeal. A statement of the case was issued in May 2016. Thereafter, the Veteran filed a substantive appeal in May 2016. The Veteran requested a videoconference hearing, which was conducted in July 2021 before the undersigned, and transcript of the hearing is of record. 1. Entitlement to service connection for right foot pes planus is granted. 2. Entitlement to service connection for left foot pes planus is granted. The Veteran contends that his bilateral pes planus started in service. Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, according to a July 2014 VA examination, the Veteran has a current diagnosis of bilateral pes planus (flat foot). His service treatment records (STRs) reflect that the Veteran was diagnosed with bilateral pes planus in November and December 2001, while he was in active service. Moreover, the Veteran credibly testified that his bilateral foot symptoms started in service and continued after his separation from the military. See hearing transcript at 3-4. The Veteran is competent to report that he experienced symptoms of bilateral foot pain. His testimony is credible and entitled to probative weight, as it is internally consistent and consistent with his STRs, which show diagnosis of bilateral pes planus. Thus, considering the totality of the evidence of record, the Veteran's current bilateral pes planus had its onset in service, as such service connection is warranted. Flynn v. Brown, 6 Vet. App. 500, 503 (1994) (noting that "the element of cause and effect has been totally by-passed in favor of a simple temporal relationship between the incurrence of the disability and the period of active duty"). Therefore, service connection for right and left feet pes planus is granted. REASONS FOR REMAND 3. Entitlement to service connection for left shin splints is remanded. 4. Entitlement to service connection for right shin splints is remanded. 5. Entitlement to service connection for left ankle disability is remanded. 6. Entitlement to service connection for left shoulder disability is remanded. Review of the record shows that the Veteran's complete service treatment records from his time with the Oklahoma National Guards is not in the claims file. A remand to obtain these records is necessary before the claims can be adjudicated. The Veteran testified that he was treated at Fort Belvoir Army Hospital as a dependent (his wife was stationed on active duty) and the record does not appear to contain these treatment records. On remand these records should be obtained. Moreover, the Veteran underwent a VA ankle examination in July 2014, where the examiner found that his bilateral shin splints (that occurred in 2001) were asymptomatic. However, during the hearing, the Veteran credibly testified that he likely told the examiner that his legs were not hurting at the time because he was wearing orthotics devices. See hearing transcript at 6. He explained he got shin splints for the first time after a march in service in 1990. Id at 14. The Veteran testified that since that time, he continued to have shin splints sporadically whenever he is active without wearing the right footwear. See hearing transcript at 18. The July 2014 VA examiner did not provide a nexus opinion regarding the Veteran's claimed bilateral shin splints. A nexus opinion that fully considers the Veteran's lay statements is necessary before the claim can be adjudicated. As to the left ankle and left shoulder disabilities, VA July 2014 examinations show that the Veteran has left ankle achilles and left shoulder rotator cuff strain. The VA examiner who conducted the ankle and shoulder examinations opined that these conditions are "less likely than not related to specific exposure event experienced by the Veteran during service in Southwest Asia." The examiner, however, does not provide rationales to support his conclusions. In addition, the opinion regarding the left shoulder disability does not discuss the Veteran's complaint of left shoulder pain, while in service, in November and December 1997. Thus, the July 2014 VA medical opinions regarding the left ankle and left shoulder disabilities are inadequate. Notably, the Veteran testified that his left ankle and left shoulder symptoms started in service. See hearing transcript at 12, 19. An adequate nexus opinion must consider his lay statements regarding the onset of his symptoms. In summary, the record lacks adequate nexus opinions regarding the Veteran's bilateral shin splints, left ankle disability, and left shoulder disability. Thus, a remand is necessary before the claims can be adjudicated. The matters are REMANDED for the following action: 1. Obtain any outstanding service treatment records, to include all records from Oklahoma National Guard 2. Obtain any necessary releases and request the Veteran's dependent treatment records from Fort Belvoir Army Hospital. 3. Thereafter, schedule the Veteran for a VA examination for his claimed bilateral shin splints. The examiner must review the claims file. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. For the purpose of this opinion, please accept that any shin splints that occurred at any time from September 2014 to the present can be a "current disability" in this claim. The examiner is asked to provide a response to the following: Are the Veteran's bilateral shin splints at least as likely as not related to service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 4. After completion of directives #1 and 2, forward the claims file to a VA medical professional of appropriate expertise to provide a medical opinion regarding the Veteran's left ankle disability. The examiner must review the Veteran's entire claims file, to include a copy of this REMAND, and that review must be noted in the report. An in-person examination is not required unless deemed necessary by the examiner. Following the completion of the examination, the examiner must provide an opinion answering the following question: Is the Veteran's left ankle disability at least as likely as not related to service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 5. After completion of directives #1 and 2, forward the claims file to a VA medical professional of appropriate expertise to provide a medical opinion regarding the Veteran's left shoulder disability. The examiner must review the Veteran's entire claims file, to include a copy of this REMAND, and that review must be noted in the report. An in-person examination is not required unless deemed necessary by the examiner. Following the completion of the examination, the examiner must provide an opinion answering the following question: Is the Veteran's left shoulder disability at least as likely as not related to service? Provide a rationale to support the opinion(s). In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? LAURA E. COLLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Solomon 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.