Citation Nr: 21071193 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 12-05 650 DATE: November 30, 2021 REMANDED Entitlement to service connection for right great toe amputation, to include as secondary to service-connected bilateral pes planus with hallux valgus and degenerative joint disease of the metatarsophalangeal joint of both great toes (bilateral foot disability), is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1976 to October 1988. He died in July 2016. The appellant is the Veteran's surviving spouse, who was recognized as the substitute appellant for the Veteran's pending claim. See May 2018 Department of Veterans Affairs (VA) letter. Most recently, in June 2021, the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for further action consistent with the Board's remand directives. As such, the case has returned to the Board for further appellate proceedings. Regrettably, the Board finds that further evidentiary development is necessary, and remand is required. In June 2021, the Board remanded the claim for an opinion regarding the nature and etiology of the Veteran's right great toe amputation. See June 2021 Board remand directives. Specifically, the clinician was directed to provide a direct service connection opinion, as well as address whether the Veteran's right great toe amputation was caused or aggravated by his service-connected bilateral pes planus with hallux valgus and degenerative joint disease of the metatarsophalangeal joint of both great toes. Additionally, the clinician was to specifically "address whether the Veteran's osteomyelitis, which led to amputation, was related to any of his service-connected conditions. The examiner should also address whether improper footwear or walking barefoot was related to the Veteran's service-connected conditions." Id. (emphasis added). As a result, a July 2021 VA opinion was produced. However, the clinician's opinion failed to adequately address the question of direct service connection as required by the June 2021 Board remand. While the July 2021 clinician made the conclusory statement that the Veteran's great right toe amputation was not "due to or incurred in events in service," the supporting rationale provided for said opinion is that of a secondary service connection opinion. Specifically, the clinician gave a rather thorough explanation as to why the Veteran's toe amputation was not caused by or aggravated by any of his service-connected disabilities, but he failed to provide any supporting rationale relevant to the question of direct service connection. See July 2021 VA opinion. A subsequent September 2021 addendum opinion was produced by the same VA clinician. This opinion addressed the June 2021 Board remand directives regarding whether the Veteran's osteomyelitis, which led to amputation, was related to any of his service-connected conditions, and whether improper footwear or walking barefoot was related to the Veteran's service-connected conditions. See September 2021 VA addendum opinion; see also June 2021 Board remand directives. However, this opinion still failed to provide any supporting rationale as to the question of direct service connection. Without supporting rationale regarding the negative nexus opinion regarding direct service connection, the Board finds the direct service opinion to be conclusory and inadequate for adjudicative purposes. See Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012) (medical opinions are adequate when they sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion). Thus, the Board finds that remand is necessary in order to afford the appellant with an opinion regarding direct service connection that contains adequate and relevant supporting rationale. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Additionally, the Board notes that the September 2021 addendum opinion stated that individuals with pes planus, hallux valgus, and degenerative joint disease are "unlikely to be comfortable walking barefoot or having improper footwear... these events/activities did not cause the veteran's service-connected conditions [sic]." See September 2021 VA addendum opinion. However, the June 2021 Board remand did not ask the question whether walking barefoot or use of improper footwear caused his service-connected disabilities, but rather whether walking barefoot or use of improper footwear are related to his service-connected foot disabilities. The distinction is important as the Board previously noted that the February 2021 and March 2021 VA examiners indicated that the Veteran's toe amputation was due in part to walking barefoot and improper footwear. See June 2021 Board remand; see also February and March 2021 VA examination reports. Thus, if the Veteran's service-connected foot disabilities were reason for walking barefoot or wearing improper footwear, then the Veteran's toe amputation could be linked to his service-connected foot disabilities given the prior findings from the February and March 2021 VA examiners. Therefore, on remand the Board will reword the question posed to ask the clinician whether the Veteran's service-connected foot disabilities caused him to walk barefoot or wear improper footwear. The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriately qualified VA clinician to determine the nature and etiology of the Veteran's great right toe amputation. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the clinician. The opinion must include a notation that this record review took place. After the record review, the reviewing clinician is asked to respond to the following: (a.) Is it at least as likely as not that the Veteran's great right toe amputation is related to the Veteran's active-duty service? (b.) Is it at least as likely as not that the Veteran's great right toe amputation was proximately caused OR aggravated by his service-connected bilateral pes planus with hallux valgus and/or degenerative joint disease of the metatarsophalangeal joint of both great toes? (c.) Is it at least as likely as not that any of the Veteran's service-connected foot disabilities caused him to walk barefoot or wear improper footwear? The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the reviewing clinician must provide a complete explanation for why an opinion cannot be rendered. In so doing, the reviewing clinician must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that question 2. After the above has been completed to the extent possible, readjudicate the claim. If any benefit sought remains denied, provide the appellant and her representative with a supplemental statement of the case (SSOC), and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Katie Poe, 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.