Citation Nr: 21071561 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 09-28 089 DATE: November 30, 2021 ORDER Entitlement to service connection for bilateral foot disability, to include as secondary to service-connected bilateral knee disability, is denied. FINDING OF FACT The Veteran's current bilateral foot disability was not shown to be related to service and was not shown to have been caused or aggravated by his service-connected bilateral knee disability. CONCLUSION OF LAW The criteria for entitlement to service connection for bilateral foot disability, to include as secondary to service-connected bilateral knee disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1971 to November 1974. He passed away in July 2017. The appellant is his surviving spouse and has been recognized as a valid substitute for purposes of continuing this appeal. See October 2017 rating decision denying service connection for the cause of death, top of page 3, indicating that the appellant has been determined to be the substitute for the Veteran's appeal for service connection for bilateral foot disability. In July 2015, a Board hearing was held before the undersigned; a transcript of the hearing is of record. In December 2015 and June 2021, the case was remanded for further development. In the June 2021 remand, the Board instructed the agency of original jurisdiction (AOJ), to obtain addendum opinions concerning the likelihood that the Veteran's current bilateral foot disability was caused or aggravated by his service-connected bilateral knee disabilities, including Osgood Schlatter disease, status post debridement, degenerative joint disease and history of chondromalacia. These opinions were provided by a VA contract physician in September 2021. The Board notes that unlike the earlier medical opinions of record, which only considered whether the Veteran's service-connected Osgood Schlatter's disease of the knees caused the Veteran's bilateral foot disability, the September 2021 medical opinions specifically considered whether the full extent of the Veteran's service connected knee disability (i.e. Osgood Schlatter disease, status post debridement, degenerative joint disease and history of chondromalacia) caused or aggravated the Veteran's bilateral foot disability. Reasoned rationales for the opinions were also provided by the VA contract physician. Accordingly, the Board finds that the September 2021 VA contract opinions are adequate and reasonably complied with the June 2021 remand instructions. Entitlement to service connection for bilateral foot disability, to include as secondary to service-connected bilateral knee disability. The appellant asserts that the Veteran had a bilateral food condition that was related to his service-connected left and right knee disabilities, each characterized as Osgood-Schlatter disease, status post debridement, with degenerative joint disease (DJD) and history of chondromalacia. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to direct service connection generally requires: (1) competent and credible evidence confirming the Veteran has the claimed disability or, at the very least, showing he has at some point since the filing of his claim; (2) competent and credible evidence of in-service incurrence or aggravation of a relevant disease or an injury; and (3) competent and credible evidence of a relationship or correlation between the disease or injury in service and the currently claimed disability - which is the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. 38 C.F.R. § 3.310. The Veteran's service treatment records are negative for any findings of foot pathology. An August 1974 inpatient physical examination was found to be within normal limits except for the knees. On his August 1974 report of medical history, the Veteran reported that he did not have any history of foot trouble. At a March 2008 VA examination, the diagnoses were degenerative joint disease of the right foot and left foot strain. The examiner opined that the right foot degenerative changes and the left foot strain were less likely than not related to the Veteran's service-connected bilateral knee Osgood Schlatter's disease. The examiner commented that the Veteran had had foot pain over the past 10 years and the Osgood Schlatter's disease is commonly seen during adolescence and resolves without complications most of the time. Thus, the examiner could not discern a relationship between the feet conditions and this bilateral knee disability. At a January 2008 VA orthopedic surgery visit, physical examination showed that the Veteran walked with a non-antalgic gait. At a March 2012 VA examination, the diagnoses were metatarsalgia, plantar calcaneal enthesopathy, right, and plantar fasciitis bilateral. On X-ray, the Veteran was found to have left foot normal bony structures. On the right, the diagnostic impression was degenerative change of the first metatarsophalangeal joint and talonavicular joint. The examiner found that the Veteran's plantar fasciitis was less likely than not proximately due to or secondary to or the result of his service-connected Osgood Schlatter's disease of the bilateral knees. The examiner explained that the current bilateral foot x-rays were compared with prior studies and showed no essential change in the findings of mild first right MTP arthritis and right plantar calcaneal spur. There was also no radiology evidence of a left foot condition noted. However pertinent physical findings disclosed a bilateral tenderness consistent with a metatarsalgia with plantar fasciitis that resolved with counter-strain positioning. The examiner indicated that this condition is never caused by or secondary to chronic Osgood Schlatter's disease but can develop from calcaneal spur irritation of the plantar fascia. The examiner also noted that the Veteran affirmatively reported that his foot problems developed over the time frame from 1978 to 1985 (i.e. after service). At the July 2015 Board hearing, the Veteran testified that he thought that the arthritis in his knees had caused an altered gait, which in turn caused problems with his feet. He indicated that he had been walking with an abnormal gait ever since he was in the military. He reported that his foot symptoms included aches and pains on certain movements, including of the balls of his feet and his heels. The Veteran also testified that his foot pain began during the military. He indicated that he would get spasms down his legs from his knee problems and would then have to loosen up his boots. In May 2017, the Veteran submitted a medical article entitled "Impact of Concurrent Foot Pain on Health and Functional Status in People with Knee Osteoarthritis, Data from the Osteoarthritis Initiative." The article concludes that the foot is a common concurrent location of pain with symptomatic knee osteoarthritis and people with foot pain and in particular bilateral or ipsilateral foot pain have reduced measures of health and physical function, including worse knee-specific measures of symptom severity. As such, clinicians should consider assessing and treating foot pain in people with symptomatic knee osteoarthritis. The article noted that longitudinal research was needed to establish causative factors and the inter-relationship of the pathology at these two sites. In a September 2021 medical opinion, a VA contract physician found that the Veteran's bilateral foot disability was less likely than not proximately due to or the result of his service-connected bilateral knee disability. The physician reasoned that there was no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5cm so that the individual's gait pattern had been altered to the extent that clinically there was an obvious Trendelenburg gait (a situation not present in the Veteran's case). The physician noted that it was not unusual for two joints to share properties in the same person, but one joint's disease did not 'spread' to another or cause damage to it. The physician indicated that the condition of the Veteran's feet was due to something intrinsic to the feet and not his bilateral knees. The physician also opined that the Veteran's foot disability was less likely than not aggravated by his service-connected knee disability. The physician reasoned that the March 2012 examination demonstrated intermittent foot pain, which did not necessitate the use of assistive devices (outside of a brace) or shoe inserts and did not have a functional impact. The physician noted that this presentation fell within the projected natural history of the condition and did not represent aggravation beyond natural progression. The above summarized evidence weighs against a finding that the Veteran's service-connected bilateral knee disability caused his bilateral foot disability. In this regard, the March 2008 VA examiner specifically opined that the bilateral foot disability was less likely than not related to the Veteran's bilateral knee Osgood Schlatter's disease, reasoning that the Veteran had had foot pain over the past 10 years; that Osgood Schlatter's is commonly seen during adolescence and resolves without complications most of the time; and that given this course of disability, there was not a discernable relationship between the foot conditions and the bilateral knee disability. Also, the March 2012 VA examiner concluded that the Veteran's plantar fasciitis was less likely than not proximately due to or secondary to or the result of his service-connected Osgood Schlatter's disease, reasoning this condition is never caused by or secondary to chronic Osgood Schlatter's disease but can develop from calcaneal spur irritation of the plantar fascia. The examiner also noted that the Veteran affirmatively reported that his foot problems developed over the time frame from 1978 to 1985. More broadly, the September 2021 VA contract physician opined that the Veteran's bilateral foot disability, was less likely than not proximately due to or the result of his service-connected bilateral knee disability, considered as a whole, reasoning that there was no clear evidence from review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5cm so that the individuals gait pattern had been altered to the extent that clinically there was an obvious Trendelenburg gait. The physician also noted that one joint's disease did not 'spread' to another or cause damage to it and determined that the condition of the Veteran's feet was due to something intrinsic to the feet and not to his bilateral knees. The September 2021 VA contract physician also opined that the Veteran's bilateral foot disability was less likely than not aggravated by his service-connected bilateral knee disability, reasoning that the March 2012 examination demonstrated intermittent foot pain, which did not necessitate the use of assistive devices (outside of a brace) or shoe inserts and did not have a functional impact, and that this this presentation fell within the projected natural history of the condition and did not represent aggravation beyond natural progression. There is no medical opinion of record contrary to those of the January 2008, March 2012, and September 2021 clinicians. Notably, the Veteran did submit the medical article in March 2017 pertaining to foot pain concurrent with knee osteoarthritis, and osteoarthritis (i.e. degenerative joint disease) was a component of his service-connected knee disability. However, this article concluded that while certain foot conditions and knee osteoarthritis often occurred concurrently, more research was needed to establish causative factors and the inter-relationship of pathology at these two sites. Also, unlike the medical opinions of record, the article did not address the specific medical history of the Veteran's knee and foot conditions. Given both these factors, to the extent the article can be considered supportive of a causal relationship between the Veteran's knee arthritis and bilateral foot disability, it is outweighed by the specific medical opinions of record discussed above. The Veteran also generally alleged that his bilateral foot disability was caused or aggravated by his service-connected knee disability, including due to the knee disability causing an altered gait. The Veteran was competent to report generally on how he felt his knee disability affected his pattern of walking. However, as a layperson with no demonstrated medical expertise concerning the etiology of bilateral foot disability, his assertion that the knee disability actually caused or aggravated the bilateral foot disability may not be afforded any significant probative value. See e.g. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). At the July 2015 Board hearing, the Veteran testified that his foot pain began during the military and also implied that the foot pain had been present ever since that time. However, the Board presumes that had the Veteran been experiencing foot pain during service, he would have reported it to medical personnel, including on his August 1974 report of medical history. Also, at the March 2008 VA examination, the Veteran reported that he had had foot pain over the past 10 years and at the March 2012 VA examination, he reported that his foot pain developed over the 1978 to 1985-time frame. Both these reports are inconsistent with the Veteran's later hearing testimony of foot pain beginning in service and continuing thereafter. Given this inconsistency and the lack of reporting of foot pathology during service, including on the August 1974 medical history report where the Veteran was specifically asked whether he had any history of this pathology, the Veteran's assertion of foot pain beginning during service and continuing thereafter is not afforded persuasive value. To the extent the Veteran more generally asserted that his foot disability was otherwise directly related to service (i.e. not based on continuity of symptomatology), as a layperson with no demonstrated medical expertise concerning the etiology of bilateral foot disability, this assertion may not be afforded any probative value. See e.g. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Also, because there is no credible evidence of foot pathology during service or continuity of foot pathology since service and no medical evidence suggesting a direct relationship between the Veteran's bilateral foot disability and military service, a medical opinion concerning whether such a direct relationship was shown is not necessary in this case. 38 C.F.R. § 3.159(c)(4). In sum, as the Veteran's bilateral foot disability was not shown to be directly related to service or to have been caused or aggravated by his service-connected knee disability, the preponderance of the evidence is against this claim and it must be denied. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dan Brook, 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.