Citation Nr: 21071729 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 15-40 425 DATE: December 1, 2021 REMANDED Entitlement to service connection for a left Achilles tendon disorder, to include as secondary to service-connected lumbar myositis, is remanded. Entitlement to service connection for a right Achilles tendon disorder, to include as secondary to service-connected lumbar myositis, is remanded. REASONS FOR REMAND The Veteran served in the Puerto Rico Army National Guard and had a period of active duty from December 2003 to December 2004. He also had a period of active duty for training (ACDUTRA) from March 1993 to August 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision. The Veteran testified at a June 2017 hearing before the undersigned Veterans Law Judge. A transcript of the proceeding is of record. The Board remanded the case for further development in September 2018 and June 2020. The case has since been returned to the Board for appellate review. Upon review, the Board finds that further development is needed prior to adjudication of the claims. The Veteran was most recently afforded a VA examination in September 2020. The examiner opined that his right and left Achilles tendon disorders were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. She noted that the Veteran was not documented as having such a disorder during active service. She observed that a February 2005 examination demonstrated range of motion with no limitations or gross abnormalities and that a January 2009 examination revealed no joint arthralgia and normal range of motion. The examiner found that there was a subsequent x-ray in October 2010 that was abnormal and noted a diagnosis of bilateral Achilles tendon enthesopathy thereafter. Based on the fact that there was over a five-year gap between the Veteran's military service and the diagnosis, she determined that the medical evidence does not support the conclusion that a persistent right or left achilles tendon disability was present in service or in the years proximal to service. She concluded that the disorder was less likely than not incurred in or caused by military service, including the Veteran's duties or wear and tear in service. In addition, the examiner noted that there was a skin condition noted on the Veteran's ankles during the February 2005 examination, but indicated that the right and left ankle dermatitis is a separate skin condition unrelated to the musculoskeletal Achilles tendon disorder. She also observed that the Veteran twisted his right ankle in June 2005, but found that it is medically separate from the claimed right Achilles tendon enthesopathy and did not occur during a period of active service. She further stated that there is no evidence for additional treatment or diagnosis of a chronic right ankle condition related to that acute event. The September 2020 VA examiner also opined that the Veteran's right and left Achilles tendon disorders are less likely than not proximately due to or the result of his service-connected disability. She explained that a bilateral Achilles tendon disorder and lumbar myositis are not medically related and are separate entities. In this regard, lumbar myositis is an inflammation of the muscles in the lumbar region of the back and does not cause the Achilles tendon abnormalities. Regarding aggravation, the examiner reiterated that the two disorders are not medically related and stated that the Veteran's gait was observed as being normal during the examination. She further stated that the claims file does not contain evidence of an abnormal gait or established leg length discrepancy to show excess wear and tear for any aggravation by a remote and separate joint or tendon, such as the Achilles tendon disorder. Nevertheless, it appears that the September 2020 VA examiner relied on an incomplete or inaccurate factual premise. Indeed, the prior remand had noted evidence showing an altered gait, which she did not address. See March 2010 VA examination report (noting an antalgic gait); October 2010 VA examination report (noting mild limping and an antalgic gait); September 2011 VA examination report (noting an abnormal and antalgic gait); April 2017 VA treatment record (noting a mild lateral shift in gait); June 2017 hearing transcript (testifying that his back disability has caused him to walk differently). The Veteran has claimed that his service-connected lumbar myositis altered his gait, thereby causing or aggravating the bilateral Achilles tendon disorder. Therefore, the Board finds that an additional VA medical opinion is needed. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand order). The matters are REMANDED for the following action: 1. The agency of original jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his bilateral Achilles tendon disorder that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the AOJ should refer the Veteran's claims file to ad VA examiner for a medical opinion as to the etiology of his bilateral Achilles tendon disorder. A physical examination is only needed if deemed necessary by the examiner. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, hearing testimony, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he has first-hand knowledge. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran's bilateral Achilles tendon disorder is causally or etiologically related to his military service, including his duties and any symptomatology therein. The Veteran has claimed that he developed the disorder in service as a result of the wear and tear from his duties while serving in Iraq. The examiner should opine as to whether it is at least as likely as not that any current bilateral Achilles tendon disorder is either caused or aggravated by his service-connected lumbar myositis. In so doing, he or she should address whether the Veteran's service-connected lumbar myositis disability altered his gait and caused a bilateral Achilles tendon disorder. In rendering this opinion, the examiner should specifically consider the March 2010 VA examination noting an antalgic gait, the September 2010 VA examination noting an abnormal/antalgic gait, the August 2014 VA treatment record noting a weak gait, and the April 2017 VA treatment record noting a mild lateral shift in gait. The examiner should also address the February 2010 letter submitted by Dr. N.O. (initials used to protect privacy) stating that the Veteran's ankle pain is secondary to his back problem and the Veteran's June 2017 testimony that his back condition has affected how he walks, which he believes caused his ankle disabilities. In rendering his or her opinion, the examiner should address both the causation and aggravation questions in his or her rationale. In other words, even if the Veteran's lumbar myositis did not cause his current bilateral Achilles tendon disorder, the examiner should still address whether his lumbar myositis could have worsened his Achilles tendon disorder. The examiner should also note that the aggravation prong of secondary service connection requires a worsening of the claimed disorder, but not a permanent worsening of the claimed disorder. The law provides that compensation is due for any incremental increase in disability, meaning any additional impairment of earning capacity above the degree of disability, regardless of its permanence. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. The AOJ should ensure compliance with the prior remand directives and conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. DeVerter, 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.