Citation Nr: 21073574 Decision Date: 12/09/21 Archive Date: 12/09/21 DOCKET NO. 16-30 088 DATE: December 9, 2021 ORDER Entitlement to service connection for a left foot disability, to include achilles tendonitis, osteoarthritis, plantar fasciitis, and pes planus and as secondary to service-connected right foot pes planus and plantar fasciitis, is denied. FINDING OF FACT A left foot disability did not have its onset during active service, was not manifested by osteoarthritis within one year of service discharge, and is not otherwise related to active service; nor was it proximately due to or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for a left foot disability, to include achilles tendonitis, osteoarthritis, plantar fasciitis, and pes planus and as secondary to service-connected right foot pes planus and plantar fasciitis, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1977 to July 1980 and from November 1990 to July 1991 with periods of active duty for training. In October 2018 and May 2020, the Board remanded the claim for adequate medical opinions. In April 2021, the Board again remanded the claim for an adequate medical opinion because the October 2020 VA examiner failed to consider aggravation of the left foot disability by the service-connected right foot disability. As discussed further below, the Board finds there was substantial compliance with prior Board remand directives. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as osteoarthritis, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Service connection may be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). A claim for secondary service connection generally requires competent evidence of a causal relationship between the service-connected disability and the nonservice-connected disease or injury. Jones v. Brown, 7 Vet. App. 134 (1994). With regard to the matter of establishing service connection for a disability on a secondary basis, the United States Court of Appeals for Veterans Claims (Court) has held that there must be evidence sufficient to show that a current disability exists and that the current disability was either caused by or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Additionally, when aggravation of a nonservice-connected disability is proximately due to or the result of a service-connected condition, such disability shall be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. Entitlement to service connection for a left foot disability, to include achilles tendonitis, osteoarthritis, plantar fasciitis, and pes planus and as secondary to service-connected right foot pes planus and plantar fasciitis. The Veteran contends his left foot disability is related to service, to include as secondary to his service-connected right foot disability. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a left foot disability. As to evidence of a current disability, a July 2021 VA examination report shows that the Veteran was diagnosed with pes planus and plantar fasciitis in the left foot. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the service treatment records (STRs) show that the Veteran was seen for a hard landing on both ankles in June 1989. Thus, the Veteran meets the second element of a service-connection claim. As to evidence of a nexus between the current disability and service, the Board finds that the preponderance of the evidence is against such a nexus. In this regard, a September 1989 Notification of Completed Medical Examination was silent for medical conditions and physical defects or assignment limitations. The Notification also documented a PULHES profile that showed all 1s. The "PULHES" profile reflects the overall physical and psychiatric condition of an individual on a scale of 1 (high level fitness) to 4 (medical condition or physical defect is below the level of medical fitness required for retention in military service). The "L" stands for "lower extremities." Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). Thus, the Veteran's lower extremities were assigned a 1, which denotes a high degree of physical fitness. A September 1989 Report of Medical Examination (RME) clinically evaluated the Veteran's lower extremities as normal, and the PULHES profile showed all 1s, which denotes a high degree of physical fitness for the lower extremities. A June 1991 SW Asia Demobilization Redeployment Medical Evaluation documented the Veteran was not receiving medicine or other treatment at that time. The June 1991 reserve separation Report of Medical History (RMH) documented the Veteran's report that he was healthy and without foot trouble. While he did document previous treatment for parachutist injuries, the Board does not find this is indicative of a left foot disability at this time as he marked no for all ailments on the RMH. The June 1991 reserve separation RME the Veteran's lower extremities were clinically evaluated as normal except for a notation of mild right patellofemoral syndrome. The PULHES profile showed a 1 for L, which denotes a high degree of physical fitness for the lower extremities A March 1996 RMH documented that the Veteran denied foot trouble, and he stated he was in good health. The only injury noted was a right leg fracture in 1994. A March 1996 RME showed the Veteran's lower extremities were clinically evaluated as normal. The PULHES profile showed a 1 for L, which denotes a high degree of physical fitness for the lower extremities. STRs are similarly silent for any complaints of left foot problems. In March 2016, Dr. E.S. provided a positive nexus opinion. He stated that one cannot say exactly how long this condition [the left foot disability] existed prior to the date of diagnosis or definitively state its cause. However, it is as likely as not that the Veteran's service-connected right foot condition contributes to or aggravates his left foot condition. Dr. E.S. provided no rationale for this opinion. A medical opinion without a rationale is inadequate, and therefore, has no probative value and cannot be the basis for the award of service connection. On the July 2016 Notice of Disagreement, the Veteran stated the March 2016 private medical opinion was not considered by the June 2016 rating decision, and his claim was denied in bad faith. However, the June 2016 rating decision not only mentions the private opinion among the evidence considered, but the March 2016 private opinion is discussed in the body of the rating decision. The Agency of Original Jurisdiction notes more weight was given to the VA opinion because it provided a detailed rationale. As noted above, the private opinion does not include a rationale for its conclusion, and it is therefore an inadequate opinion. The Veteran underwent VA examinations in May 2016, July 2019, and October 2020, which were all found to be inadequate by prior Board decisions. Most recently, the Veteran underwent a VA examination in July 2021. The examiner documented the Veteran's report of an onset of foot pain in 1990. He was diagnosed with left foot plantar fasciitis, pes planus, and degenerative changes in 2009 with symptoms of pain in the arch and heel. The Veteran's STRs are silent for any subjective left foot complaints or condition during the service. The Veteran stated that his foot disabilities are due to excessive physical activity during the service, parachute jumping, and the wearing of military issue boots. The examiner provided a negative nexus opinion. The examiner opined that his left foot acquired pes planus condition was not diagnosed until 2009, 10 years after the right foot condition. There are myriad causes of acquired flatfoot, including posterior tibialis tendon (PTT) degeneration, trauma, neuroarthropathy, neuromuscular disease, and inflammatory arthritis. Of these, PTT degeneration is, by far, the most common. The examiner could not find any medical literature that supports a unilateral pes planus condition that would have any significant impact on the opposite uninjured foot. Therefore, the claimed left foot pes planus with plantar fasciitis condition is less likely than not to have been incurred in or caused by the 65 and more parachute jumps during service. The Board affords the July 2021 VA medical opinion high probative value, as the examiner reviewed the claims file, physically examined the Veteran, and provided opinions that included a rationale that was based on evidence in the file and medical principles. The facts relied upon by the examiner that there were no complaints of left foot problems during service, and there was an onset of symptoms many years following service discharge are the facts that the Board finds are accurate. This is evidence against a nexus between the left foot disability and service. As to presumptive service connection for a chronic disease, here, osteoarthritis, an October 2009 VA examination shows the Veteran was found to have degenerative changes throughout the tarsal joints. Even if the Board considers this finding of degenerative changes as osteoarthritis, there is no competent evidence to establish the Veteran developed osteoarthritis in the left foot within one year of active service. In this regard, the first medical evidence of any left foot disorder was many years outside the presumptive period. Moreover, the Veteran has not provided any lay evidence of pertinent symptomatology. Rather, he has primarily claimed that his left foot disorder is secondary to his service-connected right foot disability. Thus, service connection on a presumptive basis based on a chronic disease is not warranted. As to secondary service connection, the Veteran has a current diagnosis of pes planus and plantar fasciitis in the left foot. Additionally, the Veteran is already service connected for right foot disability from January 2009. Thus, the facts support the first two elements of the claim for secondary service connection, which is evidence of a current disability and evidence of a service-connected disability. However, the Board finds that the preponderance of the evidence weighs against a finding that the service-connected right foot disability caused or aggravated the left foot disability. For example, the July 2021 VA examiner opined the left foot pes planus with plantar fasciitis is a separate entity entirely from the right foot pes planus with plantar fasciitis and unrelated to it. The Veteran's left foot condition was not diagnosed until 2009, while the right foot condition was diagnosed in 1998 during active duty in the military. Pes planus is a fairly common condition that can develop at any point in one's life. Acquired pes planus can be unilateral or bilateral and includes osseous, ligamentous, muscle imbalance, postural or static, and arthritic flat foot. These conditions may be a result of poor bone structure, laxity of ligaments, and weakness of supporting muscle and tendons. A fallen arch or flat feet may also develop as part of the aging process or it can result from an injury to the PTT. Injury to the PPT can present as a torn tendon or overused and swollen, which may lead the arch to collapse. A thorough review of medical literature failed to demonstrate a causal relationship. The claimed left foot pes planus with plantar fasciitis condition is less likely than not proximately due to or the result of the Veteran's service connected right foot pes planus with plantar fasciitis. The examiner also opined that the left foot pes planus with plantar fasciitis condition is less likely than not aggravated beyond its natural progression by the service connected right pes planus with plantar fasciitis condition. The Board affords the July 2021 VA medical opinion high probative value, as the examiner reviewed the file, physically examined the Veteran, and provided opinions that included a rationale that was based on evidence in the file and medical principles, where the examiner addressed both causation and aggravation. This is evidence against a finding that the left foot disability is caused or aggravated by the service-connected right foot disability. While the Veteran has reported a relationship between the left foot disability and service and/or the service-connected right foot disability, he is not competent to offer opinions as to the etiology, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran's own opinion is nonprobative evidence. At the present time, there is no competent evidence of a nexus between the left foot disability and service or the service-connected right foot disability to weigh against the July 2021 negative nexus opinions. For the reasons described above, the Board finds the preponderance of the evidence is against the Veteran's claim for service connection for a left foot disability, to include achilles tendonitis, osteoarthritis, plantar fasciitis, and pes planus and as secondary to a service-connected disability or disabilities. There is no reasonable doubt to be resolved, and the claim for service connection is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. J.N. Moats Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. McDaniels, 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.