Citation Nr: 21073689 Decision Date: 12/10/21 Archive Date: 12/10/21 DOCKET NO. 15-46 714 DATE: December 10, 2021 REMANDED Entitlement to service connection for a right foot disability, to include as secondary to service-connected disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 2010 to August 2013. In July 2019 and July 2021, the Board remanded the appeal for evidentiary development. It has since been returned to the Board for further consideration. Entitlement to service connection for a right foot disability, to include as secondary to service-connected disability is remanded. Review of the record reveals that remand is required in order to obtain any outstanding treatment records and to arrange for an addendum opinion based on additional argument received in October 2021. Pursuant to the Board's July 2021 remand, a VA opinion was provided in September 2021, wherein the examiner determined that the Veteran's right foot disability is less likely than not attributable to service. The examiner provided the following rationale: Veteran served 2010-2013. Entrance exam normal foot PE, no complaints. STRs show 3/10 bilateral foot pain, diagnosed foot pain; 6/11 R foot pain, diagnosed strain; 7/11 ER R foot pain, diagnosed plantar fasciitis; 7/11 R foot pain PCM diagnosed strain; 9/11 R foot pain, diagnosed plantar wart; 5/13 requesting shoe inserts for history of plantar fasciitis- denied foot pain. C-file is silent for any complaint, diagnosis or treatment of right foot pain from 2011 until DBQ exam 2020- a 9 year gap therefore intercurrent injury/disease cannot be ruled out as an etiology. There is no medical evidence presented to support the veterans acute and resolved plantar fasciitis was chronic or ongoing beyond service until DBQ exam 2020. A condition of suggested severity would have certainly required medical attention over the past 9 years. Post DBQ exam 10/2020 there are no medical records showing veteran has had any foot concerns or complaints. 2/21 VA note shows veteran works as groundskeeper which would involve extensive walking and standing. A nexus has not been established. Plantar fasciitis is one of the most common causes of heel pain. It involves inflammation of a thick band of tissue that runs across the bottom of your foot and connects your heel bone to your toes (plantar fascia). Your plantar fascia is in the shape of a bowstring, supporting the arch of your foot and absorbing shock when you walk. If tension and stress on this bowstring become too great, small tears can occur in the fascia. Repeated stretching and tearing can irritate or inflame the fascia, although the cause remains unclear in many cases of plantar fasciitis. Plantar fasciitis can be acute and resolve, or it can become chronic. Risk factors: age, foot mechanics, obesity, and occupations that keep you on your feet [citation omitted]. Notably, in an October 2021 correspondence, the Veteran's representative claimed that her right foot disability is secondary to her service-connected lumbar strain and requested an additional medical opinion. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Considering the above, the Board determines that an addendum medical opinion would help resolve the claim. Finally, there may be outstanding or pertinent treatments available for review. The Board finds that it would be prudent for an attempt to obtain any outstanding treatment records be made. The matters are REMANDED for the following action: 1. With the assistance of the Veteran as necessary, identify and obtain any outstanding, relevant treatment records, and associate them with the Veteran's electronic claims file. If the Agency of Original Jurisdiction (AOJ) cannot locate or obtain such records, it must specifically document the attempts that were made to locate or obtain them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AOJ must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. All attempts to obtain records should be documented in the Veteran's electronic claims file. 2. Thereafter, and regardless of whether additional treatment records are located, obtain an addendum opinion from the September 2021 VA examiner (or a similarly situated examiner) to determine the nature and etiology of the Veteran's claimed right foot disability, to include as secondary to service-connected lumbar strain. The electronic claims files and all pertinent records must be made available to the examiner and the examiner must indicate in the examination report that these records have been reviewed. It should be noted that the Veteran is competent to attest to factual matters of which she had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. (a) The VA examiner must opine whether it is at least as likely as not (50 percent or higher degree of probability) that a right foot disability manifested in-service or is otherwise causally or etiologically related to the Veteran's military service. (b) If not directly related to service, the examiner should offer an opinion as to whether it is at least as likely as not (50 percent or higher degree of probability) that any identified right foot disability is caused by her service-connected lumbar strain. (c) That examiner should then opine whether the right foot disability is aggravated (i.e., worsened beyond the normal progression of that disease) by her service-connected lumbar strain. In offering any opinion, the examiner must consider the full record, to include the lay statements in support of the Veteran's claim. The examiner should also reconcile any prior report, if necessary. The rationale for any opinions offered should be provided. If the VA examiner determines that further examination is necessary in order to render the requested medical opinion, then the Veteran should be scheduled for such an examination. 3. After the development requested has been completed, the AOJ should review any report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures at once. Emily Tamlyn Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Miller, 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.