Citation Nr: 21076015 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 18-41 153 DATE: December 22, 2021 REMANDED Service connection for left ear pain. Service connection for a back condition. Service connection for groin pain. Service connection for plantar fasciitis. Service aggravation for pes planus. REASONS FOR REMAND The Veteran served on active duty from May 1980 to May 1983. The case is on appeal from an October 2017 rating decision. In March 2021, the Veteran testified at a Board hearing. In May 2021, the Veteran submitted a VA Form 20-0995, a Supplemental Claim. However, the Veteran did not properly complete the form, as he did not check the box to opt-in from a statement of the case (SOC) or supplemental statement of the case (SSOC). As such, the Board will continue to consider his claim under the Legacy system. 1. Service connection for left ear pain. Regarding the claim of service connection for left ear pain, the Veteran was afforded an October 2017 VA examination. The examiner opined that his left ear pain was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the examiner provided that symptoms during the exam were subjective only. There was no objective evidence during the exam to support a diagnosis of a chronic ear condition that would result in a vestibular condition. Therefore, no diagnosis of an ear condition was warranted. However, the Board finds that the opinion was not completely adequate. Evidence of record provides the Veteran asserts his ear constantly hurts and that he was treated for wax build-up in his ear in service. It is not clear whether the examiner fully considered the Veteran's service treatment records (STRs) and lay statements regarding his left ear pain. As such, the Board finds that remand for an addendum opinion is warranted. 2. Service connection for a back condition. Regarding the claim of service connection for a back condition, the Veteran was afforded an October 2017 VA examination. The examiner opined the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the examiner provided that during service, the back condition was acute only. Additionally, the Veteran was seen in early 1983 for back spasms, but on a self-reported evaluation in November 1986, the Veteran denied back pain, which was evidence that the Veteran's back condition had resolved. Further, it had been 34 years since the Veteran's back condition was reported in service. Thus, a nexus was not established. The Veteran contends that his back condition began in service, following a fall in 1982 from an army personnel carrier, and that his back has bothered him ever since. During the October 2017 examination, the Veteran reported his current symptoms included constant pain all the time and that it even hurts when he has a bowel movement. He noted experiencing pain rated 10 out of 10, along with difficulty sitting, standing, or walking for any length of time. The Board finds the opinion provided was not completely adequate. Based on the medical opinion provided, it is unclear whether the Veteran's STRs noting his complaints of back pain since 1982 or note that he fell on his back during service were considered. Further, the examiner failed to consider the Veteran's lay assertion and relied on a mere absence of evidence in post-service treatment records to provide a negative opinion. Dalton v. Nicholson, 21 Vet. App. 23 (2007). As such, remand is warranted for an addendum opinion. 3. Service connection for groin pain. Regarding the claim of service connection for groin pain, the Veteran was afforded an October 2017 VA examination. The examiner opined that his groin pain was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the examiner provided that during service, the condition was acute only. Further, it had been 34 years since the Veteran's discharge from service, and there is no evidence of chronicity of care. Therefore, no nexus has been established. However, the Board finds that the opinion was not completely adequate. Evidence of record provides the Veteran contends his injury began during service with a fall and that it has continued since service, only decreasing due to the enlarged prostate and a decrease in sexual activity as a result. It is not clear whether the examiner fully considered the Veteran's lay statements, including his injury having its onset during service as noted above. Further, the opinion was based, at least in part, on a lack of evidence on the date of the examination. This fails to consider the Veteran's lay assertion that he continues to experience groin pain, though less than he did previously, and that he treats it with over-the-counter pain medication, heat, and ice. Additionally, it is unclear whether the Veteran's enlarged prostate has impacted his groin pain, if at all. Thus, the Board finds that remand for an addendum opinion is warranted. 4. Service connection for plantar fasciitis. The Board now recharacterizes the foot claim as two claims to better reflect the nature of the Veteran's claimed conditions to comport with the Veteran's assertions during the March 2021 hearing. Evidence of record provides the Veteran currently has a diagnosis for plantar fasciitis. Given his MOS as an infantryman, the Board finds there is evidence of record to suggest that his condition may be related to service. As such, the low threshold required has been met to afford the Veteran a VA examination to determine the nature and etiology of his current plantar fasciitis. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). 5. Service aggravation for pes planus. Regarding the claim of service connection for pes planus, the Veteran was afforded an October 2017 VA examination. The examiner opined the Veteran's pes planus, which clearly and unmistakably existed prior to service, was clearly and unmistakably not aggravated beyond its natural progression by an in-service injury, event, or illness. As rationale, the examiner provided temporary aggravation is plausible, but there is no evidence of permanent aggravation of the claimed pre-existing condition. Further, the examiner provided the current medical literature does not support such an outcome, as it has been 34 years since the Veteran's discharge and his symptoms are only mild. The Veteran contends that in-service trauma experienced due to his MOS as an infantryman (e.g., ruck marches and running) made his pes planus worse. Additionally, the Veteran reported being given boot insoles during service, but that they did not help with the pain. Further, evidence of record provides the Veteran's entrance examination did note flat feet, but described them as asymptomatic. The Board finds the opinion provided inadequate, as it does not appear the examiner considered the entirety of the Veteran's file or his lay assertions. As such, remand warranted to obtain an addendum opinion based on full consideration of the Veteran's documented medical history and all lay assertions, and supported by a complete, clearly stated rationale is needed to resolve the claim. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that when VA undertakes to provide a VA examination or to obtain a VA opinion, it must ensure that the examination or opinion is adequate). Additionally, this case is one of service aggravation as pes planus was noted at entrance. See 38 U.S.C. § 1153; 38 C.F.R. § 3.306. In light of the remand, updated VA treatment records should be obtained. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records dated since July 2021. 2. Schedule the Veteran for a VA foot examination (or telehealth interview, records request, etc. if an in-person examination is not feasible) by an appropriate medical professional to address the plantar fasciitis and pes planus claims. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that the Veteran's plantar fasciitis had its onset during, or is otherwise related to, the Veteran's service. Additionally, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater possibility) that the Veteran's pre-existing pes planus increased in severity during service beyond any temporary flare-up. If so, the examiner should provide an opinion as to whether any increase was medically undebatably due to the natural progress of the disease. Consideration should be given to the Veteran's STRs and lay contentions. A rationale should be provided for all opinions expressed. 3. Thereafter, the claims file should be provided to an appropriate medical professional to render the requested addendum opinions. The need for another examination (or telehealth interview, records request, etc. if an in-person examination is not feasible) for groin pain, left ear pain, and a back condition is left to the discretion of the medical professional offering the addendum opinions. The clinician should provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that groin pain, left ear pain, and a back condition, which may include pain alone that rises to the level of functional impairment, had its onset during, or is otherwise related to, the Veteran's military service. (Continued on the next page) Consideration should be given to the Veteran's STRs and lay contentions. A rationale should be provided for all opinions expressed. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Becton, 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.