Citation Nr: 21076404 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 05-25 916 DATE: December 23, 2021 REMANDED Entitlement to service connection to a headache disability, to include as secondary to the service-connected cervical and/or lumbar spine disabilities, is remanded. Entitlement to service connection for erectile dysfunction (ED), to include as secondary to the service-connected lumbar spine disability, is remanded. Entitlement to service connection for bilateral foot disabilities, other than bilateral pes planus and hallux rigidus, to include as secondary to service-connected cervical and/or lumbar spine disabilities, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1979 to November 1980. This matter comes on appeal before the Board of Veterans' Appeals (Board) from August 2004 and July 2011 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural background, the service connection claims for bilateral foot and ankle disabilities were previously before the Board in January 2008, December 2009, July 2012, May 2013, December 2014, August 2016, January 2018, and October 2018. The Board denied these claims in December 2009 and again in May 2013. After both denials, the Veteran timely appealed to the United States Court of Appeals for Veterans Claims (the Court), and the Board's December 2009 and May 2013 decisions were vacated and remanded for further consideration by the Board. After the October 2018 Board remand, the RO granted service connection for bilateral pes planus and bilateral ankle sprains, effective June 2, 2004. As these were full grants of the benefits sought on appeal, the service connection claims for these disabilities are no longer before the Board. The diagnosed foot disabilities of record, specifically bilateral metatarsalgia, tinea pedis, hallux rigidus, hallux valgus, and bilateral plantar fasciitis remained on appeal. In August 2020, the Board remanded the service connection claims allergic rhinitis (claimed as a sinus condition), headache, and ED disabilities for further development. The outstanding claims from the October 2018 and August 2020 decisions returned to the Board for further appellate consideration in November 2020. Therein, the Board denied service connection for allergic rhinitis and remanded the claims for headache disability, ED, and foot disabilities to obtain adequate medical opinions. In a September 2021 rating decision, the RO granted service connection for hallux rigidus, effective June 2, 2004. As such, that specific foot disability is no longer on appeal and is not addressed in this decision. In August 2017 and March 2018, the Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference hearings. Copies of the hearing transcripts are of record and have been reviewed. The Veteran appointed an attorney to represent him on limited issues in September 2014 but revoked the appointment in January 2018. Multiple Board decisions addressing these issues, of which the Veteran has been sent notice, have found that the Veteran elected to proceed pro se. The Veteran has not appointed a new representative in this matter. Thus, the Board will proceed to address these issues herein. 1. Entitlement to service connection to a headache disability is remanded. Pursuant to the November 2020 remand directives, the RO obtained an additional medical opinion with regard to the etiology of the claimed headache disability in August 2021. The VA examiner, a medical doctor, opined that the Veteran's headache disability is less likely as not related to service, reasoning that there is no current headache disability. The examiner noted that the sinus headache was treated and resolved in August 2000 and there has been no evidence of recurrence, progression, chronicity, residuals, or sequelae. The VA examiner also opined that the headache disability is less likely as not proximately due to or aggravated by his service-connected cervical or lumbar spine disabilities. In a September 2021 QTC addendum, the same examiner essentially reiterated the earlier opinion that the Veteran's headaches seemed to have resolved with no sequelae. The Board finds these opinions to be inadequate for several reasons. First, the examiner found there was no current diagnosis of a headache disability but did not address the notations of headaches within VA treatment records and examination reports during the pendency of the claim. See September 2010 Private Treatment Record; February 2012 VA Treatment Record; November 2019 VA Headaches Examination Report. Indeed, service connection may be warranted if there was a disability present at any point during the claim period, even if it is not present at the time of the VA examination. See McClain v. Romanowsky v. Shinseki, 26 Vet. App. 289 (2013). Second, the examiner provided no discernable rationale in support of her conclusion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Accordingly, another medical opinion is warranted. 2. Entitlement to service connection for ED, to include as secondary to the service-connected lumbar spine disability, is remanded. An August 2021 VA examiner opined that the Veteran's ED was less likely as not related to service, or proximately due to, or aggravated by, the lumbar spine disability. In a September 2021 addendum, the examiner stated that ED is a common consequence of damage to the pudendal nerve, but in the Veteran's case, the low back condition showed no nerve involvement. Back issues, the examiner explained, could cause ED when veins and nerves are pinched, leading to lessened blood flow to the pelvic area. The examiner then stated "Several causes of back pain that can cause ED include:" but did not provide the causes. Finally, the examiner noted there were no signs, symptoms, or diagnosis of ED during service. The Board finds that the August and September 2021 medical opinions inadequate. First, the examiner stated there was no nerve involvement associated with the low back disability, yet the Veteran is service connected for radiculopathy in the lower extremities, which is productive of moderate sciatic nerve involvement. Therefore, the examiner's statement that the Veteran's low back disability has no nerve involvement is inaccurate, rendering the opinion of no probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) Second, the September 2021 addendum is incomplete, as the examiner did not finish the sentence which would have revealed the several causes of back pain that could lead to ED. Third, the examiner provided no rationale in support of her conclusion. See Nieves-Rodriguez, supra. Therefore, another addendum medical opinion is required before adjudication of the claim on the merits. 3. Entitlement to service connection for foot disabilities is remanded. In conjunction with the November 2020 remand, VA obtained medical opinions for his various foot disabilities. In an August 2021 foot conditions disability questionnaire, the examiner stated that there are no findings, signs and or symptoms to support diagnoses of bilateral metatarsalgia, left hallux valgus, and bilateral plantar fasciitis. On an August 2021 VA skin conditions DBQ, the examiner indicated that there is no diagnosis of tinea pedis because the condition had resolved. As it was determined that there were no foot diagnoses on examination, the examiner provided medical opinions unfavorable to the claim on both direct and secondary bases. However, the Board finds the opinion inadequate to the extent that it did not address the previous foot diagnoses shown during the period on appeal, including metatarsalgia (July 2012 and August 2017 VA foot conditions examination report), hallux valgus (August 2017 VA foot conditions examination report), plantar fasciitis (August 2017 VA foot conditions examination report), or tinea pedis (January 2011 VA Podiatry Consultation). See McClain and Romanowsky, supra. Accordingly, additional medical opinions must be obtained. The matters are REMANDED for the following action: 1. Obtain another opinion from an appropriate clinician preferably from one that has not yet provided an opinion as to the nature and etiology of the Veteran's claimed headache disability. After a thorough review of the claims file, specifically to include the VA and private treatment records, the examiner should address the following: a) Please note that regardless of whether the 2000 headache has since resolved, the record contains diagnoses of headaches within the appeal period (September 2010 Private Treatment Record; February 2012 VA Treatment Record; November 2019 VA Headaches Examination Report). The Veteran is competent to report a headache. b) Provide an opinion, with complete rationale, as to whether any headache diagnosed during the appeal period had its onset during or is otherwise related to service. c) Provide an opinion, with complete rationale, as to whether any headache diagnosed during the appeal period was proximately due to OR aggravated by the lumbar spine and/or cervical spine disabilities. 2. Obtain another opinion from an appropriate clinician, preferably one that has not yet opined as to the etiology of the Veteran's erectile dysfunction. After a thorough review of the claims file, the examiner should address the following: Clarify whether the Veteran's erectile dysfunction was proximately due to or aggravated by the lumbar spine disability and/or radiculopathy of the lower extremities. Please provide a complete rationale. 3. Obtain another opinion from a qualified clinician, preferably one that has not yet opined as to the etiology of the Veteran's remaining bilateral foot disabilities not yet addressed. **NOTE: This claim has been pending since 2004 and the Board's appellate consideration of the case has been frustrated over the years by the lack of adequate medical opinions that are accompanied by complete rationale. It is imperative that a thorough review of this case be conducted and a complete rationale for each conclusion be provided. After a thorough review of the claims file, the examiner should address the following: a) Provide an opinion as to whether each of the following- (i) bilateral metatarsalgia; (ii) tinea pedis; (iii) hallux valgus; and (iv) bilateral plantar fasciitis, had its onset in service or is otherwise related to it. *Address the Veteran's contentions that he injured his feet while wearing a backpack during service and his MOS as a paratrooper must be considered and discussed. See June 2004 correspondence and August 2011 and September 2018 VA treatment records. b) Provide an opinion as to whether each of the following- (i) bilateral metatarsalgia; (ii) tinea pedis; (iii) hallux valgus; and (iv) bilateral plantar fasciitis, were caused or aggravated by the service-connected lumbar spine disability and/or cervical spine disability. **In doing so, address the diagnoses of metatarsalgia (July 2012 and August 2017 VA foot conditions examination report), hallux valgus (August 2017 VA foot conditions examination report), and plantar fasciitis (August 2017 VA foot conditions examination report), or tinea pedis (January 2011 VA Podiatry Consultation). If the examiner finds that the disabilities resolved, an explanation should be provided. (Continued on the next page) A complete rationale must be provided for each conclusion. 4. Ensure the medical opinions provided for these claims are adequate and if not, return them for corrective action; then readjudicate the remanded claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Moldawer, 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.