Citation Nr: 21077367 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 17-32 149 DATE: December 29, 2021 REMANDED Entitlement to service connection for a left foot disorder is remanded. Entitlement to service connection for migraine headaches is remanded. REASONS FOR REMAND The Veteran served on active duty from August 2000 to February 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from June 2016 rating decision. The Veteran was afforded a hearing before the undersigned Veterans Law Judge in December 2020. A transcript of the hearing is associated with the electric claims file. In April 2021, the Board remanded the issues for further development. The case has since been returned to the Board for appellate review. 1. Entitlement to service connection for a left foot disorder is remanded. The Veteran contends that he has a left foot disorder due to a left ankle injury during service. The June 2016 VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of pain, he did not have a diagnosis of a left foot disability. The September 2021 VA examiner evaluated the Veteran and determined that, while he experienced subjective symptoms of pain, he did not have a diagnosis of a left foot disability. Further, despite consistent treatment from May 2016 to August 2021, VA treatment records do not contain a diagnosis of a left foot disability. Instead, the record shows the Veteran complained of pain in his left foot, specifically with the left toenail. The Veteran relates that due to pain he is unable to walk long distances and does not run. The June 2016 VA examiner noted the Veteran does not have any left foot complaint but complained of an ingrown toenail on the right great toe. The Veteran related at the September 2021 VA examination that the pain is on the left toenail and feels as if he poked his toe with a nail. The Board finds an addendum opinion is warranted to clarify whether the Veteran has a current left toenail disability that is related to service. 2. Entitlement to service connection for migraine headaches is remanded. The Veteran contends that his headaches first manifested during service due to multiple occupational blasts. See Transcript of December 2020 Board Hearing at 5. Alternatively, the Veteran contends that his headaches are due to his service-connected bilateral trapezius strain. See May 2020 Statement in Support of Claim. The Veteran's VA treatment records consistently note the Veteran experiences headaches. A June 2021 VA treatment note shows headaches on the Veteran's active problem list. Upon VA examination in September 2021, the VA examiner noted the Veteran did not have a diagnosis of a headache condition. The VA examiner noted the Veteran has reported headache symptomatology, including having mild headaches two to three times per week. The VA examiner stated the Veteran's current report of severity of migraines conflicts with the severity in a March 2021 treatment note. The VA examiner found that given the conflicting evidence regarding migraine symptomatology, and in the absence of annotation of symptoms meeting criteria for a diagnosis of migraine in the medical records, and in the absence of a current diagnosis of migraine in the electronic health record, there is insufficient evidence to render a current diagnosis of migraine headache. The September 2021 VA examiner's rationale for no diagnosis of a headache condition focused on the criteria for a migraine headache. The examiner did not discuss why the Veteran's VA treatment records and lay statements regarding on-going headaches do not warrant a headache diagnosis. Accordingly, an addendum opinion is warranted to clarify whether the Veteran has a current headache disorder and, if so, whether there is a nexus to the headaches noted in service. See, e.g., Barr, 21 Vet. App. at 312. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's claimed headache condition. Further examination of the Veteran is not required unless deemed necessary by the medical professional selected to offer the opinion. (a.) The examiner should identify any current diagnoses related to headaches. The examiner should discuss the Veteran's lay statements regarding headache symptomatology. If no diagnosis is present during the period on appeal, the examiner should explain how this conclusion was reached. The September 2021 VA examiner did not discuss why the Veteran's VA treatment records and lay statements regarding on-going headaches do not warrant a chronic headache diagnosis. (b.) For any identified diagnosis, the examiner must opine whether the condition is at least as likely as not related to an in-service injury, event, or disease, including exposure to multiple occupational blasts. (c.) The examiner must also opine whether the condition is (1) proximately due to service-connected bilateral trapezius strain, or (2) aggravated beyond its natural progression by service-connected bilateral trapezius strain. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting to speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran's claimed left foot disorder. Further examination of the Veteran is not required unless deemed necessary by the medical professional selected to offer the opinion. (a.) In light of the Veteran's complaints referable to the left toe on VA examination in September 2021, the examiner must opine whether the condition is at least as likely as not related to an in-service injury, event, or disease, including complaints noted in August 2003. The examiner is requested to provide a clear rationale and explain in detail the underlying reasoning for any opinions expressed. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an examiner cannot provide the requested opinion without resorting ot speculation, he or she should expressly indicate this and provide a supporting rationale as to why an opinion cannot be made without resorting to speculation. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Alexia E. Palacios-Peters, 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.