Citation Nr: 21005279 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 18-03 716 DATE: February 1, 2021 ORDER Entitlement to service connection for a left foot disability, to include as secondary to a service-connected disability, is granted. REMANDED Entitlement to a rating higher than 10 percent for left knee retropatellar pain syndrome with degenerative changes. Entitlement to a rating higher than 10 percent for right knee retropatellar pain syndrome with degenerative changes. Entitlement to a compensable rating for left knee retropatellar pain syndrome with degenerative changes, limitation of extension. Entitlement to a compensable rating for right knee retropatellar pain syndrome with degenerative changes, limitation of extension. FINDING OF FACT The evidence is in equipoise as to whether the Veteran’s left foot disability was caused or aggravated by her service connected bilateral knee and/or right foot disabilities. CONCLUSION OF LAW The criteria for secondary service connection for a left foot disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty with the U.S. Navy from May 1991 to May 1995 and with the U.S. Army from January 1997 to March 1998. The Veteran testified at a hearing in January 2021 before the undersigned Veterans Law Judge. 1. Entitlement to service connection for a left foot disability, to include as secondary to a service-connected disability. Generally, service connection requires evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 C.F.R. § 3.303(a). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists, (2) an already service-connected disability, and (3) that the disability for which secondary service connection is sought was either (a) caused or (b) aggravated by the already service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). Per the September 2017 VA examination, the Veteran has diagnoses of pes planus, hallux valgus, and degenerative arthritis in both feet. She is already service connected for her right foot disability, as well as bilateral knee retropatellar pain syndrome with degenerative changes. Review of the Veteran’s service treatment records does not show any complaints, diagnosis or treatment of a left foot disability. There are multiple records showing right foot pain. At separation, she reported foot trouble and noted a callous had been removed from her left foot. Direct service connection is not warranted as there is no medical nexus between the Veteran’s current diagnoses and her service. Specifically, her service medical records show she had a callous removed for her left foot but no chronic condition. Rather, his records show that he had a significant right foot condition. Treatment records show the Veteran’s left foot deformity was not identified until 2012. The February 2003 VA examiner found the Veteran’s diagnosed hallux valgus was less likely than not incurred in or caused by her service. Her service records were negative for any treatment or diagnosis of a left foot bunion. At the time of separation, there were no left foot problems and the exam was normal. Post-service records show the Veteran developed the left foot deformity in 2012, over 10 years after her separation. However, based on the foregoing, the first and second elements of secondary service connection have been met. The appeal turns on whether a nexus between the Veteran’s diagnosed left foot disability and his service-connected bilateral knee and/or right foot disabilities exists. The Board finds that it does. The March 2017 examiner found that the Veteran’s left foot disability was less like than not due to or the result of a service-connected condition. The examiner noted that the precise etiology of hallux valgus was unknown but was most likely multifactorial in origin and included such factors as: abnormal foot mechanics, abnormal first metatarsophalangeal (MTP) anatomy, joint hypermobility, and genetic influences. Ultimately, the examiner found it was medically implausible that the Veteran’s hallux valgus was the result of his bilateral knee disability. Osteoarthritis of the first MTP joint is more likely than not due to the hallux valgus as that condition alters joint mechanics. Her bunionette or tailor’s bunion was more often than not a hereditary condition in her age group. Another opinion was completed in September 2017 and the examiner found that the Veteran’s left foot deformities were less likely than not proximately due to or the result of her right foot. Specifically, the examiner found that the two conditions are not medically related. The claimed disorder is a separate entity entirely from the service-connected condition and unrelated. The medical literature does not support a medical relationship. The examiner found that a nexus has not been established. A December 2017 VA treatment note indicated that it was more likely than not that her left foot deformity/pain was the result of irregular gait and increased weight placement caused by her right foot deformity and bilateral knee disabilities. The Veteran’s provider conducted an annual examination and review her bilateral foot and knee disabilities. There are three probative medical opinions of record. One is positive and the others negative. Both clinicians are competent to provide the opinions, and the Board has no reason to question their credibility. As the evidence for and against the claims are in relative equipoise, service connection for left foot disability is granted. REASONS FOR REMAND 1. Entitlement to a rating higher than 10 percent for left knee retropatellar pain syndrome with degenerative changes is remanded. 2. Entitlement to a rating higher than 10 percent for right knee retropatellar pain syndrome with degenerative changes is remanded. 3. Entitlement to a compensable rating for left knee retropatellar pain syndrome with degenerative changes, limitation of extension is remanded. 4. Entitlement to a compensable rating for right knee retropatellar pain syndrome with degenerative changes, limitation of extension is remanded. Rating decisions for the above appeals were issued in August 2017, which included the proposal to reduce the Veteran’s ratings for bilateral knee instability. The reduction for bilateral knee instability was effectuated in a November 2017 rating decision. The Veteran submitted a timely notice of disagreement in October 2017, but a statement of the case (SOC) has not yet been issued as to these issues. A remand is required for the AOJ to issue a statement of the case. 38 C.F.R. § 20.200; Manlincon v. West, 12 Vet. App. 238, 240-41 (1999). However, as there is no notice of disagreement following the November 2017 rating decision reducing the ratings for the instability in each knee, no SOC is required for the reductions. The matters are REMANDED for the following action: 1. Send the Veteran and her representative a statement of the case that addresses the issues of increased ratings for her bilateral knee arthritis and limitation of extension. If the Veteran perfects an appeal by submitting a timely VA Form 9, the issues should be returned to the Board for further appellate consideration. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Price, 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.