Citation Nr: 21006683 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 17-39 526 DATE: February 4, 2021 REMANDED Entitlement to service connection for a left foot condition, to include plantar fasciitis, is remanded. Entitlement to service connection for Reiter's Syndrome is remanded. REASONS FOR REMAND The Veteran served in the United States Navy from May 1985 to August 1998 and from March 2013 to March 2014. These matters are before the Board of Veterans’ Appeals (Board) on appeal of a September 2015 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before he undersigned Veterans Law Judge in October 2020, and a transcript of this hearing has been associated with the claims file.   1. Entitlement to service connection for a left foot condition, to include plantar fasciitis, is remanded. 2. Entitlement to service connection for Reiter's Syndrome is remanded. The Veteran contends both his plantar fasciitis and his Reiter’s Syndrome began in service. The evidence of record shows the Veteran has complained of more general heel pain and was thought to have heel spurs during service. Additionally, possible symptoms associated with Reiter’s Syndrome include heel pain and bony heel growths. Therefore, the Board will recharacterize the Veteran’s claim of service connection for left plantar fasciitis as encompassing additional foot conditions. Such recharacterization broadens the scope of the claim and is necessary to reflect the Veteran’s allegations. See Clemons v. Shinseki, 23 Vet. Appl. 1 (2009). The Veteran’s service treatment records (STRs) show that he was seen for heel pain and possible heel spurs in December 1987. The Veteran was also diagnosed with Reiter’s Syndrome in October 1994, and there are multiple flight waivers for the disease. Additionally, there is a December 2004 letter confirming the Veteran’s diagnosis of Reiter’s Syndrome. Where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994); see also 38 C.F.R. § 3.159(a)(2) (Competent lay evidence means any evidence not requiring that the proponent have specialize education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.). The Board must also assess the credibility, and therefore the probative value, of the evidence of record in its whole. Owens v. Brown, 7 Vet. App. 429 (1995). The record does not contain current treatment records reflecting a diagnosis of Reiter’s Syndrome or a left foot condition. The Veteran has provided competent and credible testimony about his symptoms both during and after service. The Veteran’s reported symptoms of stabbing pain and stiffness in his foot along with the reported diagnosis of plantar fasciitis during service, as well as the pain in his hands and lower back associated with his Reiter’s Syndrome and the Veteran’s report of a diagnosis of this condition, are all observable by a lay witness. Therefore, the Board finds the Veteran’s testimony about his symptoms and his diagnoses to be both competent and credible. Additionally, argument provided by the Veteran’s representative at the October 2020 hearing mentions that heel pain and bony growths in the heel are possible symptoms associated with Reiter’s Syndrome. This raises the issue of whether the Veteran’s foot condition is related to his Reiter’s Syndrome, creating the possibility of secondary service connection if the Veteran’s Reiter’s Syndrome is service connected. 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(a). Establishing service connection on a secondary basis requires evidence of (1) a current chronic disability for which service connection is sought; (2) an already service-connected disability; and (3) that the disability for which 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). The Veteran has not received a VA examination for his left foot condition or his Reiter’s Syndrome. When determining whether VA is required to provide a VA medical examination or a medical opinion, the following factors should be considered: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in-service, or evidence establishing certain chronic diseases were manifested during an applicable post-service presumptive period; (3) whether there is an indication that the disability or symptoms may be associated with the Veteran’s service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.150(c)(4). The third factor has a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and a veteran’s service. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In the present case, the Veteran has testified to symptoms of foot pain, to include a stabbing sensation and pain and stiffness in the mornings, both of which affect his daily life. The Veteran also asserts his Reiter’s Syndrome, which was diagnosed in service, is chronic in nature and describes current symptoms. Therefore, the first McLendon element has been met. The Veteran STRs show he was seen for heel and foot pain in December 1987 and was diagnosed with Reiter’s Syndrome in October 1994, and thus the second McLendon element is met. With respect to the third McLendon element, the Board finds that the in-service occurrence of both conditions, as well as his testimony as to current symptoms and diagnoses are sufficient evidence that indicates there may be a nexus between the Veteran’s foot condition and Reiter’s Syndrome and his service. Therefore, the Board finds that the third McLendon element has been met. Lastly, the Board requires additional evidence before it can make a determination as to whether the Veteran’s current foot condition and his Reiter’s Syndrome are related to service. As such, the Board finds that a VA examination is warranted to address these theories. Additionally, at the October 2020 hearing, the Veteran testified that he receives private treatment for Reiter’s Syndrome. He also noted receiving treatment from private Dr. B. for his left foot disabilities. The record was held open for 60 days after the hearing to provide the Veteran the opportunity to submit these pertinent treatment records; however, no records have been received and associated with the claims file at this time. As the issues are being remanded, the Veteran should be provided with another opportunity to submit his private treatment records. Accordingly, these matters are REMANDED for the following actions: 1. Ask the Veteran to complete a VA Form 21-4142 for treatment he has received for Reiter’s Syndrome and for a left foot condition, including from Dr. B. (as identified on page 12 of the October 2020 hearing transcript). Make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. 2. After completing the development requested in item 1, schedule the Veteran for an examination(s) with a qualified VA examiner (including via telehealth, if an in-person examination is not feasible). The examiner is requested to provide an opinion to the following: (a.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s left foot condition, to include plantar fasciitis, is due to or otherwise related to service? (b.) Identify whether the Veteran has a current diagnosis of Reiter’s Syndrome. (c.) Is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s Reiter’s Syndrome is due to or otherwise related to service? (d.) If it is determined that the Veteran’s Reiter’s Syndrome is due to or otherwise related to service, then is it at least as likely as not (a 50 percent or greater probability) that the Veteran’s left foot condition is caused or aggravated by (i.e., any worsening of the condition beyond its natural progression) his Reiter’s Syndrome? The examiner is to review the Veteran’s claim file and should particularly consider the following: i. The December 17, 1987 and December 29, 1987 medical notes concerning heel and foot pain; ii. The November 4, 1994, November 10, 1994, November 22, 1994, November 30, 1994, December 9, 1994, March 17, 1995, and May 17, 1995 medical notes concerning the Veteran’s diagnosis of Reiter’s Syndrome and follow-up thereof; iii. The Veteran’s multiple flight waivers for Reiter’s Syndrome; iv. The Veteran’s statements on a May 20, 1998 Report of Medical History discussing joint pain, eye issues, and foot pain; v. The January 16, 2003 letter from Dr. R.W.B. on the Veteran’s diagnosis of Reiter’s Syndrome; vi. The November 4, 2003 email and associated correspondence between the Veteran and Dr. K.P.T.; vii. The December 10, 2004 decision from the Naval Operational Medicine Institute confirming the Veteran’s diagnosis of Reiter’s Syndrome and statement that said the condition is considered to be chronic in nature; viii. The Veteran’s Statement in Support of Claim received in April 2015 describing his foot condition symptoms as well as his current Reiter’s Syndrome symptoms; ix. The Veteran’s statements on his VA Form 9, received in August 2017, concerning his foot condition symptoms, as well as the diagnosis and symptoms of his Reiter’s Syndrome; x. The Veteran’s October 2020 hearing testimony about the history of his foot condition and Reiter’s Syndrome, his current symptoms of both conditions, and statements on how plantar fasciitis and Reiter’s Syndrome are diagnosed. A complete rationale for all opinions must be provided. If the examiner cannot provide a requested opinion without resorting to speculation, it must be so stated, and the examiner must provide the reasons why an opinion would require speculation. The examiner must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the examiner must indicate whether any opinion could not be given due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Gabrielle Ongies, 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.