Citation Nr: 21007586 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 14-21 011A DATE: February 10, 2021 ORDER Entitlement to service connection for left foot tendinitis, secondary to service-connected left knee internal derangement with arthritis on a causation basis, is granted. Entitlement to service connection for right hip tendinitis, secondary to service-connected left knee internal derangement with arthritis on a causation basis, is granted. FINDINGS OF FACT 1. The Veteran’s current left foot tendinitis is caused by his service-connected left knee disorder. 2. The Veteran’s current right hip tendinitis is caused by his service-connected left knee disorder. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for left foot tendinitis, secondary to left knee disorder on a causation basis, have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. § 3.310 (2020). 2. The criteria for entitlement to service connection for right hip tendinitis, secondary to left knee disorder on a causation basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.310. REFERRED The issue of service connection for left hip strain was raised in an October 2020 VA examination but has not been adjudicated by the Agency of Original Jurisdiction (AOJ); therefore, the Board does not have jurisdiction over the claim, and it is referred to the AOJ for appropriate action, to include informing the Veteran and his representative that a claim for benefits must be submitted on the application form prescribed by the Secretary of VA and providing such forms. See 38 C.F.R. § 3.150 (a) (2018) (providing for furnishing of appropriate application form upon request for VA benefits); 38 C.F.R. § 20.904 (b) (continuing to provide for referral of unadjudicated claims). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Air Force from August 1976 to March 1986. These matters initially came before the Board of Veterans Appeals (Board) on appeal from a December 2011 rating decision denying service connection for right foot fracture, left foot tendinitis and right hip tendinitis. The claims were remanded by the Board in March 2018 and October 2019 for further development. The claim for service connection for right foot fracture was subsequently granted by the Regional Office, while the claims for service connection for left foot tendinitis and right hip tendinitis have since returned to the Board for adjudication. The Veteran testified before the undersigned Veterans Law Judge in a Board video-conference hearing in December 2017. A transcript of that hearing is of record. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). The October 2020 VA examiner noted a 1999 X-ray showed the Veteran had left foot pain manifested by tendinitis, which has continued to today and only gotten worse. Additionally, the October 2020 VA examiner noted the Veteran’s right hip tendinitis onset in 2011 and he currently experiences symptoms of constant pain in the groin region of his right hip with pain at a level of 4 out of 10. Therefore, the evidence is sufficient to establish the current disability element for both the left foot and right hip tendinitis. Additionally, the Veteran was granted service connection for internal derangement of the left knee in an October 1986 rating decision, which establishes the service-connected disability of secondary service connection. Therefore, the dispositive issue is whether either the Veteran’s current left foot tendinitis or right hip tendinitis are proximately due to or the result of his service-connected left knee disability. To that end, the October 2019 Board remanded these claims to the RO to obtain opinions from an appropriate physician as to whether the Veteran’s service-connected left knee disability caused him to become obese and, if so, whether the obesity was a substantial factor in causing the Veteran’s claimed left foot tendinitis or right hip tendinitis. Alternatively, the Board also asked the RO to obtain opinions from an appropriate physician as to whether the Veteran’s left foot tendinitis and/or right hip tendinitis was either caused by or aggravated by his service-connected left knee disability. In response, there were a number of medical opinions associated with the record, the most relevant of which were rendered in January 2020 and October 2020. The January 2020 VA examiner concluded that despite finding that the Veteran’s service-connected left knee disability did not lead to his obesity, and even though the Veteran’s service treatment records did not contain complaints or treatment, it is at least as likely as not that his left foot tendinitis and right hip tendinitis were related to service. The VA physician reasoned that the Veteran’s left foot condition and right hip tendinitis were caused over time by compensatory weight-bearing changes to alleviate the pain emanating from his service-connected left knee disability. He further noted that the Veteran’s symptom progression is consistent with degradation of the orthopedic chain of weight bearing due to unbalanced mechanical loads resulting in increased pressure on the left foot and subsequent development tendinitis. The examiner ended his opinion by noting that the Veteran’s left foot tendinitis and right hip tendinitis would not have occurred but for the development of obesity. This opinion is somewhat contradictory, as it indicates on the one hand that the left knee disorder caused the left foot and right hip disability by altering the Veteran’s gait, but also that the left foot and right hip disabilities would not have occurred without the Veteran’s obesity. The opinion may be read as indicating that the current left foot and right hip disabilities have multiple causes, including the left knee disorder and obesity. There is no requirement in the laws or regulations pertaining to secondary service connection that the service connected disease or injury be the sole cause of the current disability. Consequently, this positive medical opinion, indicating that a service connected disorder at least in part caused the left foot and right hip disabilities, is afforded significant probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). The RO requested another opinion to clarify what it perceived as a conflict in the January 2020 opinion. Therefore, an advanced registered nurse practitioner (ARNP) provided October 2020 medical opinions. First the ARNP opined that the Veteran’s left foot problem was not shown to have a biomechanical link to his left knee and is “rather consistent with inherent congenital of bilateral plano valgus” and the tendinitis in his achilles is independently occurring, noting that any favored gait would not be supportive in developing his foot problem. Additionally, the October 2020 VA ARNP noted that the Veteran’s right hip tendinitis was actually a labrum tear and contradicted the January 2020 VA examiner’s opinion regarding the orthopedic chain of weight bearing and concluded it was just conjecture and speculation. He concluded that it is not as likely as not that the Veteran’s right hip tendinitis was caused by or aggravated by his service-connected left knee disability. Considering the thorough rationale of both of these opinions, they are also afforded significant probative weight. The above evidence reflects that there are competent, probative medical opinions that weigh in favor of entitlement to service connection for the Veteran’s left foot tendinitis and right hip tendinitis, secondary to his service-connected left knee disorder on a causation basis, and competent, probative medical opinions that weigh against. The evidence is therefore at least evenly balanced as to whether the Veteran’s current left knee tendinitis and right hip tendinitis were caused by his service-connected left knee disorder. As the reasonable doubt by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for left foot tendinitis and right hip tendinitis, secondary to service-connected left knee disorder on a causation basis, is warranted. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board JR Cummings, 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.