Citation Nr: 21008722 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 14-31 119A DATE: February 17, 2021 REMANDED Entitlement to service connection for a right hip disorder, to include osteoarthritis, trochanteric pain syndrome, and trochanteric bursitis, claimed as "right hip condition with pain," is remanded. Entitlement to service connection for the residuals of cellulitis, to include tinea pedis, claimed as "right leg condition with pain," is remanded. REASONS FOR REMAND The Veteran had active service from July 1970 to July 1992. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2012 rating decision of an Agency of Original Jurisdiction (AOJ) of the U.S. Department of Veterans Affairs (VA). The Veteran requested a Board hearing in his September 2014 VA Form 9. The Veteran withdrew this request in November 2015. Outstanding records In February 2020, the Veteran claimed a total disability based upon individual unemployability (TDIU). While that claim is not part of this appeal stream, it influences it. Specifically, the Veteran submitted a VA Form 21-4142 in connection with the claim. It cited treatment at 3 facilities and by one individual – 1) VA facility in Stockbridge, Georgia (1992 – present), 2) the "Gulf Coast" VAMC (1970 – present), 3) North Okaloosa Medical Center, and 4) treatment by "B.G., Cpt, USAF"(1970 – present). VA obtained the records from the North Okaloosa Medical Center. It did not attempt to obtain the records from the Stockbridge facility or treatment by “B.G., Cpt, USAF.” That said, VA needs to attempt to clarify when or where treatment from this latter source occurred. As for the "Gulf Coast," VA's website shows that this healthcare system is based in Biloxi, Mississippi. This system includes facilities at Eglin AFB, Pensacola, and Panama City Beach. There are records from each of these facilities in the claims file. However, given that the Veteran has indicated treatment covering half a century, the Board finds it is necessary to determine if all records from these facilities have been obtained. Because these are federal records that may bear on the two claims in this appeal stream, remanded is warranted to attempt to obtain them. Tinea pedis The Veteran contends that he is entitled to service connection for this disability on either a direct or secondary basis. As background, the characterization of the claimed disability has evolved since the Veteran filed it, so the Board will recount the history here. The Veteran, in July 2011, claimed service connection for a "right leg condition with pain." The Veteran, in April 2012, clarified in a Report of General Information, that his claim pertained to the condition for which he was hospitalized during service and which affected the "lower calf region." VA, finding the Veteran was hospitalized in August 1986 for cellulitis and tinea pedis, examined the Veteran in October 2012. At that examination, the Veteran stated: I had a serious problem with right foot athlete's foot. They said it was from athletes' feet. The right leg swole up, and I spent 3 or 4 days in the hospital at Elgin AFB, probably in 1989. Occasionally, the leg will swell up now, it may be associated with being diabetic. I don't know. The claim reached the Board in April 2018 and August 2020. The Board, upon last considering it, ordered an addendum opinion to an October 2019 examination. It did so to determine, as relevant here, whether "any flare up of tinea" was directly related to the Veteran's in-service hospitalization or secondary to service-connected DM. Based on the foregoing, the Board construes the Veteran's claim as the residuals of cellulitis, to include tinea pedis. The Veteran has, at a minimum, tinea pedis, so this satisfies the first prong of a service connection claim, current disability. For the direct theory of entitlement, a medical professional in October 2020 opined: There is no objective evidence to support an etiology for the flare ups of the tinea pedis after service related to the cellulitis of the right leg with tinea pedis during service in 1986. Tinea pedis (Athletes foot) is a common fungal foot infection among service members, often related to poor foot care and wearing combat boots. There is no established medical nexus to the tinea pedis after service - which was not seen again until 1998, a gap of 6 years. There is no established medical nexus. The professional's reliance solely on "objective evidence" expressly violates the Board's August 2020 Remand directive – "The examiner may NOT rely on the absence of a medical record or medical treatment, including during service, as the sole rationale for any negative nexus opinion." This opinion is therefore inadequate, and remand is necessary to obtain another opinion. For the secondary theory of entitlement, VA has service connected the Veteran's DM. This satisfies the second prong, i.e., service-connected primary disability, of a secondary service connection claim. For the third prong of a secondary service connection claim – medical nexus – the Board highlights addendum opinions from October 2020 and January 2021. Both opinions are negative as to whether the Veteran's DM caused his tinea pedis, while only the October 2020 opinion addresses the question of aggravation. In this regard, the medical professional opined: It is at least as likely as not that the tinea pedis was aggravated beyond its natural progression by the SC Diabetes. Fungal skin infections of the feet can be more difficult to treat in diabetics and more likely to recur, particularly when the blood sugars are not well controlled. There is an established medical nexus for aggravation. The Board highlights two issues related to this positive opinion. First, the medical professional responded "no" to the question "regardless of an established baseline, was the Veteran's (claimed condition/diagnosis) at least as likely as not aggravated beyond its natural progression by service-connected condition?" This contradicts the opinion quoted above, which the medical professional supplied to support his "no" answer. Clearly, the opinion contradicts the "no." The Board find that the opinion is the examiner's reasoned answer, and it will accept is as more probative than the "no." Second, while the Board finds that the positive opinion was the medical professional's reasoned answer, the medical professional found that he could not identify the baseline level of severity of tinea pedis to determine the degree to which DM aggravated it. 38 C.F.R. § 3.310(b) requires VA to determine the baseline level of severity as a condition precedent to granting service connection. Therefore, and considering the outstanding records cited above, remand is warranted as they may bear on the baseline level of severity. The matters are REMANDED for the following action: 1. Attempt to obtain the treatment records identified in the February 2020 VA Form 21-4142. These are: a) VA facility in Stockbridge, Georgia (1992 – present), b) the “Gulf Coast” VAMC (1970 – present), and c) treatment by “B.G., Cpt, USAF” (1970 – present). For purposes of the Gulf Coast VAMC, check for records at the Eglin AFB, Pensacola, and Panama City Beach facilities from 1970 to present. For purposes of “B.G., Cpt, USAF," the Board recognizes this is unclear. Contact the Veteran to clarify where this treatment occurred. 2. Obtain an addendum opinion from the medical professional who reviewed the tinea pedis claim in October 2020 or another qualified medical professional if that one is not available. The medical professional must opine on the following: a) Is it at least as likely as not (50 percent probability) that the Veteran's tinea pedis began during, or was otherwise caused by, service? Why or why not? a. In answering this question, expressly address how the current tinea pedis is related to the tinea pedis diagnosed during service. b. In answering this question, you may NOT base a negative nexus opinion SOLEY on the absence of a medical record or medical treatment, including during service. This is the mistake that was made in October 2020 opinion. b) If the AOJ has routed the addendum task to the October 2020 medical professional, why is it not possible to determine the baseline level of severity of the Veteran's tinea pedis prior to aggravation? c) If, however, AOJ has routed the addendum task a medical professional other than the October 2020 medical professional, is it possible to determine the baseline level of severity of the Veteran’s tinea pedis prior to aggravation? If yes, why? If no, why not? 3. Undertake any development needed based on the records obtained. Tiffany Dawson Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Sopko, 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.