Citation Nr: 21010156 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 17-35 442 DATE: February 24, 2021 ORDER 1. Entitlement to service connection for corneal dystrophy, also known as Meesmann corneal dystrophy, is denied. 2. Entitlement to service connection for a right ankle disability, to include osteoarthritis, is denied. 3. Entitlement to service connection for hypertension is denied. REMANDED 5. Entitlement to service connection for a lumbar spine disability, to include degenerative joint disease and to include as secondary to metatarsalgia, fracture, third right metatarsal, and/or plantar fasciitis of the left foot, is remanded. 6. Service connection for a right foot disability other than metatarsalgia, fracture, third right metatarsal, is remanded. FINDINGS OF FACT 1. Corneal dystrophy clearly and unmistakably preexisted the first period of active duty and was clearly and unmistakably not aggravated during the first period of active duty. 2. Corneal dystrophy preexisted the second period of active duty and was not aggravated during that period of active duty. 3. Refractive error is not a disability for VA compensation purposes. 4. A right ankle disability did not have its onset during the first period of active duty, osteoarthritis was not manifested within one year following service discharge, and a right ankle disability is not otherwise related to the first period of active duty. 5. Osteoarthritis of the right ankle preexisted the second period of active duty and was not aggravated beyond the natural progress of the disease during that period of active duty. 6. Hypertension did not have its onset during the first period of active duty, was not manifested within one year of service discharge, and is not otherwise related to the first period of active duty. 7. Hypertension preexisted the second period of active duty and was not aggravated beyond the natural progress of the disease during that period of active duty. CONCLUSIONS OF LAW 1. The criteria for service connection for corneal dystrophy have not been met. 38 U.S.C. §§ 1110, 1111, 1131, 1153, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. 2. The criteria for service connection for a right ankle disability, to include osteoarthritis, have not been met. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1113, 1131, 1137, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309. 3. The criteria for service connection for hypertension have not been met. 38 U.S.C. §§ 1101, 1110, 1111, 1112, 1113, 1131, 1137, 1153, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.306, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in active duty from December 1979 to February 1990 and then from February 2007 to August 2007. The Veteran had a hearing before the undersigned Veterans Law Judge with the Board of Veterans’ Appeals (Board) on March 11, 2020. A transcript of that hearing is within the Veteran’s claims file. In July 2020, the Board sent the Veteran a letter asking if the Veteran wanted to waive initial consideration of evidence that had been received after May 2017, which is when the statement of the case was issued. It listed the exact same evidence that was listed as being considered within the May 2017 statement of the case. Compare July 22, 2020 letter in first paragraph with May 2017 statement of the case under “Evidence.” Thus, the agency of original jurisdiction considered this evidence already. The Veteran submitted four pages of records and a letter from his chiropractor along with the VA Form 9, Appeal to the Board, which was received in July 2017. These records pertain to the lumbar spine, and because the Board is remanding this claim, a waiver is not necessary. At the March 2020 Board hearing, the Veteran submitted additional evidence, which presumes a waiver unless stated otherwise. The Veteran did not include a statement or state at the hearing that he was not waiving initial consideration of this evidence by the agency of original jurisdiction. One of the documents (Functional Capacity Certificate Form 507) was duplicative of the service treatment records received in October 2015. Thus, the Board may consider this evidence in the first instance. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship, i.e., a nexus, between the claimed in-service disease or injury and the current disability. Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as hypertension and arthritis (also known as degenerative joint disease), become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111. 1. Entitlement to service connection for corneal dystrophy The Veteran believes that corneal dystrophy was aggravated while in service. During his Board hearing, the Veteran stated that he wore glasses for years and was never diagnosed with Meesmann dystrophy prior to his time in the military. The Veteran acknowledged that his eye doctor previously diagnosed him with corneal dystrophy prior to entering the service, but he stated that he had a procedure to attempt to have his cornea grow back normally at the Naval hospital in Bethesda, Maryland. He stated that, unfortunately, it did not grow back normally, and he has cysts on his eyes. He testified that when he wakes up, for the first 30 to 40 minutes, his vision is blurry. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for corneal dystrophy. The reasons follow. As to evidence of a current disability, a July 2012 VA examination report shows that the Veteran was diagnosed with corneal dystrophy. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the May 1979 Report of Medical Examination, shows that clinical evaluations of the of the eyes – general and ophthalmoscopic were normal. Therefore, the presumption of soundness attached at the time of the Veteran’s entrance into the Army in 1979. Within the Veteran’s claims file is a March 1981 letter from Dr. Robert Guiduli. Dr. Guiduli wrote that the Veteran had been seen professionally by him since April 1967. He wrote that at that time, the Veteran complained of myopia, and he had a past history of trauma to the right eye in 1966. Dr. Guiduli found that the Veteran had mixed astigmatism and corneal dystrophy. Dr. Guiduli wrote that the Veteran had been followed on a regular basis since then and his last visit was in December 1978. In the January 1986 Report of Medical History, the Veteran again denied ever having or having then eye trouble. The January 1986 Report of Medical History found the Veteran to be clinically normal in all areas, including eyes – general and ophthalmoscopic. The November 1989 Report of Medical Examination, the Veteran’s vision was noted to be “slightly abnormal.” The copy of the November 1989 Report of Medical History is incomplete, but the Veteran documented that he was in good health. He reported a positive history of having eye trouble. During the Veteran’s second period of active duty, he was seen in March 2007 and complained of blurry vision both with distance and near vision with his current glasses. The Veteran reported no significant medical history except for Meesman’s corneal dystrophy. The Veteran was afforded a VA examination in July 2012. During that examination, the examiner concluded that the Veteran’s corneal dystrophy was less likely than not incurred in or caused by an in-service injury, event, or illness. The examiner cited to the letter from Dr. Guiduli, who had written he treated the Veteran from April 1967 through December 1978. The examiner noted that Dr. Guiduli treated the Veteran for this condition prior to his time in service. The examiner found that this condition was not secondary to any treatment or condition occurring while on active duty. In the March 2017 VA examination report, the examiner diagnosed the Veteran with Meesmann’s corneal dystrophy and age-related nuclear sclerosis cataract. The examiner stated that the Veteran’s diagnosis of bilateral corneal dystrophy, as documented in Dr. Guiduli’s letter from March 1981, was definitively differential diagnosed as Meesman’s epithelial corneal dystrophy in March 2007. The examiner wrote that as referenced in the medical literature, Meesmann’s corneal dystrophy is part of a group of inherited corneal diseases that are typically autosomal dominant, are not usually associated with other ocular or systemic abnormalities, are bilateral, commonly involve the central cornea, and progress with advancing age. The examiner explained that Meesmann’s corneal dystrophy has a variable expression and persists throughout life and will recur in regenerated epithelium if the pathologic epithelium is removed. The examiner stated that autosomal dominant inheritance is well established. The examiner concluded that there was no evidence of aggravation of the Veteran’s eye condition beyond its natural progression was discovered in the service treatment records, post-service treatment records, or upon examination. The examiner found no evidence of an etiology for aggravation of the condition beyond its natural progression was discovered in current and historical literature. Therefore, the examiner concluded that the Veteran’s corneal dystrophy was not aggravated beyond its natural progression by service. The Board finds that the March 2017 opinion is highly probative, as the examiner had physically examined the Veteran, reviewed the file, researched the diagnosis, and provided opinions that were based upon the specific facts of this case and medical literature, which literature the examiner cited to in support of the opinion. The July 2012 examiner did not provide a rationale for the opinion, and thus such opinion is not probative. The March 1981 letter from Dr. Guiduli establishes clear and unmistakable evidence that corneal dystrophy preexisted the first period of active duty. The facts documented within this letter are not debatable. Thus, corneal dystrophy clearly and unmistakably existed prior to the Veteran’s first period of active duty. The Board also finds that the March 2017 opinion establishes by clear and unmistakable evidence that corneal dystrophy was not aggravated during that period of active duty. The examiner affirmatively found that there was no evidence of an etiology for aggravation of the condition beyond its natural progression based on review of current and historical literature. There is no competent evidence to weigh against the March 2017 opinion. Thus, the presumption of soundness was rebutted for the first period of active duty, and service connection is not warranted based upon this period of active duty. As to the second period of active duty from February 2007 to August 2007, the Veteran was not examined. The presumption of soundness does not attach if a veteran was not examined at service entrance. 38 U.S.C. § 1111 (“Every veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service….”) (Italics added.). Thus, the presumption of soundness does not attach to the second period of active duty. As determined above, the corneal dystrophy pre-existed the second period of active duty, and as determined by the March 2017 VA examiner, corneal dystrophy was not aggravated beyond the natural progress of the disease process. Thus, service connection is not warranted based upon this period of active duty. The evidence shows that the Veteran was also diagnosed with refractive error, astigmatism, and presbyopia in several treatment records with the latter two diagnoses being types refractive error. However, refractive error of the eye is not considered a disease or injury for which service connection is available. See 38 C.F.R. §§ 3.303(c), 4.9. Thus, service connection for refractive error, astigmatism, and presbyopia is not warranted. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to establish that corneal dystrophy was aggravated during either period of active duty, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. At the present time, there is no competent evidence of a positive nexus to service to weigh against the March 2017 VA examiner’s opinion. For all the reasons laid out above, the Board concludes that the preponderance of the evidence is against the claim for service connection for corneal dystrophy. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim for service connection for corneal dystrophy is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a right ankle disability The Veteran believes his right ankle disability had its onset in service. During his Board hearing, the Veteran testified that the initial injury to right ankle occurred during his first period of active duty. He said he was preparing for physical training and twisted his ankle and foot. He testified he limped around for some time and did not think much about it. He stated from that point on, he would periodically get pain in his ankle. In 2007, he got his ankle x-rayed. He also testified that his ankle is secondary to his hips and right foot. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a right ankle disability. The reasons follow. As to evidence of a current disability, a July 2012 VA examination report shows that the Veteran was diagnosed with a right lateral ankle sprain with avulsion fracture and lateral ankle instability on the right ankle. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service injury, event, or illness, the service treatment records show that the Veteran was not diagnosed or treated for a right ankle disability during active duty. For instance, in the January 1986 Report of Medical History, the Veteran denied a history of arthritis, rheumatism, or bursitis; or bone, joint, or other deformity. The January 1986 Report of Medical History found that clinical evaluation of the lower extremities was normal. The copy of the November 1989 Report of Medical History is incomplete, but the Veteran reported that he had aches in both knees and ankles for five to six years. However, clinical evaluation of the lower extremities was normal at that time. The Board finds that the Veteran’s report of aches in November 1989 is not a disease or injury and the clinical evaluation of the lower extremities at that time was normal. Therefore, the preponderance of the evidence is against a right ankle disease or injury during the first period of active duty. Additionally, there is no competent evidence of arthritis being manifested within one year of service discharge. Therefore, the preponderance of the evidence is against the Veteran complaining of or being treated for a chronic disease or injury related to the right ankle during the first period of active duty. There is a June 2005 service treatment record showing that the Veteran reported he had right hip and ankle pain for 10 years. The examiner concluded that the Veteran likely had osteoarthritis of his right ankle. As the Veteran was not on active duty at that time, the Board finds that the June 2005 records show that the right ankle disability pre-existed the second period of active duty. As stated above, there is no entrance examination report from the Veteran’s second period of active duty beginning in February 2007. As such, the presumption of soundness does not attach to that period of active service. Service treatment records during the second period of active duty do not show treatment for the right ankle to show aggravation. The Veteran was seen for right foot pain during this period of service in July 2007, and right ankle pain was not reported. A “Foot and Ankle Questionnaire” completed in July 2007 document only foot complaints and not ankle complaints. Within a July 2012 VA examination report, the examiner documented that the Veteran had been diagnosed with a right ankle disability in June 2005 and thus it was at least as likely as not that the right ankle disability occurred in or was caused by military service. However, the examiner believed that the Veteran was on active duty at the time the Veteran was diagnosed with osteoarthritis in June 2005, which is an incorrect factual premise. See Reonal v. Brown, 5 Vet. App. 458 (1993) (a physician’s opinion based on an inaccurate factual premise has no probative value). The diagnosis of osteoarthritis was first shown many years following the Veteran’s first period of active duty and was not aggravated during the second period of active duty in 2007. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to directly link any current disability to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. For all the reasons laid out above, the Board concludes that the preponderance of the evidence is against the claim for service connection for right ankle disability, to include osteoarthritis. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim for service connection for right ankle disability is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 3. Entitlement to service connection for hypertension The Veteran believes hypertension had its onset during service. He testified during his Board hearing that he was diagnosed with pre-hypertension in 2007 and his blood pressure kept going up. He stated he was then diagnosed with hypertension in April 2008. He stated that he had been on hypertension medication since 2009. The Veteran acknowledged that he was diagnosed with hypertension in 2005, when he was a reservist. However, his contention is that after he entered service again in 2007, he was diagnosed with it again in 2008. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for hypertension. The reasons follow. As to evidence of a current disability, the evidence of record shows that the Veteran has been diagnosed with hypertension. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of an in-service disease or injury, the service treatment records from the Veteran’s first period of active duty do not show a diagnosis of hypertension. In the January 1986 Report of Medical History, the Veteran denied ever having or having then high or low blood pressure. The January 1986 and November 1989 Reports of Medical Examination show that clinical evaluation of the heart and vascular system were normal at both times. The Veteran’s blood pressure in November 1989 was 104/68. As noted above, while the copy of page 1 is incomplete, the copy of page 2 is complete, and the Veteran specifically denied an illness or injury other than those already noted. Also on page 2 is the part where the examiner is asked to comment on the positive history documented from page 1, none of which involved a positive history involving high or low blood pressure. Therefore, the Board finds that preponderance of the evidence is against a finding that the Veteran had hypertension during his first period of active duty. Following this period of active duty, there is a June 2005 treatment record showing that the Veteran reported he had hypertension, which was not controlled. The examiner diagnosed uncontrolled hypertension. This is the first evidence of a diagnosis of hypertension, which is approximately 15 years following discharge from the first period of active duty and does not lend to a finding that hypertension had its onset during the first period of active duty from December 1979 to February 1990 or that it manifested within one year of service discharge. Thus, the preponderance of the evidence is against a finding that hypertension is otherwise related to this period of active duty. As to the second period of active duty, as stated above, there is no entrance examination report from this period of active duty, and, as such, the presumption of soundness does not attach to that period of active duty. Therefore, the Board finds that the Veteran’s hypertension was diagnosed in June 2005, which preexisted the second period of active duty. In reviewing the service treatment records from the period of active duty from February 2007 to August 2007, hypertension is not documented as one of the Veteran’s medical diagnoses, to include when discussing the Veteran’s medical history. Thus, there is no competent evidence that hypertension was aggravated during the second period of active duty. The Veteran claims he was re-diagnosed with hypertension in 2008; however, there is no competent evidence to support that opinion, and the diagnosis of hypertension is accepted as of 2005, when it is documented within the medical records. The Veteran was provided a VA examination in July 2012. During that examination, the Veteran claimed that he was diagnosed in 2008 with hypertension and he began medication for the hypertension in 2012. The examiner reviewed the Veteran’s file and noted that he was diagnosed with hypertension in 2005. The examiner concluded that the Veteran’s hypertension was at least as likely as not incurred in service because he was diagnosed with hypertension in June 2005. However, it is clear that the examiner did not understand that the Veteran was not on active duty at the time of the June 2005 diagnosis. The Board finds that the July 2012 VA opinion is not probative, as it is based on an incorrect factual premise. See Reonal, 5 Vet. App. 458. At the present time, there is no competent evidence that hypertension had its onset during the first period of active duty, that it manifested to a compensable degree within one year of service discharge, or that it was aggravated during the second period of active duty. While the Veteran is competent to report symptoms that he has experienced in service and since service, he is not competent to directly link a diagnosis of hypertension to service, as medical expertise is required. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the Veteran’s own opinion is nonprobative evidence. For all the reasons laid out above, the Board concludes that the preponderance of the evidence is against the claim for service connection for hypertension. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application, and the claim for service connection is denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 4. Service connection for a lumbar spine disability, to include degenerative joint disease, to include as secondary to metatarsalgia, fracture, the third right metatarsal, and/or plantar fasciitis of the left foot, is remanded. 5. Service connection for a right foot disability other than metatarsalgia, fracture, third right metatarsal, is remanded. The Board finds that further development is needed for the claims involving the lumbar spine and a right foot disability other than metatarsalgia, fracture, third right metatarsal. As to the claim for service connection for a lumbar spine disability, while VA provided the Veteran with an examination, it asked the examiner only about direct service connection. At the March 2020 hearing, the Veteran stated he was also seeking secondary service connection for the lumbar spine disability as being caused or aggravated by his feet. The Board finds that a VA examination is warranted as a result. As to the claim for service connection for a right foot disability, during the Board hearing, the Veteran testified that his right foot disability was separate from the service-connected metatarsalgia, fracture, third right metatarsal, and he believed it was caused or aggravated by the service-connected metatarsalgia, fracture, third right metatarsal. The Board finds that a VA examination is warranted as a result. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination with an appropriate clinician to determine if a current lumbar spine disability had its onset during a period of active duty and/or is caused or aggravated by service-connected metatarsalgia, fracture, the third right metatarsal, and/or plantar fasciitis of the left foot. The claims file must be made available to the examiner for review. A copy of the below facts should be provided to the VA examiner. All diagnostic tests deemed warranted by the examiner must be conducted. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: • The Veteran served in active duty from December 1979 to February 1990 and then from February 2007 to August 2007. • The Veteran is service connected for metatarsalgia, fracture, the third right metatarsal, and plantar fasciitis of the left foot. • The Veteran believes he developed a lumbar spine disability as a result of his periods of active duty and/or that it was caused or aggravated by the service-connected bilateral foot disabilities. • A January 1986 Report of Medical Examination shows that clinical evaluation of the spine and other musculoskeletal system was normal. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#2” in the subject field, p. 11 (item #38). • In the January 1986 corresponding Report of Medical History, the Veteran denied a history of recurrent back pain. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#2” in the subject field, p. 10 (item #11, middle column). • A November 1989 Report of Medical Examination shows that clinical evaluation of the spine and other musculoskeletal system was normal. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#3” in the subject field, p. 38 (item #38). • A June 2005 treatment record shows that the Veteran reported having low back pain for approximately 14 years. The examiner documented that the Veteran had positive straight leg raising on the right at 45 degrees and negative straight leg raising on the left. The Veteran was positive for painful forward flexion beyond the waist with notable spasm to the paraspinals. The examiner diagnosed chronic low back pain. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#1” in the subject field, pp. 37-38. • Service treatment records from the period of active duty from February 2007 to August 2007 do not show complaints of or treatment for low back pain. The list of current diagnoses/problems within these service treatment records includes hyperlipidemia, chest pain or discomfort, esophageal reflux, atypical chest pain, astigmatism, refractive error, corneal dystrophy, and presbyopia. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#1” in the subject field, p. 6. • A May 2008 private medical record shows that the Veteran was seen for blood in his stool. Within this record, it addressed the Veteran’s past medical history, and the Veteran reported a positive history of high cholesterol but denied a history of arthritis. See VBMS entry with document type, “VA Examination,” receipt date 07/19/2012, with “#1” in the subject field, p. 46. • A July 2012 VA examination report shows the Veteran was diagnosed with lumbar degenerative joint disease especially at L5-S1. See VBMS entry with document type, “VA Examination,” receipt date 07/19/2012, with “#2” in the subject field, p. 65. • July 2012 x-rays of the lumbar spine showed moderate osteoarthritis at L5-S1. There was mild degenerative spondylosis seen diffusely. No acute fracture, subluxation, dislocation, lytic destructive lesion or vertebral body compression deformity. See VBMS entry with document type, “VA Examination,” receipt date 07/19/2012, with “#1” in the subject field, p. 9. • A March 2017 VA foot examination report involving his right foot shows that the Veteran reported he had sharp and achy pain on his right third toe. The examiner found that the Veteran had metatarsalgia but did not have Morton’s neuroma. See VBMS entry with document type, “C&P Exam,” receipt date 03/03/2017, with “DBQ MUSC Foot” in the subject field. • In a letter received in July 2017, Dr. Steve Hudgins, a chiropractor, wrote that the Veteran suffered from severe lumbar degenerative joint disease and severe lumbar spondylosis with degenerative disc disease. He wrote that the Veteran’s low back pain had been increasing for several years and that the Veteran’s lumbar spine and discs appeared to be much more severe than most individuals his age. (The Veteran was one month shy of turning 65 years old.) Dr. Hudgins wrote that he had evaluated the Veteran’s gait and found that many years of antalgic positioning due to constant foot pain had drastically altered the biomechanics of the pelvis, hips, and lumbar spine. He stated that the amount of degenerative changes found in the Veteran’s spine, especially in the lumbar region, suggested strongly a correlation with altered biomechanics from problems during ambulation due to long term injuries in his feet. Dr. Hudgins concluded that in his professional opinion, he was certain that the conditions that involved the feet have accelerated and greatly worsened the degenerative changes in the lumbar spine. See VBMS entry with document type, “Medical Treatment Record – Non-Government Facility,” receipt date 07/01/2017, p. 1. • A July 2020 VA foot examination report involving his left foot shows that the examiner diagnosed plantar fasciitis involving the left foot. See VBMS entry with document type, “C&P Exam,” receipt date 07/06/2020, with “DBQ MUSC Foot” in the subject field. • The examiner’s review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions: (1) Is it at least as likely as not (50 percent probability or higher) that the Veteran’s lumbar spine disability is related to service from December 1979 to February 1990 and/or from February 2007 to August 2007? Please state what facts and medical principles you base the opinion. (2) If the answer to (1) is negative, is it at least as likely as not (50 percent probability or higher) that the Veteran’s lumbar spine disability is caused by metatarsalgia, fracture, third right metatarsal, and/or plantar fasciitis of the left foot? Please state upon what facts and medical principles you base the opinion. (3) If the answer to (2) is negative, is it at least as likely as not (50 percent probability or higher) that the Veteran’s lumbar spine disability is aggravated by metatarsalgia, fracture, third right metatarsal, and/or plantar fasciitis of the left foot? (This is a separate question from (2).) Please state upon what facts and medical principles you base the opinion. (4) If the examiner finds that metatarsalgia, fracture, third right metatarsal, and/or plantar fasciitis of the left foot aggravates the Veteran’s lumbar spine disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the lumbar spine disability prior to aggravation. If the examiner is unable to establish a baseline for the right foot disability prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). 2. Schedule the Veteran for a VA examination with an appropriate clinician to determine if the Veteran has a separate right foot disability other than metatarsalgia, fracture, the third right metatarsal. The claims file must be made available to the examiner for review. A copy of the below facts should be provided to the VA examiner. All diagnostic tests deemed warranted by the examiner must be conducted. To assist in a review of the claims file, the examiner is informed of the following facts with citations in the record, when applicable: • The Veteran served in active duty from December 1979 to February 1990 and then from February 2007 to August 2007. • The Veteran is service connected for metatarsalgia, fracture, the third right metatarsal. • The Veteran believes that he developed a right foot disability that is separate from metatarsalgia, fracture, the third right metatarsal as a result of the service-connected metatarsalgia, fracture, the third right metatarsal. • A January 1986 Report of Medical Examination shows that clinical evaluation of the feet was normal. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#2” in the subject field, p. 11 (item #36). • In the January 1986 corresponding Report of Medical History, the Veteran denied a history of foot trouble. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#2” in the subject field, p. 10 (item #11, last column). • A November 1989 Report of Medical Examination shows that clinical evaluation of the feet was normal. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#3” in the subject field, p. 38 (item #36). • The fracture to the third right metatarsal occurred in July 2007 during the Veteran’s period of service from February 2007 to August 2007. • A July 2007 service treatment record shows the Veteran was seen with complaints of pain in the right mid foot for the past few months. The examiner wrote there was tenderness on palpation of the third metatarsal and mild intermetatarsal tenderness. There was no pain with compression of distal right foot. He was assessed with metatarsalgia. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#1” in the subject field, pp. 6, 8. • A July 2007 service treatment record shows that an x-ray showed a closed fracture of the third right metatarsal shaft stress. burning pain in the right fourth and fifth digits. See VBMS entry with document type, “STR – Medical,” receipt date 10/22/2015, with “#1” in the subject field, p. 15. • A July 2012 VA foot examination report shows the examiner diagnosed hallux valgus and plantar fasciitis but did not state if both feet were involved. Within the examination report, the examiner noted that x-rays showed an incidental finding of hallux valgus, bilaterally. See VBMS entry with document type, “VA Examination,” receipt date 07/19/2012, with “#2” in the subject field, pp. 61-64. • A July 2012 x-ray of the right foot shows minimal hallux valgus deformity, no acute fracture, subluxation, dislocation, lytic destructive lesion or significant joint space narrowing, no calcaneal spur. See VBMS entry with document type, “VA Examination,” receipt date 07/19/2012, with “#1” in the subject field, p. 9. • An October 2012 VA examination report shows the Veteran’s right foot was examined, and he was diagnosed with residuals of a fracture of the third metatarsal. The medical history shows that the Veteran reported he had fractured his right foot in 1985; however, the service treatment records from that period of active duty do not support that allegation. See VBMS entry with document type, “VA Examination,” receipt date 10/22/2012, with “#1” in the subject field, pp. 7-12. • An October 2012 x-ray of the right foot shows shortening of the fifth metatarsal bone, which produced shortening of the fifth toe. No other bony abnormalities were seen. The intra-articular spaces of the joints of the foot were preserved. The soft tissues were unremarkable. See VBMS entry with document type, “C&P Exam,” receipt date 11/13/2012, with “X-ray, right foot,” in the subject field, p. 1. • A February 2017 VA examination report shows the examiner diagnosed metatarsalgia involving the right foot. See VBMS entry with document type, “C&P Exam,” receipt date 03/03/3017, with “DBQ MUSC Foot” in the subject field. • The examiner’s review of the record is NOT restricted to the evidence listed above. This list is provided in an effort to assist the examiner in locating potentially relevant evidence. The examiner is asked to answer the following questions: (1) Does the Veteran have a diagnosis involving his right foot other than metatarsalgia, fracture, third right metatarsal? What diagnosis or diagnoses does he have? (2) For any diagnosis involving the right foot other than metatarsalgia, fracture, third right metatarsal, is it at least as likely as not (50 percent probability or higher) that the disability is related to service from December 1979 to February 1990 and/or from February 2007 to August 2007? Please state what facts and medical principles you base the opinion. (3) If the answer to (2) is negative, is it at least as likely as not (50 percent probability or higher) that the right foot disability, other than metatarsalgia, fracture, third right metatarsal, is caused by metatarsalgia, fracture, third right metatarsal? Please state upon what facts and medical principles you base the opinion. (4) If the answer to (3) is negative, is it at least as likely as not (50 percent probability or higher) that the right foot disability, other than metatarsalgia, fracture, third right metatarsal, is aggravated by metatarsalgia, fracture, third right metatarsal? (This is a separate question from (3).) Please state upon what facts and medical principles you base the opinion. (5) If the examiner finds that metatarsalgia, fracture, third right metatarsal aggravates the Veteran’s separate right foot disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the right foot disability (other than metatarsalgia, fracture, third right metatarsal) prior to aggravation. If the examiner is unable to establish a baseline for the right foot disability prior to the aggravation, he or she should state such and explain why a baseline cannot be determined. A full rationale must be provided for all medical opinions given. If the examiner is unable to provide an opinion without resorting to mere speculation, he or she should explain why this is so. The examiner shall then explain whether the inability to provide a more definitive opinion is the result of a need for more information and indicate what additional evidence is necessary, or whether he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question(s). A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Griffin, 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.