Citation Nr: 21011385 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 16-53 347 DATE: March 1, 2021 REMANDED Entitlement to service connection for a headache disability is remanded. Entitlement to service connection for bilateral plantar fasciitis is remanded. REASONS FOR REMAND The Veteran, who is the appellant in this case, served on active duty from August 1990 to July 1994. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Headaches The Veteran seeks service connection for a headache disability. She is currently diagnosed with tension and migraine headaches. See VA Headaches Disability Benefits Questionnaire dated December 23, 2019. The Veteran’s service treatment records (STRs) reference two complaints of headaches. In October 1990, the Veteran complained of a right-sided headache; in March 1993, the Veteran complained of a sinus and frontal headache. See Chronological Record of Medical Care dated October 31, 1990, March 24, 1993. Migraine headaches were not diagnosed. After service, she reported in August 2014 that she had a very “slight” and “dull” headache in the bilateral temple area. See VA Treatment Record, dated August 13, 2014. In August 2015, she reported a history of daily headaches, occasional vertigo, fatigue and joint pain, and had been extensively evaluated by a rheumatologist. See VA Treatment Record, dated August 26, 2015. The Veteran was provided a VA compensation examination in December 2015 during which she was diagnosed with tension headaches, but not migraines. An opinion was not provided by the examiner regarding any relationship between the Veteran’s current headache disability and service. See VA Headaches Disability Benefits Questionnaire, dated December 1, 2015. In March 2016, the Veteran reported ongoing headaches, described as “a low dose that won’t go away, day in and day out,” which were located across the forward and temple area, and endorsed photophobia associated with the headaches. See VA Treatment Record, dated March 15, 2016. An addendum was obtained in April 2016. The examiner found the Veteran’s tension headache disability is a diagnosable chronic multisystem illness with a partially explained etiology due to precipitants of tension headaches, but is less likely as not related to service in Southwest Asia. The examiner noted the Veteran was seen for chronic myofascial pain and chronic neck pain and had significant improvement with trigger point injections. The examiner stated the pathogenesis of tension headaches is multifactorial, but the precise mechanisms are uncertain, and environment factors influenced the development of episodic tension headaches more than chronic tension headaches, while genetic factors appear to play a role in development of chronic tension headaches. Additionally, stress and mental tension were reported the most common precipitants for tension headaches, with neck and cervical muscle tenderness being common and prominent symptoms of primary headache disorders. See VA Medical Opinion Addendum, dated April 19, 2016. In a July 2016 statement, the Veteran’s spouse stated that, in 2014, the Veteran started to complain of headaches and that she continues to suffer from them. See Statement in Support of Claim, dated July 21, 2016. In August 2019, the Veteran testified in a hearing before the undersigned VLJ that she did not have headaches during service, but her headaches began after service, and that she realized when she was tense and her fibromyalgia flared up, she would experience a migraine. She also stated that prior to her fibromyalgia diagnosis, her headaches were ongoing. See Hearing Transcript dated August 19, 2010, page 22. In September 2019, the Veteran reported having migraines which last about a day, and that occurred about twice per month. See VA Treatment Record, dated September 24, 2019. A December 2019 VA examiner opined that there was no nexus between the Veteran’s military service and her current headache disability given the silence of symptoms for over 25 years. The examiner also noted that for the past year her headaches had migrainous features. See VA Headache Disability Questionnaire and medical opinion dated December 23, 2019. However, the December 2019 VA opinion is inadequate to the extent that the examiner indicated that the Veteran had no headache symptoms until 2014; the Veteran testified that she had ongoing headaches prior to her diagnosis of fibromyalgia, and that they became worse in 2014. In addition, this examiner and the 2016 VA examiner did not address the headaches assessments noted in the Veteran’s STRs and did not address whether the environmental exposures during service in Southwest Asia contributed to the Veteran’s headaches. Her MOS was a petroleum supply specialist. See also, December 2019 VA opinion regarding service connection secondary to fibromyalgia; July 2020 addendum addressing the question of service connection secondary to MDD. For these reasons, the claim must be remanded for another medical opinion prior to adjudicating the headache claim on the merits. Plantar Fasciitis The Veteran asserts that he developed plantar fasciitis as a result of service in Southwest Asia. She stated that the disability resulted from wearing boots and carrying heavy rucksacks on long marches and for extended standing times. She indicated that she the painful feet began in service, and continued until it became unbearable in 2014, at which time she sought treatment. In December 2019, the Veteran was provided a VA compensation examination. The examiner opined that the Veteran’s plantar fasciitis was less likely as not related to service or to a service-connected disability. The examiner found the Veteran developed plantar fasciitis in 2014 due to bone spurs and did not have any foot complaints in service. The examiner concluded that the Veteran’s foot disability was less likely as not due to military service given the fact that she separated in 1994 and was not symptomatic until 2014. Concerning secondary service connection, the examiner stated fibromyalgia does not cause heel spurs which are the cause of her plantar fasciitis and fibromyalgia does not aggravate plantar fasciitis. A July 2020 addendum similarly found that the Veteran’s plantar fasciitis was not related to service. In regard to the Veteran’s lay statements, the examiner stated the Veteran did not seek medical attention in service or within a reasonable amount of time from separating from service. In regard to plantar fasciitis as secondary to fibromyalgia, the examiner stated that the etiology of the plantar fasciitis was her heel spurs, that her treatment records were silent for aggravation of her feet pain due to fibromyalgia, and that she declined injections or additional treatment for her plantar fasciitis which indicated the fibromyalgia was not aggravating her plantar fasciitis. The Board finds that the VA foot opinions inadequate. First, the addendum opinion is based on incorrect information. The examiner stated the Veteran had no complaints related to her feet in service, yet, a STR shows that on October 31, 1990, the Veteran complained of pain from the ball of her feet to the heel. Second, the examiner stated that if the Veteran’s plantar fasciitis was aggravated by her fibromyalgia she would likely not decline additional treatment for feet, including injections. On review however, the Board finds that the Veteran has sought and received several different types of foot treatment including platelet-rich plasma (PRP) therapy, prolotherapy, and physical therapy. Therefore, the opinion is based on inaccurate factual premises. Furthermore, the examiner did not address the Veteran’s competent and credible lay statements of having foot pain after wearing boots and carrying a rucksack on long marches. For these reasons, the claim must be remanded for another medical opinion prior to adjudicating the claim on the merits. The matters are REMANDED for the following action: 1. Ensure all outstanding VA treatment records are associated with the file. 2. Obtain another VA medical opinion as to the etiology of the Veteran’s diagnosed headache disability. The entire claims file, including a copy of this remand, should be made available to, and reviewed by, the examiner. After a complete review of the record, the examiner is asked to provide the following opinions: a). Are the Veteran’s diagnosed tension and migraine headaches at least as likely as not (50 percent probability or greater) related to or caused by her military service, including in Southwest Asia? **Reconcile the opinion with (i) the service treatment records showing headache complaints, (ii) the Veteran’s MOS as a petroleum supply specialist, (iii) the reported exposures to chemicals and burning feces during service (see August 2015 statement and October 2016 VA ear exam report), and (iv) the Veteran’s lay reports of having developed ongoing headaches after service. b). Are the Veteran’s tension and migraine headaches at least as likely as not (50 percent probability or greater) proximately due to, or aggravated by the service-connected fibromyalgia and/or MDD? The Veteran testified that she had ongoing headaches prior to the fibromyalgia diagnosis. The VA examiner must provide a detailed rationale for all opinions rendered. 3. Obtain another VA medical opinion as to the etiology of the Veteran’s diagnosed plantar fasciitis. The entire claims file, including a copy of this remand, should be made available to, and reviewed by, the examiner. After a complete review of the record, the examiner is asked to provide the following opinions: a). Is the Veteran’s diagnosed plantar fasciitis at least as likely as not (50 percent probability or greater) related to or caused by her military service, to include the October 1990 treatment? * In doing so, address the Veteran’s statements of first noticing foot problems two to three years into her period of service, and while deployed in Saudi Arabia where she spent extensive time on her feet and working in the sand. She also reports painful feet while walking and marching on airfields when serving in the United States. b). Is the Veteran’s diagnosed bilateral plantar fasciitis at least as likely as not (50 percent probability or greater) proximately due to, caused by, or aggravated by the service-connected fibromyalgia? Attention is called to the various foot therapies the Veteran has received. The VA examiner must provide a detailed rationale for all opinions rendered. 3. Then, readjudicate the remanded issues on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Moldawer, 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.