Citation Nr: 21012288 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 14-31 517A DATE: March 4, 2021 REMANDED Entitlement to service connection for flatfeet is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1975 to February 1995, which included service in support of Operation Desert Shield/Storm from August 1990 to February 1995. In February 2015 and July 2016, the Veteran testified at Decision Review Officer hearings at the Agency of Original Jurisdiction (AOJ). He testified at a Board video conference hearing in April 2018. The Board remanded this case for additional development in June 2018 and August 2020. For the reasons described below, unfortunately, the case must be remanded again. 1. Entitlement to service connection for flatfeet is remanded. The prior Board remands have requested that a medical opinion be provided as to the likelihood that the Veteran’s flatfoot is either related to his military service, with consideration of his complaints of foot pain since service; or secondary to (meaning either caused or aggravated by) his service-connected left ankle disability. Supplemental medical opinions were provided in August 2020 and October 2020 but there is still insufficient rationale provided. It also does not appear that the examiner is considering all of the relevant information. In November 2020 the Veteran stated that when he joined the Air Force, he had normal feet. He noted that during basic training he marched on concrete slabs every day in combat boots. He further noted that in 1984 he injured his left ankle and could not perform any physical activities involving the use of his foot for several months. He noted that by not being able to put weight on his left ankle that he had to overuse his right foot when walking and standing. He noted that in 1989 the ankle pain returned, and he had to see a doctor again and was given an air splint. He further indicated that in 1990 he was provided with shoe inserts for foot pain. He stated that part of his service treatment records was missing due to the type of ink being used and time had faded it out so that it could not be read. He stated that even though his November 1994 retirement examination did not reflect any ankle disability, he was noted as having swollen and painful joints. He stated that the physician who examined his records should have commented on this. The Veteran’s representative also submitted an informal hearing presentation in November 2020 that during the Veteran’s 20 years in the Air Force he had to wear combat boots that were more likely as not poor fitting. His representative further noted that a medical provider on January 11, 2012 had noted the complaints of calluses and heel pain and noted that the good majority of the pain could be relative to remodeling secondary to a long history of pes planus and improper footwear. The Veteran’s representative also cited to a Mayo Clinic article, which noted that injury to foot or ankle increased one’s risk of flatfeet. https://www.mayoclinic.org/diseases-conditions/flatfeet/symptoms-causes/syc-20372604. It was noted that the Veteran had complaints of heel and ankle pain in military service and that therefore his symptoms began in military service. It was further noted that the Veteran contended that he has continued to have pain since military service that progressed to the point that he had to seek medical treatment was diagnosed with bilateral pes planus. The Veteran’s representative noted that despite the VA examiner referring to the March 2010 and January 2012 VA treatment records, the examiner failed to address the medical provider’s statement referring to his pes planus as a “long history of” and poor footwear but instead merely wrote it as a finding or fact. The representative further argued that the examiner did not provide an explanation for the opinion but instead simply concluded that flatfeet and sprained ankle are separate entities. The Board had previously remanded the case because the prior examiner had provided conclusory statements without adequate rationale. The August 2020 VA examination report notes that the Veteran’s flatfeet was less likely than not incurred in or caused by service because there was no record of flatfeet in service; and the entrance examination stated that the Veteran had normal feet and arches on admission to the military. The examiner also noted that there was no objective evidence of symptoms of flatfeet on active duty. The examiner further found that the flatfoot condition was not due to or the result of the left sprained ankle as a nexus had not been established. It was noted that flatfeet and a sprained left ankle are not medically related. Flatfeet disability is a separate entity entirely from a sprained ankle and unrelated. The examiner further noted that a review of medical literature failed to demonstrate a cause relationship. A supplemental opinion was provided in October 2020 noting the findings in March 2010 and January 2012. The examiner found that the claimed flatfeet was less likely than not aggravated beyond its natural progression by the Veteran’s left ankle disability. It was noted that the claimed disorder was a separate entity entirely from the service-connected condition and unrelated to it. The examiner also noted that it was 15 years after service when the Veteran started having foot pain. The medical opinions provided are still relatively conclusory in that the rationale for the flatfoot not being related to service is that there was no medical evidence in service; and the rationale for the flatfoot not being secondary to the left ankle disability is that flatfeet and sprained ankles are separate entities. The Veteran is not stating that he was treated for pes planus in service but rather that he started having foot pain in service from ill-fitting boots. There is at least some evidence suggesting that his pes planus is related to wearing ill-fitting shoes. See, e.g., January 2012 treatment record. The Veteran also submitted a Mayo Clinic article noting that a risk factor to developing pes planus includes ankle injuries. He is further arguing that overuse of his right foot due to his left ankle injury caused the pes planus. Another medical opinion is necessary to resolve this claim with full consideration of the contentions being made by the Veteran and with special consideration of the treatment records dated in March 2010 and January 2012 suggesting that the Veteran’s pes planus is related to wearing ill-fitting boots. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s flatfeet condition is at least as likely as not related to his military service or proximately due or aggravated beyond its natural progression by his service-connected left ankle disability. A rationale must be provided for all opinions; and the Veteran’s complete medical history must be reviewed, including the following: (a.) A March 23, 2010 Naval Health Clinic treatment record notes a pes planus deformity, with complaints of left heel and foot pain for five weeks. (b.) A January 11, 2012 Naval Health Clinic treatment record notes moderate to severe bilateral pes planus. It was noted that a good part of his pain could be relative to remodeling secondary to a long history of pes planus and improper footwear. (c.) An internet article from the Mayo Clinic article lists injury to foot or ankle as a risk factor for developing pes planus. https://www.mayoclinic.org/diseases-conditions/flatfeet/symptoms-causes/syc-20372604. (d.) The Veteran has submitted competent statements that he has experienced foot pain since service from wearing ill-fitting combat foots on hard surfaces; and also, that he had to overcompensate for left ankle injury resulting in pain in the feet. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sarah B. Richmond, 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.