Citation Nr: 21014396 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 19-31 688 DATE: March 12, 2021 REMANDED Entitlement to service connection for a bilateral foot disorder, claimed as gout, is remanded. REASONS FOR REMAND The Veteran was inducted into active duty service in November 1967 and served until November 1969. This case originally came before the Board of Veterans’ Appeals (Board) on appeal from a July 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The claim was last before the Board in February 2020. The Veteran did not request a hearing before the Board. See October 2019 VA Form 9. 1. Entitlement to service connection for a bilateral foot disorder is remanded. A VA addendum is required in order to more fully evaluate and address the nature and etiology of the Veteran’s claimed bilateral foot disorder. The Veteran contends that his bilateral foot disorder is related to his time in Germany at which time his feet got cold and his toenail turned black. See March 2019 Notice of Disagreement (NOD). Although the Veteran was provided VA examinations in February 2020 and November 2020, the VA examiners based their negative opinions on a lack of record of foot complaints in service and/or a lack of evidence of chronicity or continuation of symptoms. However, the Veteran has consistently contended that his current bilateral foot disorder is related to his time in Germany when his feet got cold and his toenail turned black. The Board notes that the Veteran is competent to report in-service symptoms and events, whether or not they are documented in service treatment records (STRs). Therefore, the examiners’ rationale is not adequate. In this regard, a medical opinion is inadequate if it is based solely on the absence of documentation in the record and does not take into account the Veteran’s reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). In other words, the absence of treatment or symptoms in service is not necessarily fatal to the claims for service connection. Additionally, the Veteran reported an initial manifestation of tingling and numbness in the feet with black toenails, which continued and now included swollen feet. See February 2020 VA feet examination report. However, the examiners did not address the Veteran’s suggestion of continuing symptoms, but rather based the negative December 2020 opinions on there being no evidence of chronicity or continuation of symptoms. Furthermore, although the November 2020 VA cold injury residuals examination report reflects a diagnosis of frostbite with current symptoms including arthralgia or other pain, numbness, and color changes, the examiner did not address whether the Veteran’s current symptoms and/or other bilateral foot disorders were residuals of the claimed in-service frostbite or cold injury. Although the Boar regrets the delay, another VA addendum is needed in order to more completely evaluate the nature and etiology of the Veteran’s bilateral foot disorder as it relates to service. The matter is REMANDED for the following action: 1. Obtain another VA addendum addressing the etiology of the Veteran’s claimed bilateral foot disorder. If the designated examiner determines that an additional examination is necessary, one should be provided to the Veteran. After reviewing the claims file in its entirety and examining the Veteran, if necessary and possible, the examiner is asked to address the following with complete rationale: For each diagnosis, including neuropathy, xerosis, gout, hammertoes, and acquired pes cavus (claw foot), provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) incurred in, caused by, aggravated by, or otherwise related to service. *The examiner should address the Veteran’s report of an in-service manifestation of symptoms including cold feet, numbness and tingling in the right great toe, and blackened toenail, as well as his report of the same current symptoms now with swelling. * A complete rationale should be given for any opinion rendered. Although a complete review of the record is imperative, attention is called to the following: *An April 2018 VA treatment record reflecting a complaint of numbness and tingling in the toes of both feet for 10 years, a report of developing cold toes while in Germany, working for utilities services where he wore steel-toed boots for long periods of time, and assessments of neuropathy and xerosis. *The March 2019 NOD in which the Veteran stated that he was stationed in Germany from 1967 to 1968 at which time his feet got cold and his toenail turned black with time, and that he noticed that his feet began to swell a lot with time. *A February 2020 VA skin examination report reflecting a diagnosis of bilateral feet xerosis, which began over time and first manifested with tingling in the right great toe. *A February 2020 VA feet examination report reflecting diagnoses of bilateral hammer toes and bilateral acquired pes cavus, which the Veteran contended began in Germany when his feet got cold and first manifested as numbness and tingling in the feet with black toenails, which now include swelling. *April 2020 negative opinions as to bilateral foot xerosis, bilateral foot neuropathy, and bilateral foot disorders. *A November 2020 VA foot examination report reflecting a diagnosis of bilateral gout and the Veteran’s report of terrible pain that took over his whole feet and body. *A November 2020 VA cold injury residuals examination report reflecting a diagnosis of frostbite, the Veteran’s description of exposure to cold and paresthesia in his feet, and current symptoms. *A November 2020 VA peripheral nerves examination report reflecting a diagnosis of a peripheral nerves condition. *December 2020 negative VA opinions based on a lack of evidence of chronicity or continuation of symptoms during service. 2. Thereafter, readjudicate the remanded claim on appeal. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Lee, 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.