Citation Nr: 21014538 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 17-64 791 DATE: March 12, 2021 ORDER Service connection for a right ankle sprain is granted. Service connection for plantar fasciitis is granted. REMANDED Service connection for ulcers. FINDINGS OF FACT 1. Resolving doubt in the Veteran’s favor, the Veteran’s right ankle disability is related to her active service. 2. Resolving doubt in the Veteran’s favor, the Veteran’s plantar fasciitis is related to her active service. CONCLUSIONS OF LAW 1. The criteria for service connection for a right ankle sprain are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for service connection for plantar fasciitis are met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from April 2006 to June 2013. These matters come before the Board of Veterans’ Appeals (Board) from a March 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In May 2020, the Board remanded the matters on appeal in addition to the issues of service connection for psychiatric disability, esophageal reflux disability, irritable bowel syndrome (IBS), insomnia, and cystic acne, for additional development. On remand, the RO granted service connection for major depressive disorder (claimed as adjustment disorder with depressed mood and insomnia), IBS with gastroesophageal reflux disease (GERD), and cystic acne with scarring. Because the benefits claimed have been granted in full, they are no longer on appeal. Service Connection Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection on a direct basis, the record must contain competent evidence of: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for a right ankle disability Service connection for plantar fasciitis The October 2020 VA examination reports reflect diagnoses of right ankle sprain and plantar fasciitis. Thus, current disabilities have been demonstrated. As to in-service injuries or diseases, service medical treatment records show several assessments of plantar fasciitis. A July 2012 service treatment record noted that the Veteran had tenderness on palpation of her foot. She was assessed with plantar fasciitis. A May 2006 service treatment record shows that the Veteran had an inversion sprain of the right ankle. The record indicated that the Veteran had pain, took Motrin, the joint was swollen or red, there was trauma to the joint in the past 72 hours, and obvious deformities. On examination, there was tenderness to palpation and abnormal ambulation. The separation report of examination does not reflect notations concerning the right ankle or plantar fasciitis. In April 2020 correspondence, the Veteran reported that her right ankle never healed properly after her sprain in 2006. She stated that she experienced chronic symptoms such as pain with movement and popping. In addition, she reported that she was seen in 2012 for plantar fasciitis and given inserts. The Veteran indicated that her boots caused the condition as her arches began to break down at that time and she continued to experience disabling symptoms and pain. In October 2020, the Veteran was provided VA examinations for her ankle and feet. The October 2020 VA examination report for the ankle shows that the Veteran reported that she was injured during basic training and that her ankle never healed properly. She stated that she was seen in Korea in 2013 or 2014 but had been self-managing since that time. The Veteran reported that her symptoms progressively worsened with pain, swelling, and decreased range of motion. The examiner provided a negative etiological opinion, explaining that while the Veteran was seen for her right ankle in 2006, there was no documentation of continued care and treatment. There was a 14-year gap and the examiner was unable to confirm that the Veteran’s current right ankle sprain was related to her injury during service. The separation report noted no problem and there was no chronicity of care. The October 2020 VA examination report specific to plantar fasciitis shows the Veteran’s report that her pain started during active service. She stated that she was seen in Korea and prescribed orthotics. She stated that her disability worsened since its onset with constant pain. The Veteran explained that she had to buy expensive shoes and wore tennis shoes to work. The examiner provided a negative etiological opinion, noting that while the Veteran was seen for plantar fasciitis during service, there was no documentation to show continued care and treatment. The examiner noted a 7-year gap in treatment and a normal separation examination in 2013. Here, the Board acknowledges that the VA examiner provided negative etiological opinions. However, the examiner appears to discount the Veteran’s statements as to her chronic pain and her report that she self-managed her symptoms. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 n.1 (Fed. Cir. 2006); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (both finding medical opinions inadequate due to the examiner’s reliance solely on the absence of objective documentation without consideration of a claimant’s lay statements). Notably, the examiner calculated “gaps” between treatment in service and the date of the examination, ignoring the fact that the Veteran clearly reported the existence of these disabilities when filing her October 2015 claim and continuously pursuing an appeal since. She either demonstrated remarkable foresight that she would develop new unrelated disabilities, or the same disabilities were chronic and present throughout. The Board finds the Veteran competent and credible to report her chronic ankle and foot pain since her in-service assessments of right ankle sprain and plantar fasciitis. See Jandreau v. Nicholson, 492 F.3d. 1372, 1376 (Fed. Cir. 2007); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (“A lay witness may testify as to his or her observations of the features or symptoms that a claimant exhibited.”). Accordingly, the Board will resolve doubt in the Veteran’s favor as to whether her current right ankle sprain and plantar fasciitis are related to service. Service connection for right ankle disability and plantar fasciitis is granted. REASONS FOR REMAND Service connection for ulcers The October 2020 VA examiner provided a negative etiological opinion concerning ulcers, noting that there was no current pathology and a review of the claims file was silent for ulcers. However, review of the Veteran’s private treatment records in 2017 through 2019 indicates a history of a gastric ulcer diagnosis. The opinion’s failure to address these records renders it inadequate. Furthermore, regardless of whether ulcers are currently present on physical examination, an opinion is required if a condition is present during the appeal period and a new opinion must be obtained. See McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Given that the Veteran has indicated that her ulcers are related to her service-connected GERD, an opinion as to service connection on a secondary basis should also be obtained. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record. 2. Obtain an addendum opinion from the October 2020 VA examiner; or, if unavailable, another suitably qualified examiner, as to the etiology of the Veteran’s ulcers. The claims file must be made available for review. The examiner should offer opinions as to whether it is at least as likely as not (50 percent probability or higher) that (a) the Veteran’s ulcers are related to active service, and (b) the Veteran’s ulcers are caused or aggravated by her service-connected GERD. In so doing, the examiner should address the private treatment records noting a history of gastric ulcers. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. After completing the above, and any other development deemed necessary, readjudicate the appeal. If any benefit sought remains denied, return the appeal to the Board. J. GALLAGHER Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Seay, 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.