Citation Nr: 21015701 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-01 680 DATE: March 18, 2021 REMANDED Entitlement to service connection for left foot condition to include status post left heel fracture secondary to the service-connected chondromalacia of the left knee is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1982 to August 1984. In September 2018 and July 2020, the Board remanded the case for further development. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for left foot condition Once VA undertakes the effort to provide an examination, it must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). This case was remanded as the medical opinions of record did not adequately address the theory of aggravation. An opinion obtained in July 2020 concluded that there is no literature to support that left knee condition caused left calcaneal fracture or pes planus. The examiner stated that remand instructions and lay statements were reviewed and there was no altered weight bearing or gait seen to support left foot conditions and no information found to support that left foot was aggravated beyond its natural progression. The Board finds this opinion inadequate for adjudication. A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). In this case the examiner only provided conclusions. An opinion must go beyond a generalized statement that literature does not support the Veteran’s claim and must reflect the specific facts and medical principles specific to the Veteran’s claim. As such, a remand is necessary to obtain a medical opinion that properly addresses aggravation. The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Acquire updated VA and/or private treatment records. If such records are unavailable, the Veteran’s claim file must be clearly documented to that effect and the Veteran notified in accordance with 38 C.F.R. § 3.159(e). 3. Obtain an addendum medical opinion from a medical professional with appropriate expertise. The examiner should review the Veteran’s claims file. If the examiner determines that an opinion cannot be provided without an examination, the Veteran should be scheduled for one. Based on a review of the record, and a new examination if necessary, the examiner must identify all diagnoses pertaining to the left foot during the appeal period and for all relevant diagnoses address the following: (a.) Is it at least as likely as not (i.e., probability of 50 percent or higher) that the Veteran’s left heel condition, to include pes planus and left calcaneus fracture is proximately due to or the result of the Veteran’s service-connected left knee condition? (b.) If the answer to (a) is negative, is it at least as likely as not that the Veteran’s left heel condition, to include pes planus and left calcaneus fracture is aggravated (i.e., permanently or temporarily worsened) by service-connected left knee condition? (c.) If aggravation is found, the examiner should address the following medical issues: 1) the baseline manifestations of the disorder found prior to aggravation; and 2) the increased manifestations which, in the examiner's opinion, are proximately due to the service-connected disorder. The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it. In all opinions rendered, the examiner is advised that the Veteran is competent to report his symptoms and treatment history. The examiner should consider whether altered weight bearing or gait due to the service-connected knee condition caused progression of the left foot problems. The examiner must address the lay statements reporting that falls due to the service-connected knee aggravated his left foot conditions and the medical records indicating calcaneal fracture secondary to knee instability. If there is a medical basis to doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The opinion and rationale must go beyond a generalized statement that a review of medical literature does not support the Veteran’s claim. The rationale should reflect the specific facts and medical principles specific to the Veteran’s claim and any medical literature relied upon should include a citation. A complete rationale containing clear conclusions with supporting data and a reasoned medical explanation connecting the two is required for all medical opinions. The examiner should also identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). (Continued on the next page)   If the medical professional cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation for why an opinion cannot be rendered. In so doing, the medical professional shall explain whether the 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(s). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. A. Prinsen 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.