Citation Nr: 21015896 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 12-29 753 DATE: March 18, 2021 ORDER Service connection for arthritis of the bilateral feet is granted. REMANDED The claim of entitlement to service connection for a gastrointestinal disability is remanded. The claim of entitlement to service connection for hypertension is remanded. FINDING OF FACT The Veteran’s degenerative changes of the first metatarsophalangeal joints is related to his service-connected bilateral flat feet. CONCLUSION OF LAW The criteria to establish service connection for arthritis of the bilateral feet have been met. 38 C.F.R. § 3.310(a). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection for arthritis of the bilateral feet To establish a right to compensation for a present disability, a Veteran must show: "(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"-the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). This includes any increase in disability (aggravation) that is proximately due to or the result of a service-connected disease or injury. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either caused or aggravated by a service-connected disease or injury. Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). The Veteran had active service from July 1976 to February 1985. In July 2018, the Board reopened the Veteran’s claim of entitlement to service connection for bilateral foot arthritis, which had been previously denied by the Agency of Original Jurisdiction (AOJ) in January 2007. The claim was remanded for development of the record. It was again remanded in November 2020. In the November 2020 remand, the Board pointed out that VA medical records established a diagnosis of degenerative arthritis in the bilateral first metatarsophalangeal joints (MTP) throughout the pendency of the appeal. See May 2007 VA foot X-ray reports, May 2007 VA examination report, April 2011 VA podiatry consultation, and January 2019 VA X-ray reports. The Board noted that a March 2020 contract examiner’s finding of no arthritis of either foot conflicted with the record. Regarding the May 2007 VA examination report, the examiner at that time indicated that the degenerative changes of the first MTP joints was associated with the Veteran’s flat feet. Notably, the Veteran is in receipt of service connection for bilateral flat feet. Considering the 2007 examiner’s determination that the Veteran’s first MTP joint degenerative changes are related to his service-connected flat feet, the Board concludes that service connection for this claimed disability is warranted. REASONS FOR REMAND Service connection for a gastrointestinal disability The Veteran seeks service connection for a gastrointestinal disability as secondary to his service-connected disabilities or the medication used to treat them. In the July 2018 remand, the Board pointed out that a September 2012 VA examiner did not address the Veteran’s reports of continuous symptoms of gastritis since service in making a determination that the claimed disability was not related to service. Moreover, the Board indicated that the examiner did not provide an opinion regarding whether the Veteran’s gastritis was caused or aggravated by his use of pain medication for his service-connected disabilities. In March 2020, a VA examiner determined that gastritis was not related to service, reasoning that there was no record of a gastric condition during service. He also determined that gastritis was not proximately due to or the result of a service-connected disability, reasoning that “Current rationale and current medical literature do not support that bilateral pes planus, a gastric condition, tinnitus or bilateral hearing loss cause hypertension.” In November 2020, the same examiner reviewed the record and determined that gastritis was not proximately due to or the result of a service-connected condition. He reasoned that the Veteran’s gastritis was as likely as not multifactorial, including genetics. He stated that “current literature and current rationale” did not support that his service-connected disabilities, to include pain medications, caused his gastritis. He also stated that “current literature and current rationale” did not support that his service-connected disabilities, to include pain medications, aggravated gastritis beyond natural progression. Unfortunately, the conclusory statements provided by the examiner do not adequately provide the underlying medical principles for his determinations. Thus, the Board is unable to reach a decision regarding this claim. An additional examination is necessary. Service connection for hypertension In July 2018, the Board remanded this issue to afford the Veteran an examination to determine the etiology of his hypertension. In March 2020, a VA examiner determined that hypertension was not related to service, reasoning that there was no documentation of elevated blood pressure during active duty. He also determined that hypertension was not related to a service-connected disability, reasoning that “Current rationale and current medical literature do not support that any of the bilateral pes planus, hypertension, tinnitus or bilateral hearing loss cause a gastric condition/gastritis.” In December 2020, the same examiner reviewed the record and stated that “No current good studies, rationale or records conclude that the Veteran’s hypertension is at least as likely as not caused by his service connected lumbar spine, bilateral lower extremity, psychiatric or sleep apnea disabilities.” As discussed above, the Board is unable to reach a determination absent a discussion of the medical principles underlying the examiner’s conclusions. An additional examination is necessary. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination, by an examiner who has not previously examined him, to determine the nature and etiology of his gastrointestinal disability. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. After the record review and examination of the Veteran, the examiner should provide an opinion regarding whether it is at least as likely as not that the Veteran’s gastrointestinal disability was incurred in, or is otherwise related to active service. In considering this question, the examiner should consider the Veteran’s report that he has experienced gastrointestinal symptoms since service. The examiner should also provide an opinion with respect to whether it is at least as likely as not that the Veteran’s gastrointestinal disability was caused or aggravated (worsened beyond normal progression) by the Veteran’s service-connected disabilities or the medication prescribed to treat them. In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran’s lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must 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. 2. Schedule the Veteran for an examination, by an examiner who has not previously examined him, to determine the nature and etiology of his hypertension. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. After the record review and examination of the Veteran, the examiner should provide an opinion regarding whether it is at least as likely as not that the Veteran’s hypertension was incurred in, or is otherwise related to, active service. The examiner should also provide an opinion with respect to whether it is at least as likely as not that the Veteran’s hypertension was caused or aggravated (worsened beyond normal progression) by the Veteran’s service-connected disabilities, to include the medications prescribed to treat them. In rendering these opinions, the examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran’s lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must 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. 3. Then, readjudicate the Veteran’s claims, with application of all appropriate laws, regulations, and case law, and consideration of any additional information obtained as a result of this remand. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case (SSOC) and afforded an appropriate period within which to respond thereto. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Barone, 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.