Citation Nr: 21026225 Decision Date: 04/30/21 Archive Date: 04/30/21 DOCKET NO. 17-15 584 DATE: April 30, 2021 REMANDED Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for acid reflux is remanded. Entitlement to service connection for a neck disability is remanded. Entitlement to service connection for a heart disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1996 to April 2000. She also had additional Reserve service. In December 2018, the case was remanded by the Board of Veterans’ Appeals for additional development. The Veteran had also initiated an appeal of the denial of an initial rating in excess of 30 percent for migraine headaches. Following the Board’s December 2018 remand of this issue, an August 2020 rating decision granted a 50 percent rating for migraine headaches, effective September 5, 2012 (i.e., the date VA received the Veteran’s original claim for service connection for such disability). Because that award represented a total grant of benefits sought on appeal for the entire period of claim (as 50 percent is the maximum schedular rating for migraine headaches under Diagnostic Code 8100), this matter is no longer on appeal and is not before the Board. 1. Entitlement to service connection for a right foot disability. The Veteran contends that she currently has a right foot disability which began during her active duty service and continued to the present. The Veteran’s service treatment records (STRs) document the following pertinent findings. At her December 1995 Army enlistment examination, it was noted that she had mild pes planus. In October 1996 and November 1996, she was treated for a contusion of her right great toe and a right hallux nail subungual hematoma. In September 1997, she was treated for an injury to her right foot after hitting her right foot on a dresser. Contemporaneous x-rays of her right foot in September 1997 showed mild hallux valgus but were otherwise not remarkable, and she was assessed with a right foot contusion. Post-service, the Veteran has asserted on multiple occasions (including in a May 2013 written submission, in her October 2013 notice of disagreement, and on her March 2017 VA Form 9) that after injuring her right foot on active duty, she continued to have residual pain and effects from that injury through to the present day. Pursuant to the Board’s December 2018 remand, the Veteran underwent a VA foot examination in October 2019. At that examination, she was diagnosed with bilateral pes planus (with the date of diagnosis noted to be the date of the current October 2019 examination), right hallux valgus (with the date of diagnosis noted to be 1997), and right plantar fasciitis (with the date of diagnosis noted to be the date of the current October 2019 examination). The Veteran reported that her condition started in 1997 from running and physical training and that she had pain in her right foot while running. She also stated that her foot continued to cause pain and to swell and that she treated these symptoms with Motrin, elevation, and ice. Contemporaneous x-rays of her right foot in October 2019 were negative and showed no fracture or degenerative joint disease. In an October 2019 addendum, the October 2019 VA foot examiner opined that the Veteran’s claimed right foot condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. For rationale, the VA examiner noted that the Veteran was evaluated for right foot pain in 1997 (i.e., during active duty) and that x-rays at that time showed mild hallux valgus but were otherwise normal. The VA examiner also noted that there was no evidence available for review that the Veteran continued to be seen for her foot pain to show chronicity of care. The VA examiner therefore concluded that there was no evidence in a review of the medical records to show that the Veteran’s right foot conditions were etiologically related to service, and further concluded that no nexus could be found. However, the Board notes that while this medical opinion considered the pertinent September 1997 STRs as outlined above, such opinion did not consider or address the other pertinent STRs of record (including the December 1995 enlistment examination noting mild pes planus and the October 1996 and November 1996 STRs documenting treatment for a contusion of her right great toe and a right hallux nail subungual hematoma). The Board also notes that this opinion did not consider or address the Veteran’s allegations of continuity of her right foot symptoms ever since her active duty service and her self-treatment for such ongoing symptoms. On remand, after any outstanding treatment records have been associated with the claims file, an addendum opinion is needed in order to adequately address the above-noted deficiencies regarding the etiology of each current right foot disability. 2. Entitlement to service connection for acid reflux. 3. Entitlement to service connection for a neck disability. 4. Entitlement to service connection for a heart disability. The Veteran contends that she currently has acid reflux, a neck disability, and a heart disability which each began during her Reserve service and continued to the present. The Veteran’s Reserve STRs document the following pertinent findings. In September 2008, she sought emergency medical treatment for chest pain and was treated for gastroesophageal reflux disease (GERD) at that time. In April 2011, it was noted that she was taking medication for heartburn. In August 2011, she reported having heartburn frequently, including at night in bed and after meals. After reporting neck pain, neck muscle tightness, neck stiffness, and muscle spasms in the neck in August 2011, a cervical spine MRI without contrast in September 2011 revealed a tiny focal syrinx cavity at the T1 level of uncertain etiology and clinical significance, and a follow-up cervical spine MRI with and without contrast in October 2011 revealed hydrosyringomyelia on the spinal cord and reverse lordosis of the cervical spine. In January 2012, she was treated for chest pain which was thereafter diagnosed by a private provider in January 2012 as non-ST segment elevation myocardial infarction (NSTEMI), demand type secondary to AV-nodal reentrant tachycardia (AVNRT). The Board’s December 2018 remand instructed the Agency of Original Jurisdiction (AOJ) to verify through official sources the specific periods of active duty for training (ACDUTRA) and inactive duty training (INACDUTRA) performed by the Veteran while serving in the Army Reserve. The AOJ obtained service personnel records for the Veteran in September 2019 which document that the Veteran enlisted in the Army Reserve in December 1995, then served on active duty in the Army from June 1996 to April 2000, and then served again in the Army Reserve until December 2003 as well as from November 2007 to November 2013. However, the service personnel records obtained do not include documented verification of the specific periods of ACDUTRA and INACDUTRA performed by the Veteran during her Reserve service. Such verification is necessary in order for the Board to determine the Veteran’s duty status at the time of each above-referenced pertinent treatment note documented in her Reserve STRs prior to adjudicating the claims for service connection for her currently claimed acid reflux, neck disability, and heart disability. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (where the remand orders of the Board are not complied with, the Board errs as a matter of law when it fails to ensure compliance). The matters are REMANDED for the following actions: 1. Verify through official sources the specific periods of ACDUTRA and INACDUTRA performed by the Veteran while serving in the Army Reserve. 2. Ask the Veteran to complete a VA Form 21-4142 for all private providers who have treated her for her claimed disabilities on appeal at any time during the appeal period. Make two requests for the authorized records from each identified provider, unless it is clear after the first request that a second request would be futile. 3. Obtain any VA treatment records for the Veteran for the period from March 2021 to the present. 4. After all requested records have been associated with the claims file, obtain an addendum opinion from an appropriate clinician, after review of the electronic claims file, as to whether it is at least as likely as not that any right foot disability diagnosed at any time during the period of the current claim (including the diagnoses of right foot pes planus, right foot hallux valgus, and right foot plantar fasciitis rendered at the October 2019 VA foot examination) was either incurred in or aggravated during the Veteran’s active duty service or is otherwise related to any incident of her military service (with specific consideration given to all pertinent STRs as well as her allegations of continuous right foot symptoms since her active duty service and her self-treatment for such ongoing symptoms). (Continued on the next page)   If the clinician determines that an examination is necessary to respond to the above question, then the Veteran should be scheduled for such (or a telehealth interview if an in-person examination is not feasible). A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular clinician. DUSTIN L. WARE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. B. Yantz, Counsel The Board’s decision in this case is binding only with respect to the instant matter(s) decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.