Citation Nr: 21028761 Decision Date: 05/12/21 Archive Date: 05/12/21 DOCKET NO. 15-15 767 DATE: May 12, 2021 REMANDED Service connection for left foot hallux valgus, to include as secondary to a service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1972 to July 1979 and from August 1980 to May 1993. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In a December 2018 decision, the Board denied service connection for a left foot condition, to include osteoarthritis, hallux valgus, and plantar fasciitis, to include as secondary to a service-connected disability. Thereafter, the Veteran appealed such decision to the United States Court of Appeal for Veteran's Claims (Court) and, in November 2019, the Court issued a Joint Motion for Remand (JMR), which vacated the December 2018 Board decision and remanded the issue to the Board. In May 2020, the Board remanded the case for additional development. While on remand, a February 2021 rating decision granted service connection for left foot plantar fasciitis with pes planus and degenerative arthritis as secondary to a service-connected left knee meniscectomy. As such represents a full grant of the benefits sought with respect to such issue, it is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1159 (Fed. Cir. 1997). The remaining issue now returns for further appellate review. Entitlement to service connection for left foot hallux valgus, to include as secondary to a service-connected disability. The Veteran contends his left foot hallux valgus is the result of cellulitis infections that occurred during service or, in the alternative, is related to his service-connected knee disabilities. See June 2013 Statement and January 2015 VA examination. As an initial matter, the Board notes the record reflects a current diagnosis of left foot hallux valgus, as evidenced by a September 2013 x-ray. Furthermore, the Veteran is service-connected for left knee meniscectomy and right knee degenerative joint disease (DJD). In this regard, the Veteran's service treatment records (STRs) are silent for complaints, diagnosis, or treatment of left foot hallux valgus. However, May and June 1988 STRs reflect treatment for left foot cellulitis and in January 1992 the Veteran was diagnosed with cellulitis on his great left toe. However, his April 1993 separation examination indicated he did not have foot trouble. In March 2011 the Veteran underwent a VA joint examination as a result of right knee pain. At such time, the examiner noted the Veteran had an antalgic gait. Similarly, a January 2011 letter from L.L. stated she observed the Veteran limping at a family picnic in November 2010. In August 2013, the Veteran submitted a letter from his wife, N.M., that stated the Veteran limped constantly. The Veteran underwent VA examination in September 2013. At such time, following a review of the record and physical examination, the examiner opined the Veteran's left foot disorder, to include osteoarthritis, hallux valgus, and plantar fasciitis, was less likely than not caused by the Veteran's military service or caused or aggravated by the Veteran's service-connected left knee meniscectomy. In support of such opinion, the examiner stated the Veteran's in-service diagnoses were an acute foot problem, specifically blisters with secondary cellulitis between the toes. Further, his current foot problems are distinct and different conditions and have no cause and effect relationship to his in-service foot problems. In regards to secondary service connection, the examiner stated there was no cause and effect relationship between the Veteran's current foot problems and his service-connected knee condition. X-rays of the left foot revealed no fractures, dislocations, significant degenerative changes, bony lesions, or soft tissue swelling. The impression was a normal left foot except for hallux valgus of the first toe with soft tissue bunion, pes planus, and plantar calcaneal spur. In January 2015, an addendum opinion as to the etiology of the Veteran's left foot disorder was obtained. After a review of the record, the examiner stated the Veteran's left foot disorder was less likely than not incurred in or caused by the claimed in-service injury. As rationale, the examiner stated the Veteran had a history of left foot cellulitis in May 1988 and January 1992. However, these are temporary conditions which resolved, and his April 1993 separation examination did not mention any residuals of such infections, or any foot pain. The Veteran's STRs do not reflect complaints, diagnosis, or treatment of left foot hallux valgus. His current left foot hallux valgus is new and developed many years after service and not related to the in-service left foot infection[s], as such disorder has a different pathophysiology. Further, the examiner opined the Veteran's left foot hallus valgus was less likely than not caused or aggravated by the Veteran's left knee meniscectomy or his right knee DJD. As rationale, the examiner noted the Veteran walked with a normal gait, without limping, and had no leg length discrepancy. Additionally, hallux valgus is very common among adults, and is multifactorial in origin, although the precise etiology is unknown. Many factors such as abnormal first MP anatomy, genetics, abnormal foot mechanics, and joint hypermobility can contribute to the development of this condition. As mentioned supra, in a December 2018 decision, the Board denied service connection for the Veteran's left foot hallux valgus. However, in its November 2019 JMR, the Court found the Board improperly relied on the September 2013 and January 2015 VA medical opinions as such were based on inaccurate factual premises and contained inadequate rationale. In this regard, at the September 2013 VA examination, the examiner reviewed only "limited b[u]t adequate records provided by the Veteran." Specifically, the examiner indicated that "[t]his examiner did not have access to this veteran's C[laims] file. Admin officer explained that I cannot have access." Considering this limited review, the Board erred when it found the September 2013 VA examiner "completed a detailed review of the Veteran's medical files, including past VA examinations, service medical records, post-service medical records, and a review of the Veteran's lay reports" and that the examination report was "based upon a review of both the medical and lay evidence of record." Similarly, the January 2015 addendum opinion was based on a review of the record without a physical examination of the Veteran. The VA examiner rendered a negative opinion on the incorrect factual premise that the Veteran did not walk with a limp or disturbed gait. However, such observation is contrary to the March 2011 VA examiner's description of the Veteran's gait as antalgic and the January 2011 and August 2013 statements describing how the Veteran limps. Pursuant to the JMR, the Veteran underwent another VA foot examination in December 2020. After a review of the record and physical examination, the examiner opined that his left foot hallux valgus was less likely than not related to the Veteran's military service. In support thereof, the examiner noted the Veteran's in-service cellulitis, but that such was treated with antibiotics and resolved. There were no records regarding left foot complaints until February 2013. The examiner cited to a recent article written by a chief podiatrist and assistant professor of orthopedic surgery at Harvard Medical School, that explained while shoes with narrow toes can trigger bunions [hallux valgus], they are not the underlying cause. Instead, bunions run in families because foot type (shape and structure) is hereditary, and some types are more prone to bunions than others. Low arches, flat feet, and loose joints and tendons all increase the risk. The shape of the metatarsal head also makes a difference; if it is too round, the joint is less stable and more likely to deform when squeezed into shoes with narrow toes. Thus, as there were almost 20 years between separation from service and the first records of a bunion, which is likely caused by hereditary foot shape and structure, the examiner opined it is less likely than not the Veteran's left foot hallus valgus is caused by military service. The examiner also opined the Veteran's left foot hallus valgus was less likely than not caused or aggravated by the Veteran's service-connected bilateral knee disabilities. In support thereof, she opined such disorder is most likely caused by the aforementioned factors. However, the Board notes the examiner included the factors of having low arches, flat feet, and loose joints and tendons. In this regard, the Veteran is service-connected for plantar fasciitis with pes planus and degenerative arthritis. Specifically, pes planus is a condition marked by flat feet and fallen arches. Thus, given the Veteran's left foot hallus valgus is potentially caused by his service-connected plantar fasciitis with pes planus and degenerative arthritis, remand is necessary to obtain an addendum opinion regarding secondary service connection. The matters are REMANDED for the following action: Return the record to the VA examiner who provided the February 2021 VA examination. The record, to include a copy of this remand, must be made available to and be reviewed by the examiner. If the February 2021 VA examiner is not available, the record should be provided to an appropriate medical professional so as to render the requested opinion. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. (Continued on the next page) Following a review of the record, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's left foot hallux valgus disorder is caused or aggravated by his service-connected plantar fasciitis with pes planus and degenerative arthritis. For any aggravation found, the examiner should state, to the best of their ability, the baseline of symptomatology and the amount, quantified if possible, of aggravation beyond the baseline symptomatology by the aggravation. A rationale for any opinion offered should be provided. Z. SAHRAIE Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. M. Kelly, 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.