Citation Nr: 21029457 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 16-19 227 DATE: May 13, 2021 REMANDED Service connection for bilateral flat feet is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Navy Reserve from July 1984 to November 1984. The Veteran had additional periods of active duty for training (ACDUTRA) in November 1985, May 1987, and March 1988. He then served on active duty in the U.S. Navy from June 1988 to June 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2015 rating decision by the Department of Veterans Affairs (VA). This case was remanded in September 2018 for further development; it has since been re-assigned to the undersigned. The Board finds that further development is needed before it can proceed with adjudication. As stated above, the Board remanded this matter in September 2018 for further development. However, remand is again needed to comply with the September 2018 remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Pursuant to the September 2018 Board remand, the Veteran underwent a VA foot conditions examination in December 2019. The remand order directed the examiner to opine whether there is clear and unmistakable evidence that the Veteran's pes planus preexisted his period of active duty service starting in 1988, and any other verified period of active duty, and, if so, state whether there was an increase in the severity of the preexisting pes planus during this period of active service. If an increase is shown the examiner must then also opine as to whether the increase represented a chronic worsening of the underlying pathology or whether there is clear and unmistakable evidence the increase was due to the natural progression of the disorder. If the examiner determines that pes planus did not preexist a period of active service, the examiner should state whether it is at least as likely as not that the Veteran has pes planus that manifested or is otherwise related to his service, including any symptomatology therein. The examiner opined that based on clear documentation of mild pes planus at time of enlistment in the Navy reserve, no evidence of complaints of foot pain on review of service treatment records, documentation of symptoms of foot pain on exit examination, initial documentation of complaints of mild left foot pain on 5/1/2012, and clear documentation of symptomatic pes planus in PCP note dated 8/8/2014, there is no evidence of increase in disability during service. The Board finds that this opinion is inadequate. The opinion is mainly based on the absence of complaints of foot pain in the Veteran's service treatment records. The examiner did not appear to consider the Veteran's statement that he complained of foot pain in service in 1998. Further, while the examiner does note that there is documentation of mild pes planus at the time of enlistment in the Navy reserve, the examiner did not provide the requested opinion whether there is clear and unmistakable evidence that the Veteran's pes planus preexisted his period of active duty service starting in 1988, and any other verified period of active duty. As such, remand for an addendum opinion is required to address whether the Veteran's pes planus pre-existed his active duty, and if so, whether his pes planus was aggravated therein. In addition, the Veteran reported that he complained of bilateral foot pain when he was "stationed in Germantown approximately in 1998." The examination report follows to state: "however, that record is not available." Upon remand, the examiner should clarify whether "that record is not available" means that no service treatment records were available for review or that there was no corresponding service treatment record noting a complaint of foot pain. Finally, pursuant to the September 2018 Board remand, the AOJ requested treatment records and other evidence from the Navy Reserve Personnel Command. The Board notes that 199 pages of records, which include various personnel and medical records, were added to the claim file in October 2019. See DPRIS Response received October 1, 2019. However, later that month, documentation in the claims file suggests that the AOJ received a CD from the Navy Personnel Command but was unable to scan the contents due to "no password/password invalid." See VA Memo and Correspondence associated with the claims file on October 28, 2019. On remand, the AOJ should clarify whether the contents of the CD have been retrieved and/or if these are the documents located in the DPRIS Response received October 1, 2019. The Board wants to ensure the development directed in the September 2018 Board remand is complete. The matters are REMANDED for the following action: 1. The AOJ should obtain updated VA and non-VA treatment records. 2. The AOJ should clarify whether the contents of the CD from Navy Personnel Command identified in the VA Memo dated October 28, 2019, have been retrieved and associated with the claim. The AOJ should also clarify if these records are the documents located in the DPRIS Response received October 1, 2019. 3. After the above development is completed, the AOJ should obtain an addendum opinion from the December 2019 examiner, or another qualified clinician if unavailable, regarding the Veteran's bilateral flat feet/pes planus disability. The examiner should review the claims file (including this remand) and note such review was conducted. Based on review of the record, the examiner should provide an opinion with detailed rationale that responds to the following for each lumbar spine disability identified: (a) Whether there is clear and unmistakable evidence that the Veteran's pes planus preexisted his period of active duty service starting in June 1988, and, if so, state whether there was an increase in the severity of the preexisting pes planus during the period of active service If an increase is shown, the examiner must also opine as to whether the increase represented a chronic worsening of the underlying pathology or whether there is clear and unmistakable evidence the increase was due to the natural progression of the disorder. If the examiner determines that pes planus did not preexist a period of active service, the examiner should state whether it is at least as likely as not (50 percent or greater probability) that the Veteran has pes planus that manifested in or is otherwise related to his service, including any symptomatology therein. The examiner must discuss the Veteran's statement that he complained of foot pain in service in 1998. (b) The examiner should clarify whether the comment in the examination report that "that record is not available" (referring to the Veteran's statement regarding in-service foot pain in 1998) means that no service treatment records were available for the examiner's review or that there was no corresponding service treatment record noting a complaint of foot pain. A detailed explanation is required to support the opinion. A complete and thorough rationale must be provided for any opinions expressed with consideration given to all evidence of record. If the examiner is unable to offer the opinion requested, he or she must explain in detail why that is the case. If the inability to opine is due to the fact that the examiner lacks the expertise to render such an opinion, or due to the fact that some additional testing or information is needed, and possibly available, that would permit such an opinion, the examiner should clearly and specifically state so, and, if applicable, the examiner should also state precisely what additional testing or information is needed in order to render the requested opinion. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. Kerner, 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.