Citation Nr: 21031580 Decision Date: 05/24/21 Archive Date: 05/24/21 DOCKET NO. 11-17 186 DATE: May 24, 2021 REMANDED Entitlement to service connection for a neurological disorder of the feet, other than radiculopathy of the right and left lower extremities, but including Morton's neuroma, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1989 to February 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from decisions of a Department of Veterans' Affairs (VA) Regional Office (RO). In February 2016, April 2018, June 2019, the Board remanded the appeal for additional evidentiary development. Entitlement to service connection for a neurological disorder of the feet, other than radiculopathy of the right and left lower extremities, is remanded. The Veteran is seeking service connection for two types of neurological disorder of the feet, as noted in the Board's June 2019 remand. During remand status, a June 2020 rating decision granted service connection for radiculopathy of the bilateral lower extremities associated with service-connected back disability. However, the Veteran has also been diagnosed with bilateral Morton's neuroma. While the Veteran was not diagnosed with Morton's neuroma in service, she was treated in service for bilateral foot pain and swelling. Thus, at issue is whether the Veteran's bilateral Morton's neuroma was first manifested in service (i.e., onset in service); or was caused by or related to the Veteran's active service; or is secondary to service-connected radiculopathy of the right and left lower extremities. A VA medical opinion in February 2021 concluded that the Veteran's inservice complaints of foot pain were less likely than not early symptoms of Morton's neuroma. However, the supporting rationale is not fully explained or developed. It mentions risk factors generally, but not in the context of this Veteran and her history. The opinion noted that high impact sports are a risk factor for the development of Morton's neuroma, but failed to address whether the high impact activities the Veteran participated in during her active service, such as frequent running and marching, caused or contributed to the development of the Veteran's Morton's neuroma. Therefore, the Board finds the medical opinion is inadequate because the essential rationale is not discernable. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). The October 2018 VA medical opinion reflects that the Veteran's Morton's neuroma was less likely than not aggravated by her service-connected lumbar radiculopathy. The rationale was simply that "The nerve pain of radiculopathy radiates to the feet is caused by the DDD of the spine and not Morton's neuroma." The opinion is inadequate because it dismisses the Veteran's radiculopathy as a causative factor in the development of her Morton's neuroma without fully explaining and because it is non-responsive to the question of aggravation. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (finding that a secondary opinion which addresses a causal relationship, but which does not address the question of aggravation, is inadequate). Both medical opinion reference medical literature to support the negative conclusions reached, but neither discusses vis-à-vis facts specific to the Veteran. On remand, the Board finds an addendum medical opinion is required to address the etiology of the Veteran's Morton's neuroma. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (stating that a medical rationale based solely on general medical literature without discussing the specific facts pertaining to a veteran's condition or individual circumstances is inadequate). Given the above, the Board finds that it may not rely upon the medical opinions in their present form and, therefore, concludes that the opinions are inadequate for adjudicative purposes. Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). In remanding this matter, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran's assertions. Neither the Veteran's credibility nor any lack thereof should be presumed in this remand. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician. The entire claims file, to include a copy of this REMAND, should be made available to and reviewed by the clinician. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms consistent with Morton's neuroma. The opinion should 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). NOTE (1): An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. NOTE (2): An adequate medical opinion may not be predicated solely on the absence of literature supporting causation or aggravation without discussing those facts specific to this Veteran. The clinician must opine on: Direct Service Connection (a) Whether the Veteran's Morton's neuroma at least as likely as not (1) began during active service or (2) is related to an in-service injury, event, or disease. i. Consider and expressly address the Veteran's in-service foot complaints and whether this represented the onset of Morton's neuroma. Explain. ii. Consider and expressly address whether the Veteran's in-service high impact activities caused or contributed to the development of the Veteran's Morton's neuroma? Secondary Service Connection (b) Whether the Veteran's bilateral Morton's neuroma is at least as likely as not (1) proximately due to her service-connected lumbar radiculopathy of the lower extremities; or (2) worsened beyond its natural progression by her service-connected lumbar radiculopathy of the lower extremities. 2. Ensure that the VA medical opinion obtained include a complete rationale for the conclusions reached. The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.D. Anderson, 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.