Citation Nr: 21032797 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 16-05 617 DATE: May 28, 2021 REMANDED Entitlement to service connection for bilateral plantar fasciitis is denied. Entitlement to service connection for a right ankle disorder is denied. Entitlement to service connection for a left hip disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from November 1990 to November 1998. This matter comes before the Board of Veterans' Appeals (VA) on appeal of a June 2014 rating decision issued by a regional office (hereinafter agency of original jurisdiction or AOJ) of the Department of Veterans Affairs (VA). The Veteran testified at a September 2019 hearing before the undersigned Veterans Law Judge, a transcript of which has been attached to the record. The Board previously remanded these claims for further AOJ development in an October 2020 decision. 1. Entitlement to service connection for bilateral plantar fasciitis is remanded The Veteran asserts his current bilateral plantar fasciitis is due to his active service. Service treatment records indicate the Veteran stepped on a rusty nail in November 1992 and received a tetanus shot. They also indicate he was diagnosed with plantar fasciitis of the left foot in September 1998 after complaining of heel pain for the past two weeks. The remainder of his service treatment records, to include annual flight examinations, are silent for foot complaints, and his separation examination recorded normal feet. July 2002 and 2003 private treatment records note both feet as normal as well. The Veteran denied painful feet and other physical handicaps in February 2010 and December 2013 private treatment records; and denied weakness or difficulty moving his feet as well as climbing stairs or ladders in February 2013 and January 2014 to private clinicians. March 2014 private treatment records indicate the Veteran complained of consistent right heel pain, reporting he was diagnosed with plantar fasciitis inservice during the 1990's and that this felt similar. He was diagnosed with right foot plantar fasciitis. In January 2016, he denied experiencing painful feet or other physical handicaps to a private clinician. According to October 2019 private treatment records, he complained of bilateral heel pain and was diagnosed with bilateral plantar fasciitis secondary to flatfeet. June 2020 private treatment records indicate he was seen for left foot pain and diagnosed with left foot plantar fasciitis, which he reported experiencing "off and on" since the 1990's. During the September 2019 Board hearing, the Veteran recounted his inservice diagnosis of plantar fasciitis, and reported it went away, swelled up again, went away and came back during service, but that he did not go to medical since he knew how to treat it. He indicated that when it returned post-service, he had forgotten how to treat it and sought medical help around 2014. He stated his feet were still very sensitive and his condition was worst during his first few steps in the morning. In accordance with the Board's remand instructions, the Veteran was afforded a VA foot examination in March 2021. The examiner noted the Veteran's reported inservice of onset of plantar fasciitis which "comes and goes," is triggered by prolonged walking, climbing, running, and is usually "OK in the morning after the first few steps." The Veteran stated that he was treated by a podiatrist in the early 2000's but now received VA treatment and indicated he was currently employed as an aircraft mechanic. The examiner diagnosed the Veteran with bilateral plantar fasciitis and opined that this current condition was less likely than not related to his active service. The examiner acknowledged the Veteran was treated in September 1998 for two weeks of heel pain and diagnosed with left foot plantar fasciitis but noted that his separation examination and July 2002 and 2003 treatment records noted his feet were normal bilaterally. The examiner also observed that the Veteran's first post-service treatment for plantar fasciitis was over 10 years after his separation from service and involved his right foot, as well as that his work as an aircraft mechanic requires extensive standing, squatting and bending. Reasoning that the evidence supported the conclusion that the Veteran's inservice left foot plantar fasciitis did not become a chronic problem until 2019, the examiner stated that there was no objective evidence that his right foot plantar fasciitis began in service or that his left foot plantar fasciitis had been continuous since service. The Veteran has described his plantar fasciitis as "off and on" since service and asserts his current left foot plantar fasciitis is related to his inservice diagnosis of the same. The March 2021 VA examiner noted the inservice diagnosis but relied heavily on the lack of post-service treatment for many years as the basis for the negative opinion. The examiner does not explain why or why not the Veteran's description of recurrent symptoms since service did not demonstrate the onset of chronic plantar fasciitis since service. As such, the examination report must be returned for an addendum opinion. 2. Entitlement to service connection for a right ankle injury is remanded The Veteran asserts that his current right ankle strain is due to an inservice ankle injury. The Veteran's service treatment records are silent for complaints of or treatment for a right ankle condition, and his separation examination notes normal lower extremities. However, he stated during the September 2019 Board hearing that he was injured during a flag football game and his ankle "popped a little bit." He reported that immediately after the injury he flew to Japan and treated the ankle with Motrin and Bengay. Upon his return he indicated that he failed his physical readiness training and was placed in "remedial," but that he never went to medical as the injury healed itself over time. The Veteran concluded by stating "it pops every now and then, but I just once again keep moving on." According to February 2010 and December 2011 private treatment records, the Veteran denied arthritis, swollen joints, physical handicaps or other significant problems, and demonstrated no joint, extremity, or range of motion issues upon examination. December 2011, February 2013 and January 2014 and January 2016 private treatment records note the Veteran denied weakness or difficulty with moving his legs, climbing stairs or a ladder, carrying over 25 pounds, bending, squatting, or leaning. The Veteran reiterated the narrative of his inservice right ankle injury while playing football in his June 2014 notice of disagreement. February 2019 private treatment records note full ankle muscle strength and October 2019 records note his right lower extremity exhibited no tenderness or instability as well as good range of motion and normal strength. In accordance with the Board's remand instructions, the Veteran was afforded a VA ankle examination in January 2021 during which the examiner provided a current diagnosis of a right ankle strain. The Veteran reported occasional pain, popping and an increase in flexibility of his right ankle since his inservice football injury, but no history of ankle treatment. The examiner noted no flares or functional loss other than "intermittent spontaneous episodes when he may suddenly twist the right ankle." Normal range of motion was recorded, with mild tenderness to palpation at the anterior aspect of the ankle joint consistent with the diagnosis of a strain. Finally, the examiner noted no additional functional loss with repetitive use, no assistive devices, and no functional impact on the Veteran's employment. The VA examiner opined that the Veteran's current right ankle strain less likely than not manifested in or was otherwise due to his active service. Acknowledging the Veteran's report of a 1994 or 1995 inservice football injury, the examiner observed that his periodic flight examinations from August 1996 and August 1997 recorded normal lower extremities and that no other post-service medical records linked his current ankle disorder to service. The examiner concluded that all the objective evidence indicated the Veteran's ankle was without disability through his separation from service. The Veteran is competent to report readily observable symptoms such as occasional pain, popping and an increase in flexibility of his right ankle since his inservice football injury, but no history of ankle treatment. The VA examiner did not address whether the initial injury in service involved a type of injury resulting in recurrent right ankle symptoms. As such, an addendum opinion is required. 3. Entitlement to service connection for a left hip disorder is remanded. The Veteran asserts his current left hip disorder is due to his active service, specifically an inservice fall from a pullup bar that resulted in treatment for a left hip contusion. July 1992 service treatment records indicate the treating clinician noted a minor dislocation, abnormal gait, palpable spasm and a resolving lower back strain. An October 2013 letter from a private chiropractor noted varying degrees of discomfort and limitations given the physicality of the Veteran's work. The chiropractor opined it was more likely than not that the Veteran's "condition of hip [and] lower back pain was active duty related and he will continue to have complaints and future residuals," although without further diagnosis or rationale. February 2019 private treatment records note the Veteran's hip motions were symmetrical and pain free but that he exhibited reduced hip muscle strength. At the September 2019 hearing, the Veteran reported that his left shoes would wear out faster than his right, which he attributed to an abnormal gait caused by his inservice left hip trauma. The Board remanded this issue in order to afford the Veteran a VA examination to determine the nature and etiology of his left hip disorder, which occurred in January 2021. The Board instructed the examiner to specifically address the Veteran's documented inservice hip trauma as well as the private chiropractor opinion relating the Veteran's ongoing hip pain to service and his report of his left shoes wearing out faster than his right. The examiner acknowledged the inservice injury, provided a diagnosis of a left hip strain and stated there was no evidence of the development of a chronic hip pathology. However, the examiner failed to address the October 2013 private chiropractor opinion as well as the Veteran's statements regarding shoe wear. The Board is obligated by law to ensure that the AOJ complies with its directives; 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. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Additionally, a medical examiner is not free to simply ignore the Veteran's lay statements recounting symptoms or events. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Therefore, remand is necessary to obtain an addendum VA medical opinion that complies with the Board's October 2021 remand directives. The matters are REMANDED for the following action: 1. Associate with the claims folder any outstanding VA and, with the assistance of the Veteran, private treatment records. 2. Obtain an addendum opinion regarding the nature and etiology of the Veteran's current bilateral foot condition. The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that it is related to his active service, to include his September 1998 treatment for plantar fasciitis. The examiner should specifically consider the Veteran's description of self-treatment for recurrent episodes of foot pain and swelling following his initial treatment for plantar fasciitis in service and discuss whether there is any medical reason to believe that the Veteran has manifested chronic plantar fasciitis since service. The examiner should explain the nature of plantar fasciitis including whether plantar fasciitis is the type of medical condition which can wax or wane over periods of time or whether such condition would remain chronically symptomatic. The examiner may comment on the significance, if any, of July 2002 and 2003 private treatment records noting both feet as normal, the Veteran's denial of painful feet and other physical handicaps in February 2010 and December 2013 private treatment records; and his denial of weakness or difficulty moving his feet as well as climbing stairs or ladders in February 2013 and January 2014 to private clinicians. 3. Obtain an addendum opinion regarding the nature and etiology of the Veteran's current right ankle condition. The examiner is asked to opine as to whether it is at least as likely as not (50 percent or greater probability) that it is related to his active service. The examiner is asked whether there is any medical reason to accept or reject the Veteran's belief that his current right ankle condition is related to his inservice flag football injury and reported self-treatment. The examiner must comment on the type of right ankle injury incurred during service and whether such injury was capable of causing permanent structural damage or other disability to result in recurrent symptoms of occasional pain, popping and an increase in flexibility of the right ankle. 4. Obtain an addendum opinion regarding the nature and etiology of the Veteran's current left hip disorder. The examiner should opine as to whether it is at least as likely as not (50 percent or greater) that the Veteran's left hip disorder had its onset during or is otherwise etiologically related to his active duty service. In formulating the requested opinion, the examiner should address the following: The Veteran's documented July 1992 inservice injury, identified as a left hip contusion with abnormal range of motion, tenderness, minor dislocation, abnormal gait and palpable spasm. The Veteran's September 2019 hearing statements reporting his shoes always wearing out on the left side more than the right and stating he was told by a chiropractor that his "hips were off." An October 2013 opinion from his treating chiropractor stating the Veteran's "condition of hip [and] lower back pain was active duty related and he will continue to have complaints and future residuals." T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. C. Schumacher, 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.