Citation Nr: 21040605 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 09-39 662 DATE: July 6, 2021 REMANDED Entitlement to service connection for a right lower extremity peripheral nerve disability, to include as secondary to service-connected tinea pedis with onychomycosis, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1968 to November 1969, to include service in the Republic of Vietnam. Unfortunately, the Veteran died in April 2015. The appellant is his surviving spouse. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2008 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). By way of procedural background, the Board previously remanded this matter in decisions dated March 2014, April 2015, October 2017, and March 2021. In January 2015, the Veteran requested a videoconference hearing before the Board, and in March 2015, the Veteran requested that the hearing be held in Washington, D.C. In February 2017, the appellant withdrew the request for a hearing before the Board. 1. Entitlement to service connection for a right lower extremity peripheral nerve disability is remanded. The appellant asserts that service connection is warranted for a right lower extremity peripheral nerve disability, to include as secondary to the Veteran's service-connected tinea pedis with onychomycosis. The Board regrettably finds that another remand is necessary to ensure substantial compliance with the Board's previous remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Pursuant to the Board's March 2021 Remand, additional VA medical opinions were obtained in April 2021. On review, the Board finds the April 2021 VA medical opinions inadequate for the following reasons. First, the April 2021 VA medical opinions were unclear, as they addressed multiple theories of entitlement (i.e. direct and secondary service connection) within the same medical opinion and rationale. For example, in one of the April 2021 VA medical opinions, the VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, reasoning, "[T]inea pedis is a superficial fungal infection that affects the skin on the feet and can spread to the toenails, medical literature does not describe an anatomic, biomechanical or physiologic mechanism for a superficial fungal infection to affect peripheral nerves. Medication taken for tinea pedis (ketoconazole cream) is a topical medication, is not absorbed systemically and cannot affect peripheral nerves." Here, the rationale provided (regarding secondary service connection) does not relate to the negative nexus opinion as to direct service connection. Additionally, while both causation and aggravation were addressed in the rationale provided for the April 2021 VA medical opinion as to secondary service connection, the VA examiner only provided one opinion that the claimed condition was less likely than not proximately due to or the result of the Veteran's service-connected condition. On remand, the VA examiner should clearly, and separately, address the theories of direct service connection, secondary causation, and secondary aggravation. Second, in the rationale provided for the April 2021 VA medical opinion as to secondary service connection, the VA examiner wrote, "Medical literature and review of the medical record (and STR) does not support a physiologic, biomechanical or anatomic mechanism for tinea pedis to include medications to cause or permanently aggravate right peripheral nerve condition beyond its natural progression." The Board emphasizes that any amount of aggravation is sufficient to establish secondary service connection; permanent aggravation or worsening of a non-service-connected disability is not required. See Ward & Neal v. Wilkie, 31 Vet. App. 233 (2019). On remand, the VA examiner should ensure to apply the correct standard when providing an opinion as to secondary aggravation. Accordingly, the matter is REMANDED for the following action: 1. Obtain an addendum VA medical opinion regarding the nature and etiology of the Veteran's right lower extremity peripheral nerve disability. The claims file, including a copy of this Remand, must be made available to, and be reviewed by, the examiner. After a review of the entire claims file, the examiner is asked to clearly, and separately, address the following: (a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's right lower extremity peripheral nerve disability had its onset during or is otherwise related to his active service, to include as due to an in-service car accident? (b) Is it at least as likely as not (50 percent probability or greater) that the Veteran's right lower extremity peripheral nerve disability was proximately due to or the result of his service-connected tinea pedis with onychomycosis, to include as due to any medications used to treat the service-connected disability or as due to the gait deviations caused by the service-connected disability? (c) Is it at least as likely as not (50 percent probability or greater) that the Veteran's right lower extremity peripheral nerve disability was aggravated by his service-connected tinea pedis with onychomycosis, to include as due to any medications used to treat the service-connected disability or as due to the gait deviations caused by the service-connected disability? ** Any amount of aggravation is sufficient to establish secondary service connection; permanent aggravation/worsening of a non- service-connected disability is not required. See Ward & Neal v. Wilkie, 31 Vet. App. 233 (2019). In providing the requested opinions, the examiner must specifically address the appellant's contentions that the Veteran's tinea pedis caused discomfort that caused him to limp, thus causing or aggravating his right lower extremity peripheral nerve disability, and that the medications the Veteran was taking for his tinea pedis caused or aggravated his right lower extremity peripheral nerve disability. 2. Thereafter, please review the VA medical opinions and ensure that all requested questions are fully answered by the examiner. If not, please take the appropriate corrective action. (Continued on the next page) 3. Lastly, readjudicate the remanded claim. In so doing, ensure that all applicable theories of entitlement are addressed. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. M. Gill, 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.