Citation Nr: 21041327 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 14-15 468A DATE: July 8, 2021 REMANDED Entitlement to service connection for degenerative joint disease of the left shoulder (also claimed as bone spurs of the left shoulder) is remanded. Entitlement to service connection for a posterior calcaneal spur of the right foot is remanded. Entitlement to service connection for a posterior calcaneal spur of the left foot (claimed as left foot bone spur and as left ankle bone spur) is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from February 1972 to December 1979. The Veteran died in November 2020 and the Appellant, his wife, has been substituted in his place. This case comes before the Board of Veterans' Appeals (Board) on appeal from April 2012 and January 2014 rating decisions from the Regional Office, which denied, in pertinent part, service connection for degenerative joint disease of the left shoulder and service connection for posterior calcaneal spurs of the bilateral feet. In April 2018, the Board denied service connection for the left shoulder disability, reasoning that there was no competent evidence linking the Veteran's current left shoulder condition to his in-service shoulder injury. The Board also denied service connection for the Veteran's right foot posterior heel spurs. The basis of the Board's denial was the December 2011 VA examination and opinion. At that time, the examiner noted the Veteran's heel spurs of the right foot but found that they were not related to the Veteran's in-service ankle injuries. The Veteran's in-service ankle injuries were to the lateral and medial ligaments, rather than the posterior ankle. Thus, the examiner opined that since the Veteran did not have an ongoing ankle condition related to the in-service ankle injury, the Veteran's bilateral foot spurs were more likely a new and separate condition related to the aging process. In June 2019, the Veteran, together with the Secretary of Veterans Affairs, filed a joint motion for remand (JMR) in the United States Court of Appeals for Veterans Claims (CAVC) with respect to the Board's denial of the above-mentioned disabilities. In that JMR, CAVC directed the Board to obtain a supplemental statement of the case (SSOC) considering evidence that was submitted before the records were transferred to the Board for adjudication; provide an adequate statement of reasons and bases of the adequacy of the June 2011 and December 2011 VA examinations concerning the left shoulder, including the August 2011 deferred rating decision; and provide an adequate statement of reasons and bases in addressing whether the Veteran is entitled to compensation due to functional impairment with his left shoulder and right and left foot bones spurs. The CAVC granted the joint motion in June 2019, pursuant to 38 U.S.C. § 7252(a), for action consistent with the terms of the joint motion. See Forcier v. Nicholson, 19 Vet. App. 414, 425 (2006); Stegall v. West, 11 Vet. App. 268, 271 (1998). Of note, the Veteran was granted service connection for a right ankle disability in an August 2020 rating decision. As this constitutes a full grant of benefits on this issue, it no longer before the Board and will not be further discussed. The Board remanded the matter in October 2019 to comply with the directives of the JMR. The Board regrets further delay, but another remand is necessary to further develop the claims. 1. Entitlement to service connection for degenerative joint disease of the left shoulder (also claimed as bone spurs of the left shoulder) is remanded. VA examinations were submitted for review in June 2011 and December 2011. The examiner diagnosed the Veteran with degenerative joint disease of the left shoulder, acromioclavicular arthropathy, and spurs. He opined that the Veteran's left shoulder disabilities were not related to service. The Board finds these examinations to be inadequate as the examiner did not consider the Veteran's statements that he had continuous shoulder pain from an in-service injury, with an onset in service and since that time. See December 2010 VA treatment record (veteran reported left shoulder pain since 1972); see Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that a VA examination is inadequate if it does not consider all the relevant evidence of record, including lay statements). On remand, an addendum opinion should be secured. Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). 2. Entitlement to service connection for a posterior calcaneal spur of the right foot is remanded. 3. Entitlement to service connection for a posterior calcaneal spur of the left foot (claimed as left foot bone spur and as left ankle bone spur) is remanded. The Veteran presented for a VA examination in December 2019. The Veteran was diagnosed with bilateral calcaneal spurs of the right and left foot. The examiner opined that the Veteran's calcaneal spurs were less likely than not incurred in or caused by an injury, event, or illness, in service and that his left ankle and left foot issues are not proximately related to or aggravated by a service-connected disability. He opined that the Veteran had several issues with his feet (in-service, presumably), however, none of the conditions in service were noted as calcaneal spurs or would cause any calcaneal spurs. He also opined that there was no evidence of left ankle or left foot pain in his service treatment records (STRs) due to a right ankle disability and noted that the Veteran did not have a left ankle condition while in service. He further opined that there was no evidence in his STRs that his left foot and left ankle pains/disability are due to his service-connected right foot disability. The Board finds this examination inadequate as the examiner relies heavily on the STRs in its reasoning for why his ankle and foot disabilities are not related to service instead of looking at the entirety of the Veteran's disability picture, to include lay statements and medical treatment records. See Dalton, supra. Additionally, the examiner erroneously states that the Veteran's right foot condition is service-connected (and incorrectly states that the right ankle is service-connected, which at the time of that VA examination, it was not). Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that a medical opinion based upon an inaccurate or incomplete factual premise is not probative). Moreover, the examiner does not adequately address the Veteran's right foot condition and its relationship to service. It is for the above outlined reasons an addendum opinion is required on remand. Barr v. Nicholson, 21 Vet. App. 303, 310-11 (2007). The matters are REMANDED for the following action: 1. Obtain an addendum opinion addressing the etiology of the Veteran's diagnosed left shoulder disorder. The entire claims file should be made available to the examiner. After a review of the claims file, including the lay statements provided by the Veteran, the examiner should address the following: (a.) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran's left shoulder acromioclavicular arthropathy, degenerative joint disease, and/or spurs had its/their onset in service, or is otherwise related to service, to include as a result of documented treatment therein. **Veteran has reported ongoing left shoulder pain since 1972. See e. g., December 2010 VA treatment record. ** Address the Veteran's contention that his shoulder spurs are caused by running exercises in boot camp (see May 2011 VA Form 21-4138). **Address the Veteran's contention that the residual symptoms and complaints of swelling and severe pain from his in-service left shoulder injury became chronic the rest of his military career (see May 2015 IHP). **Address the May 1972 STR notation that he injured left shoulder and that it is probably a torn muscle. **Address the August 1979 STR report of swollen or painful joints and address the August 1979 STR report of a left shoulder torn ligament. **Address the March 1979 STR regarding sharp pain in the left shoulder after pulling a muscle in the neck. **Address the August 1979 STR of left shoulder pain and a previous injury in 1972 and the statement from the Veteran's fellow service member that the Veteran suffered a left shoulder injury in July 1997 while at Ft. Riley, Kansas, and the Veteran wore a sling due to the same (see March 2015 Lay Statement). (b.) A complete rationale shall be given for all opinions and conclusions expressed. 2. Obtain an addendum opinion addressing the etiology of the Veteran's diagnosed right foot calcaneal spur, left foot calcaneal spur, and left ankle deltoid ligament sprain. The entire claims file should be made available to the examiner. After a review of the claims file, including the lay statements provided by the Veteran, the examiner should address the following: (a.) State whether it is at least as likely as not (50 percent or greater probability) that the Veteran's right foot calcaneal spur, left foot calcaneal spur, and/or left ankle deltoid ligament sprain had their onset in service, or is otherwise related to service, to include as a result of documented treatment therein. **Discuss and concede as true the Veteran's statements as to an in-service right foot/right ankle injury, and that he has experienced continuous pain, with dull pain in both heels, and swelling in the right foot along with discomfort, since that time (see April 2012 NOD, February 2015, January 2020 VA examination). **Address the Veteran's contention that his bilateral foot bone spurs are caused by running exercises in boot camp (see May 2011 VA Form 21-4138). (b.) State whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's diagnosed right foot calcaneal spur, left foot calcaneal spur, and left ankle deltoid ligament sprain are either caused or aggravated by his service-connected right ankle disability. **In addressing these questions, please address the Veteran's contention that he had a right foot/ankle injury which caused spurs on his bilateral feet/left ankle (see April 2013 Correspondence, May 2015 IHP). (c.) A complete rationale shall be given for all opinions and conclusions expressed. 3. Then, readjudicate the claims on appeal. Romina A. Casadei Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. J. Rogers, 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.