Citation Nr: 21042134 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 14-32 511 DATE: July 12, 2021 ORDER Entitlement to service connection for a left foot heel spur is denied. FINDING OF FACT The Veteran's left foot heel spur was not present during service, or for many years thereafter, and was not caused by or aggravated by the service-connected diabetes or left foot plantar fascitis. CONCLUSION OF LAW The criteria to establish entitlement to service connection for a left foot heel spur have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1965 to August 1967 and from July 1971 to August 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In December 2015, the Veteran testified at a hearing before the undersigned Veterans Law Judge. A transcript of that hearing is of record. This matter was last before the Board in March 2021, when it was remanded for further development. Service Connection Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Generally, to prove service connection there must be: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be established for a disability which is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a). Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown. Allen v. Brown, 7 Vet. App. 439 (1995). However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice- connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for a left foot heel spur The Veteran asserts that a left heel spur is secondary to his service-connected diabetes. During the December 2015 Board hearing, he testified that he received regular diabetic foot examinations, and was diagnosed with heel spurs around 2009. As an initial matter, the Veteran has a current diagnosis of left heel spur. Thus, the question for the Board is whether the Veteran's current left heel spur is related to service and/or his service-connected disabilities. The Veteran has not asserted, and the record does not suggest, that his left heel spur is directly related to service. Service treatment records show no diagnosis, or treatment for, left heel during service. A January 1991 Report of Medical Examination shows that the Veteran's lower extremities were noted to be clinically normal upon evaluation. Thereafter, the record shows no complaints of symptoms until October 2011 when the Veteran reported a left heel pain for the past year. There is no medical opinion linking the left heel spur to service. Accordingly, service connection for a left heel as directly related to service is not warranted. With respect to secondary service connection, the Board notes that the Veteran is service connected for diabetes mellitus type II effective November 6, 2000. Additionally, a January 2021 rating decision granted service connection for left foot plantar fasciitis, effective October 2, 2019. In October 2019, a VA examiner opined that the Veteran's left heel spur is less likely than not caused or aggravated by his service-connected diabetes because the medical literature does not support a relationship between the two conditions. The examiner explained that foot pain does occur with diabetes, but it is more likely related to plantar fasciitis and diabetic neuropathy, rather than heel spurs. In May 2020 a VA examiner opined that the Veteran's left heel spur is not aggravated beyond its natural progression due to diabetes. The examiner explained that although diabetes is known to contribute to foot complication such as neuropathy, calluses, ulcers, etc., medical literature does not support the condition of diabetes as an aggravating factor that would worsen a heel spur condition, which is a growth on the bone of the heel. In December 2020, a VA examiner opined that it is less likely as not that the Veteran's left heel spur is proximately caused by the Veteran's service-connected diabetes. The examiner explained that diabetes does not have a direct patho-physiological cause to a heel spur. The development of a heel spur can occur in athletes or in sedentary individuals with or without diabetes and with or without plantar fasciitis. It would be purely speculative to state the Veteran's left heel spur's proximate cause is diabetes. In April 2021, a VA examiner opined that it is less likely than not that the Veterans calcaneal spurs have been aggravated beyond the natural course due to any cause, including Veteran's diabetes. The explained that there is no physiologic or anatomic mechanism by which diabetes can impact the development of or cause aggravation of calcaneal spurs. The examiner also noted that there is no evidence of aggravation of the calcaneal spur condition beyond its natural course due to any cause. Many calcaneal spurs are asymptomatic, but some individuals require injections and/or surgical removal. There is nothing in the Veteran's history to suggest aggravation beyond the natural course. The April 2021 VA examiner also opined that it is less likely than not that the Veteran's calcaneal spurs have been aggravated beyond the natural course due to any cause, including the veteran's plantar fasciitis. The examiner cited medical literature and explained that plantar fasciitis and calcaneal spur are separate entities and unrelated to each other as to cause and aggravation. The Board finds the VA examiners' opinions, considered together, establish that the Veteran's left heel spur was not caused or aggravated by his service connected diabetes and/or left plantar fasciitis. The examiners' combined opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no medical opinion to the contrary. To the extent that the Veteran believes a left heel spur is to related service-connected diabetes and/or left foot plantar fascitis, as lay persons he has not shown that he has specialized training sufficient to render such an opinion. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis or etiology). In this regard, the diagnosis and etiology of foot disorders are matters not capable of lay observation and require medical expertise to determine. Thus, the opinion of the Veteran regarding the etiology of his left heel spur is not competent medical evidence. The Board finds the opinions of the VA examiners combined to be significantly more probative than the Veteran's lay assertions. In sum the most probative evidence is against the claim, and service connection is denied. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not for application and service connection must be denied. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Asare, 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.