Citation Nr: 21042792 Decision Date: 07/14/21 Archive Date: 07/13/21 DOCKET NO. 16-49 204 DATE: July 14, 2021 ORDER Service connection for a bilateral foot condition is denied. FINDING OF FACT The Veteran's bilateral foot condition did not begin during active service nor is it otherwise related to an in-service injury or disease, to include exposure to herbicide agents. CONCLUSION OF LAW The criteria for service connection for a bilateral foot condition are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1966 to September 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at an October 2019 Board hearing before the undersigned Veterans Law Judge (VLJ). A copy of the hearing transcript is associated with the electronic claims file. The Board remanded this matter most recently in March 2021 for an addendum medical opinion addressing service connection for the Veteran's bilateral foot condition, including peripheral neuropathy. The Board finds that an adequate medical opinion was obtained, and the remand instructions were substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran seeks service connection for his bilateral foot condition, diagnosed as hammer toes, post-surgical hallux valgus, onychomycosis, hyperkeratosis, and peripheral neuropathy. He contends that his bilateral foot condition is due to in-service treatment for plantar warts or as secondary to herbicide agent exposure while serving in Vietnam. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires competent evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service; and (3) a causal relationship or nexus between the current disability and any injury or disease during service. See Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Veterans who served in the Republic of Vietnam during the period starting on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed to an herbicide agent, unless there is affirmative evidence of non-exposure. See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307. The Veteran had qualifying service in the Republic of Vietnam during the applicable period; as such, herbicide agent exposure has been conceded. Service incurrence for certain diseases will be presumed on the basis of an association with certain herbicide agents (e.g., Agent Orange). See 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). Notably, the list includes "early onset peripheral neuropathy." Peripheral neuropathy is considered "early onset if abnormalities appear within 1 years after external exposure." Nat'l Acad. of Sci., Inst. of Med., Veterans & Agent Orange: Update 11 (2018) at 460. Here, the Veteran did not report peripheral neuropathy symptoms, such as numbness on the bottom of his feet, until April 2013, so presumptive service connection for his peripheral neuropathy based on herbicide agent exposure is not warranted. Separately, the additional diagnoses related to his bilateral foot condition, including hammer toes, post-surgical hallux valgus, onychomycosis, and hyperkeratosis, are not presumptively connected to his in-service herbicide agent exposure. Therefore, presumptive service connection for the additional diagnoses related to his bilateral foot condition is not warranted. 38 C.F.R. § 3.309(e). However, the Board will still consider whether direct service connection is warranted based on the presumed exposure under the generally applicable standards for service connection. See Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994) (holding that VA must consider direct service connection where presumptive service connection is not warranted). The Veteran's service treatment records are associated with the claims file and reference some in-service treatment for foot problems. In April 1968, he complained of a sore right foot, and his provider noted four small plantar warts which were cut out. See April 1968 Chronological Record of Medical Care. Per a note a few weeks later, he continued to experience pain at the bottom of his foot and he was referred to a surgeon for medical consultation. The affected area of his right foot was debrided in late April 1968, and, per a May 1968 note, his plantar warts were healing. Id.; see May 1968 Chronological Record of Medical. At his separation examination three months later, he denied any foot trouble, neuritis, or skin diseases. See September 1968 Report of Medical History. The Veteran's VA and private treatment records, which are associated with the claims file, do not contain any complaints or treatment for foot problems until July 1981, nearly 13 years post-service. Intermittently, from January 1981 to February 2006, he complained of and was treated for plantar warts (with the most recent mention in 1984), corns, in-grown toenails, toe pain, toenail fungus, hyperkeratosis, and onychomycosis. See, generally, Hawarden Community Hospital Records. These records do not include any reference to peripheral neuropathy or residuals from his in-service foot surgery. He began complaining of neuropathy symptoms, including intermittent leg weakness and pain/numbness in the bottom of his feet, in April 2013 and has consistently reported such symptoms since. See April 2013 Pharmacy Note; see, generally, September 2006 to February 2019 VA Treatment Records. Most recently, in November 2020, he underwent a procedure to remove an ulcer on his left foot. See November 2020 Podiatry Note. Three VA providers have noted the Veteran's herbicide agent exposure in relation to his peripheral neuropathy. In a November 2014 Podiatry Note, his podiatrist discussed his neuropathy symptoms and condition, and referred to it as neuropathy secondary to Agent Orange exposure. In a February 2016 Primary Care Note, his provider noted his November 2014 podiatry visit and noted that he was started on neuropathic medication due to history of Agent Orange exposure. Most recently, at a December 2018 Neurology Consult, his neurologist documented his report of being exposed to Agent Orange. The Veteran was afforded VA foot examinations in February 2016 and December 2020. An addendum medical opinion was provided pursuant to the most recent Board remand in April 2021. Because the Board previously found both the February 2016 and December 2020 associated medical opinions inadequate, only the April 2021 addendum opinion will be considered. The April 2021 examiner opined that the Veteran's bilateral foot condition was less likely than not incurred in or caused by an in-service injury, event, or illness. In making this conclusion, the examiner addressed both of the Veteran's contentions, reviewed medical literature, and specifically referenced the Veteran's November VA podiatry record, February 2016 VA primary care record, December 2018 VA neurology record, and the Veteran's service treatment records. As to the Veteran's contention that his bilateral foot condition was caused by herbicide agent exposure, the examiner noted that this condition did not have its onset for at least 16 years post-service (when the Veteran was first treated for corns), and explained that the Veteran's treatment records linking his neuropathy to herbicide agent exposure are not supported by medical literature as Agent Orange exposure has not been linked to remote neuropathy. The examiner explained that the same rationale applies to the Veteran's February 2016 Primary Care Note and December 2018 Neurology Consult, and noted that the December 2018 neurologist did not opine as to the cause of the Veteran's neuropathy and did not make a connection between his neuropathy and Agent Orange exposure directly. As to the Veteran's contention that his bilateral foot condition was caused by or a progression of his in-service treatment for plantar warts, the examiner stated that there is no further mention of a foot condition in the Veteran's service treatment records or at his separation examination after the in-service excision. The examiner explained that the Veteran's current foot diagnoses, including hammer toes, hallux valgus, hyperkeratosis, and onychomycosis are all unrelated to plantar warts, and it is more likely than not that all of the Veteran's subsequent foot conditions, including neuropathy, had their nexus after service and are unrelated to events in service. The Board notes that record does not reflect a current diagnosis of plantar wart(s) during the appeal period, and the most recent treatment for or notation of plantar wart(s) was in 1984, in which the Veteran's provider noted that there was no evidence of plantar warts. The Board has considered the Veteran's lay statements, including his October 2019 Board hearing testimony. He testified that he had surgery on both his right and left foot in service for what his providers thought was plantar warts. He also reported having surgery in July 2019 on his left foot for an ulcerated ulcer which involved grinding down bone, and attributed his foot condition to jumping off of the platforms of helicopters in service. The Veteran also testified that he is on the verge of being diabetic, but his doctor did not "come right out and say" whether it's service connected or not. The Board notes that the Veteran does not have a current disability of diabetes, and while a November 2020 Podiatry Note referred to him as pre-diabetic, a November 2020 Orthopedic Surgery Note described him as non-diabetic. If the Veteran is diagnosed with diabetes at a future time, he is advised to consider filing a claim with VA. While the Board recognizes that the Veteran is competent to describe his symptoms without any specialized knowledge or training, he is not competent to diagnose his symptoms as a specific disease, nor is he competent to render a nexus opinion regarding the etiology of any current disorder, as both of these determinations require medical expertise that goes beyond a simple and immediately observable cause-and-effect relationship. See Layno v. Brown, 6 Vet. App. 465, 469-470 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007). After reviewing the lay and medical evidence, the Board finds that service connection is not warranted for the Veteran's bilateral foot condition. In making this decision, the Board relied on the Veteran's normal separation examination, the nearly 13 year gap between the Veteran's in-service treatment for plantar warts and his first post-service mention of a foot condition, and the distinct nature of his in-service foot troubles and current bilateral foot condition. The Board also relied on the April 2021 VA addendum opinion. The Board finds that this opinion is probative as it reflects consideration of the Veteran's in-service treatment records and post-service treatment records, addresses the Veteran's contention that his bilateral foot condition is a result of his in-service plantar wart excision, discusses the lack of support for a relationship between remote neuropathy and herbicide agent exposure in medical literature, and provides a detailed rationale. While the Board recognizes the Veteran's sincere belief in his claims, the cumulative probative evidence does not support his assertions. The only evidence related to a bilateral foot condition in service is the Veteran's treatment for plantar warts, which he does not have a current diagnosis of. There is no evidence of his currently diagnosed hammer toes, post-surgical hallux valgus, onychomycosis, and hyperkeratosis, and peripheral neuropathy in service, and his peripheral neuropathy did not manifest until nearly 45 years post-service. While his VA treatment records reference a possible relationship between his herbicide agent exposure and peripheral neuropathy, none of these notations include a medical opinion, rationale, or discussion of relevant medical literature. These notations are outweighed by the April 2021 addendum opinion which includes a more thorough review and detailed discussion of the record, including review and discussion of the notations, as discussed above. The most probative evidence of record does not show that the Veteran's bilateral foot condition is related to service. Accordingly, service connection is not warranted. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Tierno 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.