Citation Nr: 22005136 Decision Date: 02/01/22 Archive Date: 02/01/22 DOCKET NO. 16-41 384 DATE: February 1, 2022 REMANDED Entitlement to service connection for a left foot and ankle disorder is remanded. Entitlement to service connection for a right foot and ankle disorder is remanded. Entitlement to service connection for a back disorder, to include as secondary to bilateral ankle disorders, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1980 to October 1983. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in February 2013 by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In December 2019 and August 2021, the case was remanded for additional development it now returns for further appellate review. 1. Entitlement to service connection for a left foot and ankle disorder. 2. Entitlement to service connection for a right foot and ankle disorder. As noted in the August 2021 remand, the Veteran contends he has current bilateral foot and ankle disorders as a result of multiple in-service ankle strains, to specifically include an injury incurred in May 1981 when he fell from a tank and fractured both ankles, which he asserts was misdiagnosed as a strain. He further states that he has experienced a continuity of bilateral foot and ankle symptoms since service. At such time, the Board observed that the Veteran's service treatment records (STRs) reflect numerous instances of left and right ankle sprains, to include in November 1980, November 1981, February 1982, March 1982, April 1983, May 1983, and June 1983. Further, May 1981 STRs reflect that the Veteran fell from a tank, and was hospitalized for 5 days as he could not ambulate back to the barracks. X-rays were negative for fractures and bilateral ankle sprain was diagnosed. The Veteran was placed in a bilateral short leg walking cast. Additionally, X-rays taken in March 1985 in connection with the Veteran's reenlistment in the Reserve to "evaluate bilateral old fractures" revealed distal metaphysis of the right tibia. The Board further observed that, while a February 2013 VA examination revealed that the Veteran's ankles were clinically normal, VA treatment records reflect diagnoses of tibialis tendinitis, degenerative joint disease (DJD) of the first metatarsophalangeal joint (MTP) of the bilateral feet, plantar fasciitis, and plantar fascial fibromatosis. Thus, in light of the foregoing in-service treatment for relevant complaints and current diagnoses, the Board remanded the claims in order to afford the Veteran a VA examination so as to determine the etiology of his claimed bilateral foot and ankle disorders. Thereafter, at a September 2021 VA examination, no diagnosis of a left or right ankle disorder was rendered and the examiner found that the Veteran's claimed symptoms did not impact his ability to work. In this regard, She noted that the record was silent for a chronic left or right ankle disorder after his military service, and the February 1982 STR included only a differential, rather than definitive, diagnosis of right tibial tendonitis and contemporaneous X-rays were normal. Further, the examiner found that there was no evidence that the Veteran's report of in-service bilateral ankle fractures was substantiated. The examiner further opined that, while the Veteran had current diagnoses of bilateral plantar fasciitis/fibromatosis and DJD of the first MTP, such were less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include his in-service ankle sprains in 1981 and 1982. In support thereof, she observed that he was not diagnosed with plantar fasciitis/fibromatosis until 2013, and indicated that possible risk factors include obesity, prolonged standing, flat feet, and reduced ankle dorsiflexion. In this regard, the examiner observed that the Veteran's bilateral ankle dorsiflexion was normal during range of motion testing on examination, and, while he weighed 158 pounds in service, he weighed 244 pounds with a BMI of 38.2 in 2012. Thus, she found that it was at least as likely as not that the Veteran's bilateral plantar fasciitis is caused by his obesity. With respect to the Veteran's bilateral DJD of the first MTP, the examiner noted that such was first shown on X-ray in 2013, at which time such was an incidental finding, and he had not sought treatment for toe pain or report such on the contemporaneous examination. Thus, she found that it was at least as likely as not that his bilateral DJD of the first MTP were caused by obesity and advancing age. The examiner further stated that the record does not contain a 1985 X-ray indicating distal metaphysis of the right tibia, and the February 1982 X-rays of the ankles were normal without old fractures or osteomalacia. She also noted that a handwritten notation on the February 2013 right ankle X-ray report stating "fragment often from a fracture" was referencing the accessory ossicle and tiny calcific densities. In this regard, the examiner explained that accessory ossicles are common and found often on X-rays, and do not indicate an acute or past fracture. In further support of her opinions, the examiner cited UpToDate articles discussing the risk factors for the development of plantar fasciitis, the nature of first MTP osteoarthritis, the risk factors for osteoarthritis, causes of foot problems, and the nature of accessory ossicles of the foot and ankle. Upon review, the Board finds the opinions rendered by the September 2021 VA examiner to be insufficient to decide the instant claims as she did not adequately address the breadth of the Veteran's in-service ankle injuries or address all relevant evidence of record, to include his reports of a continuity of bilateral foot and ankle symptomatology since service and pertinent in-service and post-service findings. In this regard, the remand directives requested the examiner consider all the Veteran's in-service left and right ankle sprains, to include in November 1980, November 1981, February 1982, March 1982, April 1983, May 1983, and June 1983, and the injury where he fell from a tank, injured his ankles, and required a bilateral short leg case as documented in May 1981 STRs. However, the opinion only stated that the Veteran's bilateral foot disorders were unrelated to his in-service ankle sprains in 1981 and 1982, and is silent as to the Veteran's other documented in-service ankle injuries and his reports continuity of symptomatology. Additionally, as pertinent to the etiology of the Veteran's bilateral DJD of the first MTP, the examiner states that the file does not contain a 1985 X-ray indicating a distal metaphysis of the right tibia. However, March 1985 STRs contain a radiographic report that reflects such diagnosis. Additionally, while the examiner further stated that a differential diagnosis of tibial tendinitis was made in 1982, and there is no further mention of such since that time, VA treatment records reflect a diagnosis of such disorder in April 2013. Finally, the examiner uses the incorrect standard when she concluded the Veteran's bilateral feet and right ankle disorders are at least as likely as not due to obesity and/or advancing age. In this regard, such statement indicates that "obesity and/or advancing age" is 50 percent likely the cause of the Veteran's bilateral foot disorders, and leaves open the possibility that another cause, which may be service-related, is also 50 percent likely the cause of such disorders. Thus, a remand is warranted to obtain an adequate medical opinion that addresses such matters. 3. Entitlement to service connection for a back disorder, to include as secondary to bilateral ankle disorders. The Veteran contends that he has a current back disorder as a result of the aforementioned May 1981 injury or, in the alternative, as a result of his bilateral ankle disorders as such have resulted in multiple falls causing injury to his back. In support of his claim, he submitted an opinion from his VA treating physician in July 2019 in which he indicated that the Veteran had a history of bilateral fractured ankles that directly resulted in his current condition with pain in his, as relevant, lumbar and thoracic spine. Therefore, such claim is inextricably intertwined with the remanded claims for service connection for bilateral foot and ankle disorders, and adjudication of the former must be deferred pending resolution of the latter matter. See Tyrues v. Shinseki, 23 Vet. App. 166, 177 (2009) (en banc) (explaining that claims are inextricably intertwined where the adjudication of one claim could have a significant impact on the adjudication of another claim); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). The matters are REMANDED for the following action: Forward the record, to include a copy of this remand, to an appropriate VA examiner other than the September 2021 examiner in order to render an opinion as to the nature and etiology of the Veteran's claimed bilateral foot and ankle disorders. Thereafter, the examiner should address the following inquiries: (A) State whether the Veteran has a current diagnosis of tibialis tendinitis at any time proximate to his December 2011 claim, even if such is asymptomatic or resolved. In this regard, if the examiner finds that he does not have such a diagnosis, he or she should reconcile such determination with the VA treatment records showing such diagnosis in April 2013. (B) For each diagnosed left and/or right foot and/or ankle disorder, to include bilateral plantar fasciitis/fibromatosis and DJD of the first MTP, and tibialis tendonitis if diagnosed pursuant to (A), offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder had its onset in, or is otherwise related to, the Veteran's military service, to include the left and/or right ankle sprains documented in November 1980, November 1981, February 1982, March 1982, April 1983, May 1983, and June 1983 STRs and/or the injury where the Veteran fell from a tank, injured his ankles, and required a bilateral short leg walking cast as documented in May 1981 STRs. In offering such opinion, the examiner must consider the aforementioned STRs, the March 1985 X-rays undertaken to "evaluate bilateral old fractures," which revealed distal metaphysis of the right tibia, and the Veteran's reports of a continuity of bilateral foot and ankle symptomatology since service. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. M. Kelly, 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.