Citation Nr: 22013318 Decision Date: 03/09/22 Archive Date: 03/09/22 DOCKET NO. 17-34 961 DATE: March 9, 2022 REMANDED Entitlement to service connection for a right foot condition, to include gout, is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army from July 1976 to July 1998. This case comes before the Board of Veterans' Appeals (Board) on appeal from a January 2017 legacy rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ) before a virtual videoconference hearing. A transcript of the hearing is of record. In April 2021, the Board remanded the Veteran's claim for additional development. The Board notes that there was not substantial compliance with its April 2021 remand directives See Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). As noted above, in April 2021, the Board remanded the Veteran's claim for further development, specifically requesting that an addendum VA medical opinion be provided due to the inadequacy of the June 2017 negative nexus VA medical opinion. Within the remand directives, the Board directed that the examiner must specifically discuss the following in the requested addendum opinion: The Veteran's reports of the complaint of swollen or painful joints found in the February 1998 discharge exam included his right foot pain, with symptoms that have continued ever since service; as well as, discuss the specific notation of the Veteran's gout having a diagnosed onset of 1994, a period of active duty service, found in the June 2017 VA examinations. In December 2021, the Veteran was provided a VA foot examination, where the examiner diagnosed the Veteran with right foot gout, and described the history of the condition as starting in 1994 with symptoms of pain, however, provided unfavorable nexus medical opinions as to this condition having an onset during active duty service and/or being related to the Veteran's active duty service. Subsequently, an addendum VA medical opinion was provided in December 2021 that reiterated the unfavorable nexus opinions. Nevertheless, the Board finds these medical opinions to be inadequate, as this examiner, once again, failed to discuss the specific notation of the Veteran's gout having a diagnosed onset in 1994, a period of active duty service, found in the June 2017 VA examinations. In fact, instead of discussing the onset diagnosis given by the June 2017 VA examiner, this examiner noted that the onset was given by a lay letter, and changed the onset of the Veteran's gout to be in 1999 and in June 2016, outside of the Veteran's active duty service, without any further discussion on how these new dates supersede the 1994 onset date given in June 2017, especially given that this examiner personally noted in the December 2021 VA examination medical history that the Veteran's gout began in 1994 with symptoms of pain. Additionally, the examiner failed to discuss the Veteran's reports of the complaint of swollen or painful joints found in the February 1998 discharge exam included his right foot pain, with symptoms that have continued ever since service, as it relates to a possible nexus to service. Instead, the examiner noted that the February 1998 complaint was for the Veteran's right knee and not foot, with a mere notation of the February 1998 discharge physical noting swollen right foot joint and symptoms that has continued ever since separation as it related to a nexus for the Veteran's diagnosed right foot hallux valgus, but not for his right foot gout. Lastly, the Board notes that the examiner partially rationalized that the etiology of gout is determined by elevated uric acid levels, noting that the Veteran's levels were normal in 1993, 1994, and 2021, and therefore, a nexus cannot be established. However, the Board finds this rationalization to be contradictory to the examiner's further statements (noting that a person can have normal uric acid levels by taking medication (Allopurinol) and/or following a low protein diet, and therefore, medical literature states that gout is determined based on prior history of attack and not by elevated uric acid levels), and thus, irrelevant given the examiner's explanation, and given that the examiner himself noted the Veteran has previously and is currently taking Allopurinol, which explains his normal uric acid levels. Therefore, based on the above, the Board finds that the Veteran should be provided an additional addendum VA medical opinion that adequately addresses the etiology of his claimed condition, in accordance with VA's duty to assist and in compliance with Stegall. Accordingly, a remand is necessary to address the matters discussed above. The matters are REMANDED for the following action: 1. Request the Veteran to identify all medical providers (VA and private) from whom he has received treatment for his right foot gout and obtain any outstanding records and associate them with the Veteran's claims file. 2. After associating all newly acquired records with the claims file, send the claims file back to the December 2021 VA examiner to provide the Veteran with an addendum VA medical opinion to determine the nature and etiology of the Veteran's right foot gout. If the December 2021 VA examiner is not available, obtain the necessary addendum opinions from another appropriate clinician. The entire claims file, including a copy of this remand, must be made available to the examiner, and note review of the record in the examination report. Any indicated tests or studies should be performed, and all material relevant evidence should be discussed. All pertinent medical complaints, symptoms, and clinical findings must be reported in detail. The Veteran should be scheduled for another examination if deemed necessary by the person providing the addendum report to address the following: (a) Opine whether it is at least as likely as not (50 percent or greater probability) the Veteran's right foot gout had its onset during any period of active duty service, or is otherwise etiologically related to his active duty service, to include the in-service complaint of swollen or painful joints on the February 1998 discharge examination. Please note: the examiner must specifically discuss the Veteran's reports of the complaint of swollen or painful joints found in the February 1998 discharge exam included his right foot pain, with symptoms that have continued ever since service; as well as, discuss the specific notations of the Veteran's right foot gout having a diagnosed onset of 1994, a period of active duty service, found in the June 2017 and December 2021 VA examinations. (b) Any opinion should include a detailed rationale. The examiner should consider the entire claims file and discuss the Veteran's lay statements regarding the nature and onset of symptoms. The examiner is advised that the Veteran is competent to report symptoms, and that he is reports must be considered in formulating the requested opinion. (c) If the examiner(s) is unable to offer the requested opinion(s), it is essential that the examiner offer a rational for the conclusion that an opinion could not be provided without resorting to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382. (2010). DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Carter, 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.