Citation Nr: 22014408 Decision Date: 03/12/22 Archive Date: 03/12/22 DOCKET NO. 17-51 615 DATE: March 12, 2022 REMANDED Entitlement to service connection for a right great toe fracture claimed as secondary to a service-connected disability, is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from July 1993 to July 1997, served on Active Duty for Training (ACDUTRA) from June 2008 to October 2008, and had additional service in the Army Reserve. This matter is before the Board of Veterans' Appeals (Board) on appeal from a March 2017 rating decision. In November 2019, February 2020, and June 2020, the case was remanded for further development. While the Board sincerely regrets the further delay in resolution of this matter, it finds a remand for further evidentiary development unavoidable. In June 2020 the case was remanded for an adequate medical opinion because a February 2020 opinion was inadequate for rating purposes. As discussed in greater detail below, the Board finds the December 2020 medical opinions received in response to the June 2020 remand less than fully responsive to the remand directives, and inadequate for rating purposes, requiring corrective action. See Stegall v. West, 11 Vet. App. 268 (1998). The Board, in its June 2020 remand, noted that no opinion had been obtained addressing whether the Veteran's right great toe fracture was aggravated by a service-connected disability, to include the right ankle and/or right lower extremity radiculopathy, and directed, in part, to determine whether it was at least as likely as not that any diagnosed right great toe fracture was aggravated beyond its natural progression by a service-connected disability, to include right lower extremity radiculopathy and/or a right ankle disability. The December 2020 VA opinion provider opined (in part) that nerve conditions, such as the Veteran's service-connected right lower extremity sciatica, were not medically known to cause fractures, and because no nexus could be established, a right lower extremity sciatic disorder was less likely to aggravate his right great toe fracture. She then opined that the Veteran's service-connected right ankle disability was separate and distinct from his right great toe fracture (because the ankle joint is anatomically separate and biomechanically independent of the joints of the great toe) and because no nexus could be established, a right ankle disability was less likely to aggravate his right great toe fracture. Subsequent to the December 2020 VA opinion, the Regional Office (RO) requested an addendum opinion because the December 2020 opinion did not address whether the right great toe fracture was aggravated by other service-connected disabilities such as right lower extremity painful scars and right foot degenerative arthritis. In a December 2020 VA addendum opinion, the provider opined, in part, that superficial conditions such as the Veteran's right lower extremity painful scars and the right foot fracture and repair were not known to result in or aggravate skeletal conditions such as fractures. She further opined that degenerative arthritis of the foot was known to be a multifactorial condition, and that with prior trauma, such as the Veteran's right great toe fracture, was identified to accelerate the arthritic process, it was less likely that such condition would be considered an aggravation beyond natural progression. The Board finds the December 2020 VA opinion (with addendum) to be inadequate for multiple reasons. The provider essentially opined (regarding right lower extremity sciatica and a right ankle disability) that because she had found no causal relationship between those disabilities and a right great toe fracture, that each disability was less likely to aggravate a right great toe fracture. Such an opinion is inadequate because a lack of causation between two disabilities does not necessarily mean that one disability could not still aggravate the other. Additional rationale would be needed to support such an opinion. Additionally, in the addendum opinion, it is not clear why a right foot disability would not be able to aggravate a right great toe fracture. Further, on December 2019 VA foot examination, the Veteran reported that his right great toe fracture had worsened due to bone malalignment and an inability to move the toe, and on February 2020 examination, he reported that his right great toe had been worsening over the years with pain occurring daily causing him to alter his gait. Such statements suggest that the right great toe fracture has worsened in severity either due to its own natural progression or has been worsened beyond natural progression, possibly due to an altered gait brought on by one or more service-connected disabilities. Therefore, remand is necessary to obtain an adequate medical advisory opinion to address aggravation. The most recent records of the Veteran's VA treatment in his electronic claims file are from October 2020. Updated records of VA treatment he has received for right great toe fracture are pertinent evidence with respect to the instant claim (and VA records are constructively of record) and must be secured. The matter is REMANDED for the following: 1. Secure for the record all updated VA records since October 2020. 2. Arrange for the record to be forwarded to an appropriate clinician (in orthopedics, if possible) for review and an addendum opinion regarding whether it is at least as likely as not (a 50% or greater probability) that the Veteran's right great toe fracture was aggravated by his service-connected right knee disability, right lower extremity radiculopathy, right ankle disability, and or right foot degenerative arthritis. The Veteran's record (to specifically include the December 2019 examination (with opinion), the February 2020 examination (with opinion) and December 2020 opinions, and any records currently in the claims file or obtained due to the above development which note that the Veteran has a limp or altered gait) must be reviewed by the provider in conjunction with this opinion. (a) If the opinion is that a right great toe fracture was not aggravated by a service-connected right knee disability, right lower extremity radiculopathy, right ankle disability, and or right foot degenerative arthritis, explain why a limp or altered gait (noted in the above-cited treatment records) was not significant enough to have aggravated a right great toe disability, or such an alteration in gate was solely due to the right great toe fracture alone. (b) If the opinion is that service-connected right knee disability, right lower extremity radiculopathy, right ankle disability, and/or right foot degenerative arthritis aggravated a right great toe fracture, specify, to the extent possible, the degree of disability (symptoms and/or impairment) that resulted from such aggravation. The opinion must include complete rationale that cites to factual data and medical principles/medical literature, as deemed appropriate). John R. Doolittle, II Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Bayles, 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.