Citation Nr: 22017100 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 17-54 358 DATE: March 24, 2022 REMANDED Entitlement to service connection for right knee condition is remanded. Entitlement to service connection for a bilateral foot disability, to include plantar fasciitis, is remanded. Entitlement to service connection for low back condition is remanded. REASONS FOR REMAND The Veteran had active service from April 2011 July 2014. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) which denied service connection for herniated bulging disc (claimed as low back condition), right knee condition, and plantar fasciitis. 1. Entitlement to service connection for right knee condition is remanded. 2. Entitlement to service connection for a bilateral foot disability, to include plantar fasciitis, is remanded. The Veteran asserts that his right knee condition and bilateral plantar fasciitis are causally related to the boots he wore during service, as well as ruck marches and running. At his separation examination, the Veteran reported bilateral foot pain caused by his boots and knee pain and instability. He further reported that he has not sought treatment for his knee pain and instability during service. The separation examination report noted that the Veteran had a history of plantar fasciitis but had not been seen within the past two years for the condition. The Veteran was afforded VA examinations in April 2015 for both conditions. Although the Veteran reported that his right knee buckled, especially when running, the examiner determined that upon examination, the Veteran did not have a diagnosable condition. The examiner noted that there were no service treatment records that indicated a knee condition. While the examiner noted the separation examination report notation that the Veteran had a history of plantar fasciitis, upon examination, the examiner did not find a current diagnosis of plantar fasciitis. An April 2015 VA treatment record shows that the Veteran was instructed to wear insoles in his shoes for his bilateral plantar fasciitis. See CAPRI, received May 2015. The Veteran underwent right knee replacement ACL surgery in April 2017. See CAPRI, received July 2018. The Veteran was treated for acute right knee pain and diagnosed with tendonitis in February 2019. The Veteran was also diagnosed with chronic osteoarthritis of the right knee in April 2019. See CAPRI, received April 2019. Based on the diagnoses indicated in VA treatment records associated with the claims file after the April 2015 VA examination, additional VA examinations are required for adequate determinations of whether the Veteran has a right knee or bilateral foot disability, to include plantar fascitis, that is related to service. 3. Entitlement to service connection for low back condition is remanded. The Veteran contends that his chronic low back pain began while he was in service. Service treatment records show that the Veteran was first treated for lower back pain with pain that radiated down to his hips and legs in June 2013. He reported that he had experienced low back pain for approximately nine or ten months. He continued to report low back pain and seek treatment for the pain throughout the rest of his time in active service. Moreover, he was diagnosed with bulging lumbar disc and acute back pain in February 2014. See Medical Treatment Record Non-Government Facility, received May 2015. The Veteran was afforded a VA examination in April 2015. The Veteran reported experiencing chronic back pain since service and mentioned a computed tomography (CT) image that was taken which showed that he had a herniated disc. The examiner noted in the remarks section of the examination report that claims file did not include a copy of the CT image the Veteran mentioned. The examiner then determined that at the time of the exam, the Veteran did not have any diagnosable back condition and did not provide a nexus opinion. Since the April 2015 VA examination, the Veteran has been diagnosed with lumbar radiculopathy and chronic osteoarthritis of the lumbar spine. See CAPRI, received September 2018 and April 2019. As the April 2015 examiner did not address the Veteran's February 2014 diagnoses of bulging lumbar disc and acute back pain because the private medical records had not been yet been obtained and associated with the claims file, or the diagnoses of lumbar radiculopathy and chronic osteoarthritis of the lumbar spine which were subsequently diagnosed, the issue of service connection for low back condition should be remanded for a new examination to identify any low back disability the Veteran currently has or had at any time during the appeal period, and to determine whether any diagnosed low back disability is related to the low back pain that the Veteran reported and sought treatment for during service. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his claimed bilateral foot disability, to include plantar fasciitis. The examiner must review the claims file. After reviewing the claims file, considering the lay evidence of record, and examining, the examiner should address the following: (a.) Identify/diagnose any disability of the foot, including bilateral plantar fasciitis, that presently exists or that has existed during the appeal period. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. A negative determination, i.e., no disability or functional impairment of the feet, must be reconciled with VA treatment records from May 2015 to June 2018 that list bilateral plantar fasciitis as an active problem. Such should also include discussion as to whether plantar fasciitis resolved during the appeal period. (b.) For any disorder of the feet identified during the appeal period, is it at least as likely as not (approximately a 50 percent or greater probability) related to service, including in-service bilateral foot pain and plantar fasciitis, for which the Veteran was noted as having a history of in the March 2014 separation examination report. A full rationale must be provided for any opinion offered and a thorough explanation would be helpful for the Board. Reference to findings from identified studies is preferred over reference to medical literature in the abstract. If the examiner relies on his or her medical experience as a rationale, it is appropriate to identify the specifics such as an estimate of the number of patients the examiner has seen with similar conditions, the time the examiner had been practicing in the field, or any relevant specialized education or training experiences that go beyond the examiner's degree or accreditation. 2. Schedule the Veteran for a VA examination for his right knee condition. The examiner must review the claims file. After reviewing the claims file, considering the lay evidence of record, and examining, the examiner should address the following: (a.) Identify/diagnose any disability of the right knee that presently exists or that has existed during the appeal period. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. A negative determination, i.e., no disability or functional impairment of the right knee, must be reconciled with treatment records from February 2019 that diagnosed the Veteran with tendonitis and from April 2019 that diagnosed the Veteran with chronic osteoarthritis of the right knee. Such should also include discussion as to whether right knee tendonitis and osteoarthritis of the right knee resolved during the appeal period. (b.) For any disorder of the right knee identified during the appeal period, is it at least as likely as not (approximately a 50 percent or greater probability) related to service, including right knee pain that the Veteran reported during his March 2014 separation examination. A full rationale must be provided for any opinion offered and a thorough explanation would be helpful for the Board. Reference to findings from identified studies is preferred over reference to medical literature in the abstract. If the examiner relies on his or her medical experience as a rationale, it is appropriate to identify the specifics such as an estimate of the number of patients the examiner has seen with similar conditions, the time the examiner had been practicing in the field, or any relevant specialized education or training experiences that go beyond the examiner's degree or accreditation. 3. Schedule the Veteran for a VA examination for his low back condition. The examiner must review the claims file. After reviewing the claims file, considering the lay evidence of record, and examining, the examiner should address the following: (a.) Identify/diagnose any disability of the low back that presently exists or that has existed during the appeal period. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. A negative determination, i.e., no disability or functional impairment of the low back, must be reconciled with the private treatment records from February 2014 that diagnosed the Veteran with bulging lumbar disc and acute back pain, and the VA treatment records from September 2018 that diagnosed the Veteran with lumbar radiculopathy, and from April 2019 that diagnosed the Veteran with chronic osteoarthritis of the lumbar spine. Such should also include discussion as to whether any of these diagnoses resolved during the appeal period. (b.) For any disorder of the low back identified during the appeal period, is it ast least as likely as not (approximately a 50 percent or greater probability) related to service, including chronic low back pain reported throughout active service beginning June 2013 and the February 2014 diagnosis of bulging lumbar disc. A full rationale must be provided for any opinion offered and a thorough explanation would be helpful for the Board. Reference to findings from identified studies is preferred over reference to medical literature in the abstract. If the examiner relies on his or her medical experience as a rationale, it is appropriate to identify the specifics such as an estimate of the number of patients the examiner has seen with similar conditions, the time the examiner had been practicing in the field, or any relevant specialized education or training experiences that go beyond the examiner's degree or accreditation. K. MARENNA Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Fairlie, 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.