Citation Nr: 25005451 Decision Date: 04/23/25 Archive Date: 04/23/25 DOCKET NO. 19-15 296 DATE: April 23, 2025 REMANDED Entitlement to service connection for a right foot disability is remanded. Entitlement to service connection for a left foot disability is remanded. Entitlement to service connection for a skin disability is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1972 to August 1976. These matters come before the Board of Veterans' Appeals (Board) from a February 2019rating decision. The Veteran testified before the Board at a hearing in June 2020. A transcript of the hearing has been associated with the claims file. Most recently, in March 2024, the Board remanded the Veteran's claim to obtain VA medical opinions. The claim has since been returned to the Board for review. Although the Board regrets the delay in yet another remand, for the reasons discussed below, the agency of original jurisdiction (AOJ) has not substantially complied with the remand directives, and the claims must be remanded again. Stegall v. West, 11 Vet. App. 268 (1998). 1. Entitlement to service connection for a right foot disability. 2. Entitlement to service connection for a left foot disability. October 2024 and December 2024 negative nexus opinions obtained on remand again fail to provide a reasoned medical explanation connecting the facts to the provided negative nexus conclusions. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Additionally, while the examiner reviewed the Veteran's statements of foot pain in service, the opinion improperly discounts these statements based on the lack of medical records in service or since without explaining the medical significance of the lack of notation of a medical condition or symptoms. See Buczynski v. Shinseki, 24 Vet. App. 221 (2011). 3. Entitlement to service connection for a skin condition on feet (claimed as fungus on feet). The negative October 2024 VA opinion on direct service connection obtained on remand is conclusory as it is not supported by sufficient facts and an analysis that the Board can consider and weigh against contrary opinions. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). The opinion simply states the Veteran's diagnosed onychomycosis was not noted in service or shortly after and is a fungal infection different from his in-service blisters which are due to acute overuse. Again, the opinion does not address the Veteran's statements that the itching started in service and has continued since or that this was due to the socks worn and that his feet sweated a lot. The medical opinion fails to explain the medical significance of the lack of notation of a medical condition or symptoms in service or shortly after. See Buczynski, 24 Vet. App. at 224. Additionally, the October 2024 medical opinion notes a factor of onychomycosis onset is poor hygiene, which was further explained in a December 2024 toxic exposure risk activity (TERA) opinion, to include sweating and humid conditions in boots. The Board notes the VA examinations do not contain notations of the Veteran's poor hygiene. Further, the opinion citing sweating and humid boot conditions indicates a positive connection between the Veteran's testimony regarding in-service sweaty feet and his currently diagnosed onychomycosis. Remand is required to address this evidence. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate clinician to determine the nature and likely etiology of the Veteran's diagnosed bilateral metatarsalgia and right foot hallux valgus. Copies of all pertinent records should be made available to the examiner for review. If the examiner determines that an opinion cannot be provided without an examination, one should be scheduled. After reviewing the pertinent records, the examiner is asked to answer the following: Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's bilateral metatarsalgia or right foot hallux valgus began in or was due to service? In providing the requested opinion, the examiner must consider and discuss all pertinent medical and lay evidence of record, and specifically address the August 2018 VA examination documenting the Veteran's reports that his foot pain began with frequent marching during service and has since stayed the same, and the Veteran's June 2020 Board hearing testimony that he may have injured his feet when he jumped out of a truck during service. A notation that the Veteran's assertions were read and considered is insufficient. The examiner must provide a reasoned medical explanation concerning the Veteran's testimony of in-service events and the relation, if any, to his current diagnoses. Notably, the absence of documented evidence of a diagnosis or associated symptoms during service or shortly after service should not, alone, serve as the sole basis for a negative opinion without explanation as to the medical significance of such a finding. 2. Obtain an addendum medical opinion from an appropriate clinician to determine the nature and likely etiology of the Veteran's onychomycosis. Copies of all pertinent records should be made available to the examiner for review. If the examiner determines that an opinion cannot be provided without an examination, one should be scheduled. After reviewing the pertinent records, the examiner is asked to answer the following: Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's onychomycosis began in or was due to service? In providing the requested opinion, the examiner must consider and discuss all pertinent medical and lay evidence of record, and specifically address the December 2024 TERA opinion regarding the causes of onychomycosis, to include poor hygiene and sweating humid feet, and the lack of evidence showing the Veteran has poor foot hygiene and his testimony of sweaty feet in service. Notably, the absence of documented evidence of a diagnosis or associated symptoms during service or shortly after service should not, alone, serve as the sole basis for a negative opinion without explanation as to the medical significance of such a finding. A complete rationale must be provided for all opinions, citing to supporting factual data and medical literature, as appropriate. If the examiner cannot provide an opinion without resort to speculation, the examiner must state why and what, if any, additional evidence would permit such an opinion to be made. M.E. Larkin Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Wayne, 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.