Citation Nr: 25005641 Decision Date: 04/24/25 Archive Date: 04/24/25 DOCKET NO. 18-05 972 DATE: April 24, 2025 ORDER Service connection for left foot hallux valgus, post-surgical, is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, her left foot hallux valgus, post-surgical, was aggravated beyond its normal progression by her active duty service. CONCLUSION OF LAW The criteria for service connection for left foot hallux valgus, post-surgical, have been met. 38 U.S.C. §§ 1131, 1153, 5107; 38 C.F.R. §§ 3.303, 3.306. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty for training (ACDUTRA) from October 1988 to March 1989; she served on active duty from October 2001 to April 2002 and from March 2008 to March 2009. This matter is before the Board of Veterans' Appeals (Board) on appeal from March 2015 and May 2015 rating decisions issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing held before the undersigned Veterans Law Judge in February 2021; a transcript is of record. In July 2021, the Board remanded the claim for additional development. In May 2022, the Board denied the claim. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In January 2023, the Court granted a joint motion for remand (JMR), vacating and remanding the May 2022 Board decision. The Board remanded the claim in May 2023 and October 2024 for further development. The case now returns to the Board for appellate review. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Generally, a veteran is presumed to be in sound condition, except for defects, infirmities or disorders noted when examined, accepted, and enrolled for service. 38 U.S.C. §§ 1111, 1137; 38 C.F.R. § 3.304(b). A pre-existing injury or disease will be considered to have been aggravated by active military, naval, or air service, where there is an increase in disability during such service, unless a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a). Aggravation may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). 1. Service connection for left foot hallux valgus, post-surgical, is granted. The Veteran stated at the February 2021 Board hearing that the specific foot condition she is seeking service connection for bunions on her feet. See February 2021 Hearing Transcript at 10. She has been diagnosed with bilateral hallux valgus, post-surgical. See January 2024 and April 2024 VA contract examinations. She stated that her bilateral foot condition started in 1991 while in the Army Reserve, and that it has progressed throughout her military career. See February 2016 notice of disagreement (NOD). She stated that "when wearing boots in 2008-2009, the more I walked the worse it [bilateral foot condition] got." See October 2017 VA examination. The record shows the Veteran's left post-surgical bunion/hallux valgus pre-existed active service. A June 1991 Reserve record shows a complaint of a bruise on the bottom of her left foot; the clinician noted that pain occasionally radiated from the ball of the foot to 2nd and 3rd toes. An April 1998 Report of Medical History (RMH) noted pain in the left foot toe area. In a July 2002 RMH, the examining clinician noted that the Veteran had bilateral bunion surgery in 1993. In a March 2007 RMH, the Veteran noted "Bunion surgery, metatarsal pain left foot w/surgery. Fractured 2nd toe on right foot, occasionally reoccurs"; the examining clinician noted "L foot bunion surgery in 1993. Pain, numbness, tingling on bottom of foot after removed 'another lump.' Aggravated with running." The question for the Board is whether the Veteran's pre-existing left foot hallux valgus, post-surgical, was aggravated during active service. The Veteran's service treatment records during the two periods of active service do not reveal any complaints or treatments for bunion/hallux valgus in her feet. The Board previously found that the medical opinions of record were inadequate and in October 2024 remanded the claim for an addendum medical opinion. The examiner was asked whether the Veteran's left foot hallux valgus, which existed prior to service, at least as likely as not increased in severity during either subsequent period of active duty (i.e., from October 2001 to April 2002 or from March 2008 to March 2009), and if so, whether the increase was clearly and unmistakably due to the natural progress of the disease. The examiner was to consider the Veteran's lay assertion from the January 2024 exam that she had sensitivity in the bunion area in 2008 but toughed it out. Addendum opinions were obtained in November 2024 and February 2025. In the November 2024 VA addendum opinion, the examiner marked the check box for favorable opinion; she clarified in the February 2025 opinion that the Veteran's left foot hallux valgus was less likely than not aggravated during either subsequent period of active duty. She provided the following three paragraphs as her rationale: Review of C file reveals that Veteran first documented foot pain in 1998. This was likely present prior to her hallux valgus surgery. Foot surgery was not documented until the completed in July 2002. On that same date, she had a medical exam where tenderness was documented while weight bearing and she was on permanent profile for metatarsal pain. Permanent profile likely occurred after having chronic pain that was not responsive to treatment. It is noted that Veteran did not specifically complain of pain in the surgical area and the exact area of pain and tenderness is not specifically defined in the available documentation from 2002. Evidence of a flare up in left foot pain is found in July 2002 and she was on permanent profile at that time indicating that she had been having foot pain for more than an acute episode. The only information available to consider from July 2002 (3 months after active duty) related to symptoms in the left foot is that she had "metatarsalgia" and "tenderness" while walking and running. The area of the foot affected is not documented. Because the area of the postsurgical left hallux valgus is not identified as the problematic area, it is unlikely that this was aggravated specifically. Metatarsalgia is a symptom that can encompass the ball of the foot, not just the first MTP [metatarsophalangeal] joint. Tenderness is likely from a skin abrasion or soft tissue inflammation, and again, the area is not identified. No evidence is found in C file of an aggravation in left foot hallux valgus, postsurgical during active duty March 2008- March 2009. Exam of January 2024 statement of sensitivity in bunion area in 2008 is considered. Overuse of the left foot with footwear of any kind, including military boots, can cause sensitivity in the area of the bunion surgery particularly at the scar. The nature, duration, and severity of the sensitivity reported is not clear. Walking with no shoes can also cause sensitivity. Sensitivity in "the bunion area" could also indicate the discomfort that was diagnosed as metatarsalgia. The vague nature of the symptom makes the determination of aggravation of left hallux valgus, postsurgical without clear nexus. Veteran did not discuss postsurgical issues from left hallux valgus surgery when she saw Podiatry in 2010. In the February 2025 VA addendum opinion, the examiner provided the following additional rationale: Evidence available, which is vague in nature, does not specifically support that hallux valgus increased in severity unmistakably due to the natural progress of the disease. It is not clear in subjective report if the skin/soft tissue was affected by military boots, if the discomfort was in a specific part of the joint, or if a deformity was thought to be developing. Evidence is lacking to support this claim of aggravation related to left hallux valgus due to natural progress of disease. Increase in severity of Hallux valgus, diagnosed as left hallux valgus, is less likely than not due to natural progress of disease. Upon review, resolving any doubt in the Veteran's favor, the Board finds that the Veteran's left foot hallux valgus, post-surgical, was aggravated beyond its normal progression by her active duty service. Although the November 2024 and February 2025 addendum opinions appear unfavorable, some of the contents in the rationale support the Veteran's claim. For instance, the examiner stated in the November 2024 opinion that although the July 2002 record noted metatarsalgia and tenderness in her left foot, as left hallux valgus was not specified as the problematic area, it does not indicate aggravation. While the examiner is trying to rule out left hallux valgus as one of the problematic areas, she at the same time fails to explain why left hallux valgus could not be one those areas. She further stated that metatarsalgia is a symptom that can encompass the ball of the foot, not just the first MTP joint. Similarly, she is trying to rule out left hallux valgus, but she is at the same time acknowledging that metatarsalgia could have included hallux valgus. More importantly, she made statements such as "Overuse of the left foot with footwear of any kind, including military boots, can cause sensitivity in the area of the bunion surgery particularly at the scar," and "Sensitivity in 'the bunion area' could also indicate the discomfort that was diagnosed as metatarsalgia." The Board finds these statements lend support to the Veteran's claim. The February 2025 opinion also lends support to the Veteran's claim. This opinion was in response to the Board's question as to whether the increase in severity, if any, was clearly and unmistakably due to the natural progress of the disease. If the increase was due to natural progress of the disease, it would be unfavorable to the Veteran. However, the examiner consistently stated that the evidence of record does not show that the left hallux valgus increased in severity unmistakably due to the natural progress of disease. This leaves the possibility that the increase in severity was due to her active service. Given the foregoing, the Board finds that there is an approximate balance of positive and negative evidence regarding aggravation of the Veteran's pre-existing left foot hallux valgus, post-surgical, during her active service. Resolving all reasonable doubt in the Veteran's favor, service connection for left foot hallux valgus, post-surgical, is granted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102 Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021). D. JOHNSON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Jake Choi, Attorney Advisor 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.