Citation Nr: 18131232 Decision Date: 08/31/18 Archive Date: 08/31/18 DOCKET NO. 15-28 951 DATE: August 31, 2018 ORDER Entitlement to service connection for a low back disability is denied. Entitlement to service connection for a bilateral knee disability is denied. Entitlement to an evaluation in excess of 30 percent for plantar fasciitis with degenerative arthritis of both feet is denied. REMANDED Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for an eye disability, to include iritis with vision loss, is remanded. Entitlement to service connection for hypertension, to include as secondary to service-connected other specified trauma and stressor related disorder, is remanded. Entitlement to service connection for a bilateral wrist disability, to include carpal tunnel syndrome, is remanded. Entitlement to an initial evaluation in excess of 10 percent for degenerative changes of the left first (big) toe is remanded. FINDINGS OF FACT 1. The competent and credible evidence does not demonstrate that the Veteran’s currently diagnosed lumbar spine degenerative joint disease (DJD) had its onset during active duty service, manifested within one year of separation from service, or is otherwise etiologically related to service. 2. The competent and credible evidence does not demonstrate that the Veteran’s currently diagnosed bilateral knee osteoarthritis had its onset during active duty service, manifested within one year of separation from service, or is otherwise etiologically related to service. 3. Throughout the relevant appeal period, the evidence demonstrates that the Veteran’s plantar fasciitis with degenerative arthritis of both feet manifests symptoms bilaterally of pain on use and pain accentuated on use, but symptoms are not relieved by arch supports. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a low back disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. The criteria for entitlement to service connection for a bilateral knee disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 3. The criteria for entitlement to an evaluation in excess of 30 percent for plantar fasciitis with degenerative arthritis of both feet have not been met. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.10, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5276. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from June 1978 to December 1999. These matters come before the Board of Veterans’ Appeals (Board) on appeal from rating decisions in May 2014 and January 2015 by the Department of Veterans Affairs (VA) Regional Office (RO). In the May 2014 rating decision, the RO, in pertinent part, denied service connection for a right ankle disability; a right knee disability; a left knee disability; hypertension; carpal tunnel syndrome of the left upper extremity; carpal tunnel syndrome of the right upper extremity; iritis with vision loss; and a low back disability. The Veteran appealed that decision. In the January 2015 rating decision, the RO, in pertinent part, granted service connection for degenerative changes of the left first (big) toe and assigned a 10 percent evaluation, effective June 20, 2014; and denied a higher than 10 percent evaluation for plantar fasciitis with degenerative arthritis of the both feet. The Veteran appealed for higher evaluations. During the pendency of the appeal, the RO issued a July 2016 rating decision, in pertinent part, granting a 30 percent evaluation for plantar fasciitis with degenerative arthritis of both feet, effective June 20, 2014. The Veteran continues to appeal for a higher evaluation for plantar fasciitis with degenerative arthritis of both feet. AB v. Brown, 6 Vet. App. 35 (1993) (holding that a claimant is presumed to be seeking the maximum rating). The Veteran testified before the undersigned Veterans Law Judge at a June 2017 Central Office hearing. A transcript of this hearing is of record. Although the issues certified to the Board were for iritis with vision loss, carpal tunnel syndrome of the right upper extremity, and carpal tunnel syndrome of the left upper extremity, in light of Clemons v. Shinseki, 23 Vet. App. 1 (2009), the issues have been recharacterized as reflected on the title page to comport with the record. Following the most recent July 2016 statement of the case, the Veteran submitted additional evidence in support of his appeal. The Veteran filed his substantive appeals in August 2015 and September 2016. Accordingly, under the Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, this evidence is subject to initial review by the Board because the Veteran did not request in writing that the Agency of Original Jurisdiction (AOJ) initially review such evidence. See 38 U.S.C. § 7105(e)(1). The Board acknowledges that the Veteran has filed a Notice of Disagreement on the issues of entitlement to higher evaluations for tinea versicolor, tinea pedis, and tinea unguium; and entitlement to service connection for a right big toe disability, characteristic callosities of the right foot, and characteristic callosities of the left foot. While it would be appropriate to remand the higher evaluation claim and service connection claims for issuance of a statement of the case under Manlincon v. West, 12 Vet. App. 238 (1999), a review of the record reveals that the AOJ is still taking action on these issues. As such, the Board will not accept jurisdiction over them at this time, but they will be the subject of a subsequent Board decision, if otherwise in order. While the Veteran was previously represented by an attorney regarding his claims, in a September 2015 written notice, the attorney advised both VA and the Veteran that he was withdrawing representation. In December 2015, the Veteran submitted a VA Form 21-22a appointing McCail Smith Jr. pursuant to 38 C.F.R. § 14.630. This provision allows for representation by an individual unaccredited by VA for one time only. The Veteran completed the necessary requirements with the filing of VA Form 21-22a in December 2015, signed by him and the representative, stating that no compensation would be paid or charged for the services. 38 C.F.R. § 14.630(a). The Board recognizes this change in representation. Duties to Notify and Assist Pursuant to the Veterans Claims Assistance Act (VCAA), VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C. §§ 5102, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156(a), 3.159. Neither the Veteran nor his/her representative have raised any issues with the duty to notify or duty to assist. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Service Connection The Veteran contends that his current low back disability and bilateral knee disability developed due to his in-service duties as a Yeoman in the U.S. Navy. In particular, the Veteran described how, while serving aboard a naval ship, he had to carry heavy boxes of paper and other supplies up and down the ladders of six decks, to move and relocate office equipment and supplies, and to lift and maneuver cleaning equipment during inspections. The Veteran also reported being assigned to working parties in which in he had to carry loads of the ship’s supplies during replenishments. During operational exercises, the Veteran assisted with lifting and handling firefighting equipment. As part of his service, the Veteran also noted that he had to endure physically rigorous activities, including running and exercising on metal or steel decks, to maintain his weight and health. Overall, the Veteran asserts that his back and knees deteriorated due to the wear and tear on his body caused by his duties during service. See June 2013, June 2014, and September 2014 statements and June 2017 Board hearing transcript. At his June 2017 Board hearing, the Veteran testified that he first noticed his back symptoms in 2000. With regard to his knees, he said that he had experienced continuous problems with his knees since service. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. That presumption is rebuttable by probative evidence to the contrary. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may establish service connection if a claimant can demonstrate (1) that a condition was "noted" during service; (2) there is post-service evidence of the same symptomatology; and (3) there is medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007). 1. Entitlement to service connection for a low back disability The question before the Board is whether the Veteran’s currently diagnosed lumbar spine DJD is etiologically related to his active duty service. Additionally, as a chronic disease, the Board must also address whether service connection for arthritis is warranted on a presumptive basis. Based on a careful review of all the subjective and clinical evidence, the preponderance of the evidence weighs against finding service connection for a low back disability is warranted. The evidence shows that the Veteran has a current diagnosis for lumbar spine DJD. See March 2015 VA opinion. The record includes conflicting medical opinions concerning whether the Veteran’s current low back disability is etiologically related to his active duty service. With regard to the medical opinions obtained, as with all types of evidence, it is the Board’s responsibility to weigh the conflicting medical evidence to reach a conclusion as to the ultimate grant of service connection. Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). The Board may favor the opinion of one competent medical expert over another if its statement of reasons and bases is adequate to support that decision. Owens v. Brown, 7 Vet. App. 429, 433 (1995). Stated another way, the Board decides, in the first instance, which of the competing medical opinions or examination reports is more probative of the medical question at issue. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). According to a September 2014 opinion by the Veteran’s VA treating physician, the Veteran sustained an injury to his back during service, which at least as likely as not led to the current arthritic changes in his back. However, in making this determination, the VA treating physician did not provide any supporting rationale. There was no discussion of the lack of back complaints documented or reported during service. Moreover, the VA treating physician failed to explain how the Veteran’s in-service duties specifically impacted his back causing sufficient injury to result in him developing his current low back disability. Considering that the September 2014 VA treating physician’s opinion was based on no rationale, the opinion is deemed conclusory, and thus, it provides little probative value. See Nieves-Rodriguez, 22 Vet. App. 295 (2008). By contrast, the record includes a March 2015 VA opinion, which was based on a review of the Veteran’s medical records, including his service treatment records (STRs) and an August 2014 MRI report, consideration of his lay contentions regarding his in-service duties as well as the onset of his back symptoms, and supported by a fully reasoned analysis. The March 2015 VA examiner opined that the Veteran’s currently diagnosed lumbar spine DJD was less likely than not related to his military service. In that regard, the VA examiner noted that there were no documented reports of back pain during service, and the Veteran reported that his back symptoms did not begin until a year after his discharge. Acknowledging the Veteran’s contentions that his weight bearing activities had caused his current low back disability, the VA examiner found no medical literature to support the assertion that such activities had caused his DJD. Rather, the VA examiner explained that degenerative changes of the spine are very common in this Veteran’s age demographic and such changes, by themselves, do not prove injury from service. As the March 2015 VA examiner’s opinion is based on a reasoned analysis, including reference to medical literature, and consideration of the Veteran’s complete medical history as well as his contentions, the Board concludes that this opinion is more persuasive concerning the etiology of the Veteran’s low back disability. Accordingly, the Board finds that service connection for the Veteran’s low back disability is not warranted on a direct basis. As arthritis is a chronic disease under 38 C.F.R. § 38 C.F.R. § 3.309(a), the Board has also considered whether the Veteran is entitled to presumptive service connection under 38 C.F.R. § 3.307(a)(3). However, the clinical evidence demonstrates that the earliest record documenting evidence of lumbar spine arthritis was in 2014, according to an August 2014 MRI report, almost 15 years after his separation from service. The Veteran’s STRs do not reflect any treatment or diagnosis for any back problems. Notably, the Veteran reported that his back symptoms did not have their onset until at least one year after his discharge. Moreover, his available post-service treatment records from 2010 to 2014 reflect only sporadic treatment for generalized complaints of low back pain. Thus, the Board finds that the evidence does not show that the Veteran’s current lumbar spine arthritis manifested within one year of discharge; nor does it show that he had continuous symptoms of arthritis following service. Accordingly, service connection on a presumptive basis for the Veteran’s lumbar spine arthritis is not warranted. Finally, while lay evidence may be competent to establish a medical etiology or nexus, the Veteran has not demonstrated that he has the requisite specialized knowledge or training to relate his current lumbar spine DJD to the asserted wear and tear he endured from the physical demands of his in-service duties. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Therefore, the Board finds that the Veteran's lay assertion is not competent to provide an opinion as to the etiology of his low back disability, and thus, offers little probative value. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s service connection claim for a low back disability on a direct or presumptive basis. Therefore, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for a bilateral knee disability The question before the Board is whether the Veteran’s currently diagnosed bilateral knee osteoarthritis is etiologically related to his active duty service. Additionally, as a chronic disease, the Board must also address whether service connection for arthritis is warranted on a presumptive basis. Based on a careful review of all the subjective and clinical evidence, the preponderance of the evidence weighs against finding service connection for a bilateral knee disability is warranted. The evidence shows that the Veteran has a current diagnosis for bilateral knee osteoarthritis. See September 2014 VA Primary Care Note. The record includes conflicting medical opinions concerning whether the Veteran’s current bilateral knee disability is etiologically related to his active duty service. The Veteran presented a September 2014 opinion from his VA treating physician addressing the etiology of his bilateral knee disability. Finding that the years of physical activity, including the running and working on ships with steel decks and ladders, had worn down his knees due to impact, the VA treating physician opined that it was at least as likely as not that the Veteran’s injuries sustained during service had led to the current arthritic changes in his knees. Although the VA treating physician noted the radiologic findings which verified the Veteran’s current arthritis, the VA treating physician did not identify any clinical evidence during or following service to support his conclusion. Nor did the VA treating physician indicate that he had reviewed the Veteran’s STRs. Therefore, the Board finds that the September 2014 opinion is not based on a complete rationale, and thus, it has little probative value. By contrast, the record includes two July 2015 VA opinions that are based on a thorough review of the Veteran’s complete medical history, recognition of his lay contentions, and supported by a fully reasoned analysis. With regard to the Veteran’s right knee disability, the July 2015 VA examiner, who was clarifying his March 2015 VA opinion, found that upon separation, the Veteran had normal knees and no complaints of knee pain. In 2008, there was radiographic evidence of minimal spurring of the right knee, which was almost 10 years after his separation. The July 2015 VA examiner explained that this 10-year period before evidence of minimal spurring suggested that the development of early osteoarthritis of the right knee occurred after separation. The VA examiner also noted that more recent x-rays only showed minimal signs of DJD with mild narrowing of the joint space. Collectively, the July 2015 VA examiner found that the evidence was consistent with a more recent disease rather than an onset of disease during active service. Finding no evidence that the Veteran’s activity in service caused his underlying degenerative condition, the July 2015 VA examiner opined that the Veteran’s right knee disability was less likely than not related to his active duty service. Rather, the July 2015 VA examiner concluded that the Veteran’s right knee disability was more likely incurred after service as a result of his advancing age and activities throughout his entire lifetime, instead of specific activities during service. With regard to the Veteran’s left knee disability, the July 2015 VA examiner opined that his left knee disability was less likely than not related to his active duty service. In making that determination, the July 2015 VA examiner noted that the Veteran’s STRs documented a left knee strain, which occurred in June 1985 after jogging and playing basketball. He was diagnosed with a patella ligament strain or tendonitis. However, the July 2015 VA examiner noted that the Veteran’s left knee strain was a frequent condition after performing such activities and expected to improve with rest. No further knee problems were reported. Discussing how strains and sprains are often mild and a result of minimal trauma or overuse in the military, the July 2015 VA examiner explained that they are not felt to aggravate or cause an underlying condition in many cases. However, in circumstances where the sprain is severe and can cause further problems, the July 2015 VA examiner noted such sprains are manifested by either ongoing symptoms of pain or signs and/or symptoms of knee instability. Neither of these indicators were found at the Veteran’s October 1999 separation examination. Indeed, his knees were found to be normal. The Veteran’s degenerative changes were not identified until 2014, about 15 years after his discharge. Prior x-rays were negative for degenerative changes. Overall, the July 2015 VA examiner found no evidence supporting a link between the Veteran’s current left knee disability and his isolated diagnosis for left knee strain during service; nor was there a relationship found between his degenerative arthritis and his active duty service. As arthritis is a chronic disease under 38 C.F.R. § 38 C.F.R. § 3.309(a), the Board has also considered whether the Veteran is entitled to presumptive service connection under 38 C.F.R. § 3.307(a)(3). Here, the evidence shows that the earliest evidence of arthritis in the Veteran’s right knee was found in 2008, about nine years after service. His left knee did not demonstrate arthritis until 2014. Although the Veteran reported that he had knee problems during and after service, his STRs do not reflect any complaints, treatment, or diagnosis for knee problems other than his June 1985 STR documenting his treatment for left knee strain. That injury apparently resolved as no further treatment was documented. Moreover, in his July 1998 and October 1999 reports of medical history, the Veteran did not report any knee problems. Available post-service treatment records also do not document any complaints of bilateral knee pain until January 2008. The Veteran is competent to report his history of bilateral knee symptoms; however, the Board finds that his assertions that he had continuous knee problems both during and following service are not credible, as they appear to be contrary to the clinical evidence. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Thus, the Board finds that the evidence does not show that the Veteran’s current bilateral knee osteoarthritis manifested within one year of discharge; nor does it show that he had continuous symptoms of arthritis following service. Accordingly, service connection on a presumptive basis for the Veteran’s bilateral knee osteoarthritis is not warranted. Finally, in this case, the Veteran is not competent to provide an etiology opinion, as he has not demonstrated that he has the requisite specialized knowledge or training to relate his current bilateral knee osteoarthritis to the asserted wear and tear he endured from the physical demands of his in-service duties. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). Therefore, the Board finds that the Veteran’s lay assertion as to the etiology of his bilateral knee disability has little probative value. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s service connection claim for a bilateral knee disability on a direct or presumptive basis. Therefore, the benefit-of-the-doubt rule does not apply, and the service connection claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Increased Evaluation 3. Entitlement to an evaluation in excess of 30 percent for plantar fasciitis with degenerative arthritis of both feet The Veteran contends that his plantar fasciitis with degenerative arthritis of both feet is worse than his current evaluation reflects. At his June 2017 Board hearing, the Veteran testified that he could not walk on bare feet. Aside from using shoe insoles, the Veteran said he did not receive any other treatment. He was not currently being seen by a podiatrist. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities, found in 38 C.F.R., Part 4. The rating schedule is primarily a guide in the evaluation of disability resulting from all types of diseases and injuries encountered as a result of, or incident to, military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from such diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question as to which of two evaluations shall be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria for that rating. Otherwise the lower rating will be assigned. 38 C.F.R. § 4.7. The veteran’s entire history is to be considered when making disability evaluations. 38 C.F.R. § 4.1; Schafrath v. Derwinski, 1 Vet. App. 589 (1995). Where an increase in the level of a service-connected disability is at issue, the primary concern is the present level of disability. Francisco v. Brown, 7 Vet. App. 55 (1994). Nevertheless, the Board acknowledges that a claimant may experience multiple distinct degrees of disability that might result in different levels of compensation from the time the increased rating claim was filed until a final decision is made. Hart v. Mansfield, 21 Vet. App. 505, 509-510 (2007). During the relevant appeal period, the Veteran’s plantar fasciitis with degenerative arthritis of both feet has been currently evaluated as 30 percent disabling, effective June 20, 2014, under 38 C.F.R. § 4.71a, Diagnostic Code 5276. As plantar fasciitis is not a listed condition under the rating criteria, it has been rated by analogy for acquired flatfoot. Under Diagnostic Code 5276 severe flatfoot, with objective evidence of marked deformity (pronation, abduction, etc.), pain on manipulation and use accentuated, indication of swelling on use, and characteristic callosities, is rated 20 percent disabling for unilateral disability, and is rated 30 percent disabling for bilateral disability. Pronounced flatfoot, with marked pronation, extreme tenderness of plantar surfaces of the feet, marked inward displacement, and severe spasm of the tendo Achilles on manipulation, that is not improved by orthopedic shoes or appliances, is rated 30 percent disabling for unilateral disability, and is rated 50 percent disabling for bilateral disability. Based on a careful review of all the subjective and clinical evidence, the Board finds that throughout the relevant appeal period, the Veteran’s plantar fasciitis with degenerative changes of both feet does not warrant a higher 50 percent evaluation under Diagnostic Code 5276. On that basis, the most probative evidence is reflected by the clinical findings of the December 2013, September 2014 and October 2014 VA examinations. The Veteran has consistently reported that his pain, which occurred in the sole of his feet anterior to the heel, was worse on his right foot than his left; that his pain worsened with prolonged walking and standing; and that his pain was only partially relieved by his use of shoe insoles. Because of his work as a security guard, which required him to be on his feet for prolonged periods of time, he reported his discomfort only increased. Objective findings revealed pain on use of both feet and pain accentuated on use of both feet. His pain did not contribute to functional loss, as mild tenderness to palpation over plantar fascia was noted, but no swelling or spasm was found. There was no characteristic callouses or extreme tenderness of the plantar surface. No alignment or deformity problems were identified. An MRI of both feet revealed no evidence of plantar fascia rupture or edema. Throughout the relevant appeal period, the Board finds that the evidence does not demonstrate that the Veteran’s plantar fasciitis with degenerative arthritis on both feet more closely approximates pronounced symptoms with marked pronation, extreme tenderness of plantar surfaces of the feet, marking inward displacement and severe spasm of the tendo Achilles on manipulation, that is not improved by orthopedic shoes or appliances. According, throughout the relevant appeal period, the Board concludes that there is no basis upon which to award a higher 50 percent evaluation under Diagnostic Code 5276 for the Veteran’s plantar fasciitis with degenerative arthritis of both feet. Therefore, the Veteran’s plantar fasciitis with degenerative arthritis of both feet is no more than 30 percent disabling. Additionally, the Board has considered whether other potential applicable diagnostic codes allow for separate compensable and/or higher evaluations for the Veteran’s symptoms. VA General Counsel has determined that Diagnostic Code 5284 is a general diagnostic code under which a variety of foot injuries may be rated; that some injuries to the foot, such as fractures and dislocations for example, may limit motion in the subtalar, midtarsal, and metatarsophalangeal joints; and that other injuries may not affect range of motion. Thus, General Counsel concluded that, depending on the nature of the foot injury, Diagnostic Code 5284 may involve limitation of motion and therefore require consideration under 38 C.F.R. §§ 4.40 and 4.45. VAOPGCPREC 9-98. In this case, a change in diagnostic code would not provide the Veteran with an avenue to award a higher evaluation, because under Diagnostic Code 5284, a 30 percent evaluation is the maximum allowable evaluation. As to whether the Veteran could receive a separate evaluation under Diagnostic Code 5284 for his plantar fasciitis, the Veteran is already separately service-connected for degenerative changes of the left first (big) toe under Diagnostic Code 5284. The Board finds that the primary symptomatology associated with the Veteran's plantar fasciitis with degenerative arthritis of both feet is pain, which is already compensated under Diagnostic Code 5276. There are no manifestations of the Veteran’s service-connected plantar fasciitis with degenerative arthritis of both feet that are not contemplated by Diagnostic Code 5276. Thus, to assign a separate evaluation under Diagnostic Code 5284 would constitute impermissible pyramiding. See 38 C.F.R. § 4.14. In summary, the preponderance of the evidence weighs against finding in favor of the Veteran’s higher than 30 percent evaluation claim for plantar fasciitis with degenerative arthritis of both feet. Therefore, the benefit-of-the-doubt rule does not apply, and the higher evaluation claim must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). REASONS FOR REMAND 1. Entitlement to service connection for a right ankle disability is remanded. The Veteran contends that his current right ankle disability was caused by his in-service duties as a Yeoman and the physical demands of military service. In December 2013, the Veteran was afforded a VA examination, which diagnosed him with a right ankle sprain. The VA examiner opined that it was less likely than not that his currently diagnosed right ankle sprain was related to his active duty service. Subsequently, the Veteran underwent an August 2014 MRI which showed that he had right ankle osteoarthritis. The record includes a September 2014 opinion from the Veteran’s VA treating physician concluding that his current right ankle arthritis is at least as likely as not related to injuries sustained while on active duty. However, as this opinion is not supported by a reasoned analysis, the Board finds that it is inadequate. Nevertheless, the Board recognizes that the evidence suggests that the Veteran’s currently diagnosed right ankle osteoarthritis may be related to his active duty. As the currently available competent evidence is insufficient to decide the claim, a remand is required to obtain a supplemental VA opinion to determine the etiology of the Veteran’s right ankle disability. 2. Entitlement to service connection for an eye disability, to include iritis with vision loss, is remanded. The Veteran asserts that his current symptoms of redness, irritation, and blurry vision are related to his in-service injury where he was poked in the eye. He attributes his current symptomatology to his diagnosis for iritis. However, a review of the record shows that during the appeal period, the Veteran has been diagnosed for various eye problems (i.e., iritis, anterior uveitis, myopia, astigmatism, presbyopia, hypertropia, dry eye syndrome, meibomian gland dysfunction, blepharitis, and exophoria). Furthermore, the Veteran’s STRs also reflect numerous eye diagnoses following his 1982 in-service eye injury (i.e., subconjunctival hemorrhage, diplopia, exophoria, and astigmatism) as well as complaints of decreased visual acuity and floaters. At his December 2013 VA examination, the VA examiner found that the Veteran’s iritis had resolved and that there were no residuals of iritis. That finding is disputed by the Veteran’s lay assertions as well as the clinical evidence in the record. Notably, a more recent December 2016 VA treatment record reflects that the Veteran was currently receiving treatment for iritis at the Balboa Naval Hospital. Those private treatment records are not currently a part of the record. Based on the foregoing, the Board finds that a remand is required to obtain any additional relevant treatment records and to obtain a supplemental VA opinion to address the Veteran’s numerous eye diagnoses and to determine whether any of these current eye diagnoses are related to his in-service eye injury and/or eye diagnoses. 3. Entitlement to service connection for hypertension, to include as secondary to service-connected other specified trauma and stressor related disorder, is remanded. At a December 2013 VA examination, the VA examiner opined that the Veteran’s hypertension was less likely as not related to his active duty service. On that basis, the VA examiner indicated that the Veteran clearly had hypertension in 2009 or 2010 and that he had no pattern of elevated blood pressure readings during service to suggest that his hypertension began in 1999 or earlier. However, the Veteran presented a September 2014 opinion from his VA treating physician, who found that the Veteran’s STRs showed multiple documentation of high blood pressure. Thus, the VA treating physician concluded that the Veteran’s currently diagnosed hypertension was related to his high blood pressure during service. Clearly, the record includes contradictory findings as to whether the Veteran’s blood pressure readings during service were indicative of his current diagnosis for hypertension. Accordingly, the Board finds that a remand is required to obtain a supplemental VA opinion to address this conflicting medical evidence. Furthermore, in a June 2013 statement, the Veteran alternatively suggests that his hypertension may have been caused or aggravated by his service-connected other specified trauma and stressor related disorder. However, the record does not include an etiological opinion for his hypertension addressing secondary service connection. Therefore, on remand, the examiner should also provide an opinion as to whether the Veteran’s hypertension was caused or aggravated by his service-connected other specified trauma and stressor related disorder. 4. Entitlement to service connection for a bilateral wrist disability, to include carpal tunnel syndrome, is remanded. The Veteran is seeking service connection for his bilateral wrists problems that he contends developed due to the administrative work and physical labor he performed during service. Although he asserts that his symptoms of pain and numbness in his wrists are attributed to carpal tunnel syndrome, the available clinical evidence does not support such a diagnosis. See September 2014 VA examination and November 2014 VA Neurology Diagnostic Study Report. Nevertheless, the record does show that the Veteran has been diagnosed with bilateral wrist osteoarthritis. See September 2014 VA treatment record. However, the record does not include an etiological opinion addressing whether the Veteran’s currently diagnosed bilateral wrist osteoarthritis is related to his active duty service. Accordingly, a remand is required to obtain a supplemental VA opinion to determine the etiology of the Veteran’s current bilateral wrist disability. 5. Entitlement to an initial evaluation in excess of 10 percent for degenerative changes of the left first (big) toe is remanded. The Veteran’s last VA examination for his service-connected degenerative changes of the left first (big) toe was in December 2014. At his June 2017 Board hearing, the Veteran testified that he was experiencing “excruciating pain” and was offered surgery for his left toe problems, but he had to cancel the surgery due to work. VA is required to afford the Veteran a contemporaneous VA examination to assess the current nature, extent, and severity of his service-connected disability. See Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997); see also 38 C.F.R. § 3.326(a). As the evidence suggests that the Veteran’s degenerative changes of the left first (big) toe may have worsened since his last VA examination, a remand is required to determine the current severity of his service-connected disability. The matters are REMANDED for the following actions: 1. Obtain all the outstanding treatment records for the Veteran’s right ankle disability, eye disability, hypertension, bilateral wrist disability, and degenerative changes of the left first (big) toe that are not currently of record, to include treatment records from the Balboa Naval Hospital. 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s currently diagnosed right ankle disability is at least as likely as not related to his reported in-service duties as a Yeoman and the physical demands of military service. In providing the above opinion, the VA examiner should discuss the findings of an August 2014 MRI report and consider the Veteran’s lay contentions regarding his duties during service. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 3. Obtain an addendum opinion from an appropriate clinician regarding whether any of the Veteran’s current eye disabilities are at least as likely as not related to his active duty service, to include his in-service eye injury where he was poked in the eye. 4. In providing the above opinion, the examiner should address the Veteran’s various in-service eye complaints and diagnoses, including subconjunctival hemorrhage, diplopia, exophoria, and astigmatism. The examiner should also address the Veteran’s diagnoses for eye problems during the appeal period, including iritis, anterior uveitis, myopia, astigmatism, presbyopia, hypertropia, dry eye syndrome, meibomian gland dysfunction, blepharitis, and exophoria. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 5. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s hypertension is at least as likely as not related to his active duty service. The examiner should also opine as to whether the Veteran’s hypertension is at least as likely as not proximately due to, or aggravated beyond its natural progression by, his service-connected other specified trauma and stressor related disorder. In providing the above opinions, the examiner should resolve the conflicting medical opinions of the December 2013 VA examiner and the September 2014 VA treating physician regarding whether the Veteran had elevated blood pressure readings during service that were indicative of his current hypertension. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 6. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s bilateral wrist disability is at least as likely as not related to his active duty service, to include his reported duties as an administrative clerk. In providing the above opinion, the examiner should address the August 2014 MRI report which revealed bilateral wrist osteoarthritis. A complete rationale with discussion of medical literature for any opinion expressed must be provided. If an opinion cannot be expressed without resort to speculation, discuss why this is the case. 7. Schedule the Veteran for an examination to determine the current severity of his service-connected degenerative changes of the left first (big) toe from an appropriate clinician. The examiner should provide current findings regarding all symptoms associated with the service-connected degenerative changes of the left first (big) toe and should opine as to its severity. The examiner should comment on the extent of any functional impairment caused by the Veteran’s service-connected degenerative changes of the left first (big) toe, to include in an occupational setting and in performing ordinary, daily activities. All findings should be fully documented in the examination report. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Journet Shaw
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