Citation Nr: 21062753 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 18-09 413 DATE: October 12, 2021 ORDER Service connection for bilateral pes planus is granted. Service connection for a right foot bunion (hallux valgus) is granted. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran's preexisting bilateral pes planus was aggravated beyond the natural progression of the disorder during active service by the wearing of ill-fitting military boots. 2. The evidence is at least in equipoise as to whether the Veteran's right foot bunion was caused by the wearing of ill-fitting military boots during active service. CONCLUSIONS OF LAW 1. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for bilateral pes planus have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. 2. Resolving reasonable doubt in favor of the Veteran, the criteria for service connection for a right foot bunion have been met. 38 U.S.C. §§ 101, 1101, 1110, 1131, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant in this case, had active service from June 1963 to May 1965. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a May 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The Veteran provided testimony at a March 2020 Video hearing before the undersigned Veterans Law Judge at the Columbia RO. A transcript of the hearing is associated with the claims folder. In May 2020, the Board denied service connection for bilateral pes planus, a right foot bunion, and bilateral plantar fasciitis. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In January 2021, the Court granted a Joint Motion for Partial Remand (Joint Motion). In the January 2021 Order, the Court vacated the portion of the May 2020 Board decision that had denied service connection for bilateral pes planus, a right foot bunion, and bilateral plantar fasciitis and remanded the case back to the Board for compliance with instructions provided in the Joint Motion. The Board remanded the case for further development in May 2021. Subsequently, in an August 2021 rating decision, service connection for bilateral plantar fasciitis was granted. The development requested having been completed with regard to the two remaining claims (pes planus and right foot bunion), the case is now appropriate for appellate review. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for aggravation of a pre-existing injury suffered or disease contracted in line of duty. 1. Service connection for bilateral pes planus is granted. 2. Service connection for a right foot bunion (hallux valgus) is granted. The Veteran contends that his pre-existing bilateral pes planus was aggravated by active service and that his right foot bunion was caused by active service. Specifically, he has stated that he did not have any foot problems prior to enlistment in active service, that he first learned that he had pes planus at the time of his enlistment examination, and that he began having bilateral foot pain during active service and that the foot pain has been continuous since active service. As noted in the Board's May 2020 decision, the Veteran's pes planus was noted on the April 1963 enlistment examination report; as such, the presumption of soundness at service entrance did not attach with regard to the preexisting pes planus, and the question before the Board is whether the preexisting pes planus was aggravated by active service. 38 U.S.C. § 1111. For the reasons discussed below, the Board finds that the evidence is at least in equipoise as to whether the preexisting pes planus was aggravated by active service and as to whether the right foot bunion was caused by active service. Service treatment records are silent as to any signs, symptoms, reports, findings, treatment, or diagnoses of any relevant foot conditions. At the May 1965 separation examination, the Veteran denied foot trouble on his Report of Medical History. The report also indicates mild, asymptomatic flat feet, and the Veteran was assigned a PULHES profile of 111111, indicating no limitations of the lower extremities. However, in his September 2015 notice of disagreement, the Veteran stated that during active service, he experienced foot pain during active service and was told by military doctors to take aspirin. Following separation from service, he stated he continued to have foot pain and to take aspirin, and that he developed an ulcer in 1971 from taking too much aspirin. At the March 2020 Board hearing, the Veteran reported that he first sought treatment for his foot problems following active service in 1966 or 1967, and that he did not seek treatment during active service because he did not want to be perceived as complaining and receive a poor discharge record. He testified that his family doctor also recommended insoles in the 1980s. Pursuant to the Board's May 2021 remand directives, in May 2021, the RO sent a letter to the Veteran asking him to complete a VA Form 21-4142 for several private physicians (Drs. Silkiner, Jones, and Long) with whom the Veteran had stated he sought treatment for his foot conditions so that those records could be requested and reviewed. However, the Veteran did not submit the requested forms. Following separation from service in May 1965, the first documented report or treatment for a foot problem was in August 2011, when the Veteran sought treatment from a private podiatrist, Dr. Jones, for a painful plantar left heel of three or three-and-a-half months' duration, with no history of trauma. On examination, the medial plantar surface on the left was painful at and about the insertion of the plantar fascia at the heel. An x-ray was negative for fracture or spurs. The podiatrist diagnosed plantar fasciitis and prescribed a heel insert and inlays as well as physical therapy. A November 2011 treatment note of Dr. Jones indicates that the Veteran had received injections to his feet but reported little improvement in his heel pain. The podiatrist gave him a night splint. Private podiatry notes of Dr. Jones from July 2014 indicate ongoing problems with the left foot, including spasms in the leg and foot. An x-ray study showed a bunion and small calcaneal spur. The diagnosis was a heel spur. A November 2014 private podiatry note from Dr. Long indicates the Veteran sought evaluation and treatment for plantar fasciitis. He reported that he was diagnosed and treated in the military for pes plano valgus. He described pain in his heels, and it was noted he had received treatment for plantar fasciitis. He tried over the counter orthotics, stretching, and night splints. He had also been treated by Dr. Jones and heel injections were administered. He also reported a burning sensation in his bilateral plantar soles. On examination, the podiatrist observed bilateral pes plano valgus deformities, bilateral hallux abducto deformities, and bilateral contracted proximal interphalangeal joints of toes 2, 3, and 4. An x-ray study showed bilateral decreased calcaneal inclination angles, bilateral plantar calcaneal spurs, and bilateral increased first IM angles with dorsal medial arthrosis. The podiatrist diagnosed calcaneal spur, foot pain, hammer toe, hallux valgus, pes planus, plantar fasciitis, tinea pedis, and arthritis, and recommended conservative treatment including stretching exercises, orthotics, NSAIDs, icing, and alternating shoe gear. The Veteran began treatment for his foot problems with VA in February 2015. At his initial podiatry appointment, the VA podiatrist observed a medium arch foot type, tenderness to palpation of the heels, and x-rays showed inferior heel spurs. The podiatrist diagnosed bilateral pes planus, bilateral heel spur syndrome, hammer toes, mild hallux abducto valgus, and tinea intertrigo, prescribing orthotics. An August 2015 letter from Dr. Long, the Veteran's private podiatrist, stated that the Veteran was receiving treatment for painful pes plano valgus and bilateral plantar fasciitis, and that the Veteran stated that these problems began during his active service. Dr. Long stated that his medical records reflected that he received treatment for foot-related issues during his active service, although the doctor did not cite to any specific date of treatment or treatment record. Dr. Long stated that a reconsideration of his disability request was warranted. The Veteran was afforded a VA examination in January 2018. The VA examiner diagnosed flat foot (pes planus), diagnosed in April 1963; plantar fasciitis diagnosed in 2011; and hammertoes of the second, third, and fourth toes bilaterally. The examiner opined that it is less likely as not that the Veteran's current diagnoses of bilateral pes planus and plantar fasciitis were aggravated beyond their natural progression during service, noting that there was no evidence of such aggravation (even though plantar fasciitis did not preexist active service). She reasoned that the Veteran reported, and his service treatment records reflected, that he had pes planus on entrance to service. The entrance exam in the evidence of record showed he was asymptomatic at entrance. The separation examination documented asymptomatic, mild, bilateral flat feet and the Veteran denied foot trouble on his separation examination paperwork. The examiner noted that the evidence of record was silent for any medical treatment between separation and 2011. A December 2019 treatment note of Dr. Long for follow-up evaluation and treatment of bilateral plantar fasciitis indicates that the Veteran had continued receiving conservative treatment for bilateral bunions, pes planus, tinea pedis, and plantar fasciitis. Dr. L. noted that the Veteran had applied for disability but was denied although there was documentation of treatment for his foot deformities in his military medical records while he served on active duty. Again, Dr. Long did not cite to any specific date of treatment or to a particular service treatment record. The Veteran submitted a March 2020 letter from Dr. Long which was mostly a reiteration of the previous 2015 letter, again stating that the Veteran's medical records reflected that he received treatment for foot-related issues during active service with citation to any specific date or record. Dr. Long then stated that the Veteran's bilateral pes planus/marked pronation, plantar fasciitis, and bunion deformities were more likely than not a continuation/result of his military service, reasoning that the Veteran stated that his pain began while he was in the military, that he did not have these issues prior to his military service, and that it was a medical certainty that military boots can cause and worsen the aforementioned conditions. The Veteran was afforded another VA foot examination in July 2021. The examiner diagnosed bilateral pes planus, bilateral plantar fasciitis, bilateral hammer toes, bilateral hallux valgus, and left tibial sesamoiditis. The Veteran reported onset of bilateral foot pain during active duty after vigorous physical training and military duties that required wearing ill-fitted boots, i.e., too big, and having to run, march, and complete duties. He noted feeling like the arches of his feet fell. He would take aspirin and apply topical rub during active duty to alleviate the pain. He had asymptomatic pes planus upon entrance into service. He continued to have severe bilateral foot pain and was diagnosed with bilateral plantar fasciitis in 2011. He also has bunions, hammertoes, and sesamoid pain of the left foot for which he sees a podiatrist. The examiner opined that the bilateral plantar fasciitis was caused by wearing military boots that were ill-fitted (a half size too big) to perform military duties and physical training. The bilateral foot pain developed during active duty but was not officially diagnosed until after discharge. The plantar fasciitis was chronic with ongoing treatment and evaluation by podiatry. On the basis of the favorable July 2021 nexus opinion, service connection for bilateral plantar fasciitis was granted in an August 2021 rating decision. While there is evidence against the claim of entitlement to service connection for bilateral pes planus and the right foot bunion, the Board finds, based on the foregoing, that the evidence is at least in equipoise as to whether the pes planus was aggravated by active service and the right foot bunion was caused by active service. While there is no documentation of in-service foot problems or treatment for foot problems in the several years after service separation, the Veteran is competent to describe his foot pain during and pain and treatment just after active service, and there is no reason (other than the absence of documentation) to doubt the credibility of his statements. Moreover, the July 2021 VA examiner identified an in-service "event" the wearing of ill-fitting military boots which the examiner then stated caused the plantar fasciitis, in part based on the Veteran's statements that he had foot pain during and since active service. While the examiner did not provide an opinion as to the claimed pes planus or right foot bunion, Dr. Long, in his March 2020 letter, stated that military boots can cause and worsen pes planus and foot bunions. Another remand to obtain a nexus opinion regarding the pes planus or right foot bunion would likely be unfruitful, as it would be difficult to determine whether the Veteran's reported foot pain during and after service was attributable to pes planus versus plantar fasciitis, etc. Therefore, based on the competent and credible statements of the Veteran regarding in-service foot pain and continuous foot pain and treatment following service separation, the favorable nexus opinion of Dr. Long, and the July 2021 VA examiner's favorable nexus opinion regarding the closely associated condition of plantar fasciitis based at least in part on the Veteran's reports of foot pain during and after service, and resolving reasonable doubt in favor of the Veteran, the Board finds that service connection for bilateral pes planus and a right foot bunion is warranted. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Sherrard, 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.