HALLUX VALGUS

Summary

The Veteran, who served from May 1986 to September 1987 and January 1991 to August 1991, including service in Southwest Asia, appeals the denial of service connection for a left great toe disability, claimed as secondary to service-connected pes planus. The Veteran has a current left great toe disability, diagnosed variously as bilateral hallux valgus, bilateral hallux rigidus, or bilateral hallux limitus. Service treatment records noted a complaint of an ingrown toenail on the left foot during service, but no other toe problems were documented, and subsequent military physicals showed normal foot evaluations. The Veteran also denied foot trouble or swollen/painful joints on multiple occasions during service, which the Board found more credible than his later assertions of in-service toe issues. Two VA medical opinions were considered highly probative. The July 2015 VA examiner opined that the left toe condition was less likely than not aggravated by pes planus, finding the conditions medically separate and unrelated. The July 2018 VA examiner, after reviewing medical literature, concluded that the exact cause of hallux limitus/rigidus is not well-established, but studies have not confirmed a link to altered foot mechanics or pes planus. This examiner also found it less likely than not that the Veteran's hallux limitus was due to pes planus, noting the Veteran's longstanding gout as a contributing factor. The Board found these opinions persuasive, supported by the evidence, and more probative than the Veteran's lay statements, leading to the denial of secondary service connection. Direct service connection was also denied, as no in-service event, injury, or disease was linked to the current left toe disability, and the Veteran's current statements about toe issues were found to lack credibility due to contradictions with contemporaneous service records.

Rationale

No in-service event, injury, or disease linked to current left toe disability.; Veteran's later statements about in-service toe issues lacked credibility due to contradictions with contemporaneous service records.; VA medical opinions found the left toe disability less likely than not related to or aggravated by service-connected pes planus.

Full Decision Text

Citation Nr: 21023751
Decision Date: 04/21/21	Archive Date: 04/21/21

DOCKET NO. 18-42 723A
DATE: April 21, 2021

ORDER

Entitlement to service connection for left great toe disability, to include as secondary to service-connected pes planus, is denied.

FINDING OF FACT

The Veteran’s current left great toe disability did not onset during service, is not related to an in-service event, injury or disease, and is not caused or aggravated by service-connected pes planus.

CONCLUSION OF LAW

The criteria for service connection for left great toe disability have not been satisfied.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from May 1986 to September 1987 and from January 1991 to August 1991, to include service in Southwest Asia.  He served on active duty for training from January 1998 to June 1998.

This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 rating decision issued by the Department of Veterans Affairs (VA) regional office.  The Veteran testified at a hearing with the undersigned in November 2020.

Generally, to establish service connection, a claimant must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement.  See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303; see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  Service connection may additionally be granted for disability resulting from injury incurred in or aggravated while performing active duty for training (ADT) or inactive duty for training (IADT) or a disease incurred or aggravated while performing ADT.  38 U.S.C. §§ 101(24), 106.  A disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury shall be service connected.  38 C.F.R. § 3.310.

The Veteran has a current left great toe disability.  For example, at a July 2015 VA examination he was diagnosed with bilateral hallux valgus and bilateral hallux rigidus.  It is noted that at a July 2016 VA examination he was only diagnosed with right hallux valgus and hallux rigidus was not diagnosed.  In July 2018, a VA examiner determined that the medical evidence was contradictory as to diagnosis and the left toe disability was actually bilateral hallux limitus.  As a disability is present during the appeal period, the remaining question is whether the current left great toe disability is related to service or a service-connected disability. 

Service treatment records show a complaint for an ingrown toenail on the Veteran’s left foot.  See September 1986 Service Treatment Note.  There is no other record of reports of a left toe problem or condition in the Veteran’s service treatment record.  During military physicals in March 1990, August 1994, and August 1997, evaluation of the feet were normal.  The examiners in March 1990 and August 1994 indicated that the Veteran’s pes planus was asymptomatic, and the examiner in August 1997 did not indicate the presence of pes planus.  In reports of medical history in March 1990, January 1994, August 1997, October 1998, and June 1999, the Veteran specifically denied having had foot trouble as well as swollen or painful joints.  If foot trouble, to include the left great toe, was present during service, the Board would expect the Veteran would have responded “yes” when asked these questions because a reasonable person would have interpreted the questions to include symptoms of pain or swelling in any part of the foot, including the toes.  Moreover, the Veteran responded affirmatively when asked whether he had other conditions during service and the Board would thus expect the Veteran to have also responded affirmatively to having foot or toe trouble.  

A left toe disability is not shown by medical evidence until approximately February 2009, many years after the Veteran’s separation from service.  

The Veteran presented for a VA examination in July 2015, at which time he was interviewed by the examiner who
  If foot trouble, to include the left great toe, was present during service, the Board would expect the Veteran would have responded “yes” when asked these questions because a reasonable person would have interpreted the questions to include symptoms of pain or swelling in any part of the foot, including the toes.  Moreover, the Veteran responded affirmatively when asked whether he had other conditions during service and the Board would thus expect the Veteran to have also responded affirmatively to having foot or toe trouble.  

A left toe disability is not shown by medical evidence until approximately February 2009, many years after the Veteran’s separation from service.  

The Veteran presented for a VA examination in July 2015, at which time he was interviewed by the examiner who also reviewed the pertinent medical history and performed an examination.  The examiner opined that the Veteran’s left toe condition was less likely than not aggravated by service-connected pes planus.  The examiner explained that the conditions are medically separate and unrelated and that there was no evidence of aggravation of the toe condition.  

In July 2018 opinion, an examiner offered an opinion after review of the file including materials submitted by the Veteran.  The examiner explained that medical literature theorizes a relationship between altered foot mechanics and hallux rigidus/hallux limitus, but studies have not thus far confirmed any specific cause for the conditions, other than the association of degeneration at the 1st metatarsophalangeal joint and a hereditary link.  According to the examiner, the exact cause for hallux rigidus/hallux limitus is not well established in the medical literature.  As the medical literature has been unable to establish a causal relationship between altered foot mechanics, including pes planus effects, and the development of hallux limitus or hallux rigidus, and as Veteran has longstanding gout (pre-dating diagnosis of hallux limitus) as a chronic inflammatory condition to contribute to the development of hallux limitus, the examiner found it is less likely than not that Veteran’s hallux limitus is due to or caused by bilateral pes planus.  

The Board finds the above opinions highly probative as they were made by medical professionals with consideration of the specific facts in this case and after examination of the Veteran.  Overall, the opinions indicate that the Veteran’s toe disability has not worsened and that it is not caused by pes planus.  The examiner’s offered rationale for these conclusions and there is no medical opinion or competent and credible evidence in significant conflict with the VA medical opinions.  The opinions are also supported by other evidence of record.  For example, the Veteran was actively being treated for gout as early as September 2009, 7 months before the Veteran began complaining of foot pain to medical providers, and several months before the Veteran was diagnosed with hallux limitus.  See September 2009 VA Treatment Note, February 2010 Private Treatment Note.  

As the Veteran is not shown to have medical education or experience, he is a lay person and is competent to report (1) symptoms that are observable to a layperson, e.g., pain; (2) symptoms at the time supporting a later diagnosis by a medical professional; or (3) a contemporaneous medical diagnosis.  See Davidson v. Shinseki, 581 F.3d 1313 (2009).  The Veteran is not competent to independently render a medical diagnosis or opine as to the specific etiology of a condition as these are medically complex issues.  Thus, his lay assertions do not constitute evidence upon which service connection can be granted.  In any event, the Board ultimately assigns greater probative weight to the medical evidence of record, to include the opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale.  Thus, the most probative evidence is against finding that the Veteran’s toe disability was caused or aggravated by his service-connected pes planus.  Service connection on a secondary basis is therefore denied.  38 C.F.R. § 3.310.  

Regarding direct service connection, a medical opinion is not necessary and the claim must be denied as there is no in-service event, injury, or disease to which the current left toe disability may be linked.  To the extent the Veteran had an ingrown toenail during service, no competent evidence suggests that this could have resulted in the current orthopedic issue.  While the Veteran now states that his foot and toe bothered him during service, the Board finds these statements to lack credibility.  Service examinations show normal evaluation of the feet with the exception of pes planus being noted but described as asymptomatic.  The Veteran on numerous occasions denied having had foot trouble or swollen or painful feet.  The military-related examinations and reports of medical history are more probative as to the existence of foot pain as they were done more contemporaneous to the
 there is no in-service event, injury, or disease to which the current left toe disability may be linked.  To the extent the Veteran had an ingrown toenail during service, no competent evidence suggests that this could have resulted in the current orthopedic issue.  While the Veteran now states that his foot and toe bothered him during service, the Board finds these statements to lack credibility.  Service examinations show normal evaluation of the feet with the exception of pes planus being noted but described as asymptomatic.  The Veteran on numerous occasions denied having had foot trouble or swollen or painful feet.  The military-related examinations and reports of medical history are more probative as to the existence of foot pain as they were done more contemporaneous to the time period in question and less subject to the degradation of memory.  In addition, the examinations and reports of medical history were completed for the purpose of identifying disability at the time.  As the Veteran’s more recent statements about in-service toe swelling and pain are in direct conflict with his reports during service, the current statements are found to lack credibility.   

For the above reasons, the preponderance of the evidence is against the claim and service connection is denied.

 

 

Nathan Kroes

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	T. Jarman, 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.