FLATFOOT BILATERAL ACQUIRED

Summary

The veteran, who served in the U.S. Army from October 1979 to April 1987, appeals the denial of service connection for a bilateral foot disability, other than pes planus. The veteran has a current foot disability, and service treatment records noted a pre-existing flat foot condition upon entry into service. The veteran contends this pre-existing condition was aggravated by military duties, specifically daily running and marching, leading to his current foot issues. The Board reviewed multiple medical opinions, including VA examinations and private physician statements, noting that the claim had been remanded several times due to inadequate medical opinions. The most recent VA examination in February 2026 opined that the Veteran's plantar fasciitis, Morton's neuroma, enthesopathy, and arthritis were less likely than not incurred in or caused by service. The examiner cited the Veteran's pre-existing pes planus and lack of in-service complaints or treatment as the primary reasons for the negative nexus. The Board found this opinion thorough and well-supported by medical literature, giving it more probative weight than the private opinions, which were deemed inadequate for failing to explain the etiology or nexus. The Board concluded that the evidence demonstrates the condition existed prior to service and was not aggravated by military service, thus denying service connection.

Rationale

Pre-existing pes planus noted at entrance examination.; Veteran contends pes planus aggravated by daily running and marching.; VA medical opinions found negative nexus due to lack of in-service complaints/treatment and progression of pes planus.; Board found private opinions inadequate for failing to explain etiology or nexus.

Full Decision Text

Citation Nr: 26005122
Decision Date: 04/30/26	Archive Date: 04/30/26

DOCKET NO. 16-00 951
DATE: April 30, 2026

ORDER

Entitlement to service connection for a bilateral foot disability other than pes planus is denied.

FINDING OF FACT

The persuasive weight of the evidence is against finding that a bilateral foot disability began during active service or was caused or aggravated by a service-connected disability.

CONCLUSION OF LAW

The criteria for entitlement to service connection for bilateral foot disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty in the United States Army from October 1979 to April 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). 

In April 2024, the Board denied service connection for bilateral foot disability. The Veteran appealed to the Court of Appeals for Veterans Claims (Court). In December 2024, the Court issued a Joint Motion for Remand (Remand). The parties of the Remand agreed the September 2023 VA medical opinion was inadequate. The medical opinion addressed whether the Veteran's plantar fasciitis, Morton's neuroma, and bilateral foot osteoarthritis were related to service. In the rationale, the examiner discussed several potential causes such as stress or injury from overuse, running and high-impact activities, prolonged standing, micro-tears from repetitive strain, and an anatomical predisposition to plantar fasciitis because of pes planus. The examiner noted a study discussing the high incidence of plantar fasciitis in the military, especially in the Army and the Marines. 

But the examiner noted there was no study examining the incidence of plantar fasciitis among those entering service with pes planus. The examiner also indicated the Veteran's service treatment records were silent for complaints of foot pain or a profile for foot pain excluding the injury to the left great toe. This was the basis for the negative nexus opinion. The parties agreed the examiner did not explain why the [in-service] risk factors did not lead to the Veteran's plantar fasciitis. Thus, remand was required to obtain a clarification or a new opinion because the parties could not decipher the examiner's rationale. 

The Board issued a remand in May 2025 instructing the RO to obtain outstanding records related to the claim and obtain an addendum medical opinion addressing the Veteran's statement. A remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions, and imposes upon VA a concomitant duty to ensure compliance with the terms of the remand. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The RO obtained a February 2026 addendum medical opinion. The Board finds the RO substantially complied with the May 2025 remand directives.

Entitlement to service connection for bilateral foot disability.

Service connection may be granted for a 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). Secondary service connection requires: (1) a service-connected disability; (2) a nonservice connected disability; and (3) evidence that the nonservice connected disability is either (a) proximately due to or the result of the service-connected disability or (b) aggravated (increased in severity) by the service-connected disability. See 38 C.F.R. § 3.310.

A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. 38 C.F.R. § 3.304(b). Only such conditions as are recorded in
ervice connected disability; and (3) evidence that the nonservice connected disability is either (a) proximately due to or the result of the service-connected disability or (b) aggravated (increased in severity) by the service-connected disability. See 38 C.F.R. § 3.310.

A veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. 38 C.F.R. § 3.304(b). Only such conditions as are recorded in examination reports are to be considered as noted. Id. History of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions but will be considered together with all other material evidence in determinations as to inception. 38 C.F.R. § 3.304(b)(1).

The Veteran has a current disability that meets the requirement of service connection. See e.g., January 2012 Dr. B. record (plantar fasciitis). The Veteran submitted a September 2013 medical opinion written by Dr. D. M. In the opinion, the physician indicated the Veteran complained of diffuse joint pain and discomfort involving the feet. The physician opined that this was most likely secondary to inflammation consistent with costochondritis.

Service treatment records (STR) indicated the Veteran had a foot condition upon entering service. See e.g., August 1979 entrance examination (flat feet). The Veteran contends that his foot disability was aggravated by his military service. On a March 2014 statement, the Veteran wrote that he had flat feet when he joined the Army but his feet worsened from running two to five miles each day while in the

Army. Sometimes he marched 10 to 20 miles weekly. See also January 2016 Statement; December 2018 Appellate Brief; July 2023 Appellate Brief. 

The record includes several medical opinions related to the Veteran's foot disability. However, the claim was remanded several times because the medical opinions did not adequately address all theories of entitlement. The claim was remanded in December 2021 because the Board found that an additional VA opinion was necessary to clarify the December 2020 medical opinion. 

In the December 2020 medical opinion, the examiner noted that the Veteran's pes planus was "asymptomatic" upon enlistment, and after reviewing the medical evidence the condition remained so "while in service" and at separation. The Veteran's post-service medical records first show complaints of foot issues in 2011, at which time plantar fasciitis and calcaneal spurs were diagnosed (more on these conditions below) as well as confirmation of the continuation of his bilateral pes planus. The examiner concluded that, based on the Veteran's activities in-service, "any aggravation... would've been evident during service, and certainly at separation." This was due to the fact that "separation exams are notably thorough, especially with respect to the feet." Overall, the evidence "is clear no aggravation occurred during service or proximate to it. The Board found that this medical opinion failed to address the Veteran's enthesopathy. In addition, the opinion relied on the Veteran's lack of reports or complaints of foot pain and issues with his feet in service.  

A new opinion was obtained in February 2022. However, it was also found to be inadequate. See August 2023 Board Remand. The February 2022 VA examination opinion is inadequate to resolve the appeal. The examiner provided a negative nexus opinion determining that the Veteran's plantar fasciitis, neuroma, enthesopathy, and arthritis of the feet diagnoses were not evident during active duty or in the 24 years following discharge. The examiner discussed the impact of Veteran's preexisting pes planus overtime in relation to the Veteran's diagnoses. The examiner stated that the conditions represented progression of the Veteran's pes planus but that the record does not support the diagnosis of the conditions being related to service. 

The examiner's rationale for the negative opinion was the Veteran did not have any treatment for foot pain or any other foot disability during active duty or within a year of separation. However, the examiner failed to address the Veteran's lay statements that his preexisting pes planus worsened from running and marching daily during service. See September 2013 VA Form 21-438, Statement in Support of Claim. A medical opinion is inadequate if it does not consider the Veteran's reports of symptoms and relies solely on the service medical records to provide a negative opinion. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Therefore, the claim was remanded again to obtain a
 the diagnosis of the conditions being related to service. 

The examiner's rationale for the negative opinion was the Veteran did not have any treatment for foot pain or any other foot disability during active duty or within a year of separation. However, the examiner failed to address the Veteran's lay statements that his preexisting pes planus worsened from running and marching daily during service. See September 2013 VA Form 21-438, Statement in Support of Claim. A medical opinion is inadequate if it does not consider the Veteran's reports of symptoms and relies solely on the service medical records to provide a negative opinion. Dalton v. Nicholson, 21 Vet. App. 23 (2007). Therefore, the claim was remanded again to obtain a new medical opinion. 

A new opinion was obtained in September 2023. The examiner opined the Veteran's plantar fasciitis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness as well as his other conditions of pes planus, neuroma, enthesopathy, and degenerative arthritis. First, the examiner explained how plantar fasciitis develops.

"The plantar fascia is important in shock absorption and providing support for the arch of the foot. Repetitive strain to the plantar fascia causes micro-tears. Certain variances of anatomy are predisposing factors with pes planus being one of them. Other risk factors to the development of plantar fasciitis are "running and other high-impact activities, occupations that require prolonged standing" (Flat Feet and a Diagnosis of Plantar Fasciitis in a Marine Corps Recruit - Ann R. Lurati, 2015 (sagepub.com)). Pes planus increases the risk of strains to the plantar fascia because of the plantar fascia's lack of absorbancy with the extensive pronation of the foot during ambulation (Plantar Fasciitis - StatPearls -NCBI Bookshelf (nih.gov)). The study The incidence of plantar fasciitis in the United States military -PubMed (nih.gov) looked at the incidence of plantar fasciitis in the active duty military population and found that plantar fasciitis not only have a high incidence in the military service members, they noted that it was also more common in the Marines and Army members as compared to the Air Force. Unfortunately, there was no study found that looked at the rate of plantar fasciitis among military service members with pes planus on entrance. Veteran's record review is silent for complaint of foot pain during his active-duty career outside of an injury to the left foot great toe where he hit his toe against something. Otherwise, there is not medical notation for complaint of bilateral foot pain. Veteran does report in his records that he complained during basic training and was put on a profile. The only profile noted in his chart is the one for the tonsillectomy."

For the theory of the Veteran's condition being related to neuroma, the examiner opined:

"Veteran's Morton's neuroma is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Morton's neuroma is compressive neuropathy of the interdigital nerve in the forefoot due to compression and constant irritation at the plantar aspect of the transverse intermetatarsal ligament. The exact etiology of Morton neuroma is unknown, however there is the most widely accepted hypothesis called the chronic trauma theory. Under this hypothesis, itis suspected that the "mechanical effects of walking cause chronic micro-traumas to the intermetatarsal plantar digital nerves, which become compressed between two metatarsal heads and the metatarsophalangeal joints," Morton Neuroma -StatPearls - NCBI Bookshelf (nih.gov). There is no medical documentation of foot pain during his time of service outside of the toe injury to the left great toe."

For the theory of the Veteran's condition being related to enthesopathy, the examiner opined:

"Veteran's Enthesopathy bilateral is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Enthesopathies are all encompassing of inflammation of both ligaments and tendons. This inflammatory process typically starts one of two ways: 1) repetitive mechanical stress and 2) diffuse inflammatory response. "Enthesopathies from repetitive mechanical stress can be seen in common sports-related injuries such as lateral and medial epicondylitis, and Achilles and shoulder enthesopathy. Diffuse inflammatory responses that lead to enthesopathies and enthesitis tend to affect multiple entheses. The repetitive local microtrauma allows innate immune cells to invade the local area and cause inflammation triggered by chemokines." Enthesopathies - StatPearls - NCBI Bookshelf (nih.gov). Although veteran has findings now of Enthes
 Enthesopathies are all encompassing of inflammation of both ligaments and tendons. This inflammatory process typically starts one of two ways: 1) repetitive mechanical stress and 2) diffuse inflammatory response. "Enthesopathies from repetitive mechanical stress can be seen in common sports-related injuries such as lateral and medial epicondylitis, and Achilles and shoulder enthesopathy. Diffuse inflammatory responses that lead to enthesopathies and enthesitis tend to affect multiple entheses. The repetitive local microtrauma allows innate immune cells to invade the local area and cause inflammation triggered by chemokines." Enthesopathies - StatPearls - NCBI Bookshelf (nih.gov). Although veteran has findings now of Enthesopathy, there is no medical documentation of foot pain during his time of service outside of the toe injury to the left great toe."

For the theory of the Veteran's condition being related to arthritis, the examiner opined:

"Veteran's osteoarthritis of the feet bilaterally is less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Osteoarthritis is the most common form of arthritis in the world and is progressive, worsening with time once the process starts. It is typically a diagnosis of multiple etiologies: age, female gender, obesity, anatomical factors, muscle weakness, and joint injury (occupation/sports activities) per NIH's Osteoarthritis article. The complete pathway that leads to the destruction of the entire joint is unknown; however, it is an interplay of risk factors, mechanical stress, and abnormal joint mechanics. There are specific signs found on imaging that will notate if a joint is undergoing arthritic changes. There are no imaging or complaint of foot pain during time of service that would suspect the development of arthritis at that time."

Although this medical was thorough, supported by medical literature, and addressed all the theories secondary causes, the Court found the examiner did not specifically explain why the in-service risk factors did not lead to the Veteran's plantar fasciitis. Thus, the claim was remanded for an addendum opinion. The RO obtained the December 2025 medical opinion. However, the RO concluded that the opinion did not fully address the Board's directive. Thus, an additional opinion was obtained.  

In the February 2026 addendum opinion, the examiner opined the claimed condition was less likely than not (likelihood is less than approximately balanced or nearly equal) incurred in or caused by the claimed in-service injury, event, or illness. The examiner wrote:

"The Veteran is seeking service connection for foot conditions other than pes planus, which he contends are due to military duties during service. While it is acknowledged that the Veteran's pes planus pre-existed service, it is important to note that pes planus is a well-established cause of chronic foot pain and is a known risk factor for both plantar fasciitis and degenerative arthritis. Medical research and established literature demonstrate that flat feet significantly increase stress on the plantar fascia and alter normal foot biomechanics, which over time can lead to worsening foot pain, plantar fasciitis, and degenerative changes. As such, the Veteran's pre-existing pes planus is the most likely causative factor contributing to his current foot diagnoses. Although this claim is presented as a direct service connection, a medical opinion cannot be rendered without addressing the role of the Veteran's pre-existing condition, which is the likely underlying cause of his current foot pathology, particularly plantar fasciitis. There is no alternative medical explanation to account for the progressive nature of his foot pain over the years. Additionally, the Veteran's post-service employment history includes work at the post office and in a bakery, both of which require prolonged standing. Prolonged weight-bearing activities are known to exacerbate pes planus, which in turn increases stress on the plantar fascia and accelerates degenerative changes, further contributing to chronic foot pain. Based on the above, it is less likely than not that the Veteran's plantar fasciitis and degenerative arthritis are due to military duties. A nexus has not been established."

The Board acknowledges the Veteran's contentions that his bilateral foot disability is related to his duties in service, was aggravated by service, or related to another disability. Reporting the symptom of pain is within realm of knowledge a lay person can report and it be sufficient for the purpose of service connection. See Kahana v. Shinkseki, 24?Vet. App.?428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the objective medical evidence of record doesn't support his contention. Several medical opinions included in the record support the diagnosis of a current condition. The STR indicated the Veteran had a
 established."

The Board acknowledges the Veteran's contentions that his bilateral foot disability is related to his duties in service, was aggravated by service, or related to another disability. Reporting the symptom of pain is within realm of knowledge a lay person can report and it be sufficient for the purpose of service connection. See Kahana v. Shinkseki, 24?Vet. App.?428 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). However, the objective medical evidence of record doesn't support his contention. Several medical opinions included in the record support the diagnosis of a current condition. The STR indicated the Veteran had a foot condition upon entrance into service. In this case, the medical evidence of record demonstrates that the condition existed prior to service and was not aggravated by his military service. 

The Board acknowledges the favorable evidence that supports the Veteran's contention. Again, the September 2013 private medical opinion, written by Dr. D.M., revealed that the Veteran had been examined from 2008 to 2012, during which time he complained of diffuse joint pain and discomfort, including in his feet, that was most likely due to inflammation consistent with costochondritis.

A February 2014 private medical opinion, written by Dr. T. B., indicated the Veteran presented for treatment for foot pain and discomfort since 2011. The statement reports that "the foot deformity was noted in 1983 to its current medical conditions" which "include plantar fascia pain in both feet and nerve damage right foot." A July 2017 private medical statement reports that the Veteran had diagnoses of plantar fasciitis, neuroma, abnormal gait, and degenerative changes, which were progressive and degenerative changes that were "understandable due to [the Veteran's] foot type (pes planus deformity) which was documented in [the Veteran's] military medical records."

This evidence is given little probative weight because the opinion did not express the right degree of certainty for the Board to determine the nature and etiology of his foot disability. An exam is inadequate if does not express the right degree of certainty, does not provide a rationale, or is conclusory. Stefl v. Nicholson, 21 Vet. App. 120 (2007). The September 2013 medical did not explain how the Veteran's chest condition of costochondritis affected his foot disability. It provided a conclusion but no explanation. The February 2014 statement and July 2017 statement does not offer an etiology opinion. They both restated the Veteran's contention. 

The Board affords more probative weight to the September 2023 VA medical opinion. The examiner meticulously addressed the causation for each condition, and how it was not related to the Veteran's foot disability. The examiner reviewed the claims file and articulated how each notation in the record did not support the nexus. In addition, the examiner referenced medical literature to support the opinion. The February 2026 medical opinion addressed the outstanding issue identified by the December 2024 Court Remand. The examiner indicated that the Veteran's post-service activity aggravated his flat feet. Pro-longed standing was known to aggravate pes planus and lead to additional foot disabilities to include plantar fasciitis. The Veteran worked at the post-service and a bakery. Both occupations required prolonged standing. The Veteran's plantar fasciitis was caused by the aggravation of  his flat feet. The in-service risk factors did not lead to the Veteran's plantar fasciitis. There was no alternative medical explanation to account for the progressive nature of his foot pain over the years.

Accordingly, the criteria for entitlement to service connection for bilateral foot disability other than pes planus disability have not been established, either through medical or lay evidence. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the persuasive weight of the evidence is against the claim of entitlement to service connection for bilateral foot disability, that doctrine is not applicable. 38?U.S.C. §?5107(b); 38?C.F.R. §?3.102; Gilbert v. Derwinski, 1?Vet. App.?49, 53-56 (1990).

 

 

MICHAEL MARTIN

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Harris

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.