Citation Nr: 1327788 Decision Date: 08/30/13 Archive Date: 09/05/13 DOCKET NO. 10-05 365 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to service connection for a left shoulder disorder. 2. Entitlement to service connection for a right shoulder disorder. 3. Entitlement to service connection for a lumbosacral spine disorder. 4. Entitlement to service connection for a left ankle disorder, to include the residuals of a left heel stress fracture. 5. Entitlement to service connection for a right ankle disorder, to include the residuals of a right heel stress fracture. 6. Entitlement to service connection for a right knee disorder. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD K. Osegueda, Associate Counsel INTRODUCTION The Veteran served on active duty from July 2004 to July 2008. His awards and decorations include the Combat Action Ribbon. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio, as part of the Benefits Delivery at Discharge (BDD) program. The purpose of the BDD program is to help ensure a smooth transition from military to civilian status by allowing service members to file pre-discharge claims for disability compensation with VA. In addition to the paper claims file, there is a Virtual VA paperless file associated with the Veteran's case. A review of the documents in the paperless claims file reveals a statement in support of the Veteran's claims submitted by the representative in July 2013. The remaining documents in the Virtual VA file are either duplicative of the evidence in the paper claims file or irrelevant to the issue on appeal. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The law provides that the VA shall make reasonable efforts to notify a claimant of the evidence necessary to substantiate a claim and requires the VA to assist a claimant in obtaining that evidence. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). Such assistance includes providing the claimant a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on a claim. 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2012). With regard to his ankles, the Veteran has contended that has current left and right ankle pain related to stress fractures of his left and right heels that manifested in service. A review of the Veteran's service treatment records does reveal that the Veteran complained of bilateral ankle pain and swelling in July 2004, and the diagnosis was Achilles bursitis. He was subsequently treated for complaints of ankle pain and swelling, Achilles bursitis, Achilles tendonitis, a first degree ankle sprain of his right ankle, pes planus, and bilateral calcaneal stress fractures from July 2004 to September 2004. During a July 2008 VA joints examination, the examiner noted that the Veteran complained of residual bilateral ankle pain from his healed stress fractures. The diagnosis was bilateral ankle strain; however, the examiner did not provide an etiological opinion. Therefore, the Board finds that a VA examination and medical opinion are necessary for determining the nature and etiology of any left and right ankle disorder that may be present. In addition, the Board notes that the Veteran was diagnosed with a left shoulder strain, a right shoulder strain, a lumbosacral strain, and right patellofemoral syndrome during a July 2008 VA examination. Notably, those diagnoses were rendered within approximately 25 days of the Veteran's separation from service, which suggests that they could have manifested in service. However, the examiner did not discuss whether those disorders may be related to the Veteran's military service. Therefore, the Board finds that a VA examination and medical opinion are also necessary for determining the nature and etiology of any shoulder, lumbosacral spine, and right knee disorders that may be present. Moreover, the Board notes that the claims file does not include any post-service medical records. Thus, on remand, an attempt should be made to obtain any outstanding medical records that are relevant the claimed disorders. Accordingly, the case is REMANDED for the following action: 1. The RO/AMC should ascertain if the Veteran received any VA, non-VA, or other medical treatment that is not evidenced by the current record, to specifically include, but not limited to, any VA treatment records not associated with the record. The RO/AMC should provide the Veteran with authorization forms for the release of any identified outstanding private treatment records. The RO/AMC should then obtain these records, as well as any other pertinent records, and associate them with the claims folder. If VA is unsuccessful in obtaining any medical records identified by the Veteran, it must inform him and provide him an opportunity to submit copies of the outstanding medical records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any left or right ankle disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. The examiner should specifically consider the July 2008 VA examination report, which was rendered during the same month as his separation from service. It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should provide an opinion as to whether it is at least as likely as not that the Veteran currently has a left or right ankle disorder that manifested in service or that is otherwise causally or etiologically related to his military service, including his symptomatology therein. In rendering this opinion, the examiner should address the fact that the Veteran was diagnosed with a bilateral ankle strain within 25 days of his separation from service. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. The Veteran should be afforded a VA examination to determine the nature and etiology of any right knee, right and left shoulder, and lumbosacral spine disorders that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran's service treatment records, post-service medical records, and statements. The examiner should specifically consider the July 2008 VA examination report, which was rendered during the same month as his separation from service. It should be noted that the Veteran is competent to attest to observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify all current back, bilateral shoulder, and right knee disorders. For each diagnosis, the examiner should provide an opinion as to whether it is at least as likely as not that the disorder manifested in service or is otherwise causally or etiologically related to his military service. In rendering this opinion, the examiner should address the fact that the Veteran was diagnosed with a left shoulder strain, a right shoulder strain, a lumbosacral strain, and right knee patellofemoral syndrome within 25 days of his separation from service. (The term "at least as likely as not" does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important "that each disability be viewed in relation to its history [,]" 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. After completing these actions, the RO/AMC should conduct any other development as may be indicated by a response received as a consequence of the actions taken in the preceding paragraphs. 5. When the development requested has been completed, the case should be reviewed by the RO/AMC on the basis of additional evidence. If the benefit sought is not granted, the appellant and his representative should be furnished a supplemental statement of the case (SSOC) and be afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). ______________________________________________ JESSICA J. WILLS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).