Citation Nr: 1342216 Decision Date: 12/20/13 Archive Date: 12/31/13 DOCKET NO. 10-29 905 ) DATE ) ) On appeal from the Department of Veterans Affairs Medical and Regional Office Center in Wichita, Kansas THE ISSUE Entitlement to service connection for a right lower extremity disability, claimed as a right knee disability secondary to service-connected residuals of a fracture of the second metatarsal of the right foot with metatarsalgia. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Anthony M. Flamini, Counsel INTRODUCTION The Veteran served on active duty from July 2008 to September 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Wichita, Kansas. Historically, the issue on appeal was initially characterized as a claim for entitlement to service connection for a right knee disability secondary to the Veteran's service-connected right foot fracture. However, a review of the medical evidence reveals diagnoses related to the Veteran's entire right lower extremity which may be interrelated. Therefore, for the purposes of clarity, the Board has reframed the issue as shown on the title page. The Board acknowledges that the Veteran requested a Board videoconference hearing in her July 2010 substantive appeal. However, an April 2011 Informal Conference Report indicated that the Veteran no longer desired a Board hearing, which was confirmed in an August 2011 statement from her representative. As such, her Board hearing request is considered withdrawn. 38 C.F.R. § 20.702 (2013). 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 Veteran seeks entitlement to service connection for a right lower extremity disability. Specifically, she asserts that this disability was caused or aggravated by her service-connected residuals of a fracture of the second metatarsal of the right foot with metatarsalgia. Initially, the Veteran sought entitlement to service connection for a right knee disability, sciatica, and a back disability, all claimed as secondary to her service-connected residuals of a fracture of the second metatarsal of the right foot with metatarsalgia. However, after all of these claims were denied in an October 2009 rating decision, the Veteran only filed a notice of disagreement with respect to the right knee claim. The Veteran was provided with a VA general medical examination in November 2008, at which time she described a "needle and pin and burning sensation" on the bottom of her right foot and up her right leg. The Veteran further described a history of numbness. However, the focus of the examination was on the Veteran's right foot, and she was diagnosed only as having right foot metatarsalgia. VA treatment notes also dated in November 2008 reveal that the Veteran complained of right leg pain that started in her mid-right buttock and radiated in the S1-S2 nerve distribution, as well as pain behind her right knee that went down the middle of her calf muscle. X-rays of the right knee revealed some early medial compartment narrowing; however, the right knee was otherwise unremarkable. The Veteran was again seen for tingling and burning sensation on the dorsum and plantar aspect of her right foot, with radiation of pain up toward the knee. She was diagnosed as having possible inflammation of the right peroneal nerve (as evidenced on a slow F wave per electromyography) as well as nonspecific right knee pain with complaints of locking and right greater trochanteric bursal inflammation. However, there were no objective findings of a right knee disability other than medial and lateral joint line tenderness to palpation. The Veteran again presented with right knee pain in July 2009, at which time she was noted to have swelling from the right ankle to above the right knee with some bruising noted, as well as some swelling and pain around her knee upon range of motion. The Veteran reported that she had experienced right knee pain for the past year, although it became worse three weeks prior. X-rays revealed narrowing of the medial compartment, but no fracture or dislocation. VA physical therapy progress notes dated in November 2009 and December 2009 diagnosed the Veteran as having right knee arthralgia. The Veteran was provided with a VA joints examination in February 2010, at which time she complained of right knee pain, giving way, instability, stiffness, swelling, and grinding. However, the examiner opined that the Veteran did not have a right knee disability that was caused by or secondary to her service-connected right foot fracture. In support of this opinion, the examiner noted there was no mention of right knee symptoms or complaints in the service treatment records or the November 2008 VA examination, and that a specific complaint relevant to the right knee did not appear until December 2008. Although August 2009 magnetic resonance imaging showed possible signal findings consistent with mild myxoid degeneration of the posterior horn medial meniscus, this finding was not diagnostically significant. The examiner also sensed a component of malingering or psychosomatic issues, as the Veteran's current examination results did not "match" previous medical treatment notes, particularly the treatment rendered in November 2009. Following the VA joints examination, in March 2010, the Veteran sought treatment for complaints of sharp pain in her right leg accompanied by purple discoloration and numbness. She also complained of right knee pain. In April 2010, she complained of a sharp, tingling, and stinging pain in the right leg which she had experienced for two years but had flared up two weeks prior. In an April 2010 VA primary care physician outpatient note, she was diagnosed as having arthralgia caused by right knee myxoid degeneration. With respect to the discoloration of her right leg and foot, the VA physician informed her that it could be Raynaud's phenomenon. A June 2012 VA neurology initial evaluation note indicated that the sensory disturbance in the Veteran right leg "might be explained by a compressive neuropathy involving 2 nerves, a distal portion of the saphenous nerve below the knee and the superficial peroneal nerve." The neurologist also opined that, "This might have been incurred at the time of wearing the cast and/or boot [used for treating her service-connected foot fracture] on the right leg." The neurologist found no objective motor deficits, and felt that the right hip pain seemed more musculoskeletal than neuropathic, and that the pain radiating into the groin area might suggest right hip pathology. An August 2012 VA neurology note indicated that electromyography and nerve conduction tests were normal, but again opined that the Veteran's right leg symptomatology was best explained by a compressive neuropathy involving 2 nerves, a distal portion of the saphenous nerve below the knee and the superficial peroneal nerve, and that this might have been incurred at the time of wearing the cast and/or boot on the right leg in service. Although the February 2010 VA examiner opined that the Veteran did not have a diagnostically-significant right knee disability, the other treatment notes of record have diagnosed the Veteran with several disabilities of the right knee and right leg, to include arthralgia, myxoid degeneration, and compressive neuropathy. Moreover, the VA neurologist subsequently indicated that the Veteran's compressive neuropathy "may" be related to the casting used to treat her service-connected right foot fracture. As such, the Board finds that the February 2010 VA joints examination report is inadequate. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (the requirement a current disability is satisfied when the claimant has the disability at the time the claim for VA disability compensation is filed or during the pendency of the claim and that a claimant may be granted service connection even though the disability resolves prior to VA's adjudication of the claim). Therefore, the Veteran must be provided with a new VA examination to determine the likely etiology of her diagnosed disorders of the right leg. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided); see also 38 C.F.R. § 3.159(c)(4); McLendon v. Nicholson, 20 Vet. App. 79 (2006). Accordingly, the case is REMANDED for the following action: 1. Provide the Veteran with appropriate VA examination(s) to determine the likely etiology of her diagnosed disorders of the right lower extremity, to include arthralgia, myxoid degeneration, and compressive neuropathy. The examiner(s) should note review of the prior VA examination reports. The examiner(s) is/are requested to offer an opinion as to whether it is at least as likely as not (50 percent probability or more) that each diagnosed disability is related to active service. If a disability is not found to be directly related to service, then the examiner(s) is/are requested to offer an opinion as to whether it is at least as likely as not (50 percent probability or more) that that each diagnosed disability was caused or aggravated by a service-connected disability, to include the Veteran's residuals of a fracture of the second metatarsal of the right foot with metatarsalgia. Aggravation is defined as a permanent worsening beyond the natural progression of the disease or disability. A complete rationale should be given for any opinion provided. All pertinent symptomatology and findings must be reported in detail. All indicated tests and studies must be performed. The claims file must be made available to the examiner(s) in conjunction with the examination. If no disability of the right lower extremity is found on examination, then the examiner(s) must provide an opinion as to whether a right lower extremity disability was medically shown at any time during the period of appeal, from March 24, 2009, to the present. Specifically, the examiner(s) is/are asked to comment upon the previous diagnoses of arthralgia, myxoid degeneration, and compressive neuropathy rendered by the Veteran's treating VA physicians. 2. After completion of the above, review the record and determine if service connection may be granted. If the benefit sought on appeal is not granted, then the Veteran and her representative should be furnished an appropriate supplemental statement of the case and afforded an opportunity to respond. Thereafter, the case should be returned to the Board for appellate review, if otherwise in order. The appellant has the right to submit additional evidence and argument on the matter or 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. 2013). _________________________________________________ ROBERT C. SCHARNBERGER 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) (2013).