Citation Nr: 1745599 Decision Date: 10/13/17 Archive Date: 10/19/17 DOCKET NO. 13-29 699 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a left heel spurs deformity. 2. Entitlement to service connection for a left ankle tendon strain. 2. Entitlement to service connection for right ankle tendon strain. REPRESENTATION Appellant represented by: Texas Veterans Commission WITNESSES AT HEARING ON APPEAL The Veteran and his spouse ATTORNEY FOR THE BOARD S. Anwar, Associate Counsel INTRODUCTION The Veteran had active service from July 2000 to October 2006. This matter comes before the Board of Veterans' Appeals (Board) from a July 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. Jurisdiction of the Veteran's claims was subsequently transferred to the VA RO in Houston, Texas. In June 2016, the Veteran and his spouse testified at a Travel Board hearing before the undersigned Veterans Law Judge. The undersigned noted the issues on appeal and engaged in a colloquy with the Veteran toward substantiation of the claims. See Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). A copy of the hearing transcript is associated with the claims file. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The February 2011 VA medical examiner did not opine on the Veteran's left heel spurs deformity, nor did he address the Veteran's contention that his left and right ankle tendon strains are causally related to the heel spurs deformity. A new examination is needed to fully and fairly evaluate the claims. Accordingly, the case is REMANDED for the following action: 1. Request the Veteran provide any service treatment records he possesses or identify and secure any relevant private medical records that are not in the claims file. If the Veteran identifies private records, following the securing of the appropriate waivers, make all appropriate attempts to locate such records and to associate them with the claims file. If the Veteran has no further evidence to submit, or, if after exhaustive efforts have been made, no records can be identified, so annotate the record. 2. Obtain any outstanding VA medical records and associate them with the claims file. 3. Schedule the Veteran for an appropriate VA examination with a different examiner to determine the nature and etiology of his current left heel spurs deformity, and his left and right ankle tendon strains. The entire claims file, including a copy of the Remand, should be made available to, and be reviewed by, the VA examiner. All appropriate tests, studies, and consultations should be accomplished and all clinical findings should be reported in detail. A rationale should be given for all opinions and conclusions rendered. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinions: a) Was the Veteran's left heel spurs deformity incurred in service or caused by an in-service injury, event or illness? b) Was the Veteran's left ankle tendon strain incurred in service or caused by an in-service injury, event or illness? c) Does the Veteran have a right ankle tendon strain? If so, was it incurred in service or caused by an in-service injury, event or illness? d) If the Veteran's left heel spurs deformity was incurred in service or caused by an in-service injury, event or illness, was the Veteran's left and/or right ankle tendon strains proximately due to or aggravated (e.g. worsened and if so, to what degree) by the Veteran's left heel spurs deformity? e) If aggravation is found, the examiner should also state, to the extent possible, the baseline level of disability prior to aggravation. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. The examiner must review the entire record in conjunction with rendering the requested opinions. IN ADDITION TO ANY RECORDS THAT ARE GENERATED AS A RESULT OF THIS REMAND, the VA examiner's attention is drawn to the following: * In September 2004 the Veteran was treated for Achilles pain. * In September 2006 the Veteran reported pain in his lower left calf after running or jogging. He also reported pain in his right calf, and was assessed with right leg strain gastrocnemius. * A buddy statement from T.E. indicated he observed the Veteran experience severe foot pain and witnessed the Veteran request medical attention that was refused. * In June 2008, the Veteran was diagnosed with a left heel spurs deformity. * In June 2009, the Veteran underwent endoscopic surgery to release the plantar fascia of the left heel. * A May 2010 MRI showed thickening of the anterior talo-fibular ligament "suggesting chronic injury." * In July 2010, the Veteran private foot surgeon opined the Veteran's ankle condition "relate[d] back to injuries [the Veteran] sustained to this area when he was on active military duty in the Navy." * In June 2016, the Veteran testified his private foot surgeon told him the right and left ankle tendon strains are related to the heel spurs deformity. * Service connection is in effect for obstructive sleep apnea, unspecified sleep-wake disorder, right shoulder osteoarthritis, tinnitus, and a right shoulder post-arthroscopic surgery scar. A thorough explanation must be provided for the opinions rendered. If the examiner cannot provide the requested opinions without resorting to speculation, s/he should expressly indicate this and provide supporting rationale as to why the opinions cannot be made without resorting to speculation. THE EXAMINER IS ADVISED THAT BY LAW, THE MERE STATEMENT THAT THE CLAIMS FOLDER WAS REVIEWED AND/OR THE EXAMINER HAS EXPERTISE IS NOT SUFFICIENT TO FIND THE EXAMINATION/OPINION SUFFICIENT. 4. Then, review the VA examiner's report(s) to ensure that he or she adequately responded to the above instructions, including providing an adequate explanation in support of the requested opinions. If the report(s) is (are) deficient in this regard, return the case to the VA examiner for further review and discussion. 5. Following the review and any additional development deemed necessary, re-adjudicate the claims. Should the claims not be granted in its entirety, issue an appropriate supplemental statement of the case (SSOC) and forward the claims to the Board for adjudication. The appellant 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 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 2014). _________________________________________________ Vito A. Clementi Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2016).