Citation Nr: 1746944 Decision Date: 10/20/17 Archive Date: 10/31/17 DOCKET NO. 13-35 738 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Oakland, California THE ISSUES 1. Entitlement to service connection for a left leg disability, to include a sclerotic lesion and as secondary to service-connected right ankle. 2. Entitlement to service connection for a left ankle disability, to include as secondary to service-connected right ankle. REPRESENTATION Veteran represented by: The American Legion ATTORNEY FOR THE BOARD J. R. Higgins, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Marine Corps from August 1972 to July 1974 and August 1974 to February 1984. This matter is before the Board of Veterans' Appeal (Board) on appeal from an April 2013 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO) in Lincoln, Nebraska. Jurisdiction has been transferred to the VA RO in Oakland, California. This appeal was processed using the Virtual VA/VBMS paperless claim processing system. Accordingly, any future consideration of this Veteran's case should take into account the existence of this electronic record. The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the Veteran if further action is required. REMAND The Veteran contends that both his left leg and ankle disabilities are related to his military service, or were caused or aggravated by his service-connected right ankle. The Veteran asserts that he sustained injuries in service which have resulted in his current left leg and ankle disabilities. See September 2017 IHP. Specifically, the Veteran contends that he was treated for those injuries during his active service in Elangen, Germany. The Board notes that the Veteran's service treatment records are silent as to any notation of an injury or treatment related to his left leg or ankle. The Veteran's medical records detailed a history of left ankle and leg pain. With regards to left leg pain, the Veteran underwent an x-ray at a private medical facility, which found an intramedullary sclerotic lesion seen in the distal tibia. See October 2012 Private Medical Records. The private physician provided that the sclerotic lesion may represent infract or malignant degeneration of an enchondroma, however the x-ray did not demonstrate an acute fracture, or soft tissue swelling. In a December 2011 VA treatment record, the Veteran reported fracturing his left leg below the knee, when he was hit by a truck. The Veteran also reported left leg pain that radiates to his back. The Veteran has not been provided a VA examination to determine the nature and etiology of his left leg disability. In this regard, the Board notes that the Veteran's representative asserted that the Veteran's service-connected right ankle has resulted in an antalgic gait affecting the Veteran's left leg. On remand, he should be afforded an examination to determine the etiology of his left leg disability. Additionally, review of the claims file indicates that there may be outstanding VA and private medical records. The latest VA medical records associated with the file are from August 2013. The September 2013 Statement of the Case (SOC) detailed a May 2013 VA x-ray performed in relation to the Veteran's left leg and ankle, however it does not appear to be associated with the record. The September 2013 SOC also detailed a private x-ray of the left knee performed April 2011 that is not associated with the file as well. It also appears that Veteran was involved in a car accident approximately in September 2011, which he was hit by a truck and sustained a broken left leg. There are no private or VA medical records related to this incident associated with the file. Therefore, the Board remands the matter for VA examination to determine the etiology and nature of the Veteran's left leg and ankle disabilities and for further development of the claims file. Accordingly, the case is REMANDED for the following actions: 1. With any necessary assistance from the Veteran, obtain any outstanding private and VA medical records, to specifically include those noted above. The Veteran must be provided with the necessary authorizations for the release of any private treatment records not currently on file. The AOJ must then obtain these records, as well as any other pertinent records, and associate them with the claims folder. If the AOJ 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 the foregoing development, provide the Veteran with a VA examination to determine the etiology of his left leg disability. 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 lay statements. The examiner must elicit a full medical history from the Veteran. Please address the following inquires: (a) Is it at least as likely as not (a fifty percent probability or greater) that the left leg disability, to include a sclerotic lesion was caused or aggravated by the Veteran's service-connected right ankle? (b) Is it at least as likely as not (a fifty percent probability or greater) that the Veteran's left leg disability, to include a sclerotic lesion was incurred in or aggravated by service? The examiner should consider the lay testimony of record. Specifically, the Veteran's contention that he was treated during service for a left leg injury despite absence in his service treatment records. Additionally, the examiner should consider the Veteran's contention that his service-connected right ankle has resulted in an antalgic gait, which place stress on his left leg. A detailed rationale supporting the examiner's opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. See Jones v. Shinseki, 23 Vet. App. 382 (2010). 3. After completing the above and any other action indicated as a result of the actions taken herein, readjudicate the issues on appeal. If the benefits sought on appeal remain denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board for appellate review, after the Veteran and his representative have had an adequate opportunity to respond. 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 2014). _________________________________________________ LANA K. JENG 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).