Citation Nr: 1801757 Decision Date: 01/10/18 Archive Date: 01/23/18 DOCKET NO. 15-17 216 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUES Entitlement to service connection for a bilateral leg disorder. REPRESENTATION Appellant represented by: Oklahoma Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL The Veteran and his wife ATTORNEY FOR THE BOARD D.S. Chilcote, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from October 1943 to April 1946. This case comes before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. A videoconference hearing was held before the undersigned Veterans Law Judge in July 2017. A transcript of the hearing is of record. The Board notes that the RO has adjudicated the issue on appeal as entitlement to service connection for peripheral neuropathy of the lower extremities. However, in his December 2013 VA Form 21-526 EZ, the Veteran filed a claim for service connection for leg injuries. The Veteran and his representative have stated that they are not seeking service connection for peripheral neuropathy, but rather for a bilateral leg disorder. See e.g. July 2017 hearing transcript. Therefore, the Board finds that the claim should be construed more broadly and has recharacterized the issue as entitlement to service connection for a bilateral leg disorder. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). This appeal was processed using the Veterans Benefits Management System (VBMS). This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). The appeal is REMANDED to the AOJ. VA will notify the appellant if further action is required. REMAND The Veteran testified at the July 2017 hearing that he began receiving treatment at the VA Medical Center (VAMC) in Oklahoma City in 1947, which was shortly after his separation from service. Although the April 2015 statement of the case does reference VA treatment records dating back to 1998, the claims file does not contain any VA treatment records dated prior to March 2014. In addition, the Veteran stated that he has been receiving treatment from a private physician, Dr. B. (initials used to protect privacy) for 15 years. However, the claims file only contains a June 2014 record and June 2017 letter from that physician. Therefore, the AOJ should attempt to obtain any outstanding medical records. The Board also notes that the Veteran has not been afforded a VA examination in connection with his claim. During the July 2017 hearing, he testified regarding an injury and symptoms in service. It was also alleged that he had an altered gait due to a gunshot wound in service, which could have caused the disorder. The available service treatment records do document that the Veteran sustained a bullet wound to the right foot in November 1944. Moreover, in a June 2017 letter, Dr. B. opined that the Veteran had bilateral lower extremity conditions that were related to his military service; however, he did not identify any diagnoses. Therefore, the Board finds that a VA examination and medical opinion are needed to determine the nature and etiology of any bilateral leg disorder that may be present. Accordingly, the case is REMANDED for the following action: (This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. The AOJ should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his lower extremities. A specific request should be made for treatment records from Dr. B., who was identified at the July 2017 hearing and provided a June 2017 letter. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA medical records, to include any records dated since 1947. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any bilateral leg 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 available service treatment records, post-service medical records, and statements. The examiner is advised that the Veteran's complete service treatment records are unavailable, as they are presumed to have been destroyed in a fire. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, to include 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 any current leg disorders. For each disorder identified, the examiner should opine 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, including any injuries and symptoms therein, as well as the November 1944 bullet wound to his right foot. The Veteran has alleged, in part, that the gunshot wound resulted in an altered gait, which caused his current leg disorders. (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 a conclusion as it is to find against it.) A clear rationale for all opinions should be provided, 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, the examiner should review copies of all pertinent records in the Veteran's claims file, or in the alternative, the claims file. 3. After completing the above actions, the AOJ should conduct any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs. 4. Thereafter, the case should be reviewed by the AOJ on the basis of additional evidence. If the benefits sought are not granted, the Veteran and his representative should be furnished an 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 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. §§ 5109B, 7112 (2012). _________________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C. § 7252 (2012), 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) (2017).