Citation Nr: 18146114 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 17-00 469 DATE: October 30, 2018 ORDER Entitlement to service connection for residuals of a left foot injury is granted. REMANDED Entitlement to service connection for headaches is remanded.   FINDING OF FACT The Veteran’s left foot residuals had their onset in service. CONCLUSION OF LAW The criteria for service connection for residuals of a left foot injury have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served in the Army from January 1999 to February 2005. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina. Entitlement to service connection for residuals of a left foot injury Establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff’d per curiam, 78 F. 3d 604 (Fed. Cir. 1996). The Veteran claims that she twisted her ankle during basic training when she entered service in 1999. Since that time, the Veteran has consistently reported pain in her left foot. During service in December 2002, the Veteran reported chronic pain in her left foot for the four previous months. Then in November 2004, the Veteran reported “occasionally oppressive pain” and that her “foot gets swollen when the pain doesn’t let me move.” The injury was first noted at service separation in December 2002, when an examiner noted that, “radiographs of the left foot demonstrate mild hypertrophic change and flattening of the distal third metatarsal. Findings are likely chronic in nature related to either degenerative, congenital, or ischemic etiology.” There is no indication that this condition existed prior to service. Her January 1999 service entrance examination was negative. Thus, she is presumed sound. There is not clear and unmistakable evidence that such an injury might have happened prior service. As such, the presumption of soundness is not rebutted. In short, the onset of the disease is shown to have been during active service. Subsequent evidence, including diagnostic testing at an October 2016 VA examination, indicates positive findings “suggesting prior injury”at the same site as the in-service injury. The October 2016 VA examiner gave a negative opinion, indicating that the in-service findings were not related to the current symptoms. While this may be true, such evidence tends to concern the severity and degree of the current disability, which is a matter that must be addressed when assigning an initial disability rating for the disability. See Boggs v. Peake, 520 F.3d 1330, 1335 (Fed. Cir. 2008) (explaining that “the appropriate time to consider the veteran’s symptoms is when determining the amount of compensation to which the veteran is entitled.”); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); see, also, Ferenc v. Nicholson, 20 Vet. App. 58, 62-63 (2006). That question is currently outside the scope of this decision as it pertains to the award of service connection for the left foot injury. For these reasons, the claim is granted.   REASONS FOR REMAND Entitlement to service connection for headaches is remanded The Board finds that a remand is required to obtain and associate with the record missing medical records. This includes the Veteran’s treatment records from the doctors she identified in her December 2016 VA Form 9, Appeal to Board of Veterans’ Appeals, as well as all post-service treatment records including any VA treatment records and any records on file with the Social Security Administration in connection with a disability claim. See 38 U.S.C. § 5103A(b). In her December 2016 Form 9, the Veteran noted: “when I received the statement of the case I noticed that two medical records were missing that would help support this claim, one from the first primary provider I was seeing after getting out of the military and from a neurologist who was also treating me for the headaches.” The AOJ should contact the Veteran and request that she identify any private treatment records pertaining to the issues on appeal that have not already been associated with the claims file. The matter is REMANDED for the following action: Ask the Veteran to complete a VA Form 21-4142 for records from her first primary care provider and neurologist as identified in her VA Form 9. (Continued on the next page)   Unless already in the claims file, make two requests for any authorized records, unless it is clear after the first request that a second request would be futile. C. BOSELY Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Gillespie, Law Clerk