Citation Nr: 18149888 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 11-07 552 DATE: November 14, 2018 REMANDED Service connection for a right great toe disability, to include as secondary to the service-connected left great toe status debridement with hallux rigidus and osteoarthritis (referred to hereinafter as “left great toe disability”), is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1972 to September 1976. This matter is on appeal from a November 2008 rating decision. In September 2012, the Veteran testified at a hearing before the undersigned. In May 2014, the Board of Veterans’ Appeals (Board) reopened service connection for an ingrown right toenail, recharacterized the issue as service connection for a right great toe disability, and remanded for additional development. In November 2016, the Board denied service connection for a right great toe disability. However, the United States Court of Appeals for Veterans Claims (Court) issued an Order in July 2017 granting a Joint Motion for Remand (JMR). The Board once again remanded for additional development in November 2017. Right Great Toe Disability Unfortunately, yet another remand for additional development is needed. The Veteran underwent a VA medical examination in January 2018, as directed by the Board’s last remand. He was diagnosed with hallux limitus. Arthritis was not diagnosed or even mentioned, despite X-rays showing such as far back as June 2002 and numerous previous diagnoses of such. This suggests that the examiner’s review of the claims file was less than thorough. In addition to this deficiency, very little explanation was provided in support of the opinion against service connection on a direct or secondary basis. The examiner attributed the Veteran’s right great toe disability to his peripheral neuropathy, but how this conclusion was reached is unclear. Indeed, most of the discussion revolved around the appropriate diagnosis being hallux limitus and not hallux rigidus (which was not in dispute). The examination and opinion, in sum, are inadequate. A new examination and opinion thus are needed. Barr v. Nicholson, 21 Vet. App. 303 (2007). For the opinion, the Board reiterates from its last remand that it must consist of clear conclusions with supporting evidence and a reasoned explanation connecting them. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007). Causation and aggravation for secondary service connection further must be addressed separately. El Amin v. Shinseki, 26 Vet. App. 136 (2013). To ensure the examiner has access to all the evidence, any outstanding VA treatment records first should be obtained. This includes those dated from the most recent available in October 2017 to present. It also includes any X-rays taken as part of the January 2018 VA medical examination. While the examiner indicated they had been ordered and the Veteran would get them taken the following week, whether they actually were is unclear. There is no addendum about them, and VA treatment records then have not been procured. This matter is REMANDED for the following action: 1. Follow established procedure for obtaining any outstanding VA treatment records concerning the Veteran. This includes: (a) any X-rays of his right great toe taken as part of/in conjunction with the January 2018 VA medical examination and (b) those dated from October 2017 to present. 2. After completing paragraph 1, schedule the Veteran for a VA medical examination concerning his right great toe. It shall include a review of the claims file as well as an interview and assessment of him by the examiner. The examiner then shall identify all right great toe disabilities present. Next, the examiner shall indicate whether it is at least as likely as not (a 50 percent or greater probability) that each diagnosed disability: a. was incurred during, or is related to, the Veteran’s service, whether from his multiple right great toenail removal surgeries or otherwise, b. was caused by his service-connected left great toe disability, or c. has been aggravated (permanently worsened beyond natural progression) by his service-connected left great toe disability. The examiner also shall opine as to the level of any such aggravation. A detailed explanation is required for each answer. In this regard, the examiner is advised that discussion of medical principles as they relate to the medical and lay (non-medical) evidence and of medical literature would be of assistance to the Board. 3. Then, readjudicate this matter. If the decision made is not favorable to the Veteran, issue a supplemental statement of the case. Allow him and his representative time to respond before returning this matter to the Board. No action is required of the Veteran until he is notified by VA. However, he is advised of his obligation to cooperate. Kowalski v. Nicholson, 19 Vet. App. 171 (2005); Wood v. Derwinski, 1 Vet. App. 190 (1991). His failure to help procure treatment records or to report for a scheduled VA medical examination, for example, may impact the decision made. 38 C.F.R. § 3.655 (2018). The Veteran also is advised that he has the right to submit additional argument or evidence, whether himself or through his representative. Kutscherousky v. West, 12 Vet. App. 369 (1999). All remands by the Board, including this matter, or the Court finally are to be handled expeditiously. 38 U.S.C. §§ 5109B, 7112 (2012). THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Becker, Counsel