Citation Nr: 18158825 Decision Date: 12/18/18 Archive Date: 12/17/18 DOCKET NO. 16-28 479 DATE: December 18, 2018 REMANDED Entitlement to service connection for right leg injury residuals is remanded. REASONS FOR REMAND The appellant is a veteran (the Veteran) who had active duty service from June 1969 through October 1969. The Veteran contends that his right leg was injured during basic training. Although the Board regrets the delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claims so that he is afforded every possible consideration. 38 U.S.C. § 5103(d); 38 C.F.R. § 3.159(c)(4). In April 2014, the Agency of Original Jurisdiction (AOJ) requested a VA examination for the purpose of determining whether the Veteran has a right leg disability that is related to active duty service. An April 2014 VA examination report did not provide a “diagnosis for the right leg. Right knee exam was normal; no warmth redness, swelling or tenderness, and no right knee or lower leg condition noted. However, there was evidence of right foot drop and right calf atrophy on the examination, although there was no identifiable injury or underlying cause. Additionally, weakness in the right ankle was noted but not explained. It appears that no etiological opinion was provided because there was no “diagnosis.” In August of 2015, the Veteran reported income from social security, but the disability was not identified. A July 2015 VA treatment record indicated the Veteran has had chronic right leg pain since 1969. A March 2016 VA treatment record indicated the Veteran reported having right foot drop since 1969. It appears something is wrong with the Veteran’s right leg. The April 2014 VA examination is inadequate because it did not equate the right foot drop, right calf atrophy, and right ankle weakness do a current disability. While the underlying pathology for these manifestations may not have been known at the time of the examination, they were objectively demonstrated on medical examination and equate to a current disability. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). To the extent there is a current disability – as manifested by right foot drop, right calf atrophy, and right ankle weakness – VA is now obligated to fulfill the examination request and to obtain a medical opinion as to whether such disability may be related to service. In light of the foregoing, the Board finds that the VA examination is inadequate. The Board cannot decide the remaining issue without an adequate examination. The matter is REMANDED for the following action: 1. Obtain all outstanding pertinent VA medical records dated from May 2017 to the present. 2. Obtain additional information from the Veteran regarding his right leg disability and whether he receives social security for that disability. If he does, obtain social security records related to the right leg disability. 3. Afford the Veteran an opportunity to attend a VA examination addressing the nature and etiology of any and all current right leg disabilities. After reviewing the claims file, to include the April 2014 VA examination report the examiner should determine whether it is at least as likely as not (i.e. a 50 percent probability or more) that the Veteran’s current right leg residuals began during, first manifested during, or is otherwise related to, his active duty service from June 1969 through October 1969. 4. After completing the above, and any other development deemed necessary, readjudicate the appeal. If the benefit sought remains denied, provide an additional supplemental statement of the case to the Veteran and his representative, and return the appeal to the Board. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Jackman, Associate Counsel