Citation Nr: 18112720 Decision Date: 06/21/18 Archive Date: 06/20/18 DOCKET NO. 14-23 729 DATE: June 21, 2018 REMANDED Entitlement to service connection for a left foot disability, to include plantar fasciitis, pes planus, sinus tarsi and calcaneal spurs, and to include as secondary to a service-connected disability, is remanded. Entitlement to service connection for a right foot disability, to include plantar fasciitis, pes planus, sinus tarsi and calcaneal spurs, and to include as secondary to a service-connected disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1988 to June 1992. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New York, New York. The matters are currently under the jurisdiction of the San Diego RO. Entitlement to service connection for a left and right foot disability, to include plantar fasciitis, pes planus, sinus tarsi and calcaneal spurs, and to include as secondary to a service-connected disability, is remanded. At the Board hearing, the Veteran testified that he saw a private podiatrist in the mid 1990s who treated him for foot pain and made custom short inserts. There are no private podiatry treatment records associated with the electronic claims folder. As there may be outstanding records relevant to the Veteran’s claims, the Board finds that a remand is necessary to obtain such records. On remand, the Veteran should complete an up to date VA Form 21-4142, Authorization and Consent to Release Information. The Veteran also stated that he sought treatment at the Long Beach VA Medical Center shortly after service. There are x-rays from Long Beach Medical Center in 1994, but no accompanying treatment records. On remand, the AOJ should obtain up to date VA treatment records. The Veteran is service-connected for a bilateral ankle disability. At a December 2015 VA ankle examination, he reported that he repeatedly had ankle sprains during service and the condition had worsened to the point of general foot pain. He reported that he had to get orthotics and physical therapy to manage the pain. The December 2015 VA examiner found that the Veteran’s ankle pain during service was related to his current pain. The March 2014 VA foot examiner found that the Veteran’s plantar fasciitis with calcaneal spurs was not related to service. Based on the foregoing, the Board finds that a remand is also necessary to obtain an addendum opinion from the March 2014 VA examiner regarding secondary service connection. The matters are REMANDED for the following action: 1. Associate with the claims file complete VA treatment records from the medical center in Long Beach from 1994 to present. 2. Contact the Veteran and request that he provide or authorize the release of any private treatment records regarding treatment of his bilateral foot disability, as well as any other records, not already of record, that are relevant to his claim. The Veteran testified at the Board hearing that he was treated privately for his foot pain in the 1990s. See Board hearing transcript, p.7. If, after making reasonable efforts to obtain non-VA records the AOJ is unable to secure same, the AOJ must notify the Veteran and (a) identify the specific records the AOJ is unable to obtain; (b) briefly explain the efforts that the AOJ made to obtain those records; (c) describe any further action to be taken by the AOJ with respect to the claim; and (d) inform the Veteran that he is ultimately responsible for providing the evidence. 3. Then, obtain an addendum opinion from the March 2014 VA examiner. The Veteran’s electronic claims file, including a copy of this remand, must be made available to the examiner for review in connection with the opinion. If the examiner feels another examination is necessary, another examination should be scheduled. The examiner is requested to review the claims file and offer an opinion as to the following: (a) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s bilateral foot disability was incurred in or is otherwise related to active service. The examiner’s attention is directed to the Veteran’s Board testimony that he engaged in a substantial amount of running, including running with heavy equipment for long distances. The examiner is requested to address the Veteran’s reports that he sought treatment from a podiatrist shortly after service and was given custom orthotics to manage his foot pain. (b) Whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s bilateral foot disability is caused by the Veteran’s service-connected bilateral ankle disability. (c) Whether it is at least as likely as not that Veteran’s bilateral foot disability is aggravated (i.e., worsened) beyond the natural progress by the Veteran’s service-connected bilateral ankle disability. If aggravation is found, the examiner should address the following medical issues: i. the baseline manifestations of the bilateral foot disability found prior to aggravation; and ii. the increased manifestations which, in the examiner’s opinion, are proximately due to the service-connected bilateral ankle disability. The examiner’s attention is directed to the December 2015 VA ankle examination report where the Veteran reported ankle pain during service and which also extended to general foot pain. The December 2015 VA examiner opined that the bilateral ankle disability was related to service and the Veteran is now service-connected for a bilateral ankle disability. A complete rationale for all opinions reached must be provided. 4. Ensure that the information provided in the examination report satisfies the criteria above and, if not, return the report as insufficient. Then, readjudicate the Veteran’s claim after ensuring that any other appropriate development is complete. If the benefit sought remains denied, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded an opportunity to respond. The case should then be returned to the Board for appellate review, if otherwise in order. MICHAEL A. PAPPAS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Baskerville, Counsel