Citation Nr: 19106963 Decision Date: 01/30/19 Archive Date: 01/29/19 DOCKET NO. 17-19 736 DATE: January 30, 2019 REMANDED Entitlement to service connection for an acquired left foot disability (claimed as muscular atrophy, superior posterior calcaneus traction spur, some fragmentation and insertion of the Achilles tendon on calcaneous, Achilles enthesophyte fracture thru base of enthesophyte, degenerative changes, Marcaine blocks of peroneal nerve, outward pronation, ossific densities, avulsion fracture of medial malleolus) is remanded. REASONS FOR REMAND Entitlement to service connection for an acquired left foot disability is remanded. VA must provide a claimant a medical examination or obtain a medical opinion when such an examination or opinion is necessary to make a decision on a claim for compensation. 38 U.S.C. § 5103(d)(1) (2012); 38 C.F.R. § 3.159(c)(4) (2018). To that end, 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). A thorough medical examination is one that “takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one.” Id. In July 2013, the Veteran underwent a VA examination for his claimed left foot disorder. In this case, however, there is no indication that the July 2013 examiner reviewed the Veteran’s claims file. Further, there is no medical opinion associated with the examination. In that regard, the Board notes that the RO denied service connection for several left foot disabilities not addressed by the July 2013 foot examination, and for which it acknowledged the existence of evidence in the Veteran’s service treatment records, without the benefit of a medical opinion. Consequently, the Board finds that the July 2013 examination is inadequate for rating purposes and will remand for a new foot examination and medical opinion. The matter is REMANDED for the following action: 1. Undertake appropriate efforts to obtain any relevant outstanding VA or private medical records, and associate them with the claims file. 2. Thereafter, afford the Veteran a VA examination to determine the nature and etiology of any diagnosed disability of the left foot. The examiner must review the entire claims file, including this remand, and must obtain a detailed clinical history from the Veteran. All pertinent pathology found on examination must be noted in the report of the evaluation. Any testing deemed necessary must be performed. For each disability diagnosed, the examiner must provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the diagnosed disability began during service, or is causally or etiologically related to service. In rendering this opinion, the examiner must specifically discuss the Veteran’s 2009 and 2010 in-service treatment for reflex sympathetic dystrophy and nerve dysfunction in the left foot. The examiner is advised that the Veteran is competent to report history and symptoms and that those reports must be considered in formulating any requested opinion. If the examiner rejects the Veteran’s reports, the examiner must provide a rationale for doing so. A complete rationale must be given for all opinions and conclusions expressed. If it is not possible to provide a requested opinion without resorting to speculation, the examiner should state why speculation would be required. If there are insufficient facts or data within the claims file, the examiner should identify the relevant testing, specialist’s opinion or other information needed to provide the requested opinion. CAROLINE B. FLEMING Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD David S. Katz, Associate Counsel