Citation Nr: 20002877 Decision Date: 01/13/20 Archive Date: 01/13/20 DOCKET NO. 14-25 324 DATE: January 13, 2020 REMANDED Entitlement to service connection for a left leg disability (to include hematoma) is remanded. REASONS FOR REMAND The Veteran served on active duty for training (ACDUTRA) in the United States Army from August 1985 to February 1986, and on active duty from December 1986 to March 1990, with additional service in the National Guard and Reserves. This matter comes before the Board of Veterans’ Appeals (Board) on appeal of a rating decision issued by the Department of Veterans Affairs (VA). In June 2018, the Board remanded this matter for further development to include a VA examination and medical opinion. The Veteran underwent a VA examination in June 2019. The Board finds that further medical development is necessary. See 38 U.S.C. § 5103A. The Board notes that service medical records show that the Veteran complained of left thigh pain in the fall of 1985. However, the separation physical examination in February 1990 found normal lower extremities and the Veteran did not report a left leg condition in the report of medical history. Additionally, VA treatment records show that the Veteran reported left leg symptoms in 2004. Specifically, in December 2004, the Veteran reported that he was evaluated by workers compensation personnel, who claimed that he may have neuropathy related to taking isonicotinylhydrazide (INH). In January 2005, a VA physician, Dr. P.M., stated that the Veteran seemed very concerned about finding out the cause of his neurological symptoms and that he strongly felt that his symptoms, including pain and numbness in the legs, is related to INH. In July 2015, a nursing primary care note reflects that the Veteran reported left leg pain. The 2019 examiner noted that the Veteran reported current symptoms included pain, numbness and tingling that limits walking more than 4 blocks and standing more than 2 minutes which impacts the Veteran’s work. The examiner found “[t]he exact nature of the pathology leading to this limitation is unclear and yet to be defined by further diagnostic studies. The examiner noted that an MRI of the area would potentially be beneficial “to look for muscle scarring or atrophy secondary to injury to further confirm or disprove presence of ongoing pathology. is asked to discuss these records when rendering his or her opinion. The examiner also noted that “complex regional pain syndrome has to be considered.” The matters are REMANDED for the following action: 1. Please procure all outstanding non-VA and VA treatment records, including VA treatment records from March 2019 to the present. 2. Schedule the Veteran for an MRI of the left leg (if the Veteran is willing to undergo the procedure) and an appropriate examination of the left leg for an opinion as to service connection for a left leg disorder. (a.) The examiner is asked to provide an opinion regarding whether it is "at least as likely as not" (meaning likelihood of at least 50 percent) that any current left leg disorder is related to, or is otherwise the result of any events which occurred during active duty service. (b.) The examiner is asked to specifically consider and discuss whether the Veteran has complex regional pain syndrome as suggested by the 2019 examiner. (c.) The previous (2019) examiner noted that his opinion would depend on specific findings which would be revealed on an MRI. An MRI was not scheduled. Therefore, the Veteran must be scheduled for an MRI of the left leg (unless he states that he is not willing to undergo such procedure). If the examiner believes that an MRI is not needed, an explanation must be provided. Any and all opinions must be accompanied by a complete rationale. The examiner is reminded that the term “at least as likely as not,” does not mean “within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as it is to find against. M. C. GRAHAM Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Reed, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.