Citation Nr: 20004880 Decision Date: 01/22/20 Archive Date: 01/21/20 DOCKET NO. 17-21 534 DATE: January 22, 2020 REMANDED Entitlement to service connection for left foot condition is remanded. Entitlement to service connection for a right foot condition is remanded. Entitlement to service connection for gastrointestinal condition is remanded. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 2007 to September 2013. This matter is before the Board of Veterans’ Appeals (Board) on appeal from December 2014 and June 2015 rating decisions by a Department of Veterans Affairs Regional Office (RO). REASONS FOR REMAND 1. Left Foot Condition The Veteran seeks entitlement to service connection for left foot disability. A review of the Veteran’s service treatment records (STRs) shows that in July 2011, the Veteran reported a left foot injury in November 2010 while playing basketball that had gotten better following the injury but which had recently become painful. Pain was reported in the base of the 1st and 2nd left toes. An X-ray study revealed bipartite medial and lateral sesamoid bones of the 1st metatarsal head with sesamoiditis to be excluded, with otherwise no bony or joint abnormality. The Veteran was treated with pain medication and foot pads. The Veteran was afforded a VA examination in November 2014. The VA examiner noted that the Veteran did not have a current left foot diagnosis. A review of that examination report shows the Veteran reported an in-service left foot injury while playing basketball, but that his left foot condition had resolved. A review of that examination report further shows that the Veteran denied any symptoms of left foot pain. However, in his April 2017 VA Form 9, Substantive Appeal, the Veteran asserted that he currently treated his left foot with a pad and that he was unable to put much pressure on his left foot without feeling pain. Accordingly, the Veteran has reported worsening symptoms of left foot pain since his November 2014 VA examination. The Board notes that subjective symptoms such as pain are readily amenable to lay observation. Layno v. Brown, 6 Vet. App. 465, 469 (1994). The Board further notes that pain can be a disability if it causes functional impairment. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (finding that “pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability”). Accordingly, the Board finds that a remand is necessary to obtain another VA examination to determine the nature and etiology of the Veteran’s reported left foot symptoms. 2. Right Foot Condition The Veteran contends that he has right foot pain since military service. A review of the Veteran’s service records indicate that he had airborne training and the Veteran’s Form 9 states that landing puts a tremendous amount of pressure on his feet. A statement from the Veteran’s representative indicates that the Veteran’s residual pain since service is related to his current diagnosis of plantar fasciitis. At a November 2014 VA examination, the Veteran was diagnosed with plantar fasciitis of the right foot. However, the VA examiner failed to provide an opinion as to the nature and etiology of the Veteran’s plantar fasciitis of the right foot. As such, a remand is required to obtain an adequate opinion as the nature and etiology of the Veteran’s currently diagnosed plantar fasciitis of the right foot. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). 3. Gastrointestinal Condition The Veteran seeks entitlement to service connection for a gastrointestinal condition. The Veteran was afforded a VA examination in May 2015 and an addendum to this examination was submitted in May 2015. The examiner noted that the Veteran had treatment twice for gastrointestinal issues. The examiner further noted that since separation from service, the Veteran’s medical record had been silent for any gastrointestinal complaints. No current gastrointestinal condition was diagnosed. However, since the May 2015 VA examination, the Veteran’s VA treatment records indicate treatment for gastritis in September 2015. Additionally, the Veteran has submitted private medical records which noted a diagnosis for gastroesophageal reflux disease (GERD) in June 2016. As there is an indication of a current gastrointestinal disability, The Board finds that another VA examination is required to determine the nature and etiology of his disability. Barr v. Nicholson, 21 Vet. App. 303, 311-12 (2007). The matters are REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran’s VA treatment facilities, and all private treatment records from the Veteran not already associated with the file, 2. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed gastrointestinal conditional, to include gastritis and GERD. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed gastrointestinal conditional is etiologically related to his period of service, to include as due to service in in Southwest Asia? If the examiner concludes that the Veteran does not have a diagnosed gastrointestinal or gastroesophageal condition, the examiner should discuss any conflicting medical evidence of record. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. 3. Then, schedule the Veteran for an examination by an appropriate examiner to determine the nature and etiology of any diagnosed bilateral foot disability. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran’s diagnosed bilateral foot disability is etiologically related to his period of service? If the examiner concludes that the Veteran does not have a diagnosed right or left foot condition, the examiner should discuss any conflicting evidence of record to include the Veteran’s reports of pain and treatment. The examiner should review pertinent documents in the Veteran’s claims file in connection with the examination. All indicated studies should be completed. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. CHRISTOPHER LAMB Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Rekowski 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.