Citation Nr: 20030002 Decision Date: 04/29/20 Archive Date: 04/29/20 DOCKET NO. 18-49 155 DATE: April 29, 2020 REMANDED Entitlement to service connection for a left foot disability is remanded. REASONS FOR REMAND The Veteran had active service from September 1965 to December 1966 and from June 1970 to November 1971. The Veteran contends that his left foot condition is related to his military service. Specifically, he contends that he injured his left foot in service due to an automotive accident and from marching exercises which caused a left foot sprain. See July 2018 notice of disagreement and October 2018 VA Form 9. Service treatment records (STRs) show that the Veteran was involved in an automotive accident in March 1971, after which he reported to the emergency room of a hospital where it was noted that there was trauma to his leg. The STRs also document a February 1971 treatment note showing “LS sprain.” The Veteran alleges that this is related to his left foot sprain. The separation physical examination report does not document any left foot complaints or injuries. VA outpatient treatment notes dated in 2016 and 2017 show that the Veteran was treated and seen for various issues related to his left foot, including a chronic wound to his left lower leg and foot wound infection. He was diagnosed with ulceration of the left 5th metatarsal base, chronic osteo, and blister extension. In December 2013, he underwent a VA examination for his right foot and was diagnosed with diabetic foot infection of the right foot. However, there is nothing to indicate that the Veteran was examined for his left foot disability. There was also no separate VA examination for the Veteran’s left foot disability. VA’s duty to assist includes providing a medical examination or obtaining a medical opinion when such an examination or opinion is necessary to make a decision on the claim, as in this case. McLendon v. Nicholson, 20 Vet. App. 79 (2006). As the Veteran’s medical records document complaints related to his left foot, including a chronic left foot wound, and as his STRs show that he was involved in an automobile accident that caused injury to his leg, a VA examination must be provided to determine the nature and etiology of any resulting left foot disability. McLendon v. Nicholson, supra. Accordingly, the matter is REMANDED for the following action: Schedule the Veteran for an appropriate examination to determine the nature and etiology of any left foot disability that he may have. The examiner should review the claims folder and indicate such on the examination report. Any testing deemed necessary should be conducted, and the results thereof should be noted in the examination report. Indeed, all relevant left foot pathology shown on examination should be annotated in the examination report. Following a review of the claims folder, as well as an interview with, and examination of, the Veteran, the examiner is asked to: i. Identify/diagnose any left foot disability that presently exists or that has existed during the appeal period. ii. Opine as to whether it is at least as likely as not (a 50 percent or greater probability), that any such diagnosed left foot disability was incurred in the Veteran’s active service or within one year thereafter—or is otherwise causally related to his active service or to an incident therein. In answering this question, the examiner is asked to address the March 1971 treatment note indicating that the Veteran sustained trauma to his leg due to an automobile accident. The Veteran is competent to report that he hurt his left foot in service and has had left foot problems since then. A complete rationale for all opinions expressed must be provided. An examiner’s report that he or she cannot provide an opinion without resort to speculation is inadequate unless the examiner provides a rationale for that statement. As such, if the examiner is unable to offer an opinion, it is essential that the examiner provide a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that (CONTINUED ON NEXT PAGE) could enable an opinion to be provided or whether the inability to provide the opinion is based on the limits of medical knowledge. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Trowers, 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.