Citation Nr: 21063290 Decision Date: 10/13/21 Archive Date: 10/13/21 DOCKET NO. 14-14 664 DATE: October 13, 2021 REMANDED Entitlement to service connection for lumbar spondylosis (claimed as low back disability) is remanded. Entitlement to service connection for plantar fascitis (claimed as left foot condition) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from July 1972 to July 1975, and February 1980 to July 1992. This matter is before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision of the Columbia, South Carolina, Department of Veterans Affairs (VA) Regional Office (RO). In October 2018 a Board hearing was held before the undersigned. A transcript of the hearing is associated with the Veteran's claims file. 1. Entitlement to service connection for lumbar spondylosis is remanded. 2. Entitlement to service connection for plantar fascitis is remanded. The Veteran asserts that he suffers from a left foot disability and lumbar disability as a result of service. In May 2012, the Veteran underwent an examination, and was diagnosed with lumbar spondylosis. He related back issues to running with a ruck sack on during service. The examiner remarked that the STRs are needed before rendering an opinion as to etiology of the lumbar disability. In February 2015, a statement was received from the Veteran's treating physician, Dr. T. She indicated she had treated the Veteran for osteoarthritis of the back and lower limbs since December 2006. She opined "it is more likely than not that the Veteran's osteoarthritis of the back and lower limbs is directly related to symptoms and behavior described by the Veteran shortly after he was discharged from service." In May 2016, he underwent a VA examination. He reported injuring his back during service and that it had hurt ever since. The examiner opined that it is less likely than not that the claimed disability was incurred in or caused by an in-service injury, event, or illness, with the rationale being there is a lack of documentation to support the Veteran's claim. With regard to the left foot disability, in November 2011 the Veteran underwent an examination. The Veteran was found to have heel spurs, and plantar fasciitis. He described the onset being in 1988. He reported an initial injury from a direct blow due to jumping onto a rock. The examiner noted the Veteran's STRs showed an injury to the right foot, and that on separation examination in 1975 his lower extremities and feet were normal. The examiner noted that on separation examination in May 1992, the Veteran had noted bilateral knee, bilateral ankle, and bilateral shoulder arthritis. As to the right foot, the examiner referenced the Veteran's diagnosis of plantar fascitis and heel spurs during service. The examiner opined that his right foot disability is at least as likely as not caused by or related to service. The examiner noted that the opinion was based on the Veteran's information, as the c-file was not available for review. The examiner provided an addendum in February 2012. The examiner opined it is less likely than not that the Veteran's right foot is related to service. In the rationale the examiner notes there are numerous complaints, and a positive x-ray for a heel spurt of his left foot. An opinion with regard to the left foot was not rendered. At the October 2018 Board hearing, the Veteran described a mission he was a part of in Hawaii. He reported riding in a truck, and upon stopping, he jumped over the tailgate and landed on the ball and arch of his left foot. He reported this occurred sometime in either 1991 or 1992. He indicated he went to sick call the following morning and was told he bruised the arch of his foot and gave himself plantar fasciitis. His foot was wrapped, and he was given Motrin. As for his back, he reported injuring his back during a land navigation course at Fort Stewart in Georgia. He reported falling while wearing a rucksack and carrying a weapon. He recalled going to sick call the following morning and being given Motrin. The Veteran's STRs are not complete. There is a rating decision dated December 1975, that references the Veteran's separation examination. The 2011 and 2012 examinations reference the STRs. In May 2013 the RO issued a formal finding of unavailability of STRs. Following a PIES request for records, in November 2019 it was found all available records had been submitted. In December 2019, the Veteran underwent back and foot examinations. He reported that during service, he jumped off the tailgate of a truck and landing on a rock. He indicated his left foot immediately became swollen, he went to sick call and was given Motrin. He reported being on light duty for 14 days. He reported sharp pain and swelling of the foot, and treatment including aspirin and stretches. He was diagnosed with lumbosacral spondylosis and bilateral lower extremity radiculopathy. He reported during service, participating in a land navigation course while carrying full gear, going down into a ravine, and tripped over a root or wire, and flipped over. He reported going to see the PA at the aid station, and taking Motrin. He reported taking it easy for a few days, and his back getting worse over the years. He reported stiffness, achiness, and throbbing pain that goes down his left leg at times. The examiner opined it is less likely than not that his lumbosacral spondylosis or his left foot disability were related to service, as the Veteran did not have these issues prior to service, and records are silent for the treatment of lumbosacral spondylosis or a foot disability. These opinions reference the lack of issues prior to service and records being silent for treatment. A remand was ordered, and in April 2021, opinions were rendered. In both the April 2021 back and foot opinions, the examiner made a reference to the Veteran's separation examination from May 1992, and the fact it was void for complaints. The examiner based the negative opinion on the lack of complaints at discharge. However, in the same examination, the examiner noted the separation examination document was not located. The examiner then explained that separation examinations are thorough and there is no mention of either condition on separation. The Board notes, the separation examination is not of record. In June 2021, the examiner rendered addendum opinions as to the Veteran's left foot and back disability. The examiner noted the lack of treatment during service of a left foot or back disability. The examiner noted no evidence of a chronic disability during service. Again, the Board notes the STRs available for review are very limited, as the Veteran's complete STRs are not of record. A remand is in order as a more complete review of the file and the Veteran's contentions is needed. The matters are REMANDED for the following action: 1. Forward the Veteran's claims file to an appropriate examiner for a supplemental opinion on the etiology of the claimed lumbar spine disability. It is left to the examiner's discretion whether to examine the Veteran. The examiner is asked to answer the following: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's lumbar spine disability is related to his service? The examiner is asked to address the Veteran's contentions, personnel records, and available STRs. The examiner is asked to provide a rationale for all opinions reached. He reported injuring his back during a land navigation course at Fort Stewart in Georgia. He reported falling while wearing a rucksack and carrying a weapon. He recalled going to sick call the following morning and was given Motrin. For purposes of this opinion, the examiner should assume that the Veteran's report of an injury during service is credible. Lack of documentation of treatment is insufficient to support a negative opinion. 2. Forward the Veteran's claims file to an appropriate examiner for a supplemental opinion on the etiology of the claimed left foot disability. It is left to the examiner's discretion whether to examine the Veteran. The examiner is asked to answer the following: a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's left foot disability is related to his service? The examiner is asked to address the Veteran's contentions, personnel records, and available STRs. The examiner is asked to provide a rationale for all opinions reached. The Veteran has reported while riding in a truck, and upon stopping, he jumped over the tailgate and landed on the ball and arch of his left foot. He reported this occurred sometime in either 1991 or 1992. He indicated he went to sick call the following morning and was told he bruised the arch of his foot and gave himself plantar fasciitis. His foot was wrapped, and he was given Motrin. For purposes of this opinion, the examiner should assume that the Veteran's report of an injury during service is credible. Lack of documentation of treatment is insufficient to support a negative opinion. H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Skiouris, 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.