Citation Nr: 21063434 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 14-32 385 DATE: October 14, 2021 REMANDED Entitlement to service connection for a left lower extremity disability, to include a left Achilles disability and a left foot disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1975 to September 1979. Entitlement to service connection for a left lower extremity disability, to include a left Achilles disability and a left foot disability, is remanded. In its July 2021 Remand instructions, the Board of Veterans' Appeals (Board) directed that the Veteran be afforded further Department of Veterans Affairs (VA) evaluation. The examiner was requested to opine whether it "is at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed left foot disorders, to include (i) pes planus, (ii) plantar fasciitis, and (iii) Achilles tendonitis, were incurred in service or are otherwise etiologically related to his military service" and "to include an explanation of why the Veteran's disabilities are or are not a result of the foot pain and/or physical trauma caused by the boots the Veteran wore during his military training and the significance, if any, of the continuity of symptomatology the Veteran has experienced since service." An August 2021 VA evaluation states that: the Veteran "has a diagnosis of flat feet;" "he reports onset of foot pain in 1975;" "his records show: 1976 negative for foot pain, 1979 exam negative;" and "therefore, his left foot condition is less likely incurred in service." The examiner did not address the Veteran's subjective history of foot pain and/or physical trauma caused by his military boots and post service left lower extremity pain. Therefore, the Board finds that the evaluation is of essentially no probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Further, the Board observes that service connection may be granted for disability which is proximately due to or the result of a service connected disease or injury. 38 C.F.R. § 3.310(a). Service connection shall be granted on a secondary basis under the provisions of 38 C.F.R. § 3.310(a) where it is demonstrated that a service connected disorder has aggravated a nonservice connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection has been established for left knee strain, osteoarthritis, and instability; right knee strain, osteoarthritis, and instability; a right Achilles disability; a deviated nasal septum with chronic maxillary sinusitis; and tinnitus. Clinical documentation dated after July 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claim. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any left lower extremity disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after July 2021. 3. Schedule the Veteran for a VA examination conducted by a medical doctor to assist in determining the current nature of any identified left lower extremity disability and its relationship to active service or the service connected disabilities. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all left lower extremity disabilities found, to include left Achilles and left foot disabilities. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified left lower extremity disability had its onset during active service or is related to any incident of service, including the Veteran's subjective history of foot pain and/or physical trauma caused by his military boots and post service left lower extremity pain. (c) Opine whether it is at least as likely as not (50 percent probability or greater) that any left lower extremity disability is due to or the result of the left knee strain, osteoarthritis, and instability and the other service-connected disabilities. (d) Opine whether it at least as likely as not (50 percent probability or greater) that any left lower extremity disability has been aggravated (increased in severity beyond the natural progression of the disorder) by the left knee strain, osteoarthritis, and instability and the other service-connected disabilities. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, 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.