Citation Nr: 21070578 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 18-27 079 DATE: November 24, 2021 REMANDED Entitlement to service connection for a right foot condition is remanded. Entitlement to service connection for right hip/right pelvis disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from December 1965 to March 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). On his April 2018 VA Form 9, Appeal to the Board, the Veteran requested the opportunity to present testimony at a live videoconference hearing. The Veteran and his representative were notified by mail of the details concerning the hearing scheduled for October 2021, but they did not report to the hearing. Inasmuch as there has been no explanation submitted for the missed hearing and no request for the hearing to be rescheduled, the Board will consider the previous request for a hearing to be withdrawn. 1. Entitlement to service connection for a right foot condition is remanded. The Board cannot make a fully-informed decision on the issue of entitlement to service connection for a right foot condition because no VA examination and medical opinion has been provided concerning whether the Veteran has a right foot condition etiologically related to his claimed in-service injury. The Veteran is competent to report his experience stepping into a hole during service. A November 2015 VA X-ray report demonstrated mild degenerative change in the first metatarsophalangeal joint, with small, erosive-like change in the first metatarsal head and mild degenerative change in the talonavicular joint and tibiotalar joint. Further, in a July 2018 statement, the Veteran reported that at present, his foot is discolored and half of the toenail will not grow. The Board notes that the Veteran has been granted service connection for diabetes mellitus. On remand, an examination and medical opinion should be provided concerning the nature and etiology of any current foot disorder. 2. Entitlement to service connection for right hip/right pelvis disability is remanded. The Veteran asserts that he has suffered from right groin tenderness and recurrent right hip pain since an in-service injury when he stepped into a booby-trapped pit while serving in Vietnam. The Veteran was provided with a VA examination and medical opinion in March 2016. The examination report states that the Veteran does not have a current diagnosis associated with the right hip or thigh, but later in the report states that imaging shows that the Veteran has bilateral osteoarthritis of the hips. The examiner stated an opinion that the bilateral hip osteoarthritis is most probably due to the natural progression of age and is not related to military service, and it is less likely as not that the Veteran has a right hip/leg condition that is caused by puncture wound of the right hip during service. The examiner reasoned that the Veteran stated that the right hip injury in 1966 did not result in any open wounds, there are no scars on the right hip at present, and that there is no evidence of chronicity. However, this ignores the Veteran's lay statements about chronic right groin pain and recurrent right hip pain since service and does not address the observed pain during right hip range of motion testing as compared with the lack of pain during left hip range of motion testing. Further, X-rays taken in November 2015 demonstrated moderate right hip joint degenerative changes as compared to mild to moderate for the left, and note "remote posttraumatic deformity in right inferior pubic rami." On remand, a supplemental medical opinion should be obtained concerning the nature and etiology of the Veteran's right hip and pelvis condition(s) which discusses this evidence. Recent VA treatment records document the Veteran's reports that he was treated for his injury at the Ann Arbor VA facility in the late 1960s. There is no indication in the electronic claims file that attempts have been made to locate these treatment records. Additionally, the earliest VA treatment records in the claims file, from November 2015, indicate that the Veteran was then receiving treatment for another condition through a private doctor. Given the decades between the Veteran's separation from service and when he sought to reestablish medical care through VA in 2015, earlier treatment records could shed light on the Veteran's prior medical history and any chronicity of complaints. On remand, the AOJ should take all necessary steps to request and associate these treatment records with the claims file. The matters are REMANDED for the following action: 1. Obtain the Veteran's VA treatment records from the late 1960s from the Ann Arbor VA Medical Center and associate them with the electronic claims file. All requests and responses should be documented for the file. If unsuccessful, a Formal Finding of Unavailability should be prepared, and the Veteran notified. 2. Obtain the Veteran's VA treatment records from September 2018 to the Present and associate them with the electronic claims file. 3. Ask the Veteran to adequately identify and complete a VA Form 21-4142 for any relevant private treatment records he wishes for VA to obtain on his behalf, including but not limited to those from the private doctor referenced in a November 2015 VA primary care note. Make two requests for the authorized records, unless it is clear after the first request that a second request would be futile. 4. After completing the above, and associating all responsive records with the claims file, schedule the Veteran for a VA examination for his claimed right foot disability. The examiner must review the claims file. The examiner should identify a diagnosis for any right foot disability present at any time during the relevant appeal period (April 2016 to the present). If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. The examiner's attention is directed to a November 2015 VA treatment record documenting X-ray findings pertaining to the right foot. The examiner is asked to provide a response to the following: a. Is the right foot disability at least as likely as not (50 percent or greater probability) related to service? b. Is the right foot disability at least as likely as not proximately due to service-connected diabetes mellitus? c. Is the right foot disability at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected diabetes mellitus? Provide a rationale to support any opinion stated. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 5. After completing remand directives #1-3 and associating all responsive records with the claims file, refer the claims file to an appropriate medical professional ("clinician") for a supplemental medical opinion concerning the nature and etiology of the Veteran's claimed right hip/pelvis disability. If additional examination is deemed needed in order to fully respond to the following inquiries, such should be scheduled and the Veteran provided with appropriate notice. The clinician is asked to address the following: a. Identify any right hip or pelvic disability present at any time during the relevant appeal period (November 2015 to Present). The clinician's attention is directed to a November 2015 VA treatment record documenting the findings of X-rays of the pelvis and hips. If a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinion(s) below. b. For any current right hip and/or pelvis disability identified, is it at least as likely as not (50 percent or greater probability) that the disability arose during or is otherwise related to the Veteran's service? The clinician's attention is directed to the Veteran's lay statements concerning experiencing chronic right groin tenderness and recurrent right hip pain since an in-service injury stepping into a hole/booby-trapped pit, as well as VA X-ray findings from November 2015. The clinician is asked to discuss the significance, if any, of the recorded impressions of moderate right hip joint degenerative changes (in comparison to mild to moderate degenerative changes in the left hip) and remote posttraumatic deformity in the right inferior pubic rami. The clinician must provide a rationale to support any opinion stated. In providing the requested opinion, the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms should be considered. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 6. After completing the above, and conducting any further development deemed necessary in light of the expanded record, readjudicate the issues of entitlement to service connection for a right foot disability and right hip/pelvis disability. If the benefits sought remain denied, issue the Veteran and his representative a Supplemental Statement of the Case and allow them an opportunity to respond before returning the appeal to the Board. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Solomon, 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.