Citation Nr: 21070681 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 17-12 378 DATE: November 24, 2021 REMANDED Entitlement to service connection for a recurrent right foot disability is remanded. Entitlement to an initial rating in excess of 10 percent for lumbosacral strain is remanded. REASONS FOR REMAND The Veteran had active service from January 2012 to February 2016. 1. Entitlement to service connection for a recurrent right foot disability is remanded. The report of a January 2016 examination conducted for the Department of Veterans Affairs (VA) during active service notes that the Veteran complained of right foot pain which limited his daily activities. No right foot disability was identified. In his February 2017 Appeal to the Board, VA Form 9, the Veteran reported that he had continued to experienced recurrent right foot pain and discomfort. The Veteran has not been afforded a post service VA foot examination. 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). Clinical documentation dated after February 2018 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to an initial rating in excess of 10 percent for lumbosacral strain is remanded. In his August 2018 Appeal to the Board, VA Form 9, the Veteran reported that the service connected lumbosacral strain had increased in severity since service separation. The Veteran has not been afforded a post service VA lumbosacral spine examination. These matters are 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 right foot disability or the service connected lumbosacral strain. 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 February 2018. 3. Schedule the Veteran for a VA foot examination conducted by a physician to assist in determining the nature and etiology of any identified recurrent right foot disability and any relationship to active service. 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 right foot disabilities found. If no recurrent right foot disability is identified, the examiner should specifically state that fact. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified right foot disability had its onset during active service or is related to any incident of service, including the documented right foot injury and pain. 4. Schedule the Veteran for a VA spine examination conducted by a physician to assist in determining the current nature and severity of the service connected thoracolumbar spine with degenerative joint disease. 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) Provide ranges of motion for passive and active motion of the lumbosacral spine for weight bearing and nonweight bearing. The examiner should specifically state at what degree any observed pain began and whether there is any additional loss of lumbosacral spine function due to painful motion, weakened motion, excess motion, fatigability, or incoordination. (b) Indicate whether, and to what extent, the Veteran experiences functional loss of the lumbosacral spine due to pain or any other symptoms during flare-ups or with repeated use. (c) State whether or not there is any ankylosis of any segment of the spine. J.T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Smith, 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.