Citation Nr: 21075910
Decision Date: 12/21/21	Archive Date: 12/21/21

DOCKET NO. 19-05 636
DATE: December 21, 2021

REMANDED

Service connection for a right foot disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty with the United States Army from February 1966 to January 1968.

This matter comes before the Board of Veterans' Appeals (Board) on appeal of a September 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

In October 2021, the Veteran provided testimony at a virtual Board hearing before the undersigned Veterans Law Judge.  A copy of the hearing transcript is associated with the claims file.

1. Service connection for a right foot disability is remanded.

The Veteran contends that service connection for a right foot disability is warranted.  Specifically, he states that while service treatment records document injury to his right foot from a fall from the liftgate of a truck, he fell as a result of a gunshot wound to his right foot.  

He is currently diagnosed as having degenerative arthritis of the right foot/ankle.

In an October 1967 service treatment record, it was noted that the Veteran had a possible broken ankle when he fell off a tailgate of a vehicle.  X-rays did not reveal any fracture.  Treatment included a cast of the right ankle for several weeks.  In a November 1987 treatment record, it was noted that the Veteran still had some pain which the treating physician noted was normal with a severe sprain.  The service treatment records do not document a gunshot wound to the right ankle.  

Of record is a VA examination report and a private physician report, however, both reports are inadequate for appellate review.  

In a January 2019 report, a VA examiner determined that it was less likely than not that the Veteran's current right foot/ankle disability was incurred in or caused by the claimed in-service injury, event or illness.  The examiner noted that while the Veteran did incur some type of injury during service, he currently had documented lumbar radiculopathy and diabetic neuropathy that might be causing his right foot pain.  Significantly, the examiner did not discuss whether the right foot arthritis was related to any aspect of the Veteran's service, to specifically include the documented injury. 

In a February 2019 letter, a private physician related the Veteran's arthritis of the right foot to a gunshot wound during service.  The physician did not provide a rationale for the opinion.  

Accordingly, further VA opinion is warranted.

The matter is REMANDED for the following action:

Forward the claims file to an appropriate examiner; only schedule an examination in this matter if deemed necessary by the examiner to answer the Board's question.  Following a review of the claims file, the examiner is to answer the following question:

Whether it is at least as likely as not that the Veteran's right foot arthritis was incurred in service, manifested within one year of discharge from service, or otherwise related to an in-service event, to include the documented injury during service?

The examiner is asked to comment on the Veteran's lay statements concerning the onset of right foot pain during service, as well as the February 2019 letter from the Veteran's private physician.

A complete rationale should be provided for all opinions and conclusions.

 

 

Evan M. Deichert

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. Henriquez, 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.