Citation Nr: 21010595 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 14-14 664 DATE: February 25, 2021 REMANDED Entitlement to service connection for lumbar spondylosis (claimed as low back condition) 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 (claimed as low back condition) 2. Entitlement to service connection for plantar fascitis (claimed as left foot condition) The Veteran asserts that he suffers from a left foot disability and lumbar disability as a result of service. With regard to his back, 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 direct blow 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 opinion was based on the Veteran’s information, as the c-file was not available for review. An addendum in February 2012 was rendered. 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. 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, and a foot disability. As these opinions reference the lack of issues prior to service, and “records” being silent for treatment, a remand is needed in order to clarify which records are being referenced, and the Veteran’s reports of in-service injuries. A request was made by the RO in November 2019 for a complete set of the Veteran’s STRs. There is no response in the file. An additional attempt at obtaining the Veteran’s complete STRs is in order. The matters are REMANDED for the following action: 1. Contact the appropriate records repository to obtain the Veteran’s service treatment records for his period of active service. 2. Obtain an addendum opinion as to the Veteran’s left foot disability claim. Following a review of the claims file, the examiner should prove an opinion for 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? b) The examiner is asked to address the Veteran’s contentions, personnel records, and available STRs. The examiner is asked to reference the findings of the 2011 exam and 2012 opinion as well. The examiner is asked to provide a rationale for all opinions reached. To the extent the Veteran reported a fall in service, he is competent to so report. 3. Obtain an addendum opinion as to the Veteran’s back disability. 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? b) 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. To the extent the Veteran reported a fall in service, he is competent to so report. 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.