Citation Nr: 21014542 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 14-35 426A DATE: March 12, 2021 REMANDED Entitlement to service connection for a left foot disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1966 to April 1968. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Veteran testified at a videoconference hearing before a Veterans Law Judge and a copy of the hearing transcript has been added to the record. After the Veterans Law Judge who held this hearing subsequently retired from the Board, the Veteran was offered the opportunity to appear at a new hearing before a different Veterans Law Judge. He declined a new Board hearing in an August 2020 correspondence. As such, the Board will proceed with the appeal. See 38 U.S.C. §7107 (c); 38C.F.R. §§19.3 (b), 20.707 This matter was previously remanded by the Board in October 2018 and September 2020 for further development. 1. Entitlement to service connection for a left foot disorder is remanded. Additional development is necessary with regard to the Veteran's claim for service connection for a left foot disorder. Although the Board sincerely regrets the delay, it is necessary to ensure that there is a complete record upon which to decide his claim so that he is afforded every possible consideration. The Veteran contends that he developed a left foot disorder as a result of breaking his left foot during boot camp while in service. See June 2018 Hearing Transcript. His service treatment records (STRs) show that he broke a bone and had a cast removed, but they do not identify where on the body the injury occurred. See October 1966, January 1967 STRs. The Veteran was examined by VA in August 2019, at which time no imaging studies were performed. The Board found this examination inadequate as the examiner did not provide any rationale for his conclusions and, instead, repeatedly recited medical evidence found in STRs and post service records. The examiner continuously concluding that there are no findings for “entitlement to service connection for left foot disorder incurred in or caused by the flatfoot during service or residuals of broken bone, left foot from a 26-mile march during bootcamp at Fort Dix, NJ” after each corresponding cited medical treatment. See September 2020 Board Remand. The Board ordered an addendum opinion from the August 2019 VA examiner or another qualified clinician, and directed the examiner to consider the Veteran’s lay statements surrounding the circumstances of his left foot injury, including a 26 mile march in basic training and a leg cast application and removal between October 1966 and January 1967. The same August 2019 VA examiner offered the addendum opinion in October 2020, again reciting medical evidence in the Veteran’s STRs and post service records and repeatedly concluding “There is no objective medical evidence of recurrent LEFT foot pain as a result of left foot injury, including a 26-mile march in Fort Dix, NJ during basic training as well as a leg cast application and removal at Walson Army Hospital between October 1966 to January 1967.” See October 2020 VA Medical Opinion. The Board finds the October 2020 VA Examination inadequate for the same reason it found the August 2019 VA Examination inadequate; it does not provide a sufficient rationale in support of the conclusion. Additionally, the examiner did not adequately discuss the Veteran’s in-service leg cast application and removal, despite being instructed to do so in the September 2020 Board Remand. Finally, the examiner did not discuss the Veteran’s competent and credible lay statements that he feels pain in his left foot, including his statement that the pain comes from the top front part of his foot, where he states the in-service break occurred. See June 2020 Correspondence. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Additionally, the Board notes that imaging studies have not been performed on the Veteran’s left foot, despite his STRs reflecting broken bone with cast application and cast removal between October 1966 to January 1967 and showing a blank entry for “history of broken bones” on his entrance examination and a “yes” entry for history of broken bones on his exit examination. The Board further notes that the Veteran is not service-connected for any other injury related to a broken bone. Accordingly, a new examination, including imaging studies, is warranted that addresses whether the Veteran’s left foot disorder was incurred in or caused by service. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of his left foot disorder. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease, to include the 26-mile march in Fort Dix, New Jersey during basic training. All appropriate testing, including an imaging study, must be performed on the Veteran’s left foot. The entire claims file and a copy of this REMAND must be made available to the examiner in conjunction with the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed, including the Veteran’s STRs showing broken bone with cast application in October 1966, cast removal in January 1967, and separation examination showing that he had a history of broken bones, as well as his competent and credible lay statements stating that he currently suffers pain in the top front of his foot where he believes the break occurred. See June 2020 Correspondence. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. 2. The AOJ must review the claims file and ensure that the foregoing development action has been completed in full. If any development is incomplete, appropriate corrective action must be implemented. If any report does not include adequate responses to the specific opinions requested, it must be returned to the providing examiner for corrective action. T. Berry Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Mohammad 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.