Citation Nr: 21023355 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 14-02 044 DATE: April 20, 2021 REMANDED Entitlement to service connection for a left foot condition is remanded. Entitlement to service connection for a right foot condition is remanded. Entitlement to service connection for bilateral hearing loss is remanded. Entitlement to service connection for a head condition (claimed as a knot on the back of the head) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1972 to May 1974. This matter originally came before the Board of Veterans’ Appeals (Board) from a June 2011 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. This matter was previously remanded by the Board in September 2016 so that a Board video-conference hearing could be scheduled. This matter is again before the Board. The Board notes that the Veteran was most recently scheduled for a Board video-conference hearing in May 2019 but did not appear. The Veteran has not provided an explanation as to why he did not appear for the hearing. As such, without good cause having been provided for missing the hearing, the Board finds that the Veteran’s hearing request has been withdrawn. Entitlement to service connection for a left foot disability, service connection for a right foot disability, service connection for bilateral hearing loss, and service connection for a head disability (claimed as a knot on the back of the head) are remanded. The Veteran believes that service connection for a left foot disability, right foot condition, bilateral hearing loss, and a head disability is warranted. See May 2019 VA 646. The Board finds that a remand for all of the above conditions is needed for multiple reasons. First, it does not appear that any attempt has been made to obtain the Veteran’s service personnel records for the period in which the Veteran is known to have served. See September 2010 VA 21-3101; 38 C.F.R. § 3.159. Second, the record suggests that there may be additional periods of service for which attempts have not been made to verify, nor have attempts been made to obtain service records from those periods. Specifically, the Veteran reported service prior to the date currently believed to be when he entered the military and service treatment records suggest service following the date currently believed to be when he permanently separated from the military. See July 2010 VA 21-526; July 2014 STR - Medical; 38 C.F.R. § 3.159. Finally, the Veteran’s VA treatment records have not been updated in over a decade. Attempts to obtain those outstanding records are necessary. See 38 C.F.R. § 3.159. With regard to the head condition, generally, a VA examination is required for a service connection claim when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) evidence establishing that an event, injury, or disease occurred in service; and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service; but (4) there is insufficient competent medical evidence on file for VA to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The Veteran has reported that he has a knot on the back of his head. See July 2010 VA 21-526. The Veteran is competent to report anything capable of lay observation. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Board finds that the Veteran is competent to report the knot on the back of his head. As such, the Board finds that the first prong is met. The Veteran reported that the knot on the back of his head occurred during an in-service fall. See July 2010 VA 21-526. As such, the Board finds that the second and third prongs are met. Given these facts, the Board finds that a remand is necessary to obtain a VA examination to determine the etiology of the Veteran’s head condition. See McLendon, 20 Vet. App. at 83. Finally, a VA examination for the left foot and right foot took place in September 2013. However, the examination did not provide any opinions as to whether any of the Veteran’s left foot conditions were related to a documented left foot injury during service or whether the Veteran’s bilateral foot arthritis manifested to a compensable degree within one year following active service. See October 2013 C&P Exam; Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); July 2014 STR – Medical. Therefore, the examination is inadequate, and a remand is needed for a new VA examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The matter is REMANDED for the following action: 1. Provide the Veteran with an opportunity to identify any relevant outstanding private and/or VA treatment records. After obtaining any necessary authorizations from the Veteran, make all reasonable attempts to obtain the outstanding records in accordance with 38 C.F.R. § 3.159. 2. Update VA and private treatment records. VA treatment records appear current up to September 2010. 3. Attempt to obtain the Veteran’s service personnel records from June 1972 to May 1974. All efforts to obtain these records should be documented, and if the records cannot be located, a formal finding of unavailability should be associated with the Veteran’s claims file. 4. Contact all appropriate sources to determine whether the Veteran had any additional active duty, ACDUTRA, and/or INACDUTRA service. All efforts to obtain this information as well as any responses should be documented. If any additional periods of service exist, attempt to obtain all related service treatment and personnel records.  All efforts to obtain these records should be documented, and if the records cannot be located, a formal finding of unavailability should be associated with the Veteran’s claims file.  The record suggests, at a minimum, that the Veteran may have had service in Vietnam in 1971 and may have reenlisted around 1979.   5. Make a formal finding for all periods of active service, ACDUTRA, and/or INACDUTRA in terms of specific dates.  If this cannot be accomplished, provide an explanation.  6. Schedule one or more appropriate VA examinations for the Veteran’s left foot, right foot, and head disabilities. The need for an in-person examination of the Veteran is left to the discretion of the examiner. Following a review of the claims file and a copy of this Remand, the reviewing examiner is requested to furnish an opinion with respect to the following: (A) Identify all left foot, right foot, and head disabilities existing at any point during the pendency of the appeal (i.e. since July 2010), even if they are currently asymptomatic or have resolved during the pendency of the appeal. (B) For each identified disability, is it at least as likely as not (a 50 percent or greater probability) that the disability is related to the Veteran’s active service, active duty for training, and/or inactive duty for training? If so, which periods? (C) The examiner is asked to confirm whether the feet defect noted on the service entrance examination was pes planus. If the defect was something else, state what it was. For each identified disability which matches the defect listed on the service entrance examination, is it at least as likely as not (a 50 percent or greater probability) that the disability was aggravated beyond its natural progression by the Veteran’s active service, active duty for training, and/or inactive duty for training? If so, which periods? (D) Is it at least as likely as not (a 50 percent or greater probability) that any left foot and/or right foot arthritis manifested to a compensable degree within one year following the Veteran’s separation from active service? If so, which ones? In addition to the other relevant evidence of record, the examiner is asked to consider the following information with a caution that this list is not a substitute for a review of the record: Left foot/right foot conditions (1) The Veteran’s report that his feet conditions are directly related to service. See May 2019 VA 646. (2) A medical record from 2017 showing gait problems, instability, type II diabetes mellitus, and bilateral lower extremity reduced muscle strength. See June 2017 VA 21-2680. (3) Service records showing a laceration of the great left toe from a razor blade, which was about two inches in length and 1/8th to 1/4th inch deep. The toe was sore and received treatment. The Veteran also complained about a swollen left ankle after running, hitting a rock, and twisting it. There was moderate edema. Finally, the Veteran also fell in the shower and had a two-inch cut. See July 2014 STR – Medical. (4) A medical record from 2013 showing diagnoses of right foot hammer toes, bilateral hallux valgus, chronic tinea pedis, onychomycosis, onychauxis, bilateral arthritis, and right foot pes planus. The Veteran reported having flat feet for an uncertain duration. The Veteran also reported cutting his foot during basic training. Now he had foot pain which affected his work, walking, and gait. See October 2013 CAPRI. (5) Medical records from 1999 showing the Veteran’s report of a cystic mass which caused left leg pain. He had a similar but painless mass removed from the same area in 1991. Medical records from 2005 showed the Veteran’s report of numbness and pain to the right foot. See October 2010 CAPRI. (6) The Veteran’s report of serving in Vietnam in 1971 and spending time serving at Camp Lejeune in 1974. See July 2010 VA 21-526. (7) All other relevant lay and medical evidence. Head condition (1) The Veteran’s report that his head condition is directly related to service. See May 2019 VA 646. (2) The Veteran’s report that the knot on the back of his head was due to a fall during bootcamp. The Veteran also reported that he served in Vietnam in 1971 and spent time serving at Camp Lejeune in 1974. See July 2010 VA 21-526. (3) All other relevant lay and medical evidence. A complete rationale for all opinions offered should be provided. Address the Veteran’s documented history and assertions. All necessary tests and studies should be conducted. If the examiner cannot provide an opinion without resorting to mere speculation, the examiner should provide an explanation stating why. In so doing, the examiner should explain whether the inability to provide a more definitive opinion is due to the limits of the medical community’s knowledge or the limits of the examiner’s medical knowledge. The Veteran is competent to attest to factual matters of which the Veteran 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. (Continued on the next page)   7. Thereafter, the AOJ must readjudicate the Veteran’s appealed issues in light of the totality of the evidence. If any benefit is not granted to the fullest extent, the AOJ must provide the Veteran and his representative a copy of the readjudication and provide them an adequate opportunity to respond. SCOTT W. DALE Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Dougan, 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.