Citation Nr: 21024203 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 16-18 297 DATE: April 22, 2021 REMANDED Entitlement to service connection for a left foot disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1987 to March 1988. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a September 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office in Salt Lake City, Utah. In a March 2019 decision, the Board denied entitlement to service connection for a left and right foot disorders. The Veteran appealed the March 2019 Board decision to the United States Court of Appeals for Veterans Claims (Court). In a June 2020 order, the Court granted a Joint Motion for Remand (Joint Motion) filed by the parties to vacate the portion of the March 2019 decision denying entitlement to service connection for a left foot disorder and to remand the case to the Board. The Court dismissed the issue of entitlement to service connection for a right foot disorder. Upon review, the Board finds that additional development is necessary prior to adjudication of the claim. The Veteran has not been afforded a VA examination in connection with her claim. The Veteran has asserted that she developed a left foot disorder during service and was on crutches for many months. See January 2016 Notice of Disagreement. A December 2018 VA treatment record shows that the Veteran reported left heel pain and that the medical provider found that the pain was “chronic” for “years” and interfered with physical activity and walking. Therefore, the Board finds that a VA examination is needed to determine the nature and etiology of any left foot disorder that may be present. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for her left foot. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any left foot disorder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay statements. It should be noted that the Veteran is competent to attest to matters of which she 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. The examiner should opine as to whether it is at least as likely as not that the Veteran has a current left foot disorder that manifested in service or that is otherwise causally or etiologically related to his military service, to include any injury or symptomatology therein. In rendering an opinion, the examiner should consider a November 1987 service treatment record which indicates that the Veteran was treated for her foot, a February 1988 service treatment record that shows that the Veteran was prescribed crutches for a stress fracture, a June 1988 orthopedic examination report showing a diagnosis of foot pain, and the Veteran’s assertion in the January 2016 Notice of Disagreement that she was on crutches for many months during service because of a foot disorder. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history,” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner of review. 3. After completing these actions, the AOJ should conduct any other development as may be indicated. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Williams, 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.