Citation Nr: 21027528
Decision Date: 05/06/21	Archive Date: 05/06/21

DOCKET NO. 11-14 498
DATE: May 6, 2021

REMANDED

Entitlement to service-connection for a left foot condition is remanded.

REASONS FOR REMAND

The Veteran served on active duty from November 1967 to July 1970, to include service to the Republic of Vietnam. The Veteran testified at a hearing with the undersigned in April 2017.  The matter was most recently remanded in January 2021. There has not been substantial compliance with the prior remand directives and another remand is required.  Stegall v. West, 11 Vet. App. 268, 271 (1998).

At the February 2021 VA examination, the Veteran raised a claim of service connection for a left ankle disability. The Veteran has not filed a specific claim for the left ankle and it is not before the Board. The Agency of Original Jurisdiction (AOJ) is directed to provide the appropriate form to assist the Veteran in furtherance of his claim.  

The claim is remanded again to obtain an adequate medical opinion. The claim has been pending since June 2009 and the question is whether the Veteran had any left foot disability during the pendency of the claim, regardless of whether it has since resolved, and if so, whether it is related to service or a service-connected connected disability. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The record includes previous diagnoses of left heel spur.

The February 2021 VA examiner said the Veteran "in the past had an incidental finding of a very small calcaneal spur. This is asymptomatic. This is an incidental finding on x-ray and not a disability." The opinion is inadequate because it addresses only the current findings, with no reference to whether the heel spur may have been symptomatic at any time during the appeal period and if so, whether that would be a disability. 

The matters are REMANDED for the following action:

1. Forward copies of all pertinent records to an appropriate examiner for an addendum opinion.  After reviewing the record, the examiner is asked to answer the following questions:

(a) At any time during the period on appeal (beginning June 2009), was there any identified left foot disability or diagnosis?  The examiner must specifically consider the x-ray findings of left calcaneal spur.  

(b) if (a) is answered yes, is it at least as likely as not (50 percent probability) that any left foot disability diagnosed since June 2009 was incurred in or is otherwise related to service, regardless of whether that diagnosed disability has resolved?  Why or why not? 

A complete rationale must be provided for all opinions, citing to supporting factual data and medical literature, as appropriate.  If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training) and note what, if any, additional evidence would permit such an opinion to be made.

 

M.E. Larkin

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Jarman, 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.