Citation Nr: 21029555 Decision Date: 05/13/21 Archive Date: 05/13/21 DOCKET NO. 16-27 088 DATE: May 13, 2021 REMANDED Entitlement to service connection for bilateral pes planus is remanded. Entitlement to service connection for a left arm disability is remanded. Entitlement to service connection for residuals of right leg injury is remanded. Entitlement to service connection for a right knee condition is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1977 to June 1980. Evidence affiliated with the claims file also indicates that the Veteran served in the National Guard from October 1980 to October 1981 and that he was discharged from the Reserve effective January 1983. This matter again comes before the Board of Veterans' Appeals (Board) on appeal from January 2015 and May 2015 rating decisions issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. The Board previously remanded this matter in December 2018. 1. Bilateral Pes Planus 2. Left Arm Disability 3. Residuals of Right Leg Injury 4. Right Knee Condition Unfortunately, another remand is warranted in this case. The Board sincerely regrets the additional delay; however, further evidentiary development is necessary before the Veteran's claims for service connection can be adjudicated on the merits. As a preliminary matter, the Board notes that military personnel records reflect that the Veteran served in the National Guard from October 1980 to October 1981. See October 1981 National Guard Report of Separation and Service. Evidence associated with the claims file also indicates that the Veteran served in the Reserve for an undisclosed period of time until his discharge in January 1983. See December 1982 Letter from the Depart of the Army Office of the Adjutant General. Even though there are service treatment records and service personnel records associated with the claims file revealing the Veteran's education, performance, assignments, points, and awards, the precise dates of all periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) are not available. On remand, the RO should confirm the Veteran's periods of ACDUTRA and INACDUTRA. The Board also acknowledges receipt of the October 2019 VA examinations and opinions regarding the Veteran's above-listed disabilities. However, these examinations and opinions are inadequate to determine the natures and etiologies of said disabilities. The October 2019 VA examination reports reflect that after his discharge from service, the Veteran sought medical treatment from non-VA providers. These records which could indicate the nature and etiology of the Veteran's disabilities have not been affiliated with the claims file. Accordingly, the October 2019 VA examiner did not review, consider, or address pertinent relevant evidence that could establish the etiology of the Veteran's disorders. Accordingly, the Board finds that the Veteran's private medical records should be obtained prior to the issuance of addendum opinions as to the respective natures and etiologies of the Veteran's bilateral pes planus, left arm disability, right knee disability, and residuals of right leg injury. Additionally, regarding the Veteran's right leg condition, the examiner noted that the Veteran did not have a current diagnosed right leg disorder. However, the Veteran has consistently reported experiencing pain in his right leg since his in-service injury. See February 2015 Notice of Disagreement; June 2016 VA Form 9. The Board recognizes that pain is a disability when pain reaches a level of functional impairment that affects earning capacity. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). A new examination is needed to address whether the Veteran's reported right leg pain results in functional impairment to a level to would constitute a current disability. Consequently, because the October 2019 VA examinations are inadequate, the Board finds that addendum opinions must be obtained to ascertain the natures and etiologies of the Veteran's claimed conditions. The matters are REMANDED for the following action: 1. The RO should determine the specific dates of when the Veteran served on ACDUTRA and/or INACDUTRA. In this regard a report detailing the Veteran's award of reserve retirement points will NOT represent compliance with this instruction. Rather, each and every date of active duty, ACDUTRA, and INACDUTRA must be verified. Then, issue a memorandum for inclusion in the claims file detailing each period of verified active military service, whether on active duty, ACDUTRA, or INACDUTRA. All medical treatments records associated with the Veteran's National Guard and Reserve service should also be obtained. 2. Request the Veteran to identify any and all outstanding private medical treatment records for his bilateral pes planus, left arm disability, right knee disability, and residuals of in-service right leg injury. Appropriate efforts must be made to obtain these records if he has adequately identified them and authorized their release. He should also be invited to submit these records himself. All actions to obtain the requested records should be documented in the claims file. If they cannot be located or no such records exist, the Veteran and his representative should be so notified in writing. 3. Then, forward the claims file to an appropriate clinician to determine the nature and etiology of the Veteran's bilateral pes planus. The entire claims file, including a copy of this remand, must be made available to the clinician, who must note its review. If the clinician determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be obtained. The clinician should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's bilateral pes planus manifested during, or is the result of, his active duty service, ACDUTRA, and/or INACDUTRA, including walking, running, and performing duties in combat boots. In formulating his or her opinion, the clinician should consider and address the relevant competent medical and lay evidence of record, including but not limited to: (i) The Veteran's service treatment records; (ii) The Veteran's private medical records; and (iii) The Veteran's competent lay statements regarding his first-hand experiences in service and the onset and continuity of his symptomatology. If the clinician determines that the Veteran's bilateral pes planus is less likely than not due to his active duty service, ACDUTRA, and/or INACDUTRA, the clinician should discuss what other factor(s) caused the disorder. A complete rationale must be provided for all opinions and conclusions reached. 4. Forward the claims file to an appropriate clinician to determine the nature and etiology of any and all left arm condition(s) attributable to the Veteran throughout the appellate period. The entire claims file, including a copy of this remand, must be made available to the clinician, who must note its review. If the clinician determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be conducted. (a) The clinician should identify any and all left arm condition(s) attributable to the Veteran throughout the appellate period. (b) For each condition so identified, the clinician should opine as to whether it is at least as likely as not (50 percent or greater probability) manifested during, or is the result of, his active duty service, ACDUTRA, and/or INACDUTRA. In formulating his or her opinion, the clinician should consider and address the relevant competent medical and lay evidence of record, including but not limited to: (i) The Veteran's service treatment records; (ii) The Veteran's private medical records; and (iii) The Veteran's competent lay statements regarding his first-hand experiences in service and the onset and continuity of his symptomatology. If the clinician determines that the Veteran's left arm condition(s) is/are less likely than not due to his active duty service, ACDUTRA, and/or INACDUTRA, the clinician should discuss what other factor(s) caused the disorder(s). A complete rationale must be provided for all opinions and conclusions reached. 5. Forward the claims file to an appropriate clinician to determine the nature and etiology of any and all right knee and/or right leg condition(s) attributable to the Veteran throughout the period on appeal. The entire claims file, including a copy of this remand, must be made available to the clinician, who must note its review. If the clinician determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be provided. (a) The clinician should identify any and all right knee and/or right leg condition(s) attributable to the Veteran throughout the appellate period. (b) For each condition so identified, the clinician should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's condition manifested during, or is the result of, his active duty service, ACDUTRA, and/or INADCUTRA, including an October 1979 right leg injury. In formulating his or her opinion, the clinician should consider and address the competent medical and lay evidence of record, including but not limited to: (i) The Veteran's service treatment records; (ii) The Veteran's private medical records; and (iii) The Veteran's competent lay statements regarding his first-hand experiences in service and the onset and continuity of his symptomatology. If the clinician determines that the Veteran's right knee and/or right leg condition(s) is/are less likely than not due to his active duty service, ACDUTRA, and/or INACDUTRA, the clinician should discuss what other factor(s) caused the disorder(s). A complete rationale must be provided for all opinions and conclusions reached. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Seserman 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.