Citation Nr: 21032891 Decision Date: 05/28/21 Archive Date: 05/28/21 DOCKET NO. 10-36 499 DATE: May 28, 2021 REMANDED Entitlement to service connection for a left foot disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from November 1986 to October 1989. This matter is before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in March 2015, July 2017, February 2018, November 2019, and July 2020 when it was remanded for further development. Entitlement to service connection for a left foot disability is remanded. Although the additional delay is regrettable, the Board finds an additional remand is required before a decision can be made on the Veteran's claim. In the July 2020 Board remand, the Board directed the RO to schedule the Veteran for a VA examination to determine the nature and etiology of any left foot disabilities and left foot pain. The Board asked a VA examiner to identify all left foot disabilities and then provide an opinion as to whether the disability had its onset during or is otherwise etiologically related to the Veteran's service, to include in-service treatment for left foot cellulitis and stepping on a rusty wire. In addition, if the examiner determined the Veteran did not have a diagnosable left foot disability, he or she was asked to provide an opinion as to whether the Veteran's left foot pain results in functional impairment of earning capacity. If so, the examiner was then asked to provide an opinion as to whether the Veteran's left foot pain had its onset during or is otherwise etiologically related to his active service, including in-service treatment for left foot cellulitis and stepping on a rusty wire. The examiner was asked to provide a clear rationale for all opinions provided. In the subsequent December 2020 VA examination, the examiner did not diagnose any left foot disabilities. In addition, the examiner indicated that the Veteran did not report pain; that there was no objective evidence of pain on physical examination; and there was no evidence of pain during range of motion testing for weight-bearing, nonweight-bearing, active motion, and passive motion. The examiner then opined that the Veteran's left foot pain did not result in impairment of earning capacity as there was no objective evidence of a chronic condition. However, after review of the examination report, the Board finds the examiner's findings, namely that the Veteran did not report left foot pain, are inconsistent with other evidence of record, including a February 2010 Notice of Disagreement in which the Veteran reported pain in his left foot and an April 2021 Brief where the Veteran and his representative contended that the Veteran experienced pain in his left foot since service. Thus, it is unclear whether the examiner adequately considered the Veteran's lay statements regarding pain. Furthermore, the examiner did not provide an adequate rationale for concluding the Veteran's left foot pain did not result in impairment of earning capacity. Consequently, the Board finds remand for a new VA examination and medical opinion is required. The matters are REMANDED for the following action: Schedule the Veteran for a new VA examination to determine the current nature and the etiology of his claimed left foot disability, with complaints of pain and tenderness. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The claims folder must be provided to the examiner for review in conjunction with the examination. Following a review of the claims file and examination of the Veteran, the examiner should respond to the following: (a) Identify all left foot disabilities present during the period of the claim. (b) With respect to any diagnosed left foot condition, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the condition had its onset during or is otherwise etiologically related to the Veteran's active service, including but not limited to his treatment in service for left foot cellulitis in July 1987, and treatment after stepping on a rusty wire in March 1988. See STRs at p.10-15 AND 32 of 66. (c) If the examiner determines the Veteran has no diagnosable left foot condition, he or she should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran's left foot pain results in a functional impairment of earning capacity, i.e., a disability for VA purposes. If so, the examiner should state whether it is at least as likely as not (50 percent probability or greater) that the Veteran's left foot pain had its onset during or is otherwise etiologically related to his active service, including but not limited to his treatment in service for left foot cellulitis in July 1987, and treatment after stepping on a rusty wire in March 1988. See STRs, received March 2017 at p.10-15 AND 32 of 66. A clear rationale for all opinions should be provided. A discussion of the facts and medical principles involved would be of considerable assistance to the Board. Evan M. Deichert Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Jiggetts 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.