Citation Nr: 22012179 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 16-54 179 DATE: March 2, 2022 REMANDED Entitlement to service connection for a left foot disability, other than left foot drop, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from March 1967 to July 1967, and from January 1972 to April 1973. This case comes on appeal of a February 2012 rating decision. The Veteran testified before the Board at a March 2020 video conference hearing. This case was previously before the Board in June 2020. At that time, the Board remanded the issue of entitlement to service connection for a left foot condition, as well as the issue of entitlement to service connection for peripheral neuropathy of the left lower extremity, to include left foot drop. Following the Board's remand, in a January 2022 rating decision, the agency of original jurisdiction (AOJ) granted entitlement to service connection for peripheral neuropathy of the left lower extremity. That issue is considered granted in full and is no longer before the Board. At that same time, the AOJ issued a supplemental statement of the case, continuing the denial of entitlement to service connection for a left foot condition other than foot drop. That issue remains on appeal. Entitlement to service connection for a left foot disability is remanded. The Veteran contends that he has a current left foot disability that was caused by or incurred in service, or was caused or aggravated by a service-connected disability. In its June 2020 remand, the Board noted that the record contained evidence that the Veteran had been diagnosed with a variety of left foot conditions. Specifically, the Veteran had undergone bunionectomy surgery in June 1994. In an April 2011 VA examination, the examiner diagnosed status post bunionectomy of the left big toe, mild degenerative joint disease of the bilateral big toes, and bilateral flexible flat feet. Additionally, multiple treatment records beginning in June 2013 identified a hammertoe diagnosis, as well as repeated calluses. The Board remanded the claim to obtain a new examination to address whether any of these diagnosed conditions were causally related to service. In its remand, the Board instructed the examiner to clearly identify all conditions of the left foot and to address whether each condition was caused by or incurred in service, or to address whether the condition was caused or aggravated by the Veteran's service-connected disabilities. In October 2020, the Veteran underwent a new examination. There, the examiner identified the Veteran's diagnosed conditions as left foot drop, status-post bunionectomy, and status-post fusion hammertoe repair. There was no discussion of the degenerative joint disease of the big toes or bilateral flexible flat feet documented in that April 2011 examination, nor was there discussion of the calluses identified in the Veteran's treatment records. It appears that the Veteran underwent a repair for the identified hammertoe, but it is unclear if there are residual symptoms from that procedure. In addressing a causal relationship between service or service-connected disabilities, the examiner focused on left foot drop. As was noted above, this disability has been associated with the Veteran's peripheral neuropathy and has been evaluated accordingly. In addressing whether a left foot disability was causally related to service, the examiner stated that the conditions and treatments the Veteran had in service "could and would not cause lameness, foot drop, or any current conditions the Veteran is experiencing today." This statement implies that the Veteran may have additional disabilities that the examiner did not identify. Thus, the examination did not provide the Board with sufficient information to decide the claim, and is therefore inadequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) ("a thorough medical examination is one that takes into account the records of prior medical treatment so that the evaluation of the claimed disability will be a fully informed one). Accordingly, on remand, a new examination is necessary to fully and clearly identify all disabilities of the left foot, reconciling any inconsistencies with prior diagnoses. The examiner should then provide clear medical rationale when addressing whether any such disability was caused by or incurred in service, or was caused or aggravated by a service-connected disability, to include the effects of radiculopathy and peripheral neuropathy of the Veteran's gait. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination of the left foot. The examiner should review the claims file, to include a copy of this Remand, and the report of examination should include discussion of the Veteran's documented history and assertions. All indicated tests and studies should be accomplished and all clinical findings should be reported in detail. The examiner should identify all current disabilities of the left foot, noting the Veteran's previous diagnoses including hammertoe, degenerative joint disease, and calluses. If the examiner finds that the Veteran's current disabilities are in contradiction to any disabilities that are noted in the Veteran's medical records since the time he filed this claim in December 2010, the examiner should provide a clear and thorough explanation. Then, with respect to each such disability, the examiner should render an opinion, as to whether it is at least as likely as not (i.e., there is approximately 50 percent or greater probability) that the disability had onset in, or is otherwise related to service. The examiner should also render an opinion as to whether it is at least as likely as not that the disability was caused or aggravated by a service-connected disability, to specifically include left lower extremity radiculopathy, peripheral neuropathy, and drop foot, or the effects thereof. The examiner should set forth all examination findings, along with complete rationale for the conclusions reached, in a printed report. Complete rationale should include an explanation of the evidence used in support of the conclusion, as well as an explanation as to why such evidence supports the conclusion. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Giaquinto, 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.