Citation Nr: 22012192 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 16-42 038 DATE: March 2, 2022 REMANDED Service connection for a left ankle condition. Service connection for a left shoulder condition. Service connection for a left arm condition. REASONS FOR REMAND The Veteran served on active duty from November 1973 to July 1974. The case is on appeal from a November 2012 rating decision. In October 2016, the Veteran testified at a Board hearing. In May 2018, the Board remanded the claims for additional development. While the case was in remand status, in March 2020, the RO granted service connection for a left foot condition. In August 2020, the Board remanded the claims for additional development. 1. Service connection for a left ankle condition. 2. Service connection for a left shoulder condition. 3. Service connection for a left arm condition. The Veteran is seeking service connection for a left ankle condition, left shoulder condition, and a left arm condition. He asserts that during service, while horsing around with other soldiers, he stepped in a hole and fell with another soldier falling on top of him injuring his left ankle, shoulder and arm. The Veteran reported further that he was on crutches for about six weeks until he was discharged from the military. See September 2009 VA opinion, Board Hr'g. Tr. at 4. Alternatively, the Veteran asserts that his left shoulder condition and left arm condition are secondary to his left ankle condition as his left ankle condition has caused him to fall. See January 2012 statement. Initially, the Board finds remand is warranted in order to obtain missing VA treatment records. The Veteran stated that he began receiving treatment from VA in 1981 or 1982. However, it appears VA treatment records from 1998 to September 2006 are absent from the claims file. In this regard, a September 2009 VA opinion addressing the etiology of the Veteran's left ankle condition references VA treatment records from December 2003 and January 2004 related to the treatment of the Veteran's left ankle condition after he sprained his ankle at that time. Those records are not included in the Veteran's claim file. As these records are relevant to the Veteran's claim for service connection for a left ankle condition and are potentially relevant to the Veteran's claims for service connection for a left arm and a left shoulder condition, they should be obtained on remand. In addition, while the case was in remand status, in March 2020, the RO granted service connection for a left foot condition. As such, opinions concerning whether the Veteran's left arm and left shoulder condition are secondary specifically to the service-connected left foot condition are warranted. The Board acknowledges opinions were obtained in October 2021 concerning the question of whether the Veteran's left ankle condition caused his left shoulder and arm condition pursuant to the Board's August 2020 remand. However, it is unclear whether the examiner considered whether the Veteran's left shoulder and arm condition are secondary to his service-connected left foot condition. Accordingly, new etiology opinions are warranted on remand. The matters are REMANDED for the following action: 1. Obtain VA treatment records from the Evansville, Indiana CBOC and the Marion, Indiana VAMC for the period prior to September 2006, as well as updated VA treatment records since October 2021. 2. Thereafter, schedule the Veteran for a VA examination (or telehealth interview, record review, etc., if an in-person examination is not feasible) by a qualified medical professional for an opinion to determine the nature and etiology of the Veteran's left shoulder condition and left arm condition. The need for an examination is left to the discretion of the examiner. The entire claims file should be reviewed by the examiner. After reviewing the claims file, the examiner is to state whether: It is at least as likely as not (a degree of probability of 50 percent or higher) that the Veteran's left shoulder condition is caused or aggravated by the service-connected left foot condition. It is at least as likely as not (a degree of probability of 50 percent or higher) that the Veteran's left arm condition is caused or aggravated by the service-connected left foot condition. The examiner should address the Veteran's contention that his left arm and shoulder conditions are caused by his service-connected left foot condition due to his left foot condition causing him to fall. "Aggravation" is an increase in disability beyond the natural progress of the disease. The examiner should provide rationale for all opinions expressed, including by citing to the record. RYAN T. KESSEL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Gray, 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.