BVA9503010 DOCKET NO. 93-08 903 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUES 1. Entitlement to an increased rating for residuals of a right foot injury, currently evaluated as 20 percent disabling. 2. Entitlement to service connection for arthritis of the hips, ankles and feet. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Constance C. Hickey, Associate Counsel INTRODUCTION The veteran had active service from September 1953 to January 1962. This appeal to the Board of Veterans' Appeals (Board) arises from the November 1991 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) Cleveland, Ohio which denied an increased rating for residuals of a right foot injury, currently evaluated 20 percent disabling and denied service connection for arthritis of the hips, ankles and feet. REMAND On review of the record the Board notes that the report of the veteran's most recent VA compensation examination, conducted in June 1992, contains no reference to the residuals of his service connected right foot injury and resulting right foot surgery. It is thus inadequate for rating purposes. It is noted that x-ray study was not performed; VA outpatient records dated in April 1979 reflect that x-ray showed arthritic changes in the right foot attributed to trauma. Other x-ray studies of the right foot have been interpreted as showing no evidence of arthritis. Additionally, the claims folder does not contain complete records pertaining to the veteran's 1982 right ankle fracture, which was initially treated, according to the veteran, at St. Joseph's Hospital in Lorain, Ohio, before he was referred to a VA Medical Center (VAMC) for follow-up care. The RO's July 1992 request for records from St. Joseph's Hospital identified the pertinent time period as 1979 or 1980. For these reasons, the Board finds that additional development is required, including an additional orthopedic examination, to assess the current status of the veteran's service connected right foot disability. With respect to his claim for the service connection for arthritis involving joints other than the right foot, the veteran testified under oath that he had been told by Dr. Stein, a VA physician at the VA Medical Center, Wade Park, that the arthritis in the veteran's right foot had "worked its way up" to other joints. A statement from Dr. Stein would be helpful. Accordingly, the case is REMANDED for the following actions: 1. The RO should contact the veteran and request that he provide the names and addresses of all medical care providers, VA and private, who have examined or treated him for his right foot disability since separation from service, in addition to the approximate dates of such examination or treatment. After the appropriate releases have been obtained, the RO should contact the medical care providers identified by the veteran and request that they provide copies of any previously unobtained treatment records pertaining to the veteran. Specific request should be made to St. Joseph's Hospital, in Lorain, Ohio, to provide records of treatment for a fracture of the right ankle sustained in 1982. All records received should be associated with the veteran's claims folder. 2. The RO should contact Dr. Stein, at the VA Medical Center, Wade Park, and request that he provide a statement regarding the possible relationship between arthritis of the veteran's right foot, if present, and the arthritic changes in other joints. Any supporting rationale and/or records should be included. 3. The RO should then arrange for examination of the veteran by an orthopedic specialist to assess the status of the veteran's right foot disability, in accordance with VA's Physician's Guide for Disability Evaluation Examinations. All appropriate special tests and X-rays should be performed. The examiner should thoroughly review the veteran's claims folder prior to examination with special attention to fractures sustained in service in 1959 and surgery performed in 1976, which form the basis for the grant of service connection. With respect to the veteran's right foot disability it is specifically requested that the examiner comment on range of motion, the effect of pain on motion, instability, weakness, swelling, deformity, atrophy, and any additional pertinent findings, which describe the status of the veteran's service connected disability, as distinguished from nonservice-connected disability, such as pes planus. Specifically, the examiner should state whether or not the veteran has arthritis in the right foot. Supporting rationale should be provided for all opinions expressed. 4. Following completion of all requested development the RO should again review the veteran's claim for an increased evaluation for his right foot disability and service connection for multiple joint arthritis on the basis of the entire record The RO should consider all diagnostic codes that are relevant to the clinical findings. If action remains adverse to the veteran, the RO should provide a supplemental statement of the case to the veteran and his representative. The supplemental statement of the case should contain a recitation of all relevant evidence, a citation to the relevant law and regulations, and a statement of the reasons for action taken. The appropriate period of time should be provided for response. Thereafter, the case should be returned to the Board for further appellate consideration, if otherwise in order. By this action the Board intimates no opinion, legal or factual, as to the ultimate determination in this case. No action by the veteran is required until he receives further notice. N. R. ROBIN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).