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For anyone who cares to Review and comment. Especially you Ms. Berta!!!
First document is SMR indicating my dad injured his left foot with a fracture to his 2nd metatarsal in 1969.
Second document is an X-ray result from CP exam in 2005. Please note old nonunion fracture to RIGHT foot 5th metatarsal along with all other issues to RIGHT foot and leg. And no findings or issues whatsoever to left leg or foot.
If you were the one conducting this exam just by reviewing both these documents what would your opinion be??? Please comment and Thank You All!!!!
I moved your post to VA claims research because I think it will get more views there.
Based on the info in the two documents, I believe service connection will not be granted. The most recent report indicates fracture to 5th metatarsal of right foot and the 1969 report reflects a contusion(bruise) and fracture to 2nd metatarsal of the left foot. It is not only a question of right foot versus left foot but 5th metatarsal versus 2nd metatarsal. This gives the VA even more ammo to deny the claim since the reports also differ on which bone was fractured.
In my opinion, this claim will continue to be denied without an IMO and the IMO will have to show a strong nexus between your father's current medical condition and his military service and be supported by reasonable medical rationale. Due to the amount of time that has passed and the differences in the two reports, I think it would be difficult for an orthopedic specialist to provide a credible IMO. I hope I am wrong.
The thing that is missing is the nexus. A nexus statment, which may or may not be elsewhere in your records will be something close to "the Veterans (current disability diagnosis) is at least as likely as not due to a foot fracture in 1969 during military service".
Absent a nexus, I agree that it wont fly. Im not qualifed to differentiate between the 2d and 5th metatarsals, that is a significant discrepency and would also need some sort of resolution.
1. Review your records, and look for a nexus statement. It need not be that doc, it can be another doc who examined you. If you find that elusive nexus, then keep appealing and allege a "colvin" violation. (Colvin violation means the decision maker has substituted his own unsubstantiated (medical) opinion for that of a qualified medical professional. Or, the decision maker went "against" the favorable medical opinion and did not give a reason or bases as to why he found this examiners opinion to be unpersuasive.)
2. If you find a nexus, keep appealing until you win.
3. If the nexus is missing, then try to see if it has been unincluded in your cfile for whatever reason. If its just "gone" then resbmit the nexus and you can reopen due to N and M evidence via 38 cfr 3.156.
4. If there is no nexus anywhere, then an IME/IMO will be necessary for service connection UNLESS you can get the nexus statement from a VA medical professional.
My impression is useless. I'm no radiologist and cant tell heads from tails about what the situation is without all of the fact in front of me. That being said, was the 1st report done by a VA Radiology department? If so, you might want to take the x rays to a non va radiologist/orthopedic specialist and get it read again.
I had my back re-read like that and it opened up a whole new story that got my back service connected.
unfortunately the foot has a lot of low ratings
If the report of examination is inadequate as a basis for the required consideration of service connection and evaluation, the rating agency may request a supplementary report from the examiner giving further details as to the limitations of the disabled person's ordinary activity imposed by the disease, injury, or residual condition, the prognosis for return to, or continuance of, useful work. When the best interests of the service will be advanced by personal conference with the examiner, such conference may be arranged through channels.
I agree with georgiapapa and the other members He needs to get a IMO (INDEPENDENT MEDICAL OPINION)
I think a trip to a private Foot Dr (specialist ) would be very beneficial and have Doc to read these exams and then exam your Dad and give his opinion as to the left& right leg/foot and state in his opinion this is at least as likely as not due to his prior military service on what he finds.
And take the military medical records that you have and high lite the parts that this Specialist needs to read let him know he don't need to read all the report but the main parts about what they said about your Dad leg/foot Back then, so he can state he read his past military records about his LEFT & RIGHT LEG &FOOT.
The VA will take the private foot specialist impression over a VA Regular MD.
I wish your Dad the Best and he gets a good decision soon!
Hang In There!
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