Citation Nr: 1329406 Decision Date: 09/13/13 Archive Date: 09/20/13 DOCKET NO. 11-09 690 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a left ankle disability. REPRESENTATION Veteran represented by: Florida Department of Veterans Affairs WITNESSES AT HEARING ON APPEAL Veteran, L.J., and N.D. ATTORNEY FOR THE BOARD Megan C. Kral, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1979 to September 1982. This case comes before the Board of Veterans' Appeals (Board) on appeal from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). A notice of disagreement (NOD) was received in December 2010. A statement of the case (SOC) was issued in March 2011 and a substantive appeal was received in the same month. In July 2011, a Board hearing was held before the undersigned. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The Veteran is claiming entitlement to service connection for a left ankle disability. He asserts that since an April 1980 in-service softball injury, he has had a continuous left ankle disability. The record reflects the Veteran receives Social Security Administration (SSA) disability benefits due to a number of ailments, including his left ankle disability. However, there is no indication in the claims file that VA has ever requested any of the Veteran's records in the possession of the SSA. On remand, VA must make efforts to obtain any relevant medical evidence and/or administrative decisions regarding any claim by the Veteran for SSA disability benefits. 38 C.F.R. § 3.159; Golz v. Shinseki, 590 F.3d 1317, 1321 (Fed. Cir. 2010). Additionally, the Veteran testified at the July 2011 hearing that he receives treatment for his left ankle disability at the Gainesville VA medical center (VAMC). The last VA treatment records are dated in February 2011. Updated VA medical treatment records must be obtained upon remand. 38 C.F.R. § 3.159(c)(2). The record also contains limited and incomplete treatment records from The Orthopedic Institute, which note the Veteran has a marked limp on the left. As these records may contain relevant evidence to the Veteran's claim, VA has the obligation to assist the Veteran in obtaining such records of private treatment. 38 C.F.R. § 3.159(c)(1). Further, at the July 2011 hearing, the Veteran testified that he was put on a permanent profile, relinquishing him from PT following his April 1980 ankle injury. However, service treatment records from August 1981 show the Veteran participated in PT three times a week, played football, and lifted weights. As such, the Veteran's service personnel records are needed to confirm the assignment of a physical profile. In light of the need to return the case to the RO for the actions set forth above, the Board believes it also appropriate to afford the Veteran another examination to address the question of a nexus to the inservice injury. Accordingly, the case is REMANDED for the following actions: 1. The RO should obtain copies of all relevant VA treatment records dated from February 2011 to the present from the Gainesville VAMC. 2. The RO should contact the Veteran and request that he complete and return the appropriate authorizations so that VA can obtain relevant treatment records from The Orthopedic Institute, and any other provider in which he sought treatment for his left ankle disability. The RO should then obtain copies of all treatment records (not already of record) to associate with the claims file. If any records sought are unavailable, the reason for the unavailability must be given (e.g., did not exist/were destroyed). 3. The RO should take appropriate action to request and obtain copies of the Veteran's complete service personnel records from the appropriate record depository. All requests for records and their responses must be associated with the claims folder. 4. The RO should take appropriate action to request and obtain all medical records and administrative decisions associated with any claim by the Veteran for SSA disability benefits. All requests for records and their responses must be associated with the claims folder. 5. After completion of the above to the extent possible, the Veteran should be afforded an appropriate VA examination to determine the nature and etiology of any current left ankle disability. It is imperative that the claims file be made available to the examiner for review in connection with the examination. Any medically indicated special tests should be accomplished. After reviewing the claims file and examining the Veteran, the examiner should respond to the following: a. Please identify (by medical diagnosis) the Veteran's current left ankle disability, if any: b. For each left ankle disability diagnosed, please provide an opinion whether it is at least as likely as not (a 50 percent or higher degree of probability) that the current left ankle disability is causally related to the Veteran's service, to specifically include the April 1980 injury. A rationale for all opinions should be provided with appropriate discussion of relevant evidence. 6. In the interest of avoiding a further remand, the RO should review the medical opinion obtained and ensure that an adequate opinion with rationale has been offered as to the claimed disability. 7. The RO should then readjudicate the issue on appeal. If the benefit sought on appeal remains denied, the RO must furnish the Veteran with an appropriate supplemental statement of the case and afford him and his representative the opportunity to respond. The case should then be returned to the Board for appellate review. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2012).