Citation Nr: 1335498 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 12-32 400 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for a left ankle disorder. ATTORNEY FOR THE BOARD A. VanValkenburg, Associate Counsel INTRODUCTION The Veteran served on active duty with the United States Army from January 1980 to December 1982. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the January 2011 decision by the Cleveland, Ohio, Regional Office (RO) of the United States Department of Veteran Affairs (VA), which denied service connection for a left ankle condition. The Board has not only reviewed the Veteran's physical claims file but also the electronic records maintained in the Virtual VA system to ensure complete review of the evidence of record. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran essentially contends that he has a left ankle disability due to an in-service injury. The Veteran reports that during basic training, his boot rubbed against his ankle while running, which caused swelling and redness, and resulted in a week at the hospital. Service treatment records do show the Veteran was treated for edema and cellulitis of the left ankle in-service. The Veteran additionally contends he had no history of trauma to his left ankle prior to enlistment. In this regard, a March 1979 entrance examination makes no notation of an ankle injury or disability. However, the report of medical history from March 1979 does indicate a history of an old healed fracture of the left ankle. Notes from a June 1986 report of medical history also appear to describe a fracture of the left foot that occurred at age 6 years old. The Veteran's December 2010 VA examination provided a negative opinion regarding a link between an in-service injury and the ankle condition complained of by the Veteran. The examiner found no current diagnoses. An x-ray was conducted with two views of the left ankle. The location of the Veteran's pain was not indicated. Soft tissue swelling was absent, joint spaces were normal and no fractures were seen. The physical examination and x-ray findings were all found to be normal. In support of his claim, the Veteran submitted private treatment records from Moore Regional Hospital, which show that the Veteran was treated for a left foot pain in November 2011 after his foot was run over by a vehicle. X-rays were taken of the left foot and 3 views were negative for acute fractures or dislocation. However, it was also noted that a smooth well corticated 1 cm opacity arose from the medial malleoulus (tibia fracture on the ankle), which the reviewer opined favored remote trauma or united apophysis. The impression recommended a clinical correlation to the medial malleolus. The physician's interpretation of the x-rays identified an old avulsion fracture of the distal tibia and calcifications along the second and third metatarsals. The Veteran's diagnosis was a foot injury not otherwise specified and he was reported as medically stable at the time of discharge. The Veteran argues that this x-ray evidence of an old fracture supports his contention as to the existence of a chronic disability incurred in service. The Board must note, however, that it could also be viewed as consistent with the history of fracture noted at entry into service. In either event, the fact that the history of a fracture prior to service was not noted in the report of his December 2010 VA examination raises concerns as to the adequacy of that examination. In light of the recent x-ray findings of an old avulsion fracture, and the report of medical history indicating an old heal fracture of the left ankle, the Board finds a new examination is required for clarification and consideration of the possibility of aggravation of a preexisting disability. Once VA provides an examination, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination is adequate "where it is based upon consideration of the Veteran's prior medical history and examination and also describes the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one." Stefl v. Nicholson, 21 Vet App. 120, 123 (2007). Accordingly, the case is REMANDED for the following action: 1. Request that the Veteran identify any additional medical treatment beyond November 2011, or other relevant evidence, and take appropriate steps to associate such evidence with the physical or electronic claims file. 2. Upon receipt of any new records, schedule the Veteran for an appropriate VA examination for his claim of service connection for an ankle condition. The claims file, including any pertinent evidence contained in Virtual VA, should be provided to the appropriate examiner for review, and the examiner should note that it has been reviewed. Additionally, the examiner should elicit from the Veteran a history of symptoms relating to his claimed disorder. (a) Describe in detail the nature of any current ankle condition. In doing so, please take note of the November 2011 x-ray evidence suggesting a remote fracture. (b) As to any diagnoses identified, provided an opinion as to whether such disability clearly and unmistakably (that is, obviously or manifestly) existed prior to the Veteran's active duty service. Then address, (c) or (d) as appropriate: (c) If an ankle condition did not clearly and unmistakably exist prior to service provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's ankle condition, if any, had its onset in service, or is otherwise related to his active duty service. (d) If an ankle condition did clearly and unmistakably exist prior to his active duty service the examiner should provide an opinion whether it is as least likely as not (50 percent or greater probability) as to whether it was permanently aggravated (increased in severity beyond the natural progression of the disability) due to active duty service. The examiner should provide a complete rationale for any opinion provided. 3. After completing the above, and any other development deemed necessary, readjudicate the Veteran's claims remaining on appeal. If the benefits sought on appeal are not granted, provide the Veteran and his representative with a supplemental statement of the case. An appropriate period of time should be allowed for response. 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). _________________________________________________ MICHAEL LANE 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) (2013).