Citation Nr: 1414350 Decision Date: 04/02/14 Archive Date: 04/11/14 DOCKET NO. 08-33 565 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a right ankle disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD Andrew Mack, Counsel INTRODUCTION The Veteran served on active duty from January 1987 to December 2006. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2007 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. It was remanded by the Board in January 2012 for further development. The Board has not only reviewed the physical claims file but also the Veteran's file on the "Virtual VA" and Veterans Benefits Management System (VBMS) paperless claims processing systems to ensure a total review of the evidence. FINDING OF FACT The Veteran has recurrent right ankle sprain that was incurred in service. CONCLUSION OF LAW The criteria for service connection for recurrent right ankle sprain have been met. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. § 3.303 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). In this case, the Veteran's claim for service connection must be granted. Service treatment records reflect that, in February 1987, the Veteran was treated for painful swelling to the right ankle after an inversion injury, and the diagnosis was sprained ankle. On X-ray, mortise was stable, but there was question of undisplaced fracture line of the distal fibula, and it was noted that this area was also very tender. In March 1987, the Veteran's ankle was noted to have been improving, with pain resolving, and running and weight lifting were permitted at that time. Numerous subsequent service treatment records, including annual examinations, reflect no further complaints or treatment regarding the right ankle until September 2006 separation examination. At that time, the Veteran reported increased right ankle instability since his most recent service examination, and reported several conditions, including right ankle instability, that currently limited his ability to work in his military specialty. He also reported at that time that he intended to seek VA disability benefits for a 1987 fracture of the right ankle with instability. In October 2006, he again reported a history of right ankle fracture, although the medical examiner at that time noted that there was no residual problem with the right ankle. On August 2007 VA examination, the Veteran reported weakness and stiffness in the right ankle, though none was noted that day, and some occasions of instability and giving way of the right ankle, with at least two since his separation from service in December 2006. Examination of the right ankle at that time was normal, with no objective evidence for a right ankle condition, and it was noted that X-rays at that time revealed no abnormality and, specifically, no evidence of an old fibular cortical fracture. In January 2008, the Veteran received private treatment for right ankle pain with complaints of instability and feeling of giving way when walking or running. On examination, there was noted to have been mild lateral swelling, lateral instability, positive anterior drawer test, and pain with inversion. VA X-ray in June 2009 revealed stable lateral malleolar fracture. On March 2012 VA examination, right ankle tenderness was noted and recurrent right ankle sprain was diagnosed. The VA examiner opined that she could not determine whether the Veteran's recurrent right ankle pain had its onset during active service or was related to any in-service injury without resorting to mere speculation. The examiner stated that, while lateral instability was noted in 2008, it was neither documented in service nor noted at that time. She also stated that, while service treatment records showed one episode of ankle sprain in 1987, they also showed the injury to have resolved, and even though the Veteran reported a history of ankle problems in September 2006, no abnormality was noted. It was noted that the Veteran complained of intermittent right ankle sprains over the years, with symptoms abating between episodes, and with the most recent occurring the week before, which was the reason for his current right ankle tenderness. The record thus reflects a current disability of recurrent right ankle sprain. Given the Veteran's in-service ankle injury, his reported symptoms at the end of his service including increased instability, his noted right ankle symptomatology shortly after service in January 2008, and the equivocal opinion of March 2012 VA examiner, the evidence as to whether his right ankle disability was incurred in service is at least in relative equipoise. Therefore, resolving reasonable doubt in his favor, the Board finds that his recurrent right ankle sprain was incurred in service. Accordingly, service connection for recurrent right ankle sprain must be granted. See U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). As the Veteran's claim is granted, any error that was committed with respect to any duty of VA to notify or to assist was harmless and will not be further discussed. The nature and extent of this disability is not before the Board at this time. ORDER Service connection for recurrent right ankle sprain is granted. ____________________________________________ JOHN J. CROWLEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs