Citation Nr: 1617947 Decision Date: 05/04/16 Archive Date: 05/13/16 DOCKET NO. 07-00 736 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for a right ankle disorder. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD D.M. Casula, Counsel INTRODUCTION The Veteran served on active duty from May 1980 to September 1988. He also had periods of active duty for training and inactive duty for training until December 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2006 rating decision issued by the above Regional Office (RO) of the Department of Veterans Affairs (VA). In April 2011, the Veteran testified at a Travel Board hearing at the RO, before the undersigned Veterans Law Judge. This matter was remanded by the Board for additional development in August 2011, February 2013, and September 2013. In February 2016, the Board requested a specialist medical opinion from the Veterans Health Administration (VHA) for the issue on appeal. See 38 C.F.R. § 20.901(a) (2015). The VHA report, dated March 2016, has been associated with the claims folder. FINDING OF FACT The Veteran's right ankle degenerative joint disease is caused by his service-connected right knee degenerative joint disease (right knee disability), left total knee replacement (left knee disability), and left ankle disability. CONCLUSION OF LAW The Veteran's right ankle degenerative joint disease is proximately due to his service-connected right knee disability, left knee disability, and left ankle disability. 38 U.S.C.A. §§ 1110, 1131 (West 2014); 38 C.F.R. §§ 3.303, 3.310 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION Because the claim is herein being granted in full, VA's duties to notify and assist are deemed fully satisfied and there is no prejudice to the Veteran in proceeding to decide the issue on appeal. See 38 U.S.C.A. §§ 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2015). Service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). The Veteran seeks service connection for a right ankle disability. He has contended that his current right ankle disability was caused by service, or in the alternative, was caused or aggravated by his service-connected orthopedic disabilities, including his left ankle disability, left knee disability, right knee disability, and residual fracture of the left third metatarsal. In an April 2011 opinion, a private physician diagnosed right ankle degenerative joint disease and opined that, once joints are compromised, they begin to deteriorate, which results in the contra lateral joints to be recruited to assist the damaged ones and in so doing are over worked. He explained that this hyper use results in the deterioration of the recruited joints. The physician reported that, during service, the Veteran had 13 parachute jumps, countless air assault repels, six years of running in combat boots, and countless miles of ruck sack marches. The physician explained that these activities are known to cause micro trauma (wear and tear) that over time cause degeneration of the articular cartilage, hypertrophy of the bone, and margins and changes in the synovial membrane. The physician ultimately opined that the above stated activities are consistent with and have a direct causative relation to the arthritis of the lower extremities. They physician also noted that all of the Veteran's conditions are interrelated and are directly related to and caused by service. In a May 2011 statement, a private physician opined that the right ankle disability was more likely than not a result of the right knee disability and left metatarsal disability. The rationale provided was that the right knee and left ankle injury and left chronic instability of the lower extremities, would be aggravated by the physical requirements of military service and the physical training requirements as well. In October 2011, a VA examiner opined that it was less likely as not that the right ankle disability was caused or aggravated by the left ankle disability or residuals of the left third metatarsal fracture because there was no documentation in the service treatment records or claims file about any right ankle issues. The examiner noted that the Veteran denied any right ankle problems since 2008. In a May 2013 VA clarifying opinion, the examiner opined that it was less likely as not that the Veteran's right ankle disability was caused or aggravated by the service-connected left ankle disability, residuals of a left third metatarsal fracture, or right knee orthopedic disability. For rationale, the examiner noted that there was no documented postural instability secondary to his service-connected right knee or left ankle disability. In a December 2013 VA clarifying opinion, the examiner opined it was less likely than not that the Veteran's right ankle disability was secondary to his current orthopedic conditions. The rationale provided was that current medical literature was silent for clinical based, scientific evidence from randomized clinical trials to support a nexus. The examiner reiterated there was no anatomical relationship between his right ankle and service-connected orthopedic conditions. The examiner stated that medical literature was in agreement with the possibility that known knee conditions cause a limp, but explained this was due to the incomplete knee flexion and extension throughout the gait cycle. The examiner stated it would be mere speculation to assume that a slight reduction in ankle plantar flexion caused a pronounced abnormal gait. The examiner opined it was at least as likely as not that the Veteran's abnormal gait was caused by and aggravated by the service-connected orthopedic conditions. After finding the foregoing opinions to be inadequate, the Board requested a VHA medical expert opinion as to whether, in light of the documented medical history and lay statements by the Veteran, it was at least as likely as not that his right ankle disability manifested in or is otherwise related to service; or, whether it was at least as likely as not that the Veteran's right ankle disability was caused or aggravated (permanently worsened) by his service-connected orthopedic disabilities. In a Medical Statement dated in March 2016, a VA Chief of Orthopedic Surgery, after reviewing the record, opined that the Veteran's major weight bearing joints (knees and left ankle) led to a gait disturbance which more likely than not caused abnormal loading of his right ankle with disturbance of normal biomechanics and functions of the right ankle. The examiner further opined that it was at least as likely as not that the Veteran's right ankle disability was caused by or aggravated by his service-connected orthopedic disabilities, including the right knee arthritis, the left knee arthritis, the left ankle arthritis, and possibly the left foot arthritis. Thus, in reviewing the foregoing competent evidence, the Board notes that there are opinions both for and against the Veteran's claim, however, the VHA opinion of March 2016 was based on a complete review of the record, to include a summary of the conflicting medical opinions of record. The examiner noted that these opinions were reviewed and includes an explanation and/or rationale for the opinion rendered. Thus, the Board finds that the VHA opinion is more probative and persuasive on the question of whether the Veteran's right ankle disability may be related to his other service-connected orthopedic disabilities, than the other opinions of record which did not have the benefit of reviewing the other opinions. The Board, after having carefully reviewed the record, and weighing the evidence both in support of and against the claim, finds that the most probative and persuasive medical evidence supports the Veteran's claim that his right ankle disability is related to his service-connected right and left knee disabilities and left ankle disability. Thus, entitlement to service connection for a right ankle disability has been established and the appeal is granted. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for right ankle degenerative joint disease is granted. ____________________________________________ K. MILLIKAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs