Citation Nr: 18144385 Decision Date: 10/24/18 Archive Date: 10/24/18 DOCKET NO. 15-35 241A DATE: October 24, 2018 ORDER Service connection for a lumbar spine disability as secondary to the service-connected left ankle disability is granted. REMANDED Entitlement to a disability rating in excess of 20 percent for status post chip fracture, medial malleolus, left ankle with degenerative changes is remanded. FINDING OF FACT The Veteran’s lumbar spine disability is etiologically related to the service-connected left ankle disability. CONCLUSION OF LAW The criteria for service connection for a lumbar spine disability as secondary to the service-connected left ankle disability have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310. INTRODUCTION The Veteran served in active duty from November 1974 to October 1978. REASONS AND BASES FOR FINDING AND CONCLUSION Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be warranted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). The Veteran contends that a low back disability was caused or aggravated by his service-connected left ankle disability. The Veteran has a current disability of the lumbar spine, as there is a documented history of pain and degenerative changes. As such, the central issue is whether the service-connected left ankle disability caused or aggravated the lumbar spine condition. A VA examiner in September 2013 opined that the lumbar spine disorder was not proximately due to or the result of the Veteran’s left ankle disability. The examiner reasoned there was no evidence-based literature to support a back condition being secondary to a lower extremity condition in the absence of severe gait alteration affecting the spine, which, the examiner noted, the Veteran did not present on examination. In March 2014, the Veteran submitted a private medical opinion connecting the lumbar spine condition to the left ankle disability. This opinion noted the Veteran developed a permanent gait change after years of compensation for the fracture and chronic pain in the left ankle. As previously noted, this appeal turns on whether there is a nexus between the Veteran’s current lumbar spine disability and his service-connected left ankle disability. A qualified physician has determined the Veteran’s current lumbar spine disability was caused by his left ankle disorder. She provided a competent rationale to support her conclusion. Accordingly, a nexus to service is established. Although the September 2013 VA examiner found the Veteran’s lumbar spine disability was not related to his left ankle disability, the Board does not find that opinion to be more probative than the opinion provided by the private physician, because the September 2013 VA examiner appears to have based her opinion on a single examination’s findings. In sum, the Board is satisfied that the evidence supporting a nexus between the Veteran’s currently diagnosed lumbar spine disability and his service-connected left ankle disability is at least in equipoise with the evidence against a nexus. Therefore, the Veteran is entitled to service connection for his lumbar spine disability. REASONS FOR REMAND The Veteran last underwent a VA examination in September 2013. Since then, the Veteran has asserted a worsening of symptoms in his left ankle. As such, the Board finds a remand is warranted for a new examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). On remand, relevant ongoing medical records should also be obtained. 38 U.S.C. § 5103A (c) (2012); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, this case is REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran’s remaining issue on appeal, to specifically include any more recent treatment records related to the claimed disability. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified in accordance with 38 C.F.R. § 3.159 (e). 2. Then afford the Veteran a VA examination by an examiner with sufficient expertise to determine the current severity of his service-connected left ankle disability. The electronic records should be made available to and reviewed by the examiner. Ensure the examiner provides all information required for rating purposes. 3. Finally, undertake any other indicated development, and then readjudicate the remaining issue on appeal. If the benefit sought on appeal is not granted to the Veteran’s satisfaction, the Veteran and his representative should be furnished an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Fraser, Counsel