Citation Nr: 18149912 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 15-06 495A DATE: November 14, 2018 REMANDED Entitlement to service connection for a right foot or right ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1975 to November 1978 and from August 1980 to August 1983. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In June 2018, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). RIGHT FOOT/ANKLE DISABILITY is remanded. The Veteran asserts that she has a right foot or right ankle disability that is related to service. A November 1977 service treatment record (STR) reflects the Veteran’s complaint of injuries received when involved in a wreck in a jeep and trailer. It was noted that the Veteran injured her right ankle. Edema was present in her ankle and there was some discoloration above the heel. General tenderness was present. A December 1977 STR reflects the Veteran’s complaint of ankle strength post cast removal. It was noted that the right ankle was casted for three weeks and the cast was removed two weeks prior. The Veteran further complained of ankle weakness. In February 2015, the Veteran was afforded a VA ankle conditions examination. The examiner noted that the Veteran was involved in a jeep with trailer rollover accident in October 1977. She was ejected and her right side was pinned under the jeep. She sustained injuries to the low back, right ankle, and face. The ankle was casted for five months. The Veteran recalled that there was no bony fracture, but there was damage to ligaments and tendons. The Veteran reported that for several years after this injury, the ankle was fine. She stated upon current examination that the ankle had been problematic for the past 10 to 15 years. She stated that it gradually became weak, and stiff in cold weather. She further stated that for the past 10 to 15 years, she has had several falls due to weakness in the ankle, especially on uneven terrain. She recalled that eight years ago, she fell and fractured her right ankle (lateral malleolus) requiring surgery with plate and screws. The Veteran stated that her ankle was currently bothered primarily with weakness and tendency to roll or sprain. Occasionally she had pain, especially if she had to be on her toes and with ambulating stairs. Following examination, the Veteran was diagnosed with chronic/recurrent lateral collateral ligament sprain of the right ankle. The examiner opined that the Veteran’s right ankle chronic/recurrent lateral collateral ligament sprain was less likely than not incurred in or caused by the claimed in-service injury or event. The examiner reasoned that the Veteran’s records reveal that the jeep rollover did involve injury to the right ankle for which the ankle was casted for five months. Records after the injury reveal persistence of the associated back injury, but only one other reference to the right ankle in December 1977, about the time the cast was removed. Subsequent records are silent regarding any ankle problem, including history and physical examinations in October 1978 and the separation examination in May 1983. That particular examination was checked “yes” for arthritis/bursitis, and the explantation included reference only to the right elbow. The examiner further explained that “about eight years ago, the Veteran sustained a fracture of the right lateral malleolus. She was treated by a non-VA orthopedist with open repair with plate and pins. She states today that she fell due to weakness of the ankle. However, there are no corroborating [VA treatment records] or any corresponding outside records [in the Veteran’s claims file]. The original injury is reported without fracture. Significant ligamentous injury is appropriately treated with casting, as was done. If weakness was an issue, one would expect it to show up fairly soon after rehabilitation and resumption of full duties. The current ankle complaint is far more likely related to the post-service ankle fracture, with surgical repair, than it is to the injury in service some 37 years ago.” In August 2018, the Veteran submitted a private medical opinion. The examiner recalled the Veteran’s in-service jeep roll-over accident. Physical examination of the Veteran’s feet revealed a varus heel cord insertion on the right, indicating that the right side has a varus heel insertion which predisposes toward supination. The examiner opined that it is as likely as not that the in-service motor vehicle accident and tendon tear is the cause of the Veteran’s current right foot symptoms. The examiner stated that the tendinitis and calcification that was noted later does not preclude the possibility that this is all being caused by the accident in 1977. Furthermore, the Veteran has symptoms specifically in her foot, since the burning is in her foot and subtalar motion occurs through the foot and not the ankle joint. The examiner stated that although the Veteran cannot be service-connected for her ankle symptoms based on previous medical opinion, it is entirely possible that she can be service-connected for the foot symptoms, since she now shows signs of pain with subtalar motion and has burning in her foot that is independent of the ankle symptoms. Although the Board finds the private examiner’s opinion to be speculative in nature, the examiner has suggested that the Veteran may have a right foot disability that is a result of the in-service injury to her right ankle. The Veteran has not been afforded a VA examination regarding her right foot. Based on such, the Board finds that remand is appropriate to afford the Veteran a VA examination and opinion to determine whether she has a current right foot disability that is related to the documented in-service injury during military service. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see also 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4). Lastly, the February 2015 VA examiner has pointed out that there are no private treatment records associated with the Veteran’s claims file referring to her reported post-service fracture of the right lateral malleolus in approximately 2007. Therefore, as it appears there are outstanding private treatment records, a remand is necessary in order to obtain those records and any other outstanding private or VA treatment records. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records. 2. Ask the Veteran to identify any private treatment that she had relating to the right ankle/foot injury and treatment in approximately 2007. After securing the necessary releases, attempt to obtain and associate those identified treatment records with the claims file. 3. Schedule the Veteran for a VA examination by an appropriate medical professional for her claimed right foot/ankle disability. The examiner is to provide an opinion to the following: a) Identify all diagnosed right foot/ankle disabilities the Veteran has had at any point during the course of her appeal, even if such disability is now resolved. b) For each right foot/ankle disability found at any point during the course of the appeal, the examiner must opine as to whether it is at least as likely as not (50 percent or greater probability) related to the Veteran’s active military service, to include injury to her right ankle in November 1977. The examiner’s opinion must be supported by an adequate rationale. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Gordon, Associate Counsel