Citation Nr: 18150486 Decision Date: 11/15/18 Archive Date: 11/15/18 DOCKET NO. 16-42 899 DATE: November 15, 2018 REMANDED Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a right hip disability, to include as secondary to a right ankle disability, is remanded. REASONS FOR REMAND The Veteran had active naval service from September 1977 to April 1987, with additional active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) in the United States Naval Reserves. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Muskogee, Oklahoma. Service Connection – Right Ankle and Right Hip Disabilities The Board finds that additional development is required before the appeal is decided. The Veteran has contended that his right ankle disability is related to his active service. Specifically, he stated that during his physical training to lose weight he severely sprained his right ankle in January or February 1982. He added that although the service X-rays did not reveal any bone damage, he was told that there was Grade III ligament damage and his ankle was placed in a temporary cast. Since that injury, the Veteran reported that he has had recurring right ankle sprains and it has affected his gate. Additionally, he has asserted that he has a right hip disability that is secondarily-related to his right ankle disability. Service treatment records documented that the Veteran received treatment for his right ankle during service. The Veteran’s February 1977 enlistment and March 1981 reenlistment examinations were silent for any complaints of, treatment for, or diagnosis of a right ankle disability. In February 1982, the Veteran injured his right ankle. X-ray findings revealed soft tissue swelling; but, there was no evidence of fracture or dislocation. The Veteran’s March 1987 separation examination was silent for any complaints of, treatment for, or diagnosis of a right ankle disability. However, in November 1997, the Veteran reported that he was receiving treatment for a 15-year old ankle injury and that he was diagnosed with arthritis in his ankles in August 1997. In April 1993, during a verified period of ACDUTRA/INACDUTRA service, the Veteran sprained his right ankle. A review of post-service VA treatment records did not reflect any evidence of a right ankle disability. However, the Veteran complained of right hip pain in October 2011. A right hip X-ray was ordered but the results have not been associated with the record. Additionally, the Veteran reported that he received private medical treatment for recurrent right ankle sprains between 1987 and 1997 and that he underwent a bilateral hip displacement in 2013. In light of the Veteran’s right ankle sprain during his active service and his report that he has received private medical treatment for a right ankle and right hip disability since that time; the Board finds that the Veteran should be afforded a VA examination to determine the nature and etiology of any currently present right ankle and right hip disabilities. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Additionally, there is no record that the RO provided Veterans Claims Assistance Act of 2000 (VCAA) notice to the Veteran. Further, current treatment records should be identified and obtained before a decision is made in the appeal. The matters are REMANDED for the following action: 1. Send the Veteran a VCAA notice letter. A copy of the letter must be included in the file. 2. Identify and obtain any pertinent, outstanding VA and private treatment records and associate them with the claims file. 3. Then, schedule the Veteran for a VA examination to determine the nature and etiology of any currently present right ankle disability. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and the review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present right ankle disability had its onset during active service, or is otherwise etiologically related to such active service. The rationale for all opinions expressed must be provided. 4. Then, schedule the Veteran for a VA examination to determine the nature and etiology of any currently present right hip disability. The claims file must be made available to, and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and the review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present right hip disability had its onset during the Veteran’s active service, or is otherwise etiologically related to such service. The examiner should also provide an opinion as to whether it is at least as likely as not (50 percent or better probability) that any currently present right hip disability was caused or chronically worsened by the Veteran’s right ankle disability. The rationale for all opinions expressed must be provided. 5. Confirm that the VA examination reports and all medical opinions provided comport with this remand and undertake any other development determined to be warranted. 6. Then, readjudicate the claims on appeal. If a decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Ware, Associate Counsel