Citation Nr: 18157533 Decision Date: 12/13/18 Archive Date: 12/12/18 DOCKET NO. 16-57 383 DATE: December 13, 2018 REMANDED Entitlement to service connection for a right-hand condition is remanded. Entitlement to service connection for a left ankle condition is remanded. REASONS FOR REMAND The Veteran served on active duty from January to July 2007, and December 2007 to January 2009 while a member of the Marine Corps Reserves. The Veteran declined a Board hearing in his November 2016 VA Form 9. Entitlement to service connection for a right-hand condition Entitlement to service connection for a left ankle condition The issues of service connection for a right-hand, and left ankle conditions are remanded for further development. The Veteran submitted a private treatment record from a September 2016 regarding ankle instability. The private treatment record noted that the Veteran underwent an MRI, but the results of the MRI is not on file. Although it is not clear how long the Veteran has seen this private physician, it notes that previous radiographs were reviewed. The Board infers that there may be more private records present regarding the Veteran’s ankle condition. The Board acknowledges that the Veteran was not provided a VA examination for the Veteran’s right-hand, and left ankle conditions. A VA examination is required when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). See also 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). The third prong, which requires that the evidence of record “indicate” that the claimed disability or symptoms “may be” associated with the established event, is a low threshold. McLendon, 20 Vet. App. at 83. Regarding the right-hand condition, the Veteran asserts that he injured his during deployment in 2008. See August 2017 NOD. A May 2008 service treatment record noted that the Veteran’s right hand had swollen after playing football on base. The May 2008 service treatment record found that the Veteran had a hand contusion, with pain on movement of the 3rd and 4th fingers. As such, the evidence of record indicates that the Veteran’s right-hand condition may be associated with service. Regarding the left ankle condition, the Veteran asserts that he “rolled” both of his ankles in basic training during a hike. See August 2017 NOD. A September 2016 private treatment record indicate that the Veteran is affected by ankle instability. As such, the evidence of record indicates that the Veteran’s left ankle condition may be associated with service. Consequently, the VA examinations are necessary for the Veteran’s right-hand, and left ankle conditions. Thus, remand is warranted. The matters are REMANDED for the following action: 1. Obtain and associate with the record all VA and private treatment records for the Veteran. All actions to obtain the requested records should be fully documented in the record. If they cannot be located or no such records exist, the Veteran and his representative should be so notified in writing. Particularly, the RO should obtain private treatment records from private physician associated with the September 2016 private treatment record. If possible, the Veteran and his representative are asked to submit these records themselves. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of the Veteran’s right-hand, and left ankle conditions. For the right-hand condition, the examiner must opine whether the Veteran’s right-hand condition is at least as likely as not related to an in-service swollen right hand, and right-hand contusion. For the left ankle condition, the examiner must opine whether the Veteran’s left ankle condition is at least as likely as not related to “rolling” his ankles during a basic training hike. The examiner should specifically test the range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing, for both the joint in question and any paired joint. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should specifically address the Veteran’s functional loss due to pain weakness, fatigability and incoordination as well as any other factors which are present. The functional loss should be described. The examiner should obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flare-ups from the Veteran himself. The examiner should elicit relevant information as to the Veteran’s flares with a description of the additional functional loss, if any, the Veteran has during flares. The examiner should estimate the Veteran’s functional loss due to flares based on all the evidence of record-including the lay information or sufficiently explain why the examiner cannot do so. In discussing the relevant clinical findings, the examiner should specifically note the Veteran’s current complaints, symptoms, any interference with daily and/or occupational activities, and the level of disability. The examiner must also provide information concerning the functional impairment that results from the left ankle, and right-hand conditions which may affect his ability to function and perform tasks in various occupational situations. Any opinions expressed by the examiner must be accompanied by a complete rationale. 3. Then, readjudicate the issues on appeal. If any benefit sought on appeal remains denied, provide the Veteran and his representative with a supplemental statement of the case and afford them the requisite opportunity to respond before the case is returned to the Board for further appellate action. JOHN J CROWLEY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Timothy A. Campbell, Associate Counsel