Citation Nr: 20022152 Decision Date: 03/31/20 Archive Date: 03/31/20 DOCKET NO. 17-36 321 DATE: March 31, 2020 REMANDED Entitlement to service connection for left ankle disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1994 to June 1998. The Veteran served honorably on active duty in the Army National Guard from July 1998 to December 1998, January 2000 to April 2000, November 2002 to October 2006, March 2007 to July 2007, October 2008 to November 2009, and October 2010 to July 2013. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Roanoke, Virginia. In his May 2015 notice of disagreement (NOD), the Veteran appealed entitlement to service connection for memory loss. The issue was addressed in the May 2017 statement of the case (SOC). In his July 2017 substantive appeal, the Veteran indicated he only wanted to appeal the claim for service connection for a left ankle disorder. In March 2020 the Veteran presented testimony at a travel Board hearing before the undersigned Veterans Law Judge. Left Ankle Disorder Remand is required for an adequate VA examination and opinion. Where VA provides the veteran with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Where pain alone results in functional impairment of earning capacity, even if there is no identified underlying diagnosis, it can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). The Veteran received a VA examination in September 2014. The examiner stated there was no pathology on examination to render a diagnosis. An etiology opinion was provided in December 2014. The VA examiner opined that left ankle joint pain was less likely than not incurred in or caused by service. The examiner stated there was no current pathological condition of the left ankle joint. First, the examiner failed to address the Veteran complaints of continuing left ankle pain since service. In the September 2014 VA examination, the Veteran stated he treated his left ankle pain with ice and over the counter medication. Second, the examiner failed to address whether left ankle pain alone caused functional impairment. In an April 2014 statement the Veteran indicated limitations due to his left ankle pain. Lastly, November 2015 VA treatment records included an MRI of the left ankle that showed anterior tibial fibula ligament compatible with sprain and partial tear. In an August 2017 supplemental statement of the case, the RO indicated the Veteran failed to appear for a scheduled VA examination. In an August 2017 correspondence, and at the 2020 Board hearing, the Veteran stated he did not received notice to report for a VA examination. Additionally, there is no evidence in the claim file to indicate the Veteran received notice of a VA examination. Accordingly, remand is required for an adequate VA examination and opinion. The matters are REMANDED for the following action: 1. Contact the appropriate VA Medical Center and obtain and associate with the claims file all outstanding records of treatment. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide the required notice and opportunity to respond to the Veteran and his representative. 3. After any additional records are associated with the claims file, provide the Veteran with an appropriate examination to determine the etiology of his left ankle disorder. The entire claims file must be made available to and be reviewed by the examiner. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the left ankle disorder had onset in, or is otherwise related to, active military service. The examiner must address the following: 1) the Veteran’s assertions of an in-service left ankle sprain and of left ankle symptoms that began in-service and have continued since that time; 2) a March 2009 LOD statement; 3) a July 2009 STR that diagnosed left ankle sprain; 4) a September 2009 LOD determination; 5) an April 2014 statement; and 6) a November 2015 VA left ankle MRI. 4. Notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2018). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Bruton, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.