Citation Nr: 20031220 Decision Date: 05/04/20 Archive Date: 05/04/20 DOCKET NO. 19-04 716 DATE: May 4, 2020 REMANDED Entitlement to service connection for left ankle disorder is remanded. Entitlement to service connection for a disorder of the left lower extremity, to include the hip and foot and as secondary to left ankle disorder, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from June 1967 to October 1967. 1. Entitlement to service connection for left ankle disorder 2. Entitlement to service connection for a disorder of the left lower extremity, to include the hip and foot and as secondary to left ankle disorder In a July 5, 2016 VA Form 21-526EZ, the Veteran requested service connection for limitation of movement of left ankle and pain on movement. In a July 25, 2016 VA Form 21-526EZ, the Veteran requested service connection for left lower extremity and hip swelling, aching, painful and residuals of left ankle injury. In a September 2018 VA Form 21-526EZ, the Veteran requested service connection for smaller slightly withered left foot as result of left ankle injury. The Board has recharacterized these claims more broadly to a left ankle disorder and for a disorder of the left lower extremity, to include the hip and foot and as secondary to left ankle disorder, in order clarify the nature of the benefits sought and ensure complete consideration of the claims. Clemons v. Shinseki, 23 Vet. App. 1, 5-6, 8 (2009). Review of service treatment records shows the Veteran reported a history of cramps in his legs in a June 1966 Report of Medical History. In July 1967, he reported sore knees and ankles and clinical findings revealed no swelling, but the Veteran later reported his knees and ankles were still hurting and clinical findings revealed some edema in the left ankle. In July 2016, the Veteran submitted a September 1985 statement from Dr. W. D. who reported treating the Veteran for costochondritis and advised the Veteran against heavy lifting, prolonged walking and standing, and avoid bending and squatting due to this condition. In the September 2016 VA Form 21-0958 (Notice of Disagreement), the Veteran reported his left ankle injury occurred during basic training, his left ankle did not hurt constantly but fairly regularly, and he did not seek treatment for the left ankle in service more than once or twice. He reported that he sought treatment for left ankle pain and swelling after separation from service by Dr. W. D. and has had problems with pain, swelling, and limitation of movement of the left ankle on and off since the in-service injury. He reported being seen by numerous doctors for his left ankle, left leg, and left hip through the years. The Veteran further described the top part of his left foot, the part closest to the left ankle, has constant, chronic, and almost unbearable pain. In light of the pertinent evidence noted above, the Board finds that additional development is needed to determine the existence and etiology of any current disorder or functional impairment of the Veteran’s left ankle and left lower extremity, to include the hip and foot. See 38 C.F.R. § 3.303 (2019); McLendon v. Nicholson, 20 Vet. App. 79 (2006). The Board emphasizes that it is not determining whether or not the Veteran’s statements of in-service left ankle pain; left ankle pain, swelling, and limitation since service; that he sought treatment by multiple providers for the left ankle soon after separation from service; and constant chronic pain of the left foot are credible at this time, as the additional development set forth in the directives below could impact that determination. Additionally, at this time, the Board finds that attempts to obtain any outstanding private treatment records from Dr. W. D. and/or any other medical provider for the Veteran’s left ankle and/or left lower extremity, as identified by the Veteran in the September 2016 NOD would be futile. The Veteran explained that these providers are retired, dead, or moved away and he is unable to find or access these records. The matters are REMANDED for the following actions: 1. Provide the Veteran’s claims file to an appropriate clinician to provide an opinion regarding the Veteran’s left lower extremity, to include ankle, hip, and foot. The entire claims file and a copy of this remand must be made available to the examiner for review. An examination (physical or telehealth) is only required if deemed necessary by the examiner. For the purposes of this remand only, and for the limited purpose of providing a medical opinion, the examiner should assume that the Veteran’s lay assertions of in-service left ankle pain; left ankle pain, swelling, and limitation since service; he sought treatment by multiple providers for the left ankle soon after separation from service; and constant chronic pain of the left foot are true. If there is a medical reason to doubt its veracity, the examiner should explain why the Veteran’s recollection is inconsistent with the principles of medical science and/or the evidence in this case. First, the examiner must opine as to the following: (a.) Identify whether, at any time since July 2016 (even if since resolved), the Veteran has had a diagnosis of a left ankle disorder or functional impairment due to left ankle pain and/or swelling. (b.) Then, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current disability or functional impairment of the left ankle began during active service or related to an incident of service, to include complaints and treatment for left ankle pain and swelling in July 1967. (c.) If there are clinical findings of arthritis in the left ankle, then whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s symptoms of arthritis began within one year after discharge from active service in October 1967, to include consideration of the Veteran’s reported left ankle pain, swelling, and limitation since service (asserted in the September 2016 NOD). Second, the examiner must opine as to the following: (a.) Identify whether, at any time since July 2016 (even if since resolved), the Veteran has had a diagnosis of the left lower extremity, to include the hip and foot, or functional impairment due to left lower extremity pain, swelling, and/or aching. (b.) Then, whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current disability or functional impairment of the left lower extremity began during active service or related to an incident of service, to include complaints of cramps in legs in June 1966 and sore knees in July 1967. (c.) If there are clinical findings of arthritis in the left lower extremity, to include the hip and foot, then whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s symptoms of arthritis began within one year after discharge from active service in October 1967. (d.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current disability or functional impairment of the left lower extremity was proximately due to or the result of his left ankle disorder or functional impairment of the left ankle. (e.) Whether it is at least as likely as not that the Veteran’s current disability or functional impairment of the left lower extremity was aggravated beyond its natural progression by his left ankle disorder or functional impairment of the left ankle. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 2. Then, review the medical opinions to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures. 3. Then, readjudicate the claims. If any decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Carter, 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.