Citation Nr: 20033077 Decision Date: 05/12/20 Archive Date: 05/12/20 DOCKET NO. 16-24 475 DATE: May 12, 2020 REMANDED Entitlement to service connection for a left ankle condition is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1988 to September 1993. In April 2019, he and his wife testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of the proceeding is in the record. The Veteran’s service treatment records include a September 1989 record noting chronic ankle problems status post numerous sprains. An April 1993 consultation sheet showed the Veteran injured his left ankle in a basketball game and was assessed with a severe ankle sprain. X-ray reports showed the Veteran had evidence of a well-healed avulsion fracture off the distal fibula in his left ankle that was consistent with past trauma. See October 1989 service treatment record. Post-service medical records do not show any evidence of treatment for a left ankle condition. The Veteran’s wife testified at the Board hearing that the Veteran never sought medical treatment for his left ankle after leaving military service. A July 2013 VA examiner concluded the Veteran did not have a diagnosed left ankle disability. However, the Veteran did testify to stiffness and pain in his ankle when driving in cold weather climates while working as a truck driver. Despite the lack of a formal diagnosis, pain alone may constitute disability, even without an identifiable underlying pathology, if the pain reached the level of a “functional impairment.” Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The July 2013 VA examiner concluded that it was less likely than not that the Veteran’s left ankle condition was incurred in or caused by his in-service injury. However, the examiner’s rationale misstated the Veteran’s reports concerning the onset of his left ankle problems. In the opinion, he stated that the Veteran related the onset of his left ankle symptoms as six to seven years ago. However, the examination report related that the Veteran said his left ankle symptoms began to increase in severity during this time period. In light of these factual discrepancies, the July 2013 VA examiner’s opinion is inadequate. On remand, the Veteran should be afforded a new VA examination pursuant to Saunders to clarify whether the Veteran has any diagnosed left ankle disability and if not, whether any pain alone may constitute disability, even without an identifiable underlying pathology. The matters are REMANDED for the following action: Schedule the Veteran for a VA examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) with an appropriate clinician to ascertain the nature and likely etiology of his claimed left ankle disability. Based on review of the record and interview/examination of the Veteran, the examiner is asked to address the following questions: (a) Specifically identify any diagnosable pathology associated with the Veteran’s left ankle pain. (b) If there is no diagnosable pathology for the left ankle pain, the examiner must determine whether there is any objective evidence of left ankle pain. If so, does the objectively confirmed ankle pain result in functional impairment? Specifically, does any pain impair the Veteran’s ability to function under the ordinary conditions of daily life, including employment? In answering this question, the examiner should ask the Veteran to explain the effect of pain. (b) Is it at least as likely as not (probability of 50 percent or higher) that any diagnosed left ankle pathology or identified functional impairment had its onset in or is otherwise related to active duty service? The examiner is asked to provide thorough rationales to all opinions provided that consider the medical evidence of record, as well as the Veteran’s contentions. If an opinion cannot be provided without resorting to speculation, the examiner should explain the reason why a complete opinion cannot be provided. M. E. Larkin Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Jack S. Komperda, 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.