Citation Nr: 20034487 Decision Date: 05/18/20 Archive Date: 05/18/20 DOCKET NO. 15-20 108 DATE: May 18, 2020 REMANDED Entitlement to service connection for a right ankle disorder is remanded. Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for a right elbow disorder is remanded. Entitlement to service connection for a right foot disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from May 2006 to June 2009. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in June 2018. A transcript of that hearing has been associated with the claims file. An August 2018 Board decision remanded the above issues for development, including the issue of entitlement to service connection for a left knee disorder. As a result, entitlement to service connection for a left knee disorder was granted by the Regional Office (RO) in a March 2019 rating decision. As the benefit sought is granted for the left knee disorder, the issue is no longer on appeal to the Board. The remaining issues are returned to the Board for appellate review. Remand is necessary to obtain an addendum VA opinion, or a new VA examination if necessary. When VA undertakes to obtain an opinion, it must ensure that the opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). A medical opinion is considered adequate “where it is based on consideration of the veteran’s prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board’s evaluation of the claimed disability will be a fully informed one.” Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). The Veteran’s bilateral ankle disorder, right foot disorder, and right knee disorder did not produce a diagnosis. However, the Veteran’s assertion of in-service pain and the current symptoms of pain must be assessed to determine the etiology of the Veteran’s current pain. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). 1. Entitlement to service connection for a right ankle disorder is remanded. 2. Entitlement to service connection for a left ankle disorder is remanded. Here, on the October 2018 VA ankle examination, the examiner stated that the Veteran does not have a current diagnosis of the bilateral ankles. The examiner reasoned that the Veteran had a left ankle injury in 2006, with no entries regarding injury to the right ankle. Also, the examiner stated that the separation examination was negative for any ankle complaints. The examiner observed no altered gait and stated there is no diagnosis of the bilateral ankle. The examiner stated that the Veteran’s ankle pain may be due to being overweight and being on his feet all day for work. A March 2007 service treatment record (STR) shows that the Veteran was treated for a left ankle injury during service. VA treatment records show in April 2010 the Veteran complained of left ankle pain that had its onset years prior. In June 2010 the medical provider recommended that the Veteran be treated by physical therapy for right ankle. The examiner did not address the May 2006 fall in-service that injured the Veteran’s right ankle; the March 2007 in-service injury to the left ankle; 2010 VA treatment complaints of bilateral ankle pain and treatment; VA treatment records of physical therapy, to include the bilateral ankles; the Veteran’s assertion of continued bilateral ankle pain; and the May 2017 VA treatment record documenting left ankle joint changes, as directed by the August 2018 Board decision. Therefore, an addendum VA opinion is required to determine the nature and etiology of the Veteran’s bilateral ankle disorder. 3. Entitlement to service connection for a right elbow disorder is remanded. The October 2018 VA examiner diagnosed the Veteran with lateral epicondylitis. The examiner observed the Veteran to have no symptoms except with extreme pronation against resistance. The examiner opined that the Veteran’s right elbow disorder is less likely than not caused by service. The examiner reasoned that the Veteran’s STRs and separation examination make no mention of an elbow disorder and there are no post-service treatment records within the first year after separation from service referencing a right elbow disorder. The October 2018 examiner did not address if the May 2006 fall in the shower was at least as likely as not the cause of the Veteran’s right elbow disorder. Also, the examiner did not consider the Veteran’s statements regarding continuity of symptoms, or his statements regarding functional impairment caused by pain in the elbow when pronating. Therefore, an addendum VA opinion is needed to determine the nature and etiology of the Veteran’s right elbow disorder. 4. Entitlement to service connection for a right foot disorder is remanded. Here, the October 2018 VA examiner indicated that the Veteran does not have a diagnosis of the right foot. However, VA treatment records show the Veteran to have a history of tendinitis of the foot. Further, the examiner noted that the Veteran reported functional loss of the right foot due to flare-ups, specifically in the form of aching when he has been on his feet all day. The October 2018 examiner did not address the diagnosis of the VA treatment record or the May 2006 in-service fall that injured the right side of the Veteran’s body. Further, the examiner did not consider the Veteran’s statements related to injury or any assertion of continued symptoms since separation from service that cause functional impairment. Therefore, an addendum VA opinion is required to determine the nature and etiology of the Veteran’s right foot disorder. 5. Entitlement to service connection for a right knee disorder is remanded. Here, the October 2018 VA examiner indicated that the Veteran does not have a diagnosis of a right knee disorder. However, VA treatment records show the Veteran undergoing physical therapy treatment for the right knee. The VA examiner did not address the Veteran’s VA treatment for right knee pain. The examiner also did not address the Veteran’s assertions of a May 2006 injury to his right side, or his statements that he experiences functional impairment in the form of pain with prolonged standing or walking. Therefore, an addendum VA opinion is required to determine the nature and etiology of the Veteran’s right knee pain. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate medical profession, or a new in-person or telehealth examination if deemed necessary, to address the nature and etiology of the Veteran’s claimed bilateral ankle disorder. The examiner must thoroughly review the claims file, including the Veteran’s statements related to injury and symptoms, and must provide a well-reasoned opinion as to whether it is at least as likely as not that any currently diagnosed bilateral ankle disorder, to include bilateral ankle pain, is etiologically related to the Veteran’s service, to include the 2006 fall and 2007 left ankle injury, as described by the Veteran and as documented in the STRs. The examiner must specifically discuss the 2006 in-service fall in which he injured his right side, the March 2007 left ankle injury, VA treatment of bilateral ankle pain in 2010, the May 2017 VA findings of left ankle joint changes, and must specifically consider and discuss the Veteran’s competent statements regarding continued symptoms since service, including Board hearing testimony, in any negative opinion. 2. Obtain an addendum opinion from an appropriate medical profession, or a new in-person or telehealth examination if deemed necessary, to address the nature and etiology of the Veteran’s claimed right elbow disorder. The examiner must thoroughly review the claims file, including the Veteran’s statements related to injury and symptoms, and must provide a well-reasoned opinion as to whether it is at least as likely as not that any currently diagnosed right elbow disorder, to include elbow pain, is etiologically related to the Veteran’s service, to include injury as a result of a May 2006 in-service fall, and the Veteran’s assertions of right elbow symptoms after the fall. The examiner must specifically discuss the May 2006 in-service fall in which the Veteran injured his right side, and must specifically consider and discuss the Veteran’s competent statements regarding continued symptoms since service, including Board hearing testimony, in any negative opinion. 3. Obtain an addendum opinion from an appropriate medical profession, or a new in-person or telehealth examination if deemed necessary, to address the nature and etiology of the Veteran’s claimed right foot disorder. The examiner must thoroughly review the claims file, including the Veteran’s statements related to injury and symptoms, and must provide a well-reasoned opinion as to whether it is at least as likely as not that any currently diagnosed right foot disorder, to include foot pain, is etiologically related to service, to include injury as a result of a May 2006 in-service fall. The examiner must specifically discuss the May 2006 in-service fall in which the Veteran injured his right side, including his right foot; a December 2014 diagnosis of right foot bursitis; and must specifically consider and discuss the Veteran’s competent statements regarding continued symptoms since service, including Board hearing testimony, in any negative opinion. 4. Obtain an addendum opinion from an appropriate medical profession, or a new in-person or telehealth examination if deemed necessary, to address the nature and etiology of the Veteran’s claimed right knee disorder. The examiner must thoroughly review the claims file, including the Veteran’s statements related to injury and symptoms, and must provide a well-reasoned opinion as to whether it is at least as likely as not that any currently diagnosed right knee disorder, to include knee pain, is etiologically related to service, to include injury as a result of a May 2006 in-service fall injuring his right side. The examiner must specifically discuss the May 2006 in-service fall in which the Veteran injured his right side, his post-service complaints of bilateral knee pain in VA treatment records, and must specifically consider and discuss the Veteran’s competent statements regarding continued symptoms since service, including Board hearing testimony, in any negative opinion. Caroline Fleming Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Thompson, 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.