Citation Nr: 20052390 Decision Date: 08/06/20 Archive Date: 08/06/20 DOCKET NO. 15-42 780 DATE: August 6, 2020 REMANDED Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1963 to May 1967. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In an April 2019 decision, the Board remanded these issues for additional development. 1. and 2. Entitlement to service connection for left ankle and right ankle disabilities are remanded The Veteran asserts that he experiences bilateral ankle disabilities that arose during or as a result of his active service, including as secondary to his service-connected knee disabilities. In this case, the Veteran’s service treatment records (STRs) reflect the Veteran sprained his left foot while playing sports in November 1964. The injury resulted in swelling; however, it was negative for fracture or dislocation. An undated note reflects that the Veteran complained of moderate tenderness in his right foot’s medial arch. The Veteran’s April 1967 pre-separation medical examination is negative for any complaints, treatment, or diagnoses for any ankle injuries or conditions. The Veteran did not report any ankle problems at the time of separation. In August 2014, the Veteran filed a new claim for service connection for his asserted ankle conditions. The Veteran’s VA treatment records reflect a left ankle fracture in October 2016, treatment for arthropathy of both ankles in February 2017, and complaints of pain in both ankles in February 2018. There are multiple records reflecting complaints of periodic pain, swelling, and weakness. During his November 2018 Board hearing, the Veteran asserted that his ankle conditions arose as a result of overuse during service, and his ankles frequently hurt or, in conjunction with his knee disabilities, caused him to lose his balance. During the Veteran’s November 2019 VA examination for ankle conditions, the VA examiner found that the Veteran was negative for any ankle conditions. The Veteran reported that he had sprained his right ankle several times and fractured his left ankle in 2016. He also reported periodic swelling, soreness, and instability. The Veteran’s range of motion (ROM) was normal, muscle strength was 5/5 in all categories, and the VA examiner found no other symptoms of an ankle condition in either extremity. There was no evidence of pain during active or passive ROM or during weight-bearing or non-weight-bearing testing. Consequently, the examiner opined that there was no evidence of ankle disabilities at the time of the VA examination, and it was less likely than not that the Veteran’s service or service-connected conditions had resulted in ankle disabilities. The Board finds the November 2019 VA examination inadequate for adjudication purposes. First, the examiner did not reconcile the Veteran’s reports and treatment records reflecting complaints of pain, swelling, and instability with the conclusion that the Veteran did not experience any ankle condition. Second, the examiner did not address whether the Veteran had an ankle condition during the period on appeal, which had subsequently resolved or temporarily improved. Accordingly, this claim must be remanded so that the Veteran can be provided with another VA examination. The matters are REMANDED for the following actions: After any necessary records have been associated with the claims file, forward the entire claims file to a qualified physician to obtain an addendum opinion as to the nature and etiology of any current ankle disabilities. The claims file should be made available to the examiner. A new examination may be conducted, if deemed necessary, but is not required by this remand. The examiner is asked to address the following: (a) Identify all ankle disabilities demonstrated during the appeal period or in proximity to the claim (August 6, 2014). (b) Does the November 2019 VA examination reflect that the Veteran does not have a disability of either ankle that represents a functional impairment of earning capacity? (c) If the Veteran does not now have, but previously had, any diagnosed ankle disability, when did that condition resolve? In this regard, the examiner should consider the aforementioned VA treatment records concerning ankle symptoms. (d) For each diagnosed condition from any time during the appeal period, the examiner is asked to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran’s condition had its onset during or was caused by his active service, or, in the alternative, whether it is at least as likely as not (50 percent or greater probability) that his bilateral ankle conditions were caused or aggravated (worsened beyond natural progression) by his service-connected right and left knee disabilities. All opinions and conclusions must be supported by a rationale. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Hicks, 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.