Citation Nr: 20052663 Decision Date: 08/07/20 Archive Date: 08/07/20 DOCKET NO. 11-08 164 DATE: August 7, 2020 REMANDED Entitlement to service connection for bilateral ankle condition is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1961 to September 1963. This case is before the Board of Veterans’ Appeals (Board) on appeal from a December 2013 rating decision by a Department of Veterans Affairs (VA) Regional Office. In April 2018, the Board reopened the Veteran’s service connection for bilateral ankle condition and remanded the matter along with the TDIU claim for further development. Now the matters are returned to the Board. The Veteran is seeking service connection for bilateral ankle condition. The Veteran contends that his active duty service permanently aggravated his preexisting bilateral ankle condition. After the April 2018 Board Remand Order, the Veteran was afforded a VA examination in December 2018. The examiner reported the Veteran’s diagnoses of right ankle traumatic injury, status post arthrodesis with severe residuals and left ankle degenerative arthritis, but opined that the Veteran’s condition, which clearly and unmistakably existed prior to service, was not aggravated beyond its natural progression by an in-service event, injury or illness. The examiner provided that the Veteran’s service treatment record shows only one note regarding the right ankle without any diagnosis and his separation examination did not show any complaints or diagnosis to the right ankle. The examiner also pointed out the Veteran has sustained right ankle injury in December 2000 from an accident. However, the Board finds that the December 2018 examiner did not provide sufficient rationale for the opinion requested, and the examiner failed to answer the specific questions provided in the April 2018 Board Remand directives. Therefore, the Board finds that a remand is required to obtain an addendum opinion in order to make a fully informed decision. In particular, the Board finds that the examiner should provide whether each of the Veteran’s ankle diagnosis, including the history of Charcot Marie Tooth disease, is a congenital disease, a congenital defect, or an acquired disease or injury. See August 2001 Dr. J.W.B. Letter. Also, the examiner should address the Veteran’s contention of unresolved ankle injuries from an April 1961 motor vehicle accident which was still affecting him when entering service, ankle pain during basic training in-service, and gradually increased ankle pain after separation. See May 25, 1961 Dr. B.B.A. Letter; see also February 2007 Hearing Transcript, at 3, 9. Moreover, because a decision on the remanded issue of service connection claim for bilateral ankle condition could significantly impact a decision on the issue of TDIU claim, the issues are inextricably intertwined. Thus, the Board finds that a remand of the TDIU claim is also required. Accordingly, the matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) must obtain an addendum opinion from the December 2018 VA examiner regarding the Veteran’s service connection claim for bilateral ankle condition. If the December 2018 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. If the examiner determines that a new examination is necessary, the AOJ should schedule one for the Veteran. The examiner should review the Veteran’s claims file and a copy of this REMAND order before rendering the requested addendum opinion. (a.) The examiner should identify with specificity all of the Veteran’s right and left ankle disabilities which are currently manifested, or which have been manifested at any time since March 2013, including arthrodesis, degenerative arthritis, and history of Charcot Marie Tooth disease. See August 2001 Dr. J.W.B. Letter. (b.) The examiner should indicate which, if any, of these ankle conditions constitute a congenital disease, a congenital defect, or an acquired disease or injury. The term “disease” is broadly defined as any deviation from or interruption of the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. On the other hand, the term “defect” would be definable as structural or inherent abnormalities or conditions that are more or less stationary in nature. (c.) If the examiner determines that any right or left ankle disability is a congenital defect, opine whether the Veteran now has additional disability due to an in-service disease or injury superimposed upon such defect. (d.) If the examiner determines that the Veteran had preexisting right or left ankle disabilities, including any congenital disease, opine whether it is clear and unmistakable (i.e., undebatable) that the Veteran’s preexisting disabilities underwent permanent worsening beyond normal progressions during the Veteran’s active duty service. The examiner is specifically asked to consider the Veteran’s contention of unresolved ankle injuries from an April 1961 motor vehicle accident which was still affecting him when entering service, ankle pain during basic training in-service, and gradually increased ankle pain after separation. See May 25, 1961 Dr. B.B.A. Letter; see also February 2007 Hearing Transcript, at 3, 9. (e.) The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology, must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, the examiner must provide an explanation for such rejection. (f.) The examiner must provide a complete written rationale for any opinion offered. 2. After completing the above actions and any other necessary development, the issues on appeal, including the inextricably intertwined TDIU claim, must be readjudicated. If the claims remain denied, a Supplemental Statement of the Case must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. E. Kim, 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.