Citation Nr: 21000890 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 18-25 428 DATE: January 6, 2021 ORDER Entitlement to service connection for posttraumatic stress disorder (PTSD) is granted. REMANDED Entitlement to service connection for a right ankle disability is remanded. INTRODUCTION The Veteran had active service from August 1978 to December 1987, and September 1991 to September 1991. FINDING OF FACT The Veteran’s acquired psychiatric disorder is etiologically related to his active service. CONCLUSION OF LAW The criteria for service connection for posttraumatic stress disorder have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION Legal Criteria Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after service, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection for PTSD requires medical evidence diagnosing the condition in accordance with 38 C.F.R. § 4.125 (a) (i.e., under the criteria of DSM-V); a link, established by medical evidence, between current symptoms and an in-service stressor; and credible supporting evidence that the claimed in-service stressor occurred. Factual Background and Analysis The Veteran’s claim for an acquired psychiatric disorder is based upon his reports that he was exposed to several stressful experiences in service, which were sufficient to cause posttraumatic stress disorder (PTSD). Initially, the Board finds the Veteran is certainly competent to report his experiences in service, and the Board finds no reason to question his veracity. Further, he has also provided historical documents corroborating his in-service experiences. Additionally, the Veteran’s outpatient treatment notes from the Dayton VAMC indicate the Veteran has been diagnosed with chronic PTSD by his treating Psychiatrist. Further, Dr. D.M. has indicated the Veteran’s PTSD is the result of his military traumas. In this case, the Veteran’s treating Psychiatrist has determined he meets all of the diagnostic criteria for PTSD. Additionally, the Veteran’s treating psychiatric provider has indicated that his psychiatric symptoms are proximately related to his military experiences. In sum, the Board is satisfied that the evidence supporting the claim is at least in equipoise with that against the claim. Therefore, the Veteran is entitled to service connection for his acquired psychiatric disorder. REASONS FOR REMAND While the Board regrets the delay, additional development is required before the Veteran’s remaining claim is decided. The Board notes the Veteran has not been afforded a VA examination with respect to his right ankle claim. A review of the Veteran’s outpatient treatment records from the Dayton VAMC show he was diagnosed with moderate tendinosis, which the examiner found was a sequela of remote lateral ankle sprains. At the time of his November 1987 separation examination the Veteran reported experiencing foot trouble. He has also provided a statement from a fellow service member, who recalled the Veteran experiencing a significant fall in service with a resulting limp thereafter. Based on the foregoing, the Board finds a VA examination and medical opinion is warranted. The Board also notes the Veteran initially claimed his right ankle disability may be secondary to a service-connected disability; however, the RO has not contacted the Veteran to determine which of his service-connected disabilities he believes may have caused or aggravated his right ankle disability. On remand, this should be effectuated. Accordingly, this case is REMANDED for the following actions: 1. Contact the Veteran to determine which of his service-connected disabilities he is asserting caused his right ankle disability. 2. Then, afford the Veteran a VA examination by an examiner with sufficient expertise to address the etiology of the Veteran’s right ankle disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner should state an opinion with respect to whether any diagnosed right ankle disability at least as likely as not (a 50 percent probability or greater) originated during his period of active service or is otherwise etiologically related to his active service. If the examiner finds the Veteran’s current right ankle disability did not originate in service, the examiner should state whether the Veteran’s right ankle disability at least as likely as not (a 50 percent probability or greater): a) was caused by a service-connected disability; or b) was worsened to any degree by a service-connected disability. The examiner must specifically address the Veteran’s reports relative to the etiology of the claimed disability. If the examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Fraser, 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.