Citation Nr: 21003666 Decision Date: 01/22/21 Archive Date: 01/22/21 DOCKET NO. 18-32 950 DATE: January 22, 2021 REMANDED Entitlement to service connection for a right ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from January 1996 to August 2004. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2017 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The Board issued an August 2019 decision denying the claim for service connection. In August 2020, the U.S. Court of Appeals for Veterans Claims (CAVC) granted a joint motion for remand (JMR) and remanded the case. 1. Entitlement to service connection for a right ankle disability is remanded. The Veteran claims that he should be entitled to service connection for a right ankle disability due to repeated ankle injuries during service. Further, in the event he is not entitled to direct service connection, the Veteran contends that he is entitled to secondary service connection due to his service-connected knee disability. A remand is necessary to further develop the claim including obtaining a medical opinion to determine the current severity of the Veteran’s disability. During a January 2019 VA examination, the Veteran stated that he had injured both ankles in service during bootcamp resulting in him being issued ankle braces. Additionally, he had sprained them running, and that during jump school he had a number of hard landings resulting in additional injuries to his ankles. The VA examiner diagnosed the Veteran with a current right and left ankle sprain, however he opined that although the Veteran’s left ankle condition was related to service, that his right ankle condition was not related to service. Id. In support of his opinion, the VA examiner stated that “there is no evidence seen in the STR’s or claims file of any right ankle injuries while in service.” Id. As the VA examiner failed to consider all the relevant evidence of record prior to rendering his opinion, specifically the Veteran’s reports of numerous right ankle injuries during service, the Board finds the examination to be inadequate. The mere absence of treatment records should not be the sole basis for a negative opinion. See Dalton v. Nicholson, 21 Vet. App. 23, 40 (2007). In addition, the August 2019 Board decision failed to consider the Veteran’s additional theory of entitlement for secondary service connection. In his June 2018 appeal, the Veteran stated that because his knees are bad, his ankles have been under more stress. As the January 2019 VA examiner did not provide an opinion regarding secondary service connection, the Board concludes a medical examination is necessary prior to deciding this theory of entitlement. Therefore, the Board finds an additional medical examination is warranted before the claim can be adjudicated on its merits. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination with an appropriate medical professional to determine the nature and severity of the Veteran’s right ankle disability. The claims file must be made available for review, and the examination report should reflect that such review occurred. After reviewing the claims file and completing a physical examination of the Veteran, the examiner must: a. Discuss the Veteran’s statements regarding his in-service symptoms and ankle injuries and document the Veteran’s contentions in the examination report; b. Provide an opinion for any right ankle disability found on examination, as to whether it is at least as likely as not (50 percent or greater probability) that the disorder 1) began during active duty service; or, 2) is related to any incident/event of the Veteran’s active duty service. c. Provide an opinion for any right ankle disability found on examination, as to whether it is at least as likely as not (50 percent or greater probability) that the disability 1) is proximately due to, or aggravated by, the Veteran’s service-connected knee disabilities. It should be noted that the Veteran is competent to attest to observable symptomatology. The examiner’s attention is directed to the Veteran’s statements concerning the in-service injuries and the onset of the claimed condition and the continuity of symptomatology he has experienced since service. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran’s reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed should be provided as the Board is precluded from making medical findings. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board, including citation to any supporting medical treatises. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Aubee, 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.