Citation Nr: 21004870 Decision Date: 01/28/21 Archive Date: 01/28/21 DOCKET NO. 16-54 501 DATE: January 28, 2021 REMANDED Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for a left ankle disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1977 to September 1980, with subsequent reserve service until September 1983. This case comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO or AOJ). The Veteran testified before the undersigned Veterans Law Judge (VLJ) in February 2019. A transcript of the hearing is of record. This case was previously before the Board in June 2019 when it was remanded for additional development. It has now returned to the Board for further appellate action. Left Ankle Disorder With regard to the Veteran’s left ankle disorder, the record includes a VA opinion obtained in January 2020. The examiner noted a diagnosis of osteoarthritis of the left ankle. The examiner stated that the etiology of the irregularity of the medial malleolus of the Veteran’s left ankle is unclear. However, he attributed it to “falls/accidents” after service. Such is perplexing because records indicate the Veteran’s falls/accidents caused injury to his right knee, and that no ankle pain was noted. See July 2007 treatment record. The examiner further stated that the Veteran had a history of jobs involving extensive standing and that more likely explained his present ankle condition. There was no discussion, however, of the September 2016 VA treatment record noting remote history of fractures to the left foot “about 30 years ago” noting a diagnosis of diffuse feet and ankle pain secondary to DJD and post-traumatic arthritis. Under these circumstances, the Board finds that the evidence currently of record is insufficient to adequately resolve the claim on appeal, and that remand of this matter is warranted to obtain a new VA medical opinion addressing the nature and etiology of any left ankle disorder. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Failure to Obtain Records The record further indicates that there may be outstanding records. In this regard, the record indicates the Veteran submitted forms for the release of private treatment records from Phoenix Physical Therapy. See November 2019 VA Form 21-4142, and VA Form 21-4142a. There is no indication in the record that the AOJ sought to obtain these records. Additionally, the January 2020 VA examiner indicated that the Veteran retired in 2009 on Social Security disability, due in part to a back condition. Reference was also made to the ankles. As the Veteran’s Social Security Administration (SSA) records may reasonably contain information relating to the Veteran’s disabilities on appeal, remand is required to obtain his SSA records. See Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 and VA Form 21-4142a for any private treatment records associated with his claims for service connection for a low back disorder and for a left ankle disorder, to include any records from Phoenix Physical Therapy. In the event the Veteran returns a VA Form 21-4142 and VA Form 21-4142a, make two requests for the authorized records from the clinicians or facilities identified by the Veteran, unless it is clear after the first request that a second request would be futile. 2. Undertake appropriate action to determine whether the SSA records exist or that efforts to obtain those records would be futile. See 38 C.F.R. § 3.159 (c)(2). If it is determined the SSA records are unavailable, associate with the claims file a formal determination to that effect and notify the Veteran of the unavailability of his SSA records. Follow the procedures set forth in 38 C.F.R. § 3.159 (e). All records and/or responses received should be associated with the claims file. 3. Then, provide the Veteran’s file to an appropriate clinician with knowledge and expertise to opine on the nature and etiology of his left ankle disorder. The clinician must acknowledge review of the pertinent evidence of record, including the Veteran’s reports of symptom manifestation. The examiner must address the following questions: a. Identify/diagnose any chronic disability of the left ankle or functional impairment of the left ankle that presently exists or has existed at any time during the appeal period. b. For each disorder of the left ankle, is it is at least as likely as not it had its initial onset in service or is otherwise etiologically to the Veteran’s active service. The examiner must consider and discuss the Veteran’s reports of the onset of left ankle pain during active service, including as due to a Jeep accident in September 1979. In so doing, the examiner is asked to address whether there is any evidence to accept or reject the proposition that the Veteran experienced a chronic left ankle disorder in service. Rationale for the requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, provide an explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or the limits of current medical knowledge with respect to the question. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith, 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.