Citation Nr: 21061921 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 18-42 220 DATE: October 5, 2021 ORDER Entitlement to service connection for chronic right ankle sprain with instability is granted. Entitlement to service connection for right great toe hallux rigidus with traumatic arthritis of the first metatarsophalangeal joint is granted. Entitlement to service connection for traumatic arthritis of the right hip is granted. FINDINGS OF FACT 1. The Veteran's chronic right ankle sprain with instability is attributable to an in-service right ankle sprain. 2. The Veteran's right great toe hallux rigidus with traumatic arthritis of the first metatarsophalangeal joint is proximately due to service-connected chronic right ankle sprain. 3. The Veteran's right hip traumatic arthritis is proximately due to service-connected chronic right ankle sprain. 4. The arthritis in the right hip and right foot are due to gait abnormalities and are therefore of traumatic origin, rather than a generalized or systemic process. CONCLUSIONS OF LAW 1. Chronic right ankle sprain with instability was incurred during service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. Right great toe hallux rigidus with traumatic arthritis of the first metatarsophalangeal joint is proximately due to service-connected chronic right ankle sprain. 38 C.F.R. § 3.310. 3. Right hip traumatic arthritis is proximately due to service-connected chronic right ankle sprain. 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1978 to May 1979. In February 2021 the Veteran testified at a virtual hearing before a Veterans Law Judge (VLJ). A transcript of the proceeding is of record. The VLJ clarified the issues on appeal, explained the concept of service connection claims, identified potential evidentiary defects, elicited testimony on the elements necessary to substantiate the claims, and left the record open for 60 days to allow for additional evidence to be submitted. These actions complied with any duties owed during a hearing. 38 C.F.R. § 3.103. SERVICE CONNECTION Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service or for aggravation of a preexisting injury suffered or disease contracted in line of duty. 38 U.S.C. § 1131. In general, to establish a right to compensation for a present disability, a Veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009). Service connection is warranted on a secondary basis for disability which is proximately due to, aggravated by or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310 (b). For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disease or injury; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Certain chronic diseases such as arthritis will be presumed related to service if they were noted as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if continuity of the same symptomatology has existed since service, with no intervening cause. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303 (b), 3.307, 3.309 (a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2012); Fountain v. McDonald, 27 Vet. App. 258 (2015). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Chronic right ankle sprain with instability. The Veteran seeks service connection for a right ankle disability, diagnosed as a chronic right ankle sprain with instability and pain. he contends his current right ankle disability is related to an in-service ankle sprain. After reviewing the evidence, the Board concludes that service connection is warranted for chronic right ankle sprain with instability. Service treatment records show the Veteran twisted his right ankle on subway stairs in July 1978. He was treated the next day for swelling, pain, and limited range of motion. He was assessed with a grade 3 ankle sprain and a cast was applied. He was placed on limited duty. The soft cast was removed in August 1978 and the Veteran underwent physical therapy. In December 1978 the Veteran underwent a clinical evaluation for his ankle as part of medical board proceedings. He was wearing an ankle gauntlet boot, and there was tenderness and inversion was limited to 50 percent of normal with pain. The physician determined the Veteran sustained a sprain-type injury to the right ankle most likely resulting in an incomplete rupture of the ligament of the lateral aspect of the ankle joint. The current diagnosis was a residual injury in the form of a chronic sprain, manifesting with lateral pain, limitation, and tenderness on inversion. The medical board proceedings were completed in December 1978 and found the Veteran had a chronic right ankle sprain, and he was recommended a fit for limited duty until the completion of a physical evaluation board. During a March 1979 psychiatric evaluation, the Veteran stated that he could not play basketball due to his ankle injury, that he was scheduled to undergo a medical board evaluation for the ankle, and he reported distress due to medical problems concerning his ankle. The April 1979 separation examination shows a clinically normal evaluation of the feet and lower extremities. In March 2016 the Veteran was evaluated for pain and symptoms in his right ankle by Dr. M.C., a private orthopedic surgeon. He reported that in 1978 he was on a stairway platform when his ankle and foot folded unde his leg, and that he had a severe sprain and ligament damage. He stated that he still had pain on the side of his right ankle, and that pain medication offered temporary relief. He was assessed with chronic right ankle sprain, pain, instability, and weakness. Dr. M.C. determined there is a greater than 50 percent chance that the Veteran's current chronic condition is due to the ankle sprain that he sustained while in the military in July 1978. The Veteran was provided a VA ankle examination in June 2016. The Veteran reported that he tore all the ligaments in his ankle in 1978 on a stair platform and that he was in an ankle gauntlet for about 8 months. He had pain on the side of his foot and aching over the top of his foot that worsened with activity and was better with immobilization and rest. The examiner diagnosed a grade 3 ankle sprain in July 1978. Range of motion was normal and there was no ankle pain on examination. the examiner concluded that a right ankle condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury. The examiner noted the December 1978 medical board showed that he had a stable ankle and normal gait, the April 1979 separation showed normal lower extremities and feet, and the medical records were silent for ankle complaints from the date of his April 1979 separation examination until the March 2016 private examination. VA treatment records show in September 2016 the Veteran reported chronic right ankle pain since injuring his ankle during service. On physical examination he had decreased range of motion of the ankle with discomfort on adduction. At an October 2016 podiatry consult the Veteran had pain in the calcaneofibular ligament and anterior talofibular ligament on palpation and with external rotation. He reported his in-service ankle injury with aching pain since, and that he had a history of rolling his ankle but not recently. He was assessed with an anterior talofibular ligament injury with lateral instability and pain with a history of ankle sprain and was issued an ankle splint. In a July 2018 letter, Dr. M.C. stated the Veteran had instability and chronic reinjuries of his right ankle due to his in-service injury, and that upon examination the Veteran had chronic ankle instability. The Veteran testified at a Board hearing in February 2021. He stated that he was on limited duty following his in-service ankle sprain until he separated in May 1979, that he did not have access to healthcare following separation, and that he had to continue restricting his activities after discharge. He also used a brace and shoe inserts for his ankle. After the hearing the Veteran submitted another letter from Dr. M.C. who stated that, after reviewing the Veteran's service treatment records and medical records, it is more than 50 percent likely that the Veteran's current ankle condition is a result of his service. Dr. M.C. noted that the Veteran fell down a stairwell and injured his ankle and received treatment in July 1978 and was fitted into a cast in August 1978 which was removed in November 1978. Dr. M.C. also noted that the Veteran had received an ankle brace and shoe inserts in December 2016, and that he had treated the Veteran once per year. We have considered the lay statements of record. The Veteran has reported that he continued to have ankle pain following his ankle sprain during service. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay people are competent to testify to visible or otherwise observable symptoms of disability, such as pain. Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). While there are no treatment records between the Veteran's separation from service in May 1979 and his private evaluation by Dr. M.C. in March 2016, an absence of medical records does not in and of itself render lay evidence not credible. Buchanan, 451 F.3d at 1336-7. Although the Veteran's lower extremities were evaluated as clinically normal in the April 1979 separation examination, he remained on limited duty until separation due to his right ankle. We also note he had reported ongoing problems with his right ankle three weeks prior to the separation examination. We find the Veteran's reports of constant right ankle symptoms are credible and consistent with his diagnosis of a chronic right ankle sprain. For a medical opinion to be given probative weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). A medical opinion that is factually accurate, fully articulated, and based on sound reasoning carries significant weight. Id. at 304. and February 2021 opinion are of somewhat lessened probative weight. Here, we are presented with conflicting evidence of varying probative weight. The Veteran's lay statements that he had ankle pain and symptoms since service have been consistent and are credible. There is a many-year gap between separation from service and the Veteran's first documented post-service treatments for his right ankle, which may be viewed as a factor weighing against this claim. The Veteran was diagnosed with a chronic right ankle sprain during service, which is still his active diagnosis. The June 2016 VA opinion is of lessened probative value because it does not address the Veteran's lay statements and failed to consider the entirety of the December 1978 medical board proceedings. The March 2016 opinion from Dr. M.C. contains no supporting rationale. Although the February 2021 opinion is similarly light on rationale, Dr. M.C. did consider the Veteran's treatment records, lay statements, and medical history. The July 2018 letter provides reasoning for concluding the Veteran's current right ankle disability is due to service, namely that the Veteran's ankle was weakened during service and he continued to incur chronic injuries. Given the foregoing, the evidence for and against the claim is at least in equipoise as to whether the Veteran's current chronic right ankle sprain was incurred in service. Any reasonable doubt must be resolved in favor of the Veteran, and entitlement to service connection for chronic right ankle sprain is granted. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Right great toe hallux rigidus with degenerative arthritis of the first metatarsophalangeal joint. 3. Right hip degenerative arthritis. The Veteran seeks service connection for right foot and right hip disabilities. His sole contention is that he has right foot and hip disabilities that are caused by his now service-connected right ankle sprain. The Veteran is currently diagnosed with right great toe hallux rigidus with osteoarthritis of the first metatarsophalangeal joint, and right hip osteoarthritis. After reviewing the evidence, we conclude that service connection is warranted. Service treatment records do not show any relevant complaints or treatments related to the Veteran's right foot or right hip. The April 1979 separation examination shows a clinically normal evaluation of the feet and lower extremities. VA records show the Veteran reported chronic right hip and great toe pain in September 2016. Polyarthralgia and osteoarthritis were noted. At an October 2016 VA podiatry consultation, he reported pain and stiffness in the right first metatarsophalangeal joint for a few years and denied any trauma or injury but related he had been compensating with his forefoot due to ankle pain. He also reported right hip arthritis. On physical examination of the right great toe there was pain on palpation to the metatarsophalangeal joint with significantly reduced dorsiflexion range of motion with pain throughout the range of motion. The podiatrist diagnosed right hip osteoarthritis and first metatarsophalangeal joint hallux rigidus of the right great toe. He had an OrthoFlow injection for his right great toe in October 2017.At a February 2017 appointment the Veteran reported the injection had reduced the pain in his right great toe, and the diagnosis remained first metatarsophalangeal joint hallux rigidus with pain. At an April 2018 VA orthopedic consultation, the Veteran reported right hip pain for years with popping. X-rays showed degenerative arthritis of the right hip and he was referred to physical therapy. In a July 2018 letter, Dr. M.C. noted that he had been treating the Veteran for his right ankle injuries and instability. Dr. M.C. determined the Veteran had chronic ankle instability and that due to the instability he had been overcompensating, which caused his gait to change, and ultimately caused him to have arthritis in the first metatarsophalangeal joint of the right foot. In a February 2021 letter, Dr. M.C. reiterated that he had been treating the Veteran for right ankle injuries and instability, that the chronic ankle instability had caused the Veteran to overcompensate and change his gait, which ultimately caused him to have arthritis in the first metatarsophalangeal joint (right big toe joint) and the right hip joint. Dr. M.C. also stated that he believed all the Veteran's symptoms corresponded together. The Veteran provided testimony at a February 2021 Board hearing. He stated that his ankle had never healed properly following his in-service sprain and that, due to walking and normal activities, caused further deterioration to his right big toe and hip. For a medical opinion to be given probative weight, it must be: (1) based upon sufficient facts or data; (2) the product of reliable principles and methods; and (3) the result of principles and methods reliably applied to the facts. Nieves-Rodriquez v. Peake, 22 Vet. App. 295, 302 (2008). A medical opinion that is factually accurate, fully articulated, and based on sound reasoning carries significant weight. Id. at 304. The only nexus opinions addressing the Veteran's right great toe and right hip are Dr. M.C.'s July 2018 and February 2021 letters. Although the opinions are not supported by extensive rationales, the opinions are probative evidence regarding whether a right foot and right hip disability are secondary to the Veteran's service-connected chronic right ankle sprain. Dr. M.C. had access to the Veteran's treatment records for the February 2021 opinion. The opinions are not contradicted by the remaining record. Although the opinions do not contain extensive rationale, it is clear Dr. M.C. concluded the Veteran's chronic right ankle sprain resulted in instability, which caused the Veteran to overcompensate and change his gait, which caused the arthritis in the first metatarsophalangeal joint of the right great toe and the right hip joint. Pertinently, there are no contrary opinions. Regarding the Veteran's testimony and lay statements, he is competent to report what his doctors have told him and to describe symptoms he experiences. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). For secondary service connection to be granted, generally there must be (1) evidence of a current disability; (2) evidence of a service-connected disease or injury; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin, 11 Vet. App. at 512. The only probative medical opinions show a causal relationship between the Veteran's now service-connected chronic right ankle sprain and both his right great toe hallux rigidus with degenerative arthritis of the first metatarsophalangeal joint and the right hip degenerative arthritis. There is little negative evidence of record. There are no other documented right great toe or right hip injuries, and no other medical professional has offered opinions contradicting Dr. M.C.'s letters. Although no VA examination or opinion has been obtained, none are necessary. The Board does not wish to remand for negative development. There is a competent and credible basis to conclude that the Veteran's right great toe hallux rigidus with arthritis of the first metatarsophalangeal joint, and arthritis of the right hip, are proximately caused by his service-connected chronic right ankle sprain. Accordingly, service connection is warranted. 38 C.F.R. §§ 3.303, 3.310 (a). The processes in the right hip and right foot are of traumatic origin. H. N. SCHWARTZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Morse 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.