Citation Nr: 21063554 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 17-47 870 DATE: October 14, 2021 REMANDED Entitlement to service connection for right ankle disability is remanded. Entitlement to service connection for left ankle disability is remanded. Entitlement to service connection for back muscle strain is remanded. Entitlement to service connection for bilateral foot disability is remanded. Entitlement to service connection for an acquired psychiatric disability is remanded. REASONS FOR REMAND The Veteran had active military service from July 1979 to July 1982. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2015 and July 2015 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO). To ensure that all potential psychiatric disorders noted in the Veteran's service medical records and post-service treatment records are contemplated for the acquired psychiatric disorder claimed as posttraumatic stress disorder (PTSD) and depression, the Board has recharacterized the issue on appeal as a claim for entitlement to service connection for an acquired psychiatric disorder, to include major depressive disorder and PTSD. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). The Board finds that additional development is necessary in this case. To assist the Board with making a nexus determination, an adequate medical opinion will 1) be based on a review of the medical records; 2) consider the Veteran's medical history and examinations; 3) sufficiently describe the details of the disability, including etiology; 4) be factually accurate and fully articulate; 5) contain sound reasoning rather than mere data and unsupported conclusions; 6) express the right degree of certainty; and 7) consider all relevant facts, data, and evidence of record, including lay statements. Stefl v. Nicholson, 21 Vet. App. 120, 123-24 (2007); Nieves-Rodriguez v. Peak, 22 Vet. App. 295, 304 (2008). It will also apply the appropriate legal standard and consider all raised theories of entitlement. El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013). If service connection cannot be granted under a presumptive or secondary basis, the claim should be evaluated to determine whether direct service connection is warranted. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Service Connection-Low Back, Ankles, and Feet The Veteran maintains that he sustained injuries during military training in playing basketball, lifting gallons of paint and/or falling off the back of a truck. He believes that his musculoskeletal disabilities are related to the incidents during active service. In a May 2019 letter, Dr. F opined that the low back condition is as likely as not caused by an in-service injury. He further stated that the chronic arthritic condition of both ankles and the great toe are more likely than not caused by his military service. However, the physician did not provide sufficient rationale for his opinion. For example, there was no explanation for why a muscle strain of the back would relate to arthritis. Regarding the ankles, there seems to be some inconsistency as the service treatment records show a left ankle injury but in some post-service records he reports an injury in service to the right ankle. In any event, the opinion referenced ankle injuries without specifying between ankles and without acknowledging that treatment is only seen for the left ankle in service. Therefore, the Board finds that a remand is necessary for VA examinations to determine the nature and etiology of the Veteran's claimed low back disability, and bilateral ankle and foot disabilities. See 38 C.F.R. § 3.159(c)(4) (2019); see also McLendon v. Nicholson, 20 Vet. App. 79 (2006). In addition, there is a need for updated VA examinations, given the examinations are over six years old. Service connection-Acquired Psychiatric Disability The Veteran maintains that his current psychiatric disability began during service as a result of a fellow service member committing suicide. He indicated that he has grown progressively paranoid concerning death. The Veteran stated that his dreams of being in a foxhole results in a depressed mood. In a May 2019 letter, Dr. Frigon indicated that the Veteran tested positive for depression. The physician opined that the Veteran's orthopedic conditions, including chronic pain related to his low back, bilateral ankles, and bilateral feet have contributed to and exacerbated his depression with deficiencies due to symptoms of depressed mood, anxiety, and anger. The physician did not provide any rationale for his opinion. There is no VA psychiatric examination on record addressing the issues. Therefore, the Board finds that a remand is necessary for a VA examination to determine the nature and etiology of the appellant's claimed psychiatric disabilities. See 38 C.F.R. § 3.159(c)(4) (2019); see also McLendon, 20 Vet. App. at 79. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination by an examiner with the appropriate expertise to determine the nature and etiology of any low back disability, bilateral ankle disability, and foot disabilities. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner should identify any low back disability, and bilateral ankle disability, and foot disabilities that may be present. For each disability identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that the disability was incurred in or is etiologically related to the appellant's active service, to include sports participation, work, and field training activities. In forming the opinions, the examiner must fully address the May 2019 private medical opinion. A rationale for all opinions expressed must be provided. 2. Schedule the Veteran for a VA examination by an examiner with appropriate expertise to determine the nature and etiology of any psychiatric disability that may be present. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and a review of the record, the examiner should identify any psychiatric disability that may be present. For each disability identified, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that the disability was incurred in or is etiologically related to the Veteran's active service, to include as secondary to orthopedic conditions of chronic pain related to his low back, bilateral ankles, and bilateral feet. In forming the opinions, the examiner must fully address the May 2019 private medical opinion. A rationale for all opinions expressed must be provided. 3. Confirm that the VA examination report comports with this remand and undertake any other development determined to be warranted. 4. Thereafter, readjudicate the appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. ERIC S. LEBOFF Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ivan Franklin 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.