Citation Nr: 21064623 Decision Date: 10/21/21 Archive Date: 10/21/21 DOCKET NO. 18-04 836 DATE: October 21, 2021 REMANDED Entitlement to service connection for a right ankle disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1974 to July 1976 and from February 1982 to February 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in June 2017 by a Department of Veterans Affairs (VA) Regional Office. In December 2018, the Board denied service connection for a right ankle disorder and the Veteran appealed such decision to the United States Court of Appeals for Veterans Claims (Court). In August 2019, the Court granted a Joint Motion for Partial Remand (JMPR), vacating the decision and remanding it for further adjudication. In January 2020, the Board again denied service connection a right ankle disorder, which the Veteran again appealed to the Court. In a February 2021 JMPR, the Court vacated the decision and remanded it for further adjudication. The claim now returns to the Board for further appellate review. Entitlement to service connection for a right ankle disorder. The Veteran contends that he has a current right ankle disorder related to his military service. In this regard, his service treatment records (STRs) reflect that he had a right ankle sprain with slight edema in April 1976. In January 1985, it was noted that he had another right ankle sprain with a torn ligament and some edema on the right lateral side of the ankle, resulting in limited range of motion. While no fracture was noted, the record indicates that the Veteran had a cast over his right ankle. In the December 2018 decision, the Board denied the Veteran's claim on the basis that his right ankle disorder was unrelated to his military service. In this regard, the Board noted that, while the Veteran's post-service treatment records and a May 2017 VA examination were silent for any relevant complaints, treatment, or diagnosis, a July 2016 treatment record included a notation of osteoarthritis of the right ankle in the medical history section; however, the evidence failed to show that such disorder was related to his military service. However, in the August 2019 JMPR, the parties found that the Board failed to consider an April 2017 VA examination, which the Board appears to have miscited as the May 2017 VA examination. Thus, in January 2020, the Board readjudicated the Veteran's claim, but again denied service connection based on a lack of a current disability. In this regard, the Board acknowledged that the Veteran's treatment records reflected a diagnosis of osteoarthritis of the right ankle in his medical history, but found that such was not shown in any other treatment records, to include X-rays. The Board further observed that April 2017 and May 2019 VA examinations, to include an X-ray performed in connection with the latter examination, found no diagnosis of a right ankle disorder, to include osteoarthritis, and no functional impairment associated with the Veteran's reported symptoms of pain and instability. However, in the February 2021 JMPR, the parties noted that the May 2019 VA examination, and associated X-rays, was performed on the left ankle, not the right ankle. Thus, the Court concluded that the Board's decision was based on an inaccurate factual premise and, consequently, the Board did not provide an adequate statement or reasons or bases for its decision. Accordingly, in light of the notation of osteoarthritis in the right ankle in the Veteran's medical history in contemporaneous treatment records and his reports of current right ankle symptomatology, the Board finds that a remand is necessary in order to afford the Veteran a VA examination to determine the nature and etiology of his claimed right ankle disorder. The matter is REMANDED for the following action: Afford the Veteran an appropriate VA examination so as to determine the nature and etiology of his claimed right ankle disorder. The record, to include a copy of this Remand, must be made available to the examiner, and all indicated tests, to include X-rays, should be conducted. Thereafter, the examiner should address the following inquiries: (A) Identify all current right ankle disorders that have been present at any time proximate to the Veteran's June 2016 claim, even if such is asymptomatic or has since resolved. In offering such opinion, the examiner should confirm whether the Veteran has a diagnosis of osteoarthritis of the right ankle as noted in his medical history in his treatment records. If the examiner finds that the Veteran does not have a current diagnosed disorder of the right ankle, he or she should offer an opinion as to whether his reported symptomatology of pain and instability results in functional impairment of earning capacity. If so, the examiner should accept that the Veteran has a current disability for VA purposes. (B) For each diagnosed right ankle disability, offer an opinion as to whether it is at least as likely as not (i.e., a 50 percent or greater probability) that such disorder had its onset in, or is otherwise related to, the Veteran's military service, to include the right ankle sprains documented in the April 1976 and January 1985 STRs, which required a cast of the right ankle. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Waite 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.