Citation Nr: 21065694 Decision Date: 10/27/21 Archive Date: 10/27/21 DOCKET NO. 18-38 898 DATE: October 27, 2021 REMANDED Service connection for a left ankle disability, to include as secondary to service-connected right ankle sprain with pain on motion, is remanded. REASONS FOR REMAND The Veteran had active service from November 1990 to November 1994. He contends that his left ankle disability is secondary to his service-connected chronic right ankle sprain with pain on motion. The record has also raised a theory of direct service connection. By way of history, the Board denied service connection for a left ankle disability in a June 2019 decision. The Veteran appealed, and the Court of Appeals for Veterans Claims (Court), in May 2020, issued an Order granting a Joint Motion for Remand (JMR). The parties to the JMR agreed that the Board erred in relying on an August 2017 VA medical opinion because it contained an inadequate rationale as to whether the left ankle disability was proximately caused or aggravated by the Veteran's service-connected right ankle disability. In addition, the parties agreed that the Board erred in denying the Veteran's claim on a direct basis, given notations on his August 1994 military separation examination that he experienced bilateral ankle and foot trouble. Accordingly, new opinions were obtained in May 2021. Opining as to direct service connection, the VA clinician stated that the left ankle disability was less likely than not related to service with the rationale that despite notations of ankle complaints upon separation from service, there was a 12-year gap between separation and the first documented left ankle treatment in 2006, when the Veteran sustained a fracture to his left ankle. Given the gap in treatment, the examiner stated that "longitudinal evidence" was not seen, and chronicity was "not substantiated." Rather, the examiner concluded that the current left ankle symptoms were the result of the post-service 2006 left ankle fracture and unrelated to any ankle issues in service. Opining as to secondary service connection, the examiner concluded that a thorough review of medical literature failed to show a causal relationship between the Veteran's current left ankle disabilitystatus post left medial malleolar fracture open reduction and internal fixation (ORIF)and his service-connected right ankle sprain. The examiner reasoned that it was not unusual for two joints to share properties, but that one joint's disease did not spread to another or cause damage to it. Thus, the examiner stated that he believed the current left ankle disability was due to repetitive use and naturally age-related changes, and not to the right ankle disability. The Board initially notes that there appears to be an internal inconsistency in the opinions. In the opinion pertaining to direct service connection, the examiner stated that the Veteran's left ankle disability was related to a post-service 2006 left ankle fracture, and in the opinion pertaining to secondary service connection, the examiner concluded that the left ankle disability was due to repetitive use and naturally age-related changes. The May 2021 VA examiner also did not adequately explain, from a medical standpoint, why a 12-year gap between separation from service and the first documented treatment of left ankle treatment in 2006 is relevant to the overall question of whether the Veteran's left ankle disability is related to service. Stated another way, the examiner did not explain why the documented ankle issues at separation from service did not represent initial manifestations of his subsequent left ankle issues, and whether the 2006 left ankle sprain worsened a left ankle disability that was already present. Finally, the Board finds that the examiner's nexus, like the August 2017 opinion, lacks well-reasoned medical explanations. The examiner provided nearly no rationale on the question of whether the service-connected right ankle disability aggravated the left ankle condition. For all these reasons, additional opinions are necessary. The matter is REMANDED for the following action: 1. Obtain a medical opinion from an examiner other than the one who provided the May 2021 opinion, addressing the etiology of the Veteran's diagnosed left ankle disability. The selected examiner must review the entire claims file, and then address the following: (a.) Is it at least as likely as not (approximately 50 percent probability) that the Veteran's left ankle disability had onset during the Veteran's period of active service? In providing a response, the examiner must address the reports of "tender bilateral ankle joint" and "foot trouble" acknowledged at the Veteran's August 1994 military separation examination. If the examiner bases any portion of the opinion on a gap in medical treatment, the examiner must explain why or how that gap informs his or her opinion. (b.) Alternatively, is it at least as likely as not (approximately 50 percent probability) that the Veteran's left ankle disability has been caused or aggravated by the Veteran's service-connected right ankle disability? The examiner is advised that causation and aggravation are separate inquiries, and both must be answered. In providing any opinion, the examiner must consider all lay assertions, to include as to the nature, onset and continuity of symptoms. If there are medical reasons to either support or call into question the Veteran's assertions of experiencing left ankle symptoms since service, the examiner should so state, with supporting explanation. Thorough medical rationales must accompany all opinions offered. 2. Then, readjudicate the issue on appeal. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Polly Johnson, 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.