Citation Nr: 21069745 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 17-44 097 DATE: November 19, 2021 ORDER Service connection for residuals of left ankle strain is granted. FINDING OF FACT The Veteran sustained a left ankle strain in service; it is at least as likely as not that the strain has resulted in a current disability manifested by residuals of pain and functional impairment of the left ankle. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for an award service connection for residuals of left ankle strain have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from April 2010 to May 2011 and from November 2012 to November 2013, to include service in Afghanistan from May 2010 to April 2011. She also had service in the United States Army Reserve, to include a period of active duty for training from August 2007 to July 2009. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a January 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in North Little Rock, Arkansas. This appeal was previously before the Board in March 2019, when it was remanded for additional development. Pursuant to the remand directives, among other things, the RO was to afford the Veteran an opportunity to report for a VA examination given that she had moved and was unable to attend a previously scheduled examination. Unfortunately, notice of the new examination was not mailed to the Veteran's then-current address. As the Board is granting the appeal, however, there is no risk of prejudice in proceeding with adjudication at present. Service connection for residuals of left ankle strain is granted. The Veteran seeks to establish service connection for residual impairment of her left ankle that resulted from an in-service injury during basic training in 2007. See August 2017 VA Form 9 (explaining that her left ankle strain "was a chronic condition while on active duty. When I first injured my ankle, it was a severe condition. . .. It wasn't until I left the military that I started to get proper care."). Service connection is warranted where the evidence of record establishes that a particular injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Generally, in order to prove service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). The term "disability" as used for VA purposes contemplates functional impairment resulting in loss of earning capacity. See 38 C.F.R. § 4.1; Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). 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; 38 C.F.R. § 3.102. See also Gilbert v. Derwinski, 1 Vet. App. 49 (1990). In the present case, the Board finds that the evidence supports the Veteran's claim. The record clearly reflects that she sustained a left ankle sprain, rule out ankle fracture, during basic training in September 2007. Notably, after X-rays, the clinician noted "I think there might be a cortical defect lat[eral] fib[ula] 10 mm above tolar dome" and assessed "ankle sprain: left: poss[ible] dist[al] fib[ula] f[racture]." At that time, the Veteran was given a profile that modified her military duties. See September 2007 service treatment report. Following a second set of X-rays in late September, the clinician noted that the ankle still demonstrated mild edema and minimal tenderness and felt much better in a "cam walker." In reviewing the most recent X-ray results, the clinician remarked "still no cl[ea]r changes, but!" and assessed "ankle sprain: left dist[al] fib[ula] pain: resolving." Significantly, the evidence also demonstrates that Veteran's left ankle problems continued throughout service. Just prior to the end of her first period of active duty for training, in June 2009, she reported that "she hurt her left ankle while in Basic Training and . . . when she tries to run her ankle hurts a little but it is very difficult to run[] and she has been limping a lot." She also stated that she took "Tylenol for pain [and] is on a no-running profile for the military." See June 2009 service treatment report. Indeed, she was assessed with "Chronic L[eft] ankle pain by h[istory]" and was issued a permanent profile expressly due to, in part, "left ankle pain." See November 2009 Physical Profile. Thereafter, in a November 2010 service treatment record, during a period of active duty, she reported "chronic left ankle pain . . . she relates an injury that occur[r]ed while in basic training back in 2007 and that she was told she broke her ankle. She reports pain since . . . [and] admits to recent episodes of 'instability' - turning her ankle walking." Notably, the clinician at that time assessed "tendonitis personal left," referred her for physical therapy, and commented that "[s]he may have a chronic CFL [calcaneofibular ligament] sprain." She also reported in her post-deployment questionnaire of April 2011 that she was on a profile for her lower extremity, which she said worsened during deployment. See April 2011 service treatment report. The comments note "Hx of stress f[racture], shin splint and ankle sprain 200[]7-08 got worse. Has L2 profile. Wants to see VA," and the Veteran indicated that she had health concerns related specifically to her "foot and ankle." Id. Following her discharge from active duty, the Veteran again sought treatment for continuing complaints related to her left ankle. See, e.g., December 2014 VA treatment report ("L[eft] ankle pain with walking since [m]ilitary in 2008"); August 2015 reserve service periodic health assessment (noting "Permanent profile for her left ankle due to f[racture] 11/2007 without surgery" and checking the box for chronic pain/ankle pain . . . [status post] f[racture] ankle. Permanent profile. No rehab. Uses motrin."); April 2016 VA treatment report ("has some chronic left ankle pain with an occasional exacerbation"); June 2016 VA treatment report ("Had an ankle sprain and fracture on the left ankle when she fell into a hole while marching. This was 2007. She was on crutches and in a boot; she was told to manage it conservatively without surgery. She is in the reserves and [has] flares up the pain; she does not run. Since the initial injury, pain comes and goes."). Even though the Veteran has not had an opportunity to be examined by VA during the course of the appeal, the Board finds that there is competent evidence demonstrating that she experiences functional impairment of the left ankle so as to establish that she has a current disability of the left ankle. Specifically, at the time of the Veteran's VA initial physical therapy assessment for the left ankle in June 2016, it was noted that she experienced "functional impairments" of "walking; difficulty walking in heals; feels she changes her walking pattern based on how her ankle feels[;] running [] makes pain worse[;] jumping [] makes pain worse." See June 2016 VA treatment report. Importantly, the examining clinician noted that the goal was to "improve strength in the left ankle" and stated that her lower extremity functional scale was at "56/80." Id. It was further assessed that the Veteran "presents to clinic with signs and symptoms consistent with lateral ankle pain due to instability and weakness" and that she would "benefit from skilled P[hysical] T[herapy] intervention to improve above mentioned deficits, increase knowledge for self management of condition all to allow improved functional mobility and increased A[ctivities of[ D[aily] L[iving] tolerance." Id. Thus, even in the absence of a VA examination setting out a current diagnosis, this evidence sufficiently establishes that the Veteran has a current disability of the left ankle manifested by pain and other symptoms constituting functional loss. Given the documented in-service injury, evidence of chronic residuals such as pain since service and continuing thereafter, and VA treatment records identifying current functional impairment of the left ankle, the Board is persuaded that the criteria for an award of service connection have been met. The evidence, at a minimum, gives rise to a reasonable doubt on the matter. 38 C.F.R. § 3.102. The appeal is granted. DAVID A. BRENNINGMEYER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Gielow, 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.