Citation Nr: 21071514 Decision Date: 11/30/21 Archive Date: 11/30/21 DOCKET NO. 14-31 475A DATE: November 30, 2021 REMAND Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran had active military service from August 1975 to December 1985. In October 2018 and February 2021, the Board remanded the appeal for further development. 1. Entitlement to service connection for a left ankle disability. The Veteran contends that his currently diagnosed residuals of left ankle fracture and osteoarthritis are related to his documented in-service ankle sprains. He specifically contends that he has manifested a chronic left ankle disability since service which made him more susceptible to a severe left ankle injury in 2010. The Veteran's service treatment records (STRs) note a 1977 left ankle injury and a 1981 left ankle injury, and a four left ankle sprains. In periodic physical examinations between 1978 and 1985, the Veteran noted broken bones but denied recurrent left ankle pain or problems and the examining physician noted that normal findings for his ankle. In a September 1985 separation examination, the Veteran again denied recurrent left ankle pain and the examining physician noted that normal findings for his left ankle. VA treatment records show the Veteran was not diagnosed with a left ankle disability until February 2011, over a decade after his separation from service. In October 2019, the Veteran was afforded a VA examination to determine the etiology of his current left ankle condition. The examiner diagnosed the Veteran with traumatic arthritis of the left ankle. The VA examiner opined that the Veteran's left ankle condition is not at least as likely as not related to an in-service injury, event, or disease, including his in-service left ankle sprains. The rationale was that the in-service injuries were acute temporary conditions which resolved with treatment. Also, the examiner noted that there were no residuals of the injuries, or further complaints or treatment, per the Veteran's STRs. The examiner noted a normal x-ray of the left ankle in 1995. The examiner further detailed that the Veteran worked a post-service job which was physically demanding, and that he had a significant left ankle injury due to a fall in 2010 and was diagnosed with a comminuted distal tibia fracture with follow-on pilon fracture surgery. The examiner noted that pilon fractures "may be difficult to fixate and are historically associated with high rates of complications and poor outcomes." Ultimately, the examiner did not find an etiological relationship between the currently diagnosed left ankle disability and his in-service left ankle injuries. However, the VA examiner did not explain the abnormal x-ray examinations in service which included a May 1982 radiologist interpretation of a small 1-2 mm fragment of bone inferior to the medial malleolus which may have been old and of no clinical significance as well as a June 1982 radiologist interpretation that there was slight spurring along the superior aspect of the talus. The examiner also did not explicitly address the remand question of whether there is any medical reason to accept or reject the Veteran's contention that his left ankle fracture is due to the cumulative effects of multiple ankle strains during service. As such, the Board found this examination inadequate and remanded for another VA examination and etiological opinion. The Board also affords this examination minimal probative value. In May 2021, the Veteran was afforded another VA examination to determine the etiology of his current left ankle condition. The examiner explained that bone spurs were smooth, hard bumps of extra bone that formed on ends of bones which may or may not cause pain with the most common cause being joint damage from osteoarthritis (OA), injury or overuse of a joint. The examiner found no chronic left ankle disability occurring during service but did not explain whether the bone spurs were in fact evidence of a chronic disability or a chronic underlying joint injury. This examination report must be returned for an addendum. 2. Entitlement to service connection for a low back disability. The Veteran contends that his currently diagnosed lumbar disc disease is related to his documented in-service low back strain, and that he has experienced chronic low back pain since service. Alternatively, the Veteran claims that his low back disability is caused or aggravated by service-connected bilateral knee disability. In May 2021, the Veteran was afforded a VA examination to determine, in part, whether a low back disability was caused or aggravated by service-connected bilateral knee disability. The examiner asserted that conditions of the low back and "SC Disabilities" are not medically related and that medical literature failed to demonstrate a causal relationship, and that the current low back disability was due to an acute lifting injury after service. This opinion did not explain prior examiner opinions in 1999 and 2004 that the Veteran had chondromalacia patella which caused arthritis symptoms in his lower back. This examination report must be returned for an addendum. Accordingly, the matters are REMANDED for the following: 1. Associate with the claims folder updated VA treatment records. 2. Obtain and addendum opinion from an orthopedic physician to determine whether the Veteran has manifested a chronic left ankle disability since service. The examiner is asked to determine whether it is at least as likely as not (50 percent or greater probability) that the Veteran has manifested a chronic left ankle disability since service, or that any current left ankle disability is related to service. The examiner is requested to explain whether there is any medical reason to accept or reject the Veteran's contentions that his experiencing chronic left ankle since separation did not represent the onset of a chronic orthopedic disability and whether there is any medical reason to accept or reject the contention that his left ankle fracture in 2010 is due to the cumulative effects of multiple ankle strains during service. The examiner should specifically discuss the radiologist interpretation of x-ray abnormalities in service which included a May 1982 radiologist interpretation of a small 1-2 mm fragment of bone inferior to the medial malleolus which may have been old and of no clinical significance as well as a June 1982 radiologist interpretation that there was slight spurring along the superior aspect of the talus in connection with a December 1996 VA examination report x-ray (noting minimal spurring at the medial talus at the tibiotalar joint and minimal enthesophyte formation at the dorsal aspect of the talus) prior to the 2010 left ankle injury), and explain why or why not these x-ray abnormalities demonstrated evidence of a chronic left ankle disorder. 3. Obtain and addendum opinion from an orthopedic physician to determine whether the Veteran's current low back disability a) first manifested in service, b) is related to service or c) is caused by service-connected disability OR d) that the Veteran's service-connected disabilities result in any additional functional impairment associated with his low back disability (e.g., a medically discernible increase in motion loss, functional use, etc., above the degree associated with that expected from baseline level of disability). In providing this opinion, the examiner should consider the Veteran's treatment for low back problems in January 1993 as well as September 1999 and October 2004 medical statements that the Veteran has chondromalacia patella which causes arthritis symptoms in his lower back and knees. See Medical Treatment Record Government Facility received June 22, 2011. The examiner is requested to discuss the reasons for agreement or disagreement with the September 1999 and October 2004 medical statements. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Michael J. O'Connor, 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.