Citation Nr: A21018480 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 211008-190597 DATE: November 18, 2021 ORDER Entitlement to service connection for a left ankle condition is granted. FINDING OF FACT The Veteran's currently diagnosed left ankle condition is related to an in-service ankle injury. CONCLUSION OF LAW The criteria for establishing entitlement to service connection for a left ankle condition have been met. 38 U.S.C. §§ 1110, 1131, 5103(a), 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1963 to August 1966. In an August 2021 rating decision, the Agency of Original Jurisdiction (AOJ) denied entitlement to service connection for a left ankle condition. The Veteran timely appealed this rating decision to the Board of Veterans' Appeals (Board) and requested direct review of the evidence considered by the AOJ. See October 2021 VA Form 10182. Entitlement to Service Connection for a Left Ankle Condition Is Granted The Veteran contends that service connection is warranted for a left ankle condition. Specifically, he asserts that he injured his ankle in service and that he has continued to experience ankle problems since service. The AOJ found that the Veteran had a current diagnosis of lateral collateral ligament sprain. Legal Criteria 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). Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F. 3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table); 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after the military discharge, when all the evidence, including that pertinent to the period of military service, establishes that the disease was incurred during the active military service. 38 U.S.C. § 1113 (b); 38 C.F.R. § 3.303 (d). A lay witness is competent to testify as to the occurrence of an in-service injury or incident where such issue is factual in nature. Grottveit v. Brown, 5 Vet. App. 91, 93 (1993). Additionally, where symptoms are capable of lay observation, a lay witness is competent to testify to a lack of symptoms prior to service, continuity of symptoms after in-service injury or disease, and receipt of medical treatment for such symptoms. Charles v. Principi, 16 Vet. App 370, 374 (2002). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the Veteran. Facts and Analysis In the present case, the Veteran has a current diagnosis of lateral collateral ligament sprain and tibiotalar joint degenerative changes of the left ankle. See August 2021 VA Examination Report; May 2021 Private Treatment Record. Thus, the Veteran has satisfied the first Shedden requirement of a current disability. Additionally, the Board finds that the second Shedden element, in-service incurrence of an injury, is also satisfied. The Board notes that the Veteran's service treatment records are unavailable. The Veteran reported that he sprained his ankle after jumping into a ditch during basic training. He further reported that his drill sergeant told him to tightly tie his boot laces and continue training and that he did not seek further treatment during service because he did not want to have to start basic training again. He also reported that he has continued to experience ankle dislocations. See October 2016 Correspondence. The Veteran also submitted an October 2016 statement from a fellow soldier, who confirmed that he was with the Veteran when he injured his left ankle in basic training and that he witnessed the Veteran's left ankle "going out" after the initial injury. Although there are no service treatment records available, the Veteran is competent to report his experiences during service, to include injuring his ankle. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Moreover, the Board finds these reports to be credible and consistent with the Veteran's service, and they are further supported by the statement of the Veteran's friend. See 38 U.S.C. § 1154 (a). Thus, there is evidence of an event, injury, or disease in service. Accordingly, the issue turns upon whether there is evidence of a nexus between the in-service injuries and the present disability. In a May 2021, the Veteran's primary care physician, Dr. J.L.S., opined that the Veteran's left ankle condition was "more likely to have originally occurred during the [Veteran's] miliary service." Dr. J.L.S. indicated that she reviewed the Veteran's medical records and that she had been treating the Veteran for two years. She noted the Veteran's reports of injuring his left ankle during training and experiencing symptoms of pain and dislocations since his injury. She also noted that x-rays of the Veteran's left ankle showed severe degenerative changes at the tibiotalar joint, which she indicated "is consistent with the described mechanism of injury." The Veteran was afforded a VA examination in August 2021. The examiner diagnosed the Veteran with chronic/recurrent lateral collateral ligament sprain and opined that it was at least as likely as not related to service. The examiner noted that degenerative changes can be part of the natural aging process; however, the examiner indicated that the Veteran does not have similar findings of the right ankle. Thus, the examiner concluded that the Veteran's current left ankle condition is due to his in-service ankle injury. There are no contrary opinions of record, nor is there sufficient basis for the Board to reject these supportive opinions and to further develop the claim. Cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003) (holding that, because it is not permissible for VA to undertake additional development to obtain evidence against an appellant's case, VA must provide an adequate statement of reasons or bases for its decision to pursue such development where such development could be reasonably construed as obtaining additional evidence for that purpose). CONTINUED ON NEXT PAGE Based on the evidence above, and resolving all reasonable doubt in the Veteran's favor, the Veteran has a current diagnosis of a left ankle condition, an in-service left ankle injury, and two medical opinions linking the current diagnosis to the in-service injury. Therefore, the Board finds that service connection for a left ankle condition is warranted. 38 U.S.C. 5107; 38 C.F.R. 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54 (1990). B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Kipper, 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.