Citation Nr: 21072305
Decision Date: 12/02/21	Archive Date: 12/02/21

DOCKET NO. 13-26 805
DATE: December 2, 2021

ORDER

Entitlement to service connection for left ankle arthritis is granted.

FINDING OF FACT

The evidence is at least in equipoise that the Veteran's current left ankle arthritis is directly related to his in-service left ankle injury.

CONCLUSION OF LAW

The criteria for service connection for left ankle arthritis have been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a).

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from June 1964 to May 1967 and from August 1970 to February 1977.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Following appeal of a December 2019 Board decision denying the claim, the U.S. Court of Appeals for Veterans Claims issued a February 2021 order granting a joint motion for partial remand and directing for a new Board decision in compliance with the terms of the motion. 

The Board now adjudicates the Veteran's claim for service connection for a left ankle condition. 

Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires evidence of (1) a current disability, (2) an in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the claimed in-service event, injury, or disease and the present injury or disease. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 

The evidence reflects that the Veteran is currently diagnosed with posttraumatic degenerative arthritis with spur in the left ankle. The Veteran contends that the condition is due to an injury sustained in Vietnam in February or March 1971 when, during a softball match, a loud explosion was heard which they believed to be an enemy attack, and as the Veteran ran for cover he stumbled on a depression in the road. He felt and heard a popping sensation in his left ankle, which rapidly became painful and swollen. 

A March 1971 service treatment record showed that the Veteran sustained an injury to his left ankle during the softball game and that the ankle was swollen. X-rays showed no fracture, and a diagnosis of a severe sprain was given. The Veteran notes that his clinicians told him that he was "going to wish it was broke[n] because... it's really bad."

The service treatment note also indicated that the Veteran could not be casted because he was going on leave; however, the Veteran related that once he returned to the States, he received further treatment at Brunswick Naval Air Station where they did apply a soft cast, gave him a brace, and directed him to stay on crutches, which he used for the entirety of his time on leave.

When the Veteran returned from leave, he worked in his occupational specialty as a Special Offset Pressman, which he stated could accommodate the ankle symptoms he was still experiencing after the injury. Military personnel records confirm that he was later reassigned to a specialty as light weapons infantry, which the Veteran stated was "more rigorous" and demanded "more time spent on his feet, carrying heavy equipment, with little opportunity for rest or elevation of his ankle." He related that while he applied for reassignment his application was rejected, and no longer being able to tolerate the demands of the new occupational specialty, he left active duty in 1977.

The Veteran has stated that ever since the ankle injury, he has had pain and a slight limp, both of which have worsened over the years. Though the left ankle bothered him through his post-service career, his other life priorities including taking care of his wife and daughters led him to "just bit[e] the bullet . . . and put up with it." The Veteran's wife and mother-in-law have submitted statements that the Veteran's ankle has bothered him ever since he hurt it in Vietnam.

Regarding a medical link between the Veteran's currently diagnosed arthritis and the in-service injury, there are several opinions of record.

Following a C&P examination in July 2013, the clinician opined that though the service treatment records confirmed the Veteran sustained the ankle sprain in 1971, because the Veteran did not report any problems at his 1976 separation examination or 1978 Reserve enlistment examination, and as the first objective treatment records were from 2008, "[t]he ankle sprain in 1971 was an acute condition," "chronicity cannot be established," and "his current [arthritis] of the left ankle is more than likely developmental."

Another C&P examination was provided in March 2019. Observing that the service treatment records did not note "any ecchymosis [or] problems with ambulation, [weightbearing], or significant loss of function or motion," the examiner concluded that the in-service sprain was "a grade 2 sprain and not a grade 3 sprain." The examiner asserted that "according to medical literature . . . a grade 2 sprain . . . heals well over a period of time and does not result in arthritis." Combined with the finding of no problems in the ankle at separation and the absence of objective medical records from the years immediately post service, the March 2019 clinician opined that the condition was less likely due to service and more likely due to another cause.  

Following the order granting the joint motion for partial remand, in October 2021 Dr. C.P.C. prepared an opinion letter after interview with the Veteran and thorough review of the Veteran's service and post-service medical history. Citing an article from the Journal of Orthopedic Research finding "the majority (as high as 95%) of severe ankle sprains result in OCLs [Osteo-Chondral Lesions] and over half of patients with OCLs develop [arthritis]" and the American Academy of Orthopedic Surgeons website's statement that "posttraumatic arthritis . . . can develop many years after the initial injury," Dr. P.C.P. concluded that the Veteran's current left ankle condition is at least as likely as not a direct result of the severe sprain injury during service.

Based on all the evidence, the Board finds that the evidence is at least in equipoise that the Veteran's current left ankle arthritis is related to his in-service injury. 

Though the negative etiology opinions from the July 2013 and March 2019 examiners are acknowledged, both opinions did not discuss or otherwise note that they were aware of the Veteran's continuing pain and limping since the service injury, as competently reported by the Veteran and his wife and mother-in-law. Additionally, the March 2019 clinician reasoned that there were not objective medical records for years after service to substantiate that the Veteran had continuing symptoms, but the clinician did not appear to take into consideration the Veteran's statement that he did not seek medical treatment in the intervening years because he simply dealt with the pain in order to keep supporting his family. Moreover, the March 2019 clinician appeared to downplay the findings of the March 1971 service treatment note, remarking that it did not note "any ecchymosis [or] problems with ambulation[, weightbearing,] or significant loss of function or motion." But the March 1971 record noted swelling at that time and an apparent indication for a cast, and the Veteran has competently testified that he subsequently was casted and on crutches for approximately a month, with a limp continuing ever since that time. Thus, because both the July 2013 and March 2019 opinions do not appear to have fully considered all the competent evidence relevant to the etiology inquiry, the opinions are of lesser probative value.

In contrast, the October 2021 opinion from Dr. C.P.C. thoroughly reviewed all of the relevant information reported by the Veteran about the injury, the treatment immediately thereafter, and his continuing symptoms through the years. Moreover, Dr. C.P.C.'s opinion cited medical sources supporting that posttraumatic arthritis can be directly related to injuries many years prior, and found that in this case the Veteran's current arthritis is at least as likely as not related to the in-service injury. The Board finds that this opinion is of high probative value.

Accordingly, the evidence is found to be at least in equipoise that there is a direct connection between the Veteran's current left ankle arthritis and his in-service injury, and where the evidence is in relative equipoise the claimant prevails. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 

In turn, with evidence of a current disability related to an in-service injury, the claim for service connection for a left ankle is granted. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a).

 

 

K. Parakkal

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M. Davis, Associate 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.