Citation Nr: 21072390 Decision Date: 12/03/21 Archive Date: 12/03/21 DOCKET NO. 17-65 948 DATE: December 3, 2021 REMANDED Entitlement to service connection for a right ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from September 2009 to September 2013. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office. In a June 2019 Board decision, the Board, in part, denied entitlement to service connection for a right ankle disability and abdominal pain. The Veteran appealed his denial to the United States Court of Appeals for Veterans Claims (Court). The Court issued a June 2020 decision to vacated and remand the issues back to the Board for re-adjudication. In March 2021, the Board remanded these issues to the agency of original jurisdiction (AOJ) for further development. Thereafter, in an October 2017 rating decision, the AOJ granted service connection for the Veteran's claimed abdominal pain disability (diagnosed as abdominal wall strain). This represents a full grant of benefits with regard to that claim. As such, the issue is no longer before the Board. See AB v. Brown, 6 Vet. App. 35 (1993). The Board finds that additional development is needed prior to final adjudication of the Veteran's appeal. The Veteran seeks service connection for a right ankle disability as due to service. He reported repeated right ankle sprains on active duty, and that his ankle has never felt stable since the first incident occurred while running in A school. See Veteran's June 2017 Lay Statement. He further revealed that the worst incident occurred while playing basketball, resulting in a high ankle sprain and his being on crutches for 2 weeks, and his right ankle has never been the same. Id. The Veteran's service treatment records (STRs) document the Veteran injured his right ankle while playing basketball. Radiology findings noted a prominent soft tissue injury without underlying fracture, and the treatment record indicated the Veteran was restricted to home on quarters for 48 hours. See October 15, 2012 STR. Of note, the Veteran's August 2013 separation examination indicated the Veteran had been treated in the emergency department, with the examiner noting the sprained ankle resolved with no complications. The Veteran underwent a contract VA examination for the ankle in September 2021. The examiner reviewed the evidentiary file and conducted an in-person examination. The examiner opined that the right ankle disability was less likely as not due to service, providing as rationale that there was no evidence for chronic right ankle pain in service to link the disability to service. However, the examiner failed to account for the Veteran's reported complaints of continued symptoms, to include chronic pain and easy sprains, since service. Also, the examiner failed to address a September 2021 radiology report taken in conjunction with the VA contracted examination, which revealed soft tissue calcifications superior to the calcaneus were most likely due to previous trauma. The Board finds the September 2021 opinion is inadequate; the examiner failed to account for the Veteran's statements regarding the onset, nature, frequency and duration of his right ankle pain, instead concluding that the Veteran's current knee pain was not related to service without further explanation, to include addressing the radiology report that related soft tissue calcifications to previous trauma. As such, remand is necessary to obtain a new medical opinion. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Obtain a medical opinion on the nature and etiology of the Veteran's right ankle sprain disability. The entire claims file, including a copy of this REMAND, must be made available to the examiner. The examiner must confirm the record review took place. If, and only if, the examiner deems necessary, the Veteran should be scheduled for examination; all evaluations, studies, and tests should be conducted. Then, the examiner should opine whether it is at least as likely as not (probability of 50 percent or greater) that the Veteran's right ankle disability had its onset during active service or is etiologically related to the Veteran's active duty service. The examiner is asked to specifically address the September 2021 radiology report that relates soft tissue calcifications were most likely due to previous trauma, as well as the Veteran's assertions of continued right ankle symptoms and instability since service. See Veteran's June 2017 Lay Statement; September 2021 contract VA ankle examination. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports and assertions must be specifically acknowledged and considered in formulating any opinions. The examiner must provide a complete rationale for any opinion provided. 2. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran and his representative should be furnished a supplemental statement of the case and be afforded the opportunity to respond. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Gipson, 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.