Citation Nr: 21072687 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 16-53 750A DATE: December 6, 2021 REMANDED Entitlement to service connection for a right ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty with the U.S. Army from June 2006 to April 2011. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). This appeal previously came before the Board in March 2019 and June 2021, at which time the issue currently before the Board was remanded for additional development. The case has now been returned to the Board for appellate review. 1. Entitlement to service connection for a right ankle disability In the most recent June 2021 Board remand, VA was directed to provide the Veteran with an addendum opinion to determine the nature and etiology of his right ankle disability. Review of the record shows that the directed opinion was obtained in June 2021. In that opinion, the VA examiner found that the Veteran does not have a current right ankle disability and does not have functional impairment in the right ankle. However, the examiner failed to address evidence showing chronic pain just before and just after separation, as well as evidence of a history of an ankle sprain as documented throughout the Veteran's post-service medical record. Perhaps most concerning to the Board is the 2021 addendum opinion's reliance upon a 2006 x-ray report, which the examiner used to conclude that the condition in question did not become chronic. However, the Veteran's in-service ankle injury occurred in 2009, three years after the x-ray report discussed by the examiner. Upon review, there is no evidence that the Veteran's ankle has been subject to imaging at any point during the appeal period. Further, while the Veteran has shown generally normal range of motion on examination, he has been found to have swelling, popping and stiffness in that ankle, and has complained of ongoing pain in that ankle from the time of his 2009 sprain. Given this evidence, and the fact that the addendum opinion relied upon evidence created prior to the injury in question to determine that no chronic disability exists, the Board would request a new examination which includes imaging of the ankle to determine if his ankle has manifestations of any disability such as arthritis. The matters are REMANDED for the following action: 1. Invite the Veteran to submit any additional evidence in support of his appeal. 2. Schedule the Veteran for a new VA examination in connection with his right ankle claim. The complete claims file should be made available to the examiner selected to conduct the examination. The examiner should conduct a thorough examination of the Veteran's right ankle, to include any and all necessary imaging. The examiner is then requested to state whether or not the Veteran has a presently diagnosed right ankle disability, which may account for his reported history of right ankle pain, as well as the documented swelling, popping, and stiffness noted in the prior examination report. If the examiner cannot provide a diagnosis to account for the Veteran's symptoms, a complete rationale should be included for that conclusion, as well as a discussion of whether or not those symptoms cause functional loss. For any and all diagnosed conditions, if found, the examiner is requested to state whether or not they had onset during active service, within one year of separation from active service, or are otherwise related to the Veteran's in-service ankle sprain and noted chronic ankle pain. A rationale for all opinions expressed should be provided. M. Pryce Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. Umez-Eronini, 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.