Citation Nr: A21020649 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 190527-32513 DATE: December 29, 2021 ORDER Service connection for a left ankle disability is granted. Service connection for a right ankle disability is granted. FINDINGS OF FACT 1. The Veteran's left ankle disability is proximately due to her service-connected pes planus. 2. The Veteran's right ankle disability is proximately due to her service-connected pes planus. CONCLUSIONS OF LAW 1. The criteria for service connection for a left ankle disability as secondary to service-connected pes planus are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for service connection for a right ankle disability as secondary to service-connected pes planus are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 2001 to February 2005, and from May 2010 to May 2011. In August 2018, the Veteran filed a Fully Developed Claim seeking service connection for her left ankle, and for her right ankle as secondary to her left. In September 2018, a rating decision was issued in the legacy system by a Department of Veteran Affairs (VA) Regional Office (RO) that denied service connection for the Veteran's left and right ankles. The Veteran timely submitted a notice of disagreement. In April 2019 the agency of original jurisdiction (AOJ) issued a statement of the case (SOC). In May 2019, the Veteran opted into the modernized review system, also known as the Appeals Modernization Act (AMA), by submitting Form 10182 Notice of Disagreement and selecting the Direct Review lane. Therefore, the April 2019 SOC is the decision on appeal, and the Board may only consider the evidence of record at the time the SOC was issued. 38 C.F.R. § 20.301. Service Connection To prevail on a direct service connection claim, there must be competent evidence of (1) a current disability, (2) in-service incurrence or aggravation of a disease or injury, and (3) a nexus between the in-service disease or injury and the current disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009); 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted on a secondary basis, for a disability that is proximately due to, or aggravated by, a service-connected disease or injury. 38 C.F.R. § 3.310. In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). 1. Entitlement to service connection for a left ankle disability. 1. Entitlement to service connection for a right ankle disability. The Veteran seeks service connection for both a left and right ankle disability. More specifically, in a statement received from the Veteran's representative in August 2018, the representative stated the Veteran was seen in-service on numerous occasions for her left ankle; that this disability has persisted since discharge; that she has continued care for her left ankle and is currently seen at the Dallas VAMC; and, that her right ankle is secondary to her left ankle due to overcompensation. As relevant to the discussion below, the Board notes the Veteran is already service connected for pes planus. Service treatment records are associated with the Veteran's claim file. The May 2001 entrance Report of Medical Examination reflects the Veteran had an abnormal foot exam with mild asymptomatic pes planus noted. The companion May 2001 entrance Report of Medical History reflects the Veteran specifically denied any foot trouble, impaired use of legs or feet, and swollen or painful joints. A September 2002 treatment record reflects a complaint of left ankle pain, off and on for 3 months, and noted that the Veteran was diagnosed with "chronic ankle pain secondary to flat feet." Another September 2002 treatment record reflects the Veteran was placed on light duty for a diagnosis of "ankle pain." A later September 2002 record reflects a continued complaint of ankle pain described as "sharp pain to left ankle that comes and goes," and that the examiner diagnosed the Veteran with "left ankle pain, may be secondary to pes planus." An October 2003 Report of Medical History reflects the Veteran indicated she had foot trouble and that she specifically noted "history of sprained ankle." VA treatment records from the Dallas VAMC are associated with the Veteran's claims file. In summary, these records reflect the Veteran complained of left and right ankle pain over the years since service. A February 2013 podiatry consult reflects a complaint of soreness on the plantar aspect of the arches of the feet as well as bilateral ankle pain. An August 2014 record reflects a complaint that her ankles still hurt and throb even at rest. A September 2014 record reflects a complaint of constant dull aching pain to the bilateral ankles that increased after long distance walking. X-rays showed bilateral pes planus. An October 2014 record reflects a complaint of chronic foot and ankle pain. A November 2015 record reflects the visit was for an initial evaluation for physical therapy of the ankles. It was noted the Veteran's chief complaint was bilateral pain, left more than right, for a few years. A January 2016 record reflects complaint of right foot soreness, even at the ankle. An April 2018 record reflects a consult for bilateral velcro ankle braces. Finally, a July 2018 record reflects the Veteran continued to have ankle issues and that the examiner noted instability and past lateral ankle ligament pathology. A VA examination was conducted in September 2018. The examiner opined that the Veteran's left and right ankle disabilities were less likely than not directly related to service or to the Veteran's service-connected migraines. In addition, the examiner opined that the Veteran's right ankle disability was less likely than not secondary to her left ankle disability. However, the examiner stated the claimed conditions are at least as likely as not proximately due to or the result of the Veteran's service-connected pes planus. As rationale, the examiner stated that pes planus can affect the alignment of the body when walking, standing, and running, and as a result can increase likelihood of pain and instability in the ankles. The Board notes that a second VA examination was obtained in April 2019 in which the examiner found the Veteran's ankle disabilities to be less likely than not related to her service-connected pes planus. However, by way of rationale, the examiner stated only that he "disagreed" with the prior opinion, as the September 2018 examiner's rationale was "not consistent with the objective medical record and reputable medical literature." No explanation was given as to why the positive opinion was inconsistent with the record or with relevant medical research or literature. As this rationale is insufficient and incomplete, the Board affords this examination little probative value. In light of the above, the Board finds that service connection for the Veteran's left and right ankle disability, as secondary to her service-connected pes planus, is appropriate. The Veteran has competently and credibly reported bilateral ankle pain both during and since service, and her contentions are supported by the weight of the competent and probative medical evidence of record. Service treatment records document complaints of ankle pain; VA treatment records since service document complaints of bilateral ankle pain and instability; and the Veteran has a current diagnosis of ankle instability in both ankles. The Board also notes that the Veteran's complaints and treatment of bilateral ankle pain has most often been associated with her diagnosed pes planus, for which she is already service-connected. Accordingly, the Board finds that reasonable doubt must be resolved in favor of the Veteran, and entitlement to service connection for a left and right ankle disability, secondary to her service-connected pes planus, is warranted. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The claims are granted. The nature and extent of the right and left ankle disabilities are not before the Board at this time. Caroline B. Fleming Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Jiggetts, Tenisha 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.