Citation Nr: 21005310 Decision Date: 02/01/21 Archive Date: 02/01/21 DOCKET NO. 10-29 588 DATE: February 1, 2021 REMANDED Entitlement to service connection for a left ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 2006 to March 2009, with additional service in the Air National Guard and Army Reserves. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2009 rating decision. The Veteran testified before the undersigned during a March 2017 hearing. This matter was most recently before the Board in August 2020, when it was remanded for additional development. In an October 2020 medical opinion obtained in response to the Board’s remand directives, a VA examiner opined that the Veteran’s current left ankle disability, which had been diagnosed as a lateral collateral ligament sprain in an earlier December 2017 VA examination, was not at least as likely as not related to an ankle injury sustained while in service. As noted in the most recent remand, attempts to contact the Veteran to schedule a new examination in recent years have failed, so the October 2020 examiner provided this opinion based on a review of the Veteran’s records. In providing this opinion, the examiner stated that the Veteran suffered a documented inversion injury in February 2008 during active service; however, the current lateral collateral ligament sprain would be the result of eversion injury, implying a separate injury. The examiner also notes that a medical board exam prior to discharge noted a mild ankle sprain in February 2008, and a VA compensation and pension (C&P) examination from 2008 found no residuals from the in-service ankle sprain. For these reasons, the examiner regarded the in-service injury as acute and self-limited. On review of the cited medical evidence, the Board notes that the December 2008 C&P examination cited by the examiner notes a later September 2008 twisting injury of the ankle, after which the Veteran used crutches for two weeks and continued to feel pain during cold weather. Though no pain was noted on examination and x-rays conducted at that time were unremarkable, the examiner diagnosed the Veteran with chronic left ankle strain. This finding does not appear consistent with the October 2020 examiner’s description of the findings of this 2008 C&P examination report, and a September 2008 injury is not discussed at all in the October 2020 medical opinion. Furthermore, the October 2020 examiner failed to address any lay statements provided by the Veteran in the course of this appeal, including his testimony before the Board from March 2017. In this testimony, the Veteran stated that he first injured his ankle around 2005 or 2006 during training, and he has continued to have pain in the ankle in cold weather or with prolonged use since leaving active service. VA has a duty to ensure any medical examination or opinion it provides is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (overruled on other grounds, Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). A medical opinion is adequate where it is based upon consideration of the full medical history and describes a disability in sufficient detail so that the Board’s evaluation will be fully informed. Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). As the October 2020 examiner failed to address the Veteran’s complete medical history, including lay statements and the complete findings noted in the medical reports cited in the provided rationale, the Board finds his opinion is inadequate. Therefore, a remand is necessary to obtain a new medical opinion. The matters are REMANDED for the following action: Obtain a new medical opinion regarding the nature and etiology of any left ankle disability. The Veteran should only be scheduled for a new examination if deemed necessary by the selected examiner. If the selected examiner determines that a new examination is necessary and the Veteran fails to report for the scheduled examination, the examiner should provide an explanation for why the requested opinion cannot be provided without a new examination. The examiner must opine whether any current left ankle disability is at least as likely as not related to an in-service injury, event, or disease, including the Veteran’s documented in-service ankle injuries and complaints of chronic left ankle pain since service. The examiner is advised that the Veteran is competent to report his symptoms and history, to include through statements submitted to VA, made in the course of treatment, or in his testimony before the Board. Such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran’s reports, he or she must provide a reason for doing so. The fact that his report of symptoms is not corroborated by contemporaneous medical treatment records is not, by itself, a sufficient reason to reject the Veteran’s report of symptoms capable of lay observation. The examiner is further advised that it is not necessary for pain to be attributable to a specific diagnosis or pathology to be considered a service-connected disability so long as the pain is productive of functional impairment. The examiner’s report must include a complete rationale for the opinion provided. M. HYLAND Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D. Pitman, 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.