Citation Nr: 21006773 Decision Date: 02/05/21 Archive Date: 02/05/21 DOCKET NO. 14-31 475A DATE: February 5, 2021 REMAND Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran had active military service from August 1975 to December 1985. At the outset, the Board notes that this claim was originally denied in a May 1996 rating decision, which the Veteran did not appeal, and the decision became final. 38 C.F.R. §§ 3.104, 20.302, 20.1103. The claim was denied on the basis that the Veteran’s disability could not be related to military service due to him being assessed as normal at separation. Subsequent to that final decision, the Veteran testified at an April 2018 hearing discussing the chronicity of his disability and the symptoms he experienced since service. As this evidence was clearly new and material to the basis for the prior final denial, the Board reopened on that basis and reviewed the appeal on the merits. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. In October 2018, the Board remanded the appeal for further development. 1. Entitlement to service connection for a left ankle disability. The Veteran contends that his currently diagnosed residuals of left ankle fracture and osteoarthritis are related to his documented in-service ankle sprains. He specifically contends that he has manifested a chronic left ankle disability since service which made him more susceptible to a severe left ankle injury in 2010. Whenever VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The probative value of a medical opinion comes from its reasoning. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The “factually accurate, fully articulated, sound reasoning for the conclusion” contributes probative value to a medical opinion. Id. On the other hand, a medical opinion based on an inaccurate factual predicate has reduced probative value. Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). In October 2019, the Veteran was afforded a VA examination to determine the etiology of his current left ankle condition. The VA examiner opined that the Veteran’s left ankle condition is not at least as likely as not related to an in-service injury, event, or disease, including his in-service left ankle sprains. The rationale was that the in-service injuries were acute temporary conditions which resolved with treatment. Also, the examiner noted that there were no residuals of the injuries, or further complaints or treatment, per the Veteran’s service treatment records (STRs). The examiner noted a normal x-ray of the left ankle in 1995. The examiner further detailed that the Veteran worked a post-service job which was physically demanding, and that he had a significant left ankle injury due to a fall in 2010 and was diagnosed with a comminuted distal tibia fracture with follow-on pilon fracture surgery. The examiner noted that pilon fractures are “may be difficult to fixate and are historically associated with high rates of complications and poor outcomes.” Ultimately, the examiner did not find an etiological relationship between the currently diagnosed left ankle disability and his in-service left ankle injuries. However, the VA examiner did not explain the abnormal x-ray examinations in service which included a May 1982 radiologist interpretation of a small 1-2 mm fragment of bone inferior to the medial malleolus which may have been old and of no clinical significance as well as a June 1982 radiologist interpretation that there was slight spurring along the superior aspect of the talus. The examiner also did not explicitly address the remand question of whether there is any medical reason to accept or reject the Veteran’s contention that his left ankle fracture is due to the cumulative effects of multiple ankle strains during service. The Board requires an addendum opinion. 2. Entitlement to service connection for a low back disability. The Veteran contends that his currently diagnosed lumbar disc disease is related to his documented in-service low back strain, and that he has experienced chronic low back pain since service. The Veteran’s service treatment records (STRs) note an acute back strain in February 1978. In periodic physical examinations between 1978 and 1985, the Veteran denied recurrent back pain and the examining physician noted that normal findings for his back. In a September 1985 separation examination, the Veteran again denied recurrent back pain and the examining physician noted that normal findings for his back. In October 2019, the Veteran was afforded a VA examination to determine the etiology of his current low back condition. The VA examiner opined that the Veteran’s low back condition, diagnosed as lumbar disc disease, is not at least as likely as not related to an in-service injury, event, or disease, including his in-service low back strain. The rationale was that the in-service injury was an acute temporary condition which resolved with treatment. Also, the examiner noted that there were no residuals of the injury, or further complaints or treatment, per the Veteran’s STRs. The examiner further detailed that the Veteran worked a post-service job which was physically demanding, and that he had several back injuries, and was diagnosed with a lumbar disability beginning in November 1995. The examiner did not find an etiological relationship between the currently diagnosed lumbar disability and his in-service injury. However, the examiner did not discuss the significance, if any, of the in-service x-ray finding of scoliosis in November 1983 or the fact that the Veteran was treated for lumbar muscle strain as early as January 1993. The Board requires an addendum opinion. Accordingly, the matters are REMANDED for the following: 1. Associate with the claims folder updated VA treatment records. 2. Obtain and addendum opinion to determine whether the Veteran has manifested a chronic left ankle disability since service. The examiner is asked to determine whether it is at least as likely as not (50 percent or greater probability) that the Veteran has manifested a chronic left ankle disability since service, or that any current left ankle disability is related to service. The examiner is requested to explain whether there is any medical reason to accept or reject the Veteran’s contentions that his experiencing chronic left ankle since separation did not represent the onset of a chronic orthopedic disability and whether there is any medical reason to accept or reject the contention that his left ankle fracture 2010 is due to the cumulative effects of multiple ankle strains during service. The examiner should specifically discuss the radiologist interpretation of x-ray abnormalities in service which included a May 1982 radiologist interpretation of a small 1-2 mm fragment of bone inferior to the medial malleolus which may have been old and of no clinical significance as well as a June 1982 radiologist interpretation that there was slight spurring along the superior aspect of the talus in connection with a December 1996 VA examination report x-ray (noting minimal spurring at the medial talus at the tibiotalar joint and minimal enthesophyte formation at the dorsal aspect of the talus) prior to the 2010 left ankle injury), and explain why or why not these x-ray abnormalities demonstrated evidence of a chronic left ankle disorder. 3. Obtain and addendum opinion to determine whether the Veteran’s current low back disability a) first manifested in service, b) is related to service or c) is caused by service-connected disability OR d) that the Veteran’s service-connected disabilities result in any additional functional impairment associated with his low back disability (e.g., a medically discernible increase in motion loss, functional use, etc., above the degree associated with that expected from baseline level of disability). In providing this opinion, the examiner should consider the Veteran’s treatment for low back problems in January 1993 as well as an October 2004 medical statement that the Veteran has “chondromalacia patella which causes arthritis symptoms in his lower back and knees.” T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Michael J. O’Connor 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.