Citation Nr: 21007111 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 16-44 904 DATE: February 8, 2021 REMANDED Entitlement to service connection for a left ankle disorder is remanded. Entitlement to service connection for a right ankle disorder is remanded. Entitlement to service connection for a lumbar disorder is remanded. Entitlement to service connection for residuals of right thumb and little finger trauma is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1988 to September 2012. This matter comes before the Board of Veteran’s Appeals (Board) from an August 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously before the Board in November 2018 when the claims were remanded for VA examinations. The Board finds the November 2018 remand directives have been substantially complied with, and the matters are again before the Board. Stegall v. West, 11 Vet. App. 268, 271 (1998). 1. Entitlement to service connection for a left ankle disorder is remanded. 2. Entitlement to service connection for a right ankle disorder is remanded. The Veteran seeks service connection for a bilateral ankle condition. In favor of his claim, the Veteran asserts that he suffered multiple ankle strains in service but that he self-treated and did not seek medical treatment for them. See Ankle Conditions Disability Benefits Questionnaire (Ankle DBQ) of October 2019. In the Ankle DBQ of October 2019, the examiner noted a diagnosis of lateral collateral ligament ankle strain (chronic/recurrent) and opined that the Veteran’s bilateral ankle lateral collateral ligament strain (chronic/recurrent), which is a condition with a clear etiology and diagnosis, is less likely than not related to his service. In favor of his opinion the examiner noted the Veteran’s service treatment records and medical examinations during his service noted no ankle conditions and that the diagnosed disability of ankle sprain was caused by a direct mechanical injury and not related to a disability pattern related to any specific exposure in Southwest Asia. See Ankle DBQ of October 2019. The examination report also noted that no diagnostic testing was performed. Where VA provides the Veteran with an examination, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). A medical opinion based solely on the absence of documentation in the service treatment records or that fails to take into account lay statements is inadequate. See Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006) (VA examiner’s opinion inadequate that relied on the absence of contemporaneous medical evidence); see also Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007) (holding that an examination was inadequate where the examiner did not comment on the Veteran’s report of in-service injury but relied on the service medical records to provide a negative opinion). The Board finds this medical opinion inadequate for adjudication purposes as the examiner did not provide a complete rationale for the opinion expressed, did not consider the Veteran’s lay statement and heavily relied on the absence of contemporaneous medical evidence to support a negative nexus opinion. Accordingly, the Board finds the matter must be remanded for a new examination and medical opinion that addresses the Veteran’s lay statements. 3. Entitlement to service connection for a lumbar disorder is remanded. The Veteran seeks service connection for a lumbar disorder. In favor of his claim, the Veteran asserts that he injured his back aboard Navy ships, lifting avionics equipment, and with sea duty. He reported that he did not seek medical attention for his back while in service. See Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire (Back DBQ) of October 2019. In the Back DBQ of October 2019, the examiner noted a diagnosis of lumbosacral strain and opined that the claimed condition was less likely than not related to the Veteran’s service as the Veteran’s service treatment records do not document any lower back conditions or specific back injuries. The examiner also noted that the diagnosed condition of lumbosacral strain was caused by direct mechanical injuries and is not part of a disability pattern or related to some specific exposure event in Southwest Asia. See Back DBQ of October 2019. This Back DBQ indicates that no diagnostic testing was performed. The Board finds this medical opinion inadequate for adjudication purposes as the examiner did not provide a complete rationale for the opinion expressed, did not consider the Veteran’s lay statements and heavily relied on the absence of the contemporaneous medical evidence to support a negative nexus opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). Accordingly, the Board finds a remand is necessary to obtain a new examination and a new medical opinion that addresses the Veteran’s lay assertions. 4. Entitlement to service connection for residuals of right thumb and little finger trauma is remanded. The Veteran seeks service connection for residuals of right thumb and little finger trauma. In favor of his claim, the Veteran asserts that while in service he jammed his little finger and thumb in a door aboard a Navy ship. The Veteran reported that he developed swelling at the base of the right thumb and right little finger, which decreased over time. He also reported that he self-treated his injury and did not seek medical treatment. See Hand and Finger Conditions Disability Benefits Questionnaire (Hand DBQ) of October 2019. In the Hand DBQ of October 2019, the examiner noted diagnoses of right thumb MCP strain and right little finger MCP strain. Following the examination, the examiner opined that the Veteran’s diagnosed conditions were less likely than not related to his service. In favor of this opinion the examiner noted that the Veteran’s service treatment records did not contain treatment or diagnoses for a right hand condition. The examiner also noted that the Veteran’s strains were caused by a direct mechanical injury and are not part of a disability pattern related to some specific exposure event in Southwest Asia. See Hand DBQ of October 2019. The examination report notes that no diagnostic testing was performed. The Board finds this medical opinion inadequate for adjudication purposes as the examiner did not provide a complete rationale for the opinion expressed, did not consider the Veteran’s lay statements and heavily relied on the absence of the contemporaneous medical evidence to support a negative nexus opinion. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008); Buchanan v. Nicholson, 451 F. 3d 1331, 1336-37 (Fed. Cir. 2006); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2010); Dalton v. Nicholson, 21 Vet. App. 23, 39 (2007). Accordingly, the Board finds a remand is necessary to obtain a new examination and a new medical opinion that addresses the Veteran’s lay assertions. Additionally, the Board notes there is no indication in the electronic claims file that the Veteran has received any recent treatment for the disabilities being remanded. The RO is requested to contact the Veteran and request that he identify any outstanding medical records relevant to his claims. If he provides the necessary authorizations, the RO is then requested to undertake reasonable efforts to obtain the identified medical records. The matters are REMANDED for the following action: 1. Contact the Veteran and determine whether he has undergone VA treatment within the appellate period. If so, obtain these VA treatment records and associate them with the electronic claims file. If any requested records are not available, or the search for any such records otherwise yields negative results, that fact must clearly be documented in the claims file. Efforts to obtain these records must continue until it is determined that they do not exist or that further attempts to obtain them would be futile. The non-existence or unavailability of such records must be verified, and this should be documented for the record. Required notice must be provided to the Veteran and his representative. 2. Contact the Veteran and afford him the opportunity to identify by name, address and dates of treatment or examination any relevant private medical records regarding his claimed disabilities within the appellate period. Ask the Veteran to complete a VA Form 21-4142 for all private medical providers that he identifies. Make two requests for the authorized records from these medical providers unless it is clear after the first request that a second request would be futile. 3. After any additional records are associated with the claims file, schedule the Veteran for a new examination regarding his bilateral ankle disorder. The examiner is asked to opine: a. Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s bilateral ankle disorder had its onset in or is otherwise etiologically related to active duty service, to include his lay statements regarding multiple ankle strains in service. 4. Schedule the Veteran for a new examination regarding his lumbar disorder. The examiner is asked to opine: a. Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s lumbar disorder had its onset in or is otherwise etiologically related to active duty service, to include his lay statements regarding injuring his back aboard Navy ships, lifting avionics equipment, and with sea duty. 5. Schedule the Veteran for a new examination regarding his right thumb and little finger trauma. The examiner is asked to opine: a. Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s right thumb and little finger trauma had its onset in or is otherwise etiologically related to active duty service, to include his lay statements regarding jamming his little finger and thumb in a door aboard a Navy ship. The examiner is asked to provide a complete rationale for all opinions expressed. If the examiner cannot provide the requested opinion(s) without resorting to speculation, the report should expressly indicate this, and the examiner should explain why an opinion cannot be provided without resorting to speculation. If the inability to provide an opinion is the result of a need for additional information, the physician must identify the additional information needed. Any clinically indicated diagnostic testing should be performed. 6. After completing the above requested actions, and any additional notification and/or development deemed warranted, readjudicate the issue on appeal. If the benefit sought on appeal remains denied, furnish to the Veteran and his representative an appropriate supplemental statement of the case that includes clear reasons and bases for all determinations, and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Gonzalez-Maldonado 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.