Citation Nr: 21009580 Decision Date: 02/22/21 Archive Date: 02/22/21 DOCKET NO. 15-01 260 DATE: February 22, 2021 REMANDED Entitlement to service connection for left knee injury, to include as secondary to left ankle injury, is remanded. Entitlement to service connection for left ankle injury is remanded. REASONS FOR REMAND The Veteran had active duty military service from June 1982 to December 1987. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a November 2010 rating decision by a Department of Veteran’s Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in a February 2021 virtual hearing. The Board’s review of the record reveals that further development is warranted to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. The Veteran contends he is entitled to service connection for a left knee injury and left ankle injury sustained during active duty service. Specifically, he reported that he injured his left knee and left ankle after he “stepped in a hole” and tore ligaments. The injury did not heal properly, which resulted in him being reassigned from Patrol Commander to a desk job. See VA form 21-526, August 2010. Service treatment records contain a record from March 1987 in which the Veteran was seen for complaints of a left knee “twisting injury” after running at night. A November 2010 Joints VA Compensation and Pension examination noted a November 2010 left knee x-ray, with normal results. Constant pain, stiffness, intermittent swelling, weakness, and instability were all noted, in addition to pain with prolonged walking. A private medical record from September 2010 noted the Veteran was seen for complaints of pain and swelling in his left ankle, with the condition present since 1985. See Dr. S., September 2010. Additionally, the Veteran has reported pain and sought treatment for his left knee and left ankle pain. Under Saunders v. Wilkie, “pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability.” See Saunders v. Wilkie, 886 F.3d 1356 (2018). To establish the presence of a disability, a veteran will need to show that his pain reaches the level of a functional impairment of earning capacity. Id. at 1356. Given the Veteran’s assertions that his current left knee and left ankle pain is related to service, and his service treatment records confirm an injury in service, the Board finds that another VA examination is necessary to determine whether he has functional impairment in the left knee and left ankle due to service. Thus, these issues must be remanded so that the Veteran can be provided a VA examination and medical opinions can be obtained regarding the nature and etiology of his left knee and left ankle injury and regarding any functional impairment. Accordingly, the matters are REMANDED for the following actions: 1. Obtain and associate with the Veteran’s claims file any outstanding VA treatment records documenting treatment for a left knee or left ankle injury, to include those from Pensacola JACC and Durham VAMC. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his left knee and left ankle disability. The claims folder, along with a copy of this remand, must be made available to the examiner for review. The examiner should identify all disabilities affecting his left knee and left ankle, to include residuals of any disability found at any time during the appeal period (from November 2009). If any previously diagnosed disability is not found on examination, the examiner should address the prior diagnoses of record and indicate whether they may have resolved or been misdiagnosed. Note: pain itself may constitute a disability for VA purposes if it rises to the level of a functional impairment of earning capacity. For each diagnosed disability or finding of functional impairment in the left knee and left ankle, the examiner should provide an opinion regarding whether it is at least as likely as not (i.e., probability of 50 percent) that the disability manifested during active service; or is otherwise related to an event, injury, or disease incurred during active service. The medical examiner should also provide a medical opinion as to whether the Veteran has a left knee disability that developed secondary to or was aggravated by his left ankle injury (if service-connected on remand). The medical examiner is asked to provide an opinion as to both causation and aggravation for the secondary opinion. A complete rationale for any opinion rendered must be provided. The examiner is asked to accept as true the Veteran’s reports regarding a left knee and left ankle injury. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Krista Johnson, 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.