Citation Nr: 21009734 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 18-17 821 DATE: February 23, 2021 REMANDED Entitlement to service connection for a right ankle condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from September 1986 to December 1988. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2016 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). The Board denied the Veteran’s above claim in a May 2019 decision. The Veteran then appealed to the United States Court of Appeals for Veteran’s Claims (CAVC), and in September 2020 CAVC vacated the May 2019 Board decision, granted a joint motion for remand, and returned the case to the Board for action consistent with the joint motion for remand. Remand Although the Board regrets the additional delay, a remand is necessary to ensure that due process is followed and that there is a complete record upon which to decide the Veteran’s claim so that he is afforded every possible consideration. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. While there are VA examinations in the record regarding the Veteran’s claimed right ankle disability, the Board finds them to be inadequate. During the Veteran’s September 2015 examination, the Veteran reported that prior to joining the Military he had fractured his right ankle while in high school. The Veteran continued to report that he strained his ankle in basic training and fractured it again in 1986 when he stepped out of a truck. During the Veteran’s January 2018 examination, he reported that—while in service—he injured his right ankle stepping out of a waterbed, injured it again stepping out of a truck, and experiences pain with ambulation. Further, the Board notes that the examiner documented remote ankle trauma consistent with the Veteran’s reported history. The examiners opined that the Veteran’s right ankle disability was less likely than not etiologically related to his active duty service. In proffering these opinions, neither examiner considered the Veteran’s competent lay statements regarding injuries prior to, and during, active duty service. As noted above, the Veteran indicated that he had fractured his ankle while in high school, prior to joining the military. However, neither examiner opined whether the Veteran’s right ankle disability pre-existed, and was aggravated by, the Veteran’s military service. Further, the Board notes that in a December 2020 Appellant’s Brief, the Veteran argued that he may currently have myositis ossifications related to his in-service injuries due to a January 2018 radiographic report suggesting calcifications related to remote trauma. As such, the Board finds it prudent to obtain an additional medical opinion in order to determine whether the Veteran’s current right ankle disability is etiologically related to his active service, to include as a pre-existing condition aggravated by military service. The matters are REMANDED for the following action: Afford the Veteran a VA examination by an examiner, who has not examined the Veteran before, with sufficient expertise to address the etiology of the Veteran’s claimed right ankle disability. All pertinent evidence of record must be made available to and reviewed by the examiner. Any indicated studies should be performed. Following a review of the relevant records and lay statements, the examiner should state whether the Veteran’s claimed right ankle disability at least as likely as not (a 50 percent probability or greater): originated during his period of active service or was otherwise etiologically related to his active service. The examiner should also comment on whether the Veteran has a diagnosis of myositis ossifications of his ankle which is at least as likely as not (a 50 percent probability or greater) etiologically related to his active duty service. Additionally, the examiner should address whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran’s right ankle condition pre-existed service and whether it was aggravated by his claimed in-service injuries. For purposes of this opinion, the examiner should assume that the Veteran is a reliable historian and must not ignore the Veteran’s competent reports of in-service injuries, or of symptoms experienced during active service and since. In this regard, the examiner must discuss and consider the Veteran’s competent lay statements. Specifically, the examiner must comment on the Veteran’s lay reports of injuries in service, his report of a right ankle fracture prior to service, and the January 2018 VA examiner’s finding of remote ankle trauma consistent with the Veteran’s reported history. The examiner must provide a complete rationale for all proffered opinions. If an examiner is unable to provide any required opinion, he or she should explain why. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation as to why this is so. If the inability to provide a more definitive opinion is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Gresham 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.