Citation Nr: 21010745 Decision Date: 02/25/21 Archive Date: 02/25/21 DOCKET NO. 18-37 476 DATE: February 25, 2021 REMANDED Entitlement to service connection for a left ankle disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1967 to June 1969. This case comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2018 rating decision of the Department of Veteran Affairs (VA) Regional Office (RO) in Houston, Texas. In February 2019 the Veteran presented testimony at a travel Board hearing before the undersigned Veterans Law Judge (VLJ). Service Connection Remand is required to comply with the September 2020 remand directives. The Board is obligated by law to ensure that the RO complies with its directives. Stegall v. West, 11 Vet. App. 268, 271 (1998). RO compliance with remand directives is not optional or discretionary and the Board errs as a matter of law when it fails to ensure remand compliance. Stegall, 11 Vet. App. at 271. The issue was remanded in September 2020 for an addendum opinion. The examiner was instructed to address all left ankle disorders found in the record. The examiner was instructed to provide an opinion for each diagnosed left ankle disorder. A November 2020 addendum opinion was provided. The examiner opined the left ankle disorder was less likely than not incurred in or caused by service. The examiner stated the Veteran had two separate incidents involving a sprained ankle in December 1968 and April 1969. The examiner stated the events appeared to be separate, acute, self-limiting events. The examiner noted the separation examination was negative for ankle complaints. The examiner stated separation examinations are notably thorough and involve both medical history and medical officer examination. The examiner stated that given the proximity to the events, the examination almost certainly would have noted an abnormality of the ankle. The examiner noted there was no further complaint of an ankle condition until 2015, despite the Veteran’s and buddy statements to the contrary. The examiner pointed to a March 2019 VA treatment record where the Veteran reported several years of left ankle pain. The examiner stated this is more consistent with onset in 2015 than in 1969, a gap of 45 plus years. The examiner stated the Veteran is diagnosed with mild degenerative disease of the ankle and possible intra articular loose body. The examiner stated the MRI was not confirmatory. The examiner restates prior opinion and noted a left ankle fracture was unsubstantiated by his service treatment records (STRs). The examiner concluded noting that degenerative arthritis of the ankle was common, and a comparison film of the right ankle would likely show the same amount of change. The examiner stated that if loose body were due to events in-service, the condition would have manifested before 2015 and if degenerative changes were due to service it would be more severe. The January 2018 and December 2019 VA examinations diagnosed left ankle lateral collateral ligament sprain (chronic/ recurrent). This diagnosis was not addressed in the November 2020 VA addendum opinion. Notably, both VA examinations indicated the left ankle lateral collateral ligament sprain was chronic/recurrent. The September 2020 remand directives explicitly stated the examiner provide an opinion for each diagnosed left ankle disorder. The November 2020 VA opinion does not address left ankle lateral collateral ligament sprain. Accordingly, there has not been substantial compliance with the September 2020 remand directives, and remand is required. The matters are REMANDED for the following action: 1. Obtain an addendum opinion regarding the etiology of the left ankle disorders from a VA examiner. The entire claims file must be made available to and be reviewed by the examiner. If an examination is deemed necessary, it shall be provided. An explanation for all opinions expressed must be provided. First, the examiner must address all left ankle disorders found in the record, including but not limited to intra-articular loose body within tibiotalar joint, minimal degenerative changes, and lateral collateral ligament sprain (chronic/recurrent). Second, the examiner must provide an opinion regarding whether it is at least as likely as not (50 percent or greater probability) that each diagnosed left ankle disorder had onset in, or is otherwise related to, active service. The examiner must address the following: 1) Veteran February 2019 Board hearing testimony; 2) the Veteran’s lay statements regarding continuity of symptoms after service; 3) July 2020 buddy statements corroborating the Veteran’s ankle pain immediately after service; 4) July 2020 buddy corroborating ankle pain since at least 2000; and 4) all relevant STRs. For purposes of this examination only, the examiner must presume that the Veteran experienced ankle pain after service. 2. If an examination is deemed necessary, notify the Veteran that it is his responsibility to report for any scheduled examination and to cooperate in the development of the claim, and that the consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2020). In the event that the Veteran does not report for any scheduled examination, documentation must be obtained which shows that notice scheduling the examination was sent to the last known address. It must also be indicated whether any notice that was sent was returned as undeliverable. K. MILLIKAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Bruton, 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.