Citation Nr: 21011079 Decision Date: 02/26/21 Archive Date: 02/26/21 DOCKET NO. 19-24 873 DATE: February 26, 2021 REMANDED Entitlement to service connection for a left ankle disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from November 1954 to October 1956. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, the Veteran and his daughter testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the record. Entitlement to service connection for a left ankle disorder is remanded. The Veteran has contended that he developed a left ankle disorder as a result of a bayonet injury and resultant surgery during hand-to-hand combat training in Worms, Germany, in 1955 to 1966. Initially, the Board notes that the RO has attempted to obtain the Veteran’s service treatment records. However, a July 2018 information request response indicates that the records are fire-related and cannot be recovered. In cases where a veteran’s records are damaged or destroyed through no fault of his/her own, there is a heightened duty to assist in the development of the case. See O’Hare v. Derwinski, 1 Vet. App. 365 (1991). In-service hospitalization records are typically stored separately from individual service treatment records. Review of the claims file does not reveal a request for hospitalization records for the Veteran’s left ankle surgery in Worms, Germany, or to an archive facility in possession of such records. Therefore, the Board finds that remand is warranted in this case to obtain the missing hospitalization records, if possible, and associate these records with the Veteran’s claims file. In addition, the Board cannot make a fully informed decision on the entitlement to service connection for a left ankle disorder because no VA examiner has opined whether the Veteran has a current left ankle disorder that is related to service. On remand, the Veteran should be provided a VA examination to address the nature and etiology of his left ankle disorder. Pain resulting in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability. Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018). In the event that the criteria for a diagnosis of disability of the left ankle are not met, the examiner should specifically state whether there is any functional impairment associated with the Veteran’s complaints of pain. The matters are REMANDED for the following action: 1. Contact the appropriate repository to obtain all outstanding records pertaining to a 1955 or 1956 left ankle surgery and hospitalization in Worms, Germany, for the Veteran’s bayonet injury. 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 unavailability of such records must be verified and this should be documented for the record. Required notice must be provided to the appellant and his representative. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any left ankle disorder. The examiner must opine whether it is at least as likely as not related to an in-service injury, event, or disease. In the case of arthritis, the examiner must opine as to whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. In the event that the criteria for a diagnosis of a left ankle disorder are not met, the examiner should specifically state whether there is any functional impairment associated with the Veteran’s complaints. Please complete the “Functional Impact” section of the report of examination. If there is functional impairment, please offer an opinion as to whether it is at least as likely as not (Continued on the next page)   that such impairment is associated with the Veteran’s service. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Osegueda, 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.