Citation Nr: 21011388 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 17-44 994 DATE: March 1, 2021 REMANDED Entitlement to service connection for a right ankle condition is remanded. Entitlement to service connection for a left ankle condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1972 to November 1974. This matter is before the Board of Veterans’ Appeal (Board) on appeal from an October 2016 rating decision issued by the Department of Veteran Affairs (VA) Regional Office (RO). The Veteran appeared at a hearing before the undersigned Veterans Law Judge in October 2020. A transcript of the hearing is in the Veteran’s file. 1. Entitlement to service connection for a right ankle condition is remanded. 2. Entitlement to service connection for a left ankle condition is remanded. The Veteran is seeking service connection for a bilateral ankle disability. The Veteran contends that his bilateral ankle disability is due to his active duty service, to include his MOS as a Vulcan gunner, and stress placed upon his ankles because of basic training. Previously, much of the focus here was on whether the Veteran’s disability pre-existed his active service. The Veteran contends that his bilateral ankle condition is related to being diagnosed with Polio at age 2. Moreover, the Veteran stated that he suffered ankle sprains prior to service while playing sports in high school. Every Veteran shall be taken to have been in sound condition when examined, accepted, and enrolled for service, except as to defects, infirmities, or disorders noted at the time of the examination, acceptance, and enrollment, or where clear and unmistakable evidence demonstrates that the injury or disease existed before acceptance and enrollment and was not aggravated by such service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304. To rebut this presumption, VA must show by clear and unmistakable evidence that the condition pre-dated the Veteran’s service and that the condition was clearly and unmistakably not aggravated during service. Here, the Board does not find that clear and unmistakable evidence establishes that the Veteran’s bilateral ankle disability pre-existed his active duty service. The Veteran’s entrance records do not indicate that the Veteran suffered from a chronic bilateral disability prior to his entrance into military service. There are no other records regarding the type and severity of the Veteran’s possible pre-existing disabilities to allow the Board to find that such disabilities clearly and unmistakably pre-existed service. As such, the Veteran is presumed to be sound. The Veteran was afforded a May 2016 VA examination to determine the nature and etiology of the Veteran’s bilateral ankle disability. The Board, however, finds that the VA examination is inadequate for rating purposes, as the VA examiner focused on whether the Veteran’s disability pre-existed service and whether the pre-existed disability was aggravated beyond its natural progression by his service. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (holding that if VA provides a Veteran with an examination in a service-connection claim, the examination must be adequate). As the Board has found the Veteran to be sound, the May 2016 VA examination report does not address the correct etiological question in this matter. The Board also acknowledges that the Veteran submitted two private medical opinions in October 2020. The Board, however, find both medical opinions inadequate for rating purposes. First, the medical opinion authored by K. J. Collins, M.D., found that the Veteran’s post-polio condition was expeditated by his military service. Specifically, Dr. Collins puts forth that the stress of military service contributed to the rapid deterioration of the Veteran’s ankles that were already weaken by polio. The second medical statement was provided by M.C. Chilvers, M.D. Dr. Chilvers stated that she, “think(s) that his military service has caused ankle pain…...” The Board finds both of private medical opinions to be inadequate. Neither private opinion identified a specific bilateral ankle disability besides pain. The opinion provided by Dr. Chilvers is vague and does not appear to offer a medical opinion at all. Dr. Collins’s medical opinion focus on the Veteran’s polio diagnoses as a child and connects that to his bilateral ankle pain. This opinion is primarily based on the belief that the Veteran entered service with a pre-existing bilateral ankle disability, however, as noted above the Veteran is presumed to be sound at service entrance. Moreover, the Veteran has endorsed that he was very active in sports prior to service entrance and was not diagnosed with a chronic bilateral ankle disability prior to service. Under these circumstances, the Board will not proceed with final adjudication of the claims until a competent medical opinion with supporting rationale is obtained that adequately addresses the etiology of the Veteran’s claimed disabilities. McLendon v. Nicholson, 20 Vet. App. 79 (2006). The matters are REMANDED for the following actions: 1. Obtain the Veteran’s VA treatment records dated from June 2017 and thereafter and associate them with his claims file. 2. With any necessary assistance from the Veteran, obtain private treatment records regarding his claimed bilateral ankle disability, to include any records from Drs. Chilvers or Collins. 3. Schedule the Veteran for an appropriate VA examination to determine the nature and possible relationship to service of his claimed bilateral ankle disability. The evidence of record, to include a copy of this Remand, must be made available to the examiner and the examiner must indicate that the pertinent medical records and lay statements have been reviewed. Following a review of the record, the examiner must address the following: (a) Provide diagnoses for all current ankle disabilities, to include those noted during the appeal period. (b) State whether it is at least as likely as not that any bilateral ankle disability had its onset during or are otherwise related to the Veteran’s active service, to include MOS as a Vulcan gunner, and stress placed upon his ankles because of basic training. As the Board has already determined that the Veteran was sound at entry, no discussion of whether his disability preexisted service is required. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.R. Higgins, 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.