Citation Nr: 21011404 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 12-28 201 DATE: March 1, 2021 REMANDED The appeal as to the claim of entitlement to service connection for bilateral ankle disability, to include sprain and Achilles tendonitis, is remanded. REASONS FOR REMAND The Veteran had active service in the United States Navy from May 1979 to May 1985. His service was under honorable conditions. The matter is on appeal from a November 2009 rating decision. This issue has been previously remanded by the Board for further development in November 2016, February 2018, November 2019, and October 2020. Entitlement to service connection for a bilateral ankle disorder, to include sprain, and Achilles tendonitis. The Veteran asserts that he has a bilateral ankle disability that began during his active military service and is due to prolonged standing on hard surfaces. He further asserts that his symptoms of bilateral ankle pain and swelling began during service and have progressively worsened. Service treatment records include an April 1985 separation examination, which shows the Veteran checked swollen or painful joints, and arthritis, rheumatism, or bursitis. The examiner noted that the Veteran has right ankle swelling when walking on concrete for long periods. Post-service treatment records include VA examination reports dated in October 2009, March 2017, and August 2018. The October 2009 examination report indicates a diagnoses of bilateral ankle strain. The August 2018 examination report notes a diagnosis of bilateral ankle Achilles tendonitis. A July 2019 x-ray report of the right ankle demonstrates soft tissue edema and swelling, mild degenerative changes to the medial malleolus, ossification of the Achilles tendon, and a large plantar calcaneal spur. An October 2019 VA outpatient treatment record shows the Veteran was referred for physical therapy to treat his Achilles tendonitis. When the Board last reviewed the case in October 2020, it noted that in each of the previous three remands, the VA examiner was instructed to take into account the evidence of right ankle swelling from the Veteran's 1985 separation examination, as well as his statements of ankle swelling occurring while in service. None of the VA examiners discussed this evidence in their medical opinions. Rather the VA examiner from the January 2020 VA examination, reported that the medical records available to the examiner did not support the Veteran's currently diagnosed right ankle strain being due to his active service, as there was no complaint, diagnosis, or treatment while in service. In the VA examiner's opinion from August 2018, it was reported that after reviewing medical records the examiner was unable to find objective evidence showing a record of complaint, diagnosis, or treatment for the Veteran's ankle while in service. The VA examiner's opinion from March 2017, provided that to form an opinion 37 years after the Veteran's discharge from the service, on whether his right ankle strain was a result of his military service, would require resorting to speculation. Thus, the Board remanded the case to obtain a medical opinion that takes into account and discusses the Veteran's complaints of ankle swelling while in service, as well as the evidence from the Veteran's April 1985 separation examination, where the Veteran was documented to have right ankle swelling when walking on concrete for long periods of time. The Veteran underwent a VA examination in January 2020. Upon examination and review of the record, the examiner diagnosed bilateral ankle strain. The VA examiner opined that the Veteran’s current bilateral ankle disorder was not due to his active service, as service treatment records are negative for complaints of, treatment for, or a diagnosis of an ankle disorder. In a November 2020 addendum opinion, the VA examiner noted the Veteran’s report of bilateral ankle swelling with weight bearing activities, on separation examination in April 1985. The examiner opined that the current bilateral ankle strain disorder was less likely related to the Veteran’s active service, as there is no evidence of chronicity of treatment during service, or immediately following service. The Board finds the January 2020 and November 2020 VA opinions inadequate for adjudication purposes. In this regard, the examiners’ failed to consider the Veteran’s assertion that his symptoms of bilateral ankle pain and swelling began during service and have progressively worsened. Further, the aforementioned VA examiners failed to offer an etiology of the Veteran’s current diagnosis of bilateral Achilles tendonitis. Accordingly, another medical opinion is necessary to make a determination in this case. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Further, development to obtain any outstanding medical records pertinent to the Veteran’s claims should be completed. The matter is REMANDED for the following actions: 1. Undertake appropriate development to obtain any outstanding records pertinent to the Veteran's claim, to include updated VA outpatient treatment records dated from July 2020, to the present, and any private treatment records identified by the Veteran. If any requested records are unavailable, or the search for such records otherwise yields negative results, that fact should clearly be documented in the record and the Veteran so notified in accordance with 38 C.F.R. § 3.159(e). All steps taken to attempt to obtain the above records should clearly be documented in the record. 2. Once the record is developed to the extent possible, all pertinent evidence must be made available to and reviewed by an appropriate VA intestinal physician who has not provided a prior opinion in this case. The Veteran need not appear for an examination unless deemed necessary by the physician assigned to offer an opinion. Following review of the record, the physician should first identify all ankle disorders demonstrated by the Veteran during the pendency of this appeal, to include strain and Achilles tendonitis. For each identified diagnosis, the examiner must then opine whether it is at least as likely as not (i.e., at least 50 percent probable) that the condition manifested during, or as a result of, active military service. In providing the opinion, the Veteran's complaints of ankle swelling while in service, as well as the Veteran's April 1985 separation examination, where the Veteran was documented to have right ankle swelling when walking on concrete for long periods of time. The examiner must discuss the Veteran’s assertions that his symptoms of pain and swelling began during active service, and they have worsened since separation from service. For purposes of the opinions, the physician should assume that the Veteran is credible to report a history of the aforementioned symptoms. A complete rationale must be provided for all opinions offered. If an opinion cannot be offered without resort to mere speculation, the examiner must fully explain why this is the case and identify what additional evidence, if any, would allow for a more definitive opinion. 3. Then, the AOJ should readjudicate the issue on appeal. If the benefits sought on appeal are not granted to the Veteran’s satisfaction, he and his representative should be provided a supplemental statement of the case and an appropriate period for response before the case is returned to the Board for further appellate action. B. MULLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Sara Schinnerer, 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.