Citation Nr: 21014454 Decision Date: 03/12/21 Archive Date: 03/12/21 DOCKET NO. 16-29 371 DATE: March 12, 2021 REMANDED Entitlement to service connection for a right ankle disability, to include as secondary to a left ankle disability, is remanded. Entitlement to a rating in excess of 10 percent for a left ankle disability is remanded. REASONS FOR REMAND 1. Entitlement to service connection for a right ankle disability, to include as secondary to a left ankle disability, is remanded. In March 2020, the Board remanded the claim for the scheduling of a VA medical examination to determine the etiology of any right ankle disability. In the remand instructions, the Board requested that the VA examiner attempt to reconcile the requested opinion with the other opinions of record, to particularly include a November 2014 private medical opinion in which a private examiner opined that the Veteran's claimed right ankle disability was at least as likely as not caused by his service-connected left ankle disability. In a subsequent March 2020 VA examination and medical opinion, a VA examiner opined that a right ankle disability was less likely than not secondary to a service-connected left ankle disability. In hat opinion, the March 2020 VA examiner did not refer to any of the previous opinions, to include the November 2014 VA private medical opinion. A remand is necessary to schedule an additional examination. 2. Entitlement to a rating in excess of 10 percent for a left ankle disability is remanded. Because the current severity of the service-connected left ankle disability is relevant to the claim for service connection for a right ankle disability, as part of any examination resulting from this remand, the examiner should also provide findings regarding the current severity of the service-connected left ankle disability. The matters are REMANDED for the following action: Schedule the Veteran for a VA orthopedic examination by an orthopedist who has not previously examined the Veteran to determine the severity of the service-connected left ankle disability and the etiology of any right ankle disability. The examiner must review the record and should note that review in the report. In reviewing the record, the examiner should note the service medical records; the post-service treatment records; the November 2014 private medical opinion, opining that the Veteran's right ankle disability was caused by the service-connected left ankle disability; the January 2015 VA medical opinion; the March 2020 VA medical opinion; and the Veteran's lay statements regarding symptoms during and since service. A complete rationale should be stated for all opinions and conclusions expressed. All appropriate tests or studies, to include X-rays if considered to be necessary, should be accomplished, and all clinical findings should be reported in detail. If the examiner disagrees with any opinion of record, to particularly include the November 2014 private medical opinion, the examiner should note the disagreement in the required opinion and explain the disagreement using clinical findings or data. Regarding the left ankle, the examiner must report the range of motion of the ankle, expressed in degrees, to include measurements for weight-bearing, nonweight-bearing, passive motion, and active motion. The examiner must make specific findings as to whether, during the examination, there is objective evidence of additional loss of function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. If pain on motion is observed, the examiner should indicate the point at which pain begins. The examiner should also indicate whether, and to what extent, the Veteran experiences functional loss of the ankle or any other symptoms during flare-ups or with repeated use. To the extent possible, the examiner should express any additional functional loss in terms of additional degrees of limited motion. After an examination of the right ankle, a review of the claims file, and an interview with the Veteran, the examiner is asked to also provide the following opinions: (a). Is it at least as likely as not (50 percent probability or greater) that any identified right ankle disability had its onset during the Veteran's service or is related to any event, injury, or disease during the Veteran’s service? (b). If arthritis of the right ankle is diagnosed, is it at least as likely as not (50 percent or greater probability) that the disability (1) began during the Veteran's period of active service, (2) manifested within one year after the Veteran's March 2004 separation from service, or (3) was noted during service with continuity of the same symptomatology since service? (c). Is a right ankle disability at least as likely as not (50 percent or greater probability) proximately due to a service-connected left ankle disability or any gait disturbance due to a service-connected left ankle disability? (d). Was a right ankle disability at least as likely as not (50 percent or greater probability) aggravated (worsened beyond the natural progression) by the service-connected left ankle disability or any gait disturbance due to a service-connected left ankle disability? Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.M. Gillett 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.