Citation Nr: 21015087 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 16-11 252A DATE: March 16, 2021 REMANDED Entitlement to service connection for a right ankle condition is remanded. Entitlement to service connection for a bilateral knee condition is remanded. Entitlement to service connection for a left shoulder condition is remanded. REASONS FOR REMAND The Veteran has confirmed active duty service from June 1983 to December 1983 and from May 1987 to June 1989. These matters were last before the Board in December 2018, whereupon they were remanded to the Agency of Original Jurisdiction (AOJ) for further development of the record. Following the issuance of an August 2020 supplemental statement of the case continuing the denial of the claim, the case was returned to the Board for its adjudication. In its prior December 2018 remand, the Board directed the AOJ to verify whether the Veteran has additional service prior to the active service listed on the available DD Form 214, which reflects active service from May 1987 to June 1989. Upon receipt of the case, the AOJ made multiple requests for information through available military document repositories. Furthermore, the AOJ sent the Veteran correspondence in January 2020 requesting that he provide any copies of separation paperwork or any other documents which would indicate his active duty service. Personnel records added to the file in January 2020 reflect that the Veteran had documented active duty service from June 1983 to December 1983 as well as the period from May 1987 to June 1989 indicated on the DD Form 214 already in VA’s possession. In addition, those records also suggest that the Veteran had additional service for a period of three or more years prior to when his documented service began in May 1987. An internal memorandum dated in August 2020 shows that the AOJ was aware of the possible additional active service and recommended that further development be undertaken prior to any adjudication on the appeal. However, the AOJ subsequently issued the August 2020 supplemental statement of the case continuing the denial of all three service connection claims and then certified those claims back to the Board without engaging in any additional development. In the Board’s estimation, the AOJ neglected to implement the development that it was directed to do in the prior December 2018 remand; as such, another remand is necessary in order to effectuate those prior instructions. See Stegall v. West, 11 Vet. App. 268 (1998). Specifically, on remand the AOJ must carry out all available methods of obtaining any documentation which would serve to verify the additional active duty service suggested by the currently available personnel records. In addition, the Board highlights two further deficiencies in the AOJ’s implementation of the prior December 2018 remand instructions. With regard to the left shoulder service connection claim, the Board notes that the AOJ was directed to secure an opinion as to the likely etiology of the condition. In a March 2020 VA examination, the VA examiner offered a positive etiology opinion for the Veteran’s distinct right shoulder condition but did not offer any opinion as to the likely etiology of the claimed left shoulder condition. This must be corrected on remand. Stegall, supra. As for the right ankle service connection claim, the Board notes that the AOJ was also directed to secure an opinion as to the likely etiology of the condition. In a March 2020 VA examination, the VA examiner identified a right ankle strain as the only ankle diagnosis of record, and detailed that it manifested in July 1985. The examiner did not set forth any current right ankle diagnosis. She then opined that it was less likely than not that any right ankle condition was incurred in or otherwise attributable to service. In support thereof, she acknowledged that the Veteran reported experiencing right ankle pain in early 1987 (but prior to his verified period of active service); however, she found no evidence of a continuity of symptoms following these isolated instances of complaints of right ankle pain. The March 2020 right ankle etiology opinion is insufficient for the Board’s evaluation as the examiner did not address the Veteran’s detailed account of having experienced right ankle pain throughout his period of service as well as after his discharge. Furthermore, she did not set forth an opinion to account for the Veteran’s current complaints of right ankle pain, which raises the suggestion that the right ankle strain which she did identify has persisted since manifesting in 1985. On remand, after confirming the dates of the Veteran’s service, the AOJ must secure a new examination to confirm the proper diagnosis for the Veteran’s current right ankle condition and then sets forth an etiology opinion consistent with the medical and lay evidence of record. Stegall, supra. The matters are REMANDED for the following action: 1. The AOJ should verify whether the Veteran had any earlier period of active service. A DD Form 214 shows that the Veteran had a period of active duty from May 1987 to June 1989, but also indicates that he had also had three years and three months of prior active service. In addition, a service record information report dated in August 2020 suggests that the Veteran had active duty service for the entirety of the period from June 25, 1983 to June 27, 1989. Finally, service medical records available in the claims file document active duty service treatment during the period of time when the Veteran does not have currently verified active service. The AOJ must document all efforts to verify the Veteran’s periods of active duty service, and document all responses received from all attempts to obtain the records. 2. Once the foregoing development is completed, schedule the Veteran for a VA ankle examination in order to determine the proper diagnosis to account for the Veteran’s current right ankle symptomatology and then elicit an opinion as to the likely etiology of any diagnosed right ankle condition. The claims file, to include a copy of this remand, must be made available to the chosen examiner, who must indicate that they reviewed the file prior to preparing any examination report. Any and all studies, tests, and evaluation deemed necessary by the examiner should be performed. After confirming a proper current diagnosis for the right ankle condition, the examiner is asked to opine as to whether it as at least as likely as not (a 50 percent probability or greater) that any right ankle condition is directly related to active military service. In setting forth this opinion, the examiner must consider and comment upon as necessary the documented treatment for a right ankle strain presumed to have occurred during active duty service in March and April 1987. A complete rationale is required for any and all opinions. The lay contentions of the Veteran must be considered. The Board recognizes the practical difficulties of scheduling an examination in view of the COVID-19 epidemic, and requests flexibility and understanding in affording the Veteran an opportunity to report for an examination.  To the extent that telehealth technology permits an alternative to an in-person examination, such opportunity is fully acceptable in lieu of an in-person examination.  3. Provide the claims file to the individual who administered the March 2020 VA shoulder examination, or to another qualified medical professional if she is not available, in order to elicit an addendum opinion as to the likely etiology of the claimed left shoulder condition. The claims file, to include a copy of this remand, must be made available to the chosen examiner, who must indicate that they reviewed the file prior to preparing any examination report. The examiner is asked to opine as to whether it as at least as likely as not (a 50 percent probability or greater) that any left shoulder condition is directly related to active military service. A complete rationale is required for any and all opinions. The lay contentions of the Veteran must be considered. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Christopher M. Collins, 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.