Citation Nr: 21015236 Decision Date: 03/17/21 Archive Date: 03/17/21 DOCKET NO. 19-31 468 DATE: March 17, 2021 REMAND Entitlement to service connection for a left ankle disability is remanded. REASONS FOR REMAND The Veteran served in the U.S. Army from October 1961 to October 1964. The Veteran appeals the denial of service connection for a left ankle disability. He argues that he injured his left ankle when he fell during service in 1962 which resulted in traumatic arthritis. He further claims that his ankle problems are due to the stress on the ankles from performing the inservice job as a telephone lineman in cold weather conditions. The Veteran’s claims continuity of treatment since his original incident while on active duty. Service treatment records show that in September 1962 the Veteran fell on the stairs and twisted his left ankle. At that time, he had some tenderness and swelling. The impression was sprain ankle. X-ray revealed no evidence of fracture. Service treatment records show no other complaints, treatment and/or diagnoses for the left ankle. The August 1964 separation examination disclosed normal findings for the feet. At that time, the Veteran denied a history of foot trouble. The Board further notes that arthritis is not shown within one year after separation from active duty. Post-service, a 2009 VA clinic record first discloses a non-specific report of ankle pain. During a July 2014 VA examination, the Veteran was diagnosed with left ankle arthritis. The Veteran reported that his left ankle problems started about ten years earlier (approximately 2004) and that he was just diagnosed with arthritis that year (2014). An x-ray examination was interpreted as showing hypertrophic changes along the syndesmosis suggestive of sequela of repetitive or old trauma. The VA examiner opined that it was less likely than not (less than 50 percent probability) that the Veteran’s condition was incurred in or caused by the claimed in-service injury, event or illness. The examiner reasoned that there was no evidence of chronicity for a left ankle condition in the service treatment records and there was no continuity of care for the left ankle condition in the years proximal to military service. An October 2014 private medical letter stated that the Veteran had fractured his left ankle in service. VA clinic records in 2015 reflect the Veteran’s report of a history of left ankle give-way which caused falling injuries. He was seen for a falling injury in August 2015. VA clinic records in January 2016 included the Veteran’s impression of having arthritis in every joint of his body with left ankle give-way which he attributed to hurting his wrists and ankles while performing various military duties. May 2016 reflect treatment for left ankle pain following a falling injury. An x-ray examination was interpreted as showing mild soft tissue swelling, small joint effusion in the anterior tibial joint and productive changes in the syndesmosis which were stable and likely sequela of prior trauma. A December 2016 VA clinic record included the Veteran’s report of having diffuse degenerative joint disease (DJD) of the wrists, ankles and back due to military trauma. He reported left ankle instability since his military service. In an August 2020 statement, the Veteran reported that his claim concerned his “right” ankle. During the November 2020 VA examination, the VA examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned the claims file had insufficient evidence regarding a diagnosis, treatment, evaluations, and/or referrals during or one year after the military confirming a diagnosis for the left ankle. The examiner noted that there is documented evidence of the Veteran sustaining a left ankle injury and acute sprain while in service with an impression demonstrating left ankle sprain. The medical evidence, however, he noted was silent for chronicity and continuity of care for the acute left ankle sprain. According to the examiner, the available medical evidence demonstrates a left ankle X-ray in July 2014 with degenerative arthritis of the left ankle, occurring 52 years after the original injury and 50 years after discharging from active duty. The examiner acknowledged the May 2016 x-ray noting finding suggestive of prior trauma, but noted that the Veteran has had intermittent complaints with two noted urgent care visits in August 2015 and May 2016. It was noted that degenerative arthritis or osteoarthritis is related to aging, and wear and tear on a joint which can occur in adults 55 and older and/or can run in families. It was further noted that the impression to prior trauma was referencing the already reported arthritis of the left ankle and not a residual of injury. The examiner stated there are some risk factors associated with developing arthritis including obesity or fractures and that the Veteran had several risk factors associated with developing arthritis including: (1) he was diagnosed at 76 years old, (2) chronic obesity, and (3) his history of recurrent acute ankle sprains as evidence by documented reports of acute sprains in August 2015, May 2016, August 2018 and November 2020. The examiner further found that the medical evidence is silent for documented evidence of a fracture/stress fracture to the left ankle during active duty. The examiner opined that it was less likely than not the arthritis of the left ankle was incurred by the left ankle injury related to the in-service injury, event or disease during service. The examiner found that the current left achilles tendonitis diagnosed was acute, with no chronic diagnosis noted, nor continuity or chronicity of care, and was unrelated to the claimed in-service injury, event, or disease. The examiner further found that with regard to the Veteran’s claims of repetitive stress related to the in-service job as a telephone linesman, the medical evidence “does not demonstrate any indication of a stress fracture/fracture on the left ankle X ray on 9/13/62, continuity, or chronicity of care to indicate a chronic left ankle condition to support this statement.” On review of the entirety of the record, the Board finds that the 2020 VA opinion is inadequate. The Board requested the examiner to provide an explanation as to whether any current findings, including the May 2016 impression of “likely sequela of prior trauma,” is attributable to the mechanism of injury in service. The examiner referenced prior injuries in 2015 and 2016 as responsible for these changes but notably this finding was present at the 2014 VA examination. An addendum opinion is necessary. According, this matter is REMANDED for the following: 1. Associate with the claims folder updated VA treatment records. 2. Obtain an addendum opinion by an appropriate clinician to determine the nature and etiology of the Veteran’s left ankle disability. The examiner must be provided access to the Veteran’s electronic claims file. After review of the record, the examiner is requested to provide an opinion as to whether it is at least as likely as not that any left ankle disability, that is diagnosed in the record, is related to an in-service injury, event, or disease. In doing so, the examiner must address: (1) the Veteran’s claim of stress on the ankles from performing the inservice job as a telephone lineman, (2) the September 1962 service treatment record which reflects that the Veteran fell on the stairs and twisted his left ankle and had some tenderness and swelling. The impression was ankle sprain and x-ray at that time revealed no evidence of fracture, (3) the Veteran’s August 1964 separation examination which showed normal findings for the feet and the Veteran’s denial of foot trouble at that time, (4) the Veteran’s claim of continuity of treatment since the original incident while on active duty (5) the 2014 x-ray finding of syndesmosis suggestive of sequela of repetitive or old trauma and (5) the May 2016 treatment record showing an impression of mild soft tissue swelling with likely anterior tibiotalar joint effusion and findings of “productive changes in the syndesmosis are stable and likely sequela of prior trauma.” The examiner must explain whether there is any medical reason to accept or reject the Veteran’s report of continuity of treatment since the original incident while on active duty, including an explanation as to whether any current findings, including the 2014 and May 2016 impressions of “likely sequela of prior trauma” is attributable to the mechanism of injury in service. The examiner should explain whether any current x-ray findings are indicative of traumatic arthritis and, if so, whether such arthritis can be attributable to the in-service injury. The examiner is reminded that the absence of treatment, alone, is not a sufficient basis to find that a disability has not existed since service. T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T.S. Willie 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.