Citation Nr: 21015487
Decision Date: 03/17/21	Archive Date: 03/17/21

DOCKET NO. 18-39 402
DATE: March 17, 2021

REMANDED

Entitlement to service connection for a left ankle disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty from July 2013 to July 2017. 

This matter was previously before the Board in April 2019. The Veteran appealed the Board’s decision to the United States Court of Appeals for Veterans Claims (Court). In an October 2020 order, the Court remanded the case to the Board for action consistent with an October 2020 Joint Motion for Partial Remand (JMPR).

1. Entitlement to service connection for a left ankle disability is remanded.

The April 2017 VA examination of record was determined to be inadequate. Service treatment records show complaints of left ankle pain and that the Veteran was placed on profile in February 2017 for a left ankle problem. Further, the 

 

Veteran reported during the April 2017 examination that she felt sharp pain in the ankle when pressure is applied. However, the examiner recorded that no pain was noted on examination. The examiner also indicated that the Veteran’s medical records were not reviewed. As the examination is not based upon consideration of the Veteran’s prior medical history, it is inadequate. Remand is necessary to obtain an adequate examination. 

The matter is REMANDED for the following action:

1. Schedule the Veteran for a VA examination for the left ankle. The examiner must review the claims file.

Does the Veteran have a pathology (disease or residual of injury) to account for the complaint?  If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below.

The examiner is asked to provide a response to the following question.

For any identified left ankle disability: Is the disability at least as likely as not related to service? 

Provide a rationale to support the opinion(s).  

2. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal.  If the benefit sought is not granted to 

 

the Veteran’s satisfaction, send the Veteran and her representative a Supplemental Statement of the Case and provide an opportunity to respond.  If necessary, return the case to the Board for further appellate review.

  

 

 

H. N. SCHWARTZ

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	A. Creegan

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.