Citation Nr: 21021598 Decision Date: 04/13/21 Archive Date: 04/13/21 DOCKET NO. 16-19 649 DATE: April 13, 2021 REMANDED The claim of entitlement to service connection for a bilateral ankle disability is remanded. The claim of entitlement to service connection for a bilateral knee disability is remanded. The claim of entitlement to service connection for a low back disability is remanded. The claim of entitlement to service connection for headaches, as secondary to service-connected posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1987 to November 1991 and from March 1996 to February 1999 with additional service in the National Guard from 1991 to 1994. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this matter in February 2019 for additional development. The matter is now returned to the Board for further appellate review. 1. The claim of entitlement to service connection for a bilateral ankle disability is remanded. The Veteran contends his bilateral ankle disability was caused by his active duty service in the infantry. Specifically, the Veteran contends his duties as a paratrooper, rucking with heavy weight, and physical training caused his bilateral ankle disability. The Board notes the Veteran’s DD-214 reflects his military occupational specialty as “Infantry” and he received the “Parachutist Badge.” Pursuant to the February 2019 Board remand, the Veteran was afforded a VA examination in December 2019 to determine the nature and etiology of his claimed bilateral ankle disability. Significantly, while the December 2019 VA examiner noted that the Veteran was found to have subtalar arthrodesis in May 2018 after falling off a ladder, the examiner ultimately found that the Veteran did not have a current bilateral ankle disability. The examiner also opined that it was less likely than not that any current ankle disability is related to the Veteran’s military service as the examiner was unable to find evidence of an ankle condition in active duty service or recent VA records though it had been indicated previously. Significantly, the examiner noted that a left ankle disability is due to post-service trauma in 2018. Unfortunately, the December 2019 VA examination and medical opinion is inadequate to make an informed decision on the Veteran’s claim. First, with regard to the left ankle, the December 2019 VA examiner found both that the Veteran did not have a current left ankle disability and that the Veteran’s current left ankle disability was due to post-service trauma in 2018. As such, clarification is required as to whether the Veteran currently has a left ankle disability and if so, what that disability is. With regard to both ankles, while the December 2019 VA examiner found that the Veteran did not have a current bilateral ankle disability, the Board finds several references to ankle pain. For example, in a December 2011 VA treatment note, the Veteran reported bilateral ankle pain since the early 1990s. Moreover, the examiner attributed the Veteran’s left ankle pain to an injury after active duty service; however, the examiner does not explain why such condition is related to a 2018 injury as opposed to an in-service event or injury, to include his duties as a paratrooper and infantryman. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (probative value of a medical opinion is derived from it being factually accurate, fully articulated, and soundly reasoned). 2. The claim of entitlement to service connection for a bilateral knee disability is remanded. The Veteran contends his bilateral knee disability was caused by his active duty service in the infantry. Specifically, the Veteran contends his duties as a paratrooper, rucking with heavy weight, and physical training caused his bilateral knee disability. Moreover, the Veteran contends he injured his left knee when he crashed his dirt bike while using an on-base motocross track. As noted above, the Veteran’s DD-214 reflects his military occupational specialty as “Infantry” and he received the “Parachutist Badge.” Pursuant to the February 2019 Board remand, the Veteran was afforded a VA examination in December 2019 to determine the nature and etiology of his claimed bilateral knee disability. Significantly, the examiner diagnosed right knee strain as well as bilateral degenerative arthritis and was unable to state with 50 percent or greater probability whether the Veteran’s current knee conditions are related to his active duty service as knee degenerative joint disease (DJD) is a process occurring over time and not necessarily related to any issue that may have previously occurred. The examiner noted that there were no post-service treatment records showing a continuity of symptoms relating to knee strain or any other knee condition. Unfortunately, the December 2019 VA examination and medical opinion is inadequate to make an informed decision on the Veteran’s claim. First, the examiner does not appear to consider the Veteran’s unique circumstances as an infantryman, paratrooper, rucking, physical training, nor his dirt bike accident. Second, the examiner, in part, relied on the absence of post service medical records to support the negative medical opinion even though the Veteran has provided competent lay evidence that his bilateral knee condition began during active duty and continued since. The examiner appears to have impermissibly dismissed the Veteran’s reports of continuous knee problems solely because these complaints were not documented in medical treatment records. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). Therefore, a remand is necessary to obtain a new opinion that provides a reasoned rationale, based upon the entire record, in support of its conclusion. 3. The claim of entitlement to service connection for a low back disability is remanded. The Veteran contends his low back disability was caused by his active duty service in the infantry. Specifically, the Veteran contends his duties as a paratrooper, rucking with heavy weight, and physical training caused his low back disability. As noted above, the Veteran’s DD-214 reflects his military occupational specialty as “Infantry” and he received the “Parachutist Badge.” Pursuant to the February 2019 Board remand, the Veteran was afforded a VA examination in December 2019 to determine the nature and etiology of his claimed low back disability. Significantly, the examiner diagnosed lumbosacral strain and was unable to state whether any back symptoms the Veteran had in service would be related to his current symptoms as the medical records available do not support a back condition in active duty service that would be chronic or long lasting. Unfortunately, the December 2019 VA examination and medical opinion is inadequate to make an informed decision on the Veteran’s claim. First, as above, the examiner does not appear to consider the Veteran’s unique circumstances as an infantryman, paratrooper, rucking, physical training, nor his dirt bike accident. Second, the examiner, in part, relied on the absence of post service medical records to support the negative medical opinion even though the Veteran has provided competent lay evidence that his back condition began during active duty and continued since. The examiner appears to have impermissibly dismissed the Veteran’s reports of continuous back problems solely because these complaints were not documented in medical treatment records. Finally, the examiner did not opine whether the Veteran’s claimed low back disability was at least as likely as not related to his active duty. Rather, the examiner reported he was unable to state that any back symptoms the Veteran had in active duty service would be related to his current symptoms. The Board finds that the examiner did not state the likelihood of service connection with the appropriate degree of certainty. See Stefl v. Nicholson, 21 Vet. App. 120 (2007). 4. The claim of entitlement to service connection for headaches, as secondary to service-connected PTSD is remanded. The Veteran contends his headaches are caused by his service-connected PTSD. Pursuant to the February 2019 Board remand, the Veteran was afforded a VA examination in December 2019 to determine the nature and etiology of his claimed headaches. Significantly, the December 2019 VA headache examiner diagnosed migraine, including migraine variants, and was unable to state with 50 percent or greater probability that the Veteran chronic headaches are secondary to his service-connected PTSD as migraine headaches “are not related in causation to MH (mental health) issues.” Unfortunately, the December 2019 VA examination and medical opinion is inadequate to make an informed decision on the Veteran’s claim. First, the examiner failed to address whether the Veteran’s service-connected PTSD aggravates his headache disability. See 38 C.F.R. § 3.310; see also Atencio v. O'Rourke, 30 Vet. App. 74, 91 (2018) (causation and aggravation are independent concepts and should have separate findings and rationale); El-Amin v. Shinseki, 26 Vet. App. 136 (2013) (findings of “not due to,” “not caused by” and “not related to” are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b)). Further, while the examiner found that, as a general principle, headaches are not related to mental health issues but did not offer any support to this conclusion. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes to provide an examination, it must provide an adequate one). The matters are REMANDED for the following action: 1. Obtain an opinion from an appropriate clinician, preferably with a clinician other than the December 2019 examiner, to determine the nature and etiology of any bilateral ankle disability. Following evaluation of the Veteran, the clinician should identify any current disability of the ankles. If the clinician determines that an additional in-person examination is required, one should be scheduled. Please note, if the clinician deems it reasonable, an alternate format such as a telehealth interview is acceptable. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should: (a) clarify as to whether the Veteran has had an ankle disability during the appeal period, to include subtalar arthrodesis noted in May 2018 after falling off a ladder, and if so, what that disability is. (b) if the Veteran has had a disability of either ankle during the appeal period, opine whether it is at least as likely as not (50 percent or greater probability) that the ankle condition began in or is otherwise caused by the Veteran’s active service. The examiner should address a December 2011 VA treatment note, the Veteran reported bilateral ankle pain since the early 1990s. The examiner should also address the Veteran’s lay statements regarding his duties as a parachutist, infantryman, rucking, and physical training. If the examiner determines that disability of either ankle is related to a post-service injury, the examiner must explain why the ankle disability would be more likely due to a post-service injury than the in-service injuries described by the Veteran. This explanation must be supported by a rationale that goes beyond simply noting that the post-service injuries are documented in treatment records and the in-service injuries are not. 2. Obtain an opinion from an appropriate clinician, preferably with a clinician other than the December 2019 examiner, to determine the nature and etiology of any bilateral knee disability. Following evaluation of the Veteran, the clinician should identify any current disability of the knees. If the clinician determines that an additional in-person examination is required, one should be scheduled. Please note, if the clinician deems it reasonable, an alternate format such as a telehealth interview is acceptable. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any knee condition began in or is otherwise caused by the Veteran's active service. The examiner should address any other pertinent evidence of record, including the Veteran’s lay statements regarding his duties as a parachutist, infantryman, rucking, physical training, and his dirt bike accident. 3. Obtain an opinion from an appropriate clinician, preferably with a clinician other than the December 2019 examiner, to determine the nature and etiology of any low back disability. Following evaluation of the Veteran, the clinician should identify any current disability of the back. If the clinician determines that an additional in-person examination is required, one should be scheduled. Please note, if the clinician deems it reasonable, an alternate format such as a telehealth interview is acceptable. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that any low back condition began in or is otherwise caused by the Veteran’s active service. The examiner should address any other pertinent evidence of record, including the Veteran’s lay statements regarding his duties as a parachutist, infantryman, rucking, and physical training. 4. Obtain an opinion from an appropriate clinician, preferably with a clinician other than the December 2019 examiner, to determine the nature and etiology of the Veteran’s headaches. If the clinician determines that an additional in-person examination is required, one should be scheduled. Please note, if the clinician deems it reasonable, an alternate format such as a telehealth interview is acceptable. The selected examiner should provide an opinion addressing whether the Veteran’s headaches are at least as likely as not (50 percent probability or greater) proximately due to, or aggravated by, his service-connected PTSD. The examiner should also discuss whether, as a general principle, headaches are related to mental health issues as posited by the December 2019 VA examiner. The opinion must address both causation and aggravation to be deemed adequate. The examiner must be advised aggravation means an increase in the severity of the underlying disability beyond its natural progression. If aggravation is found, the examiner should attempt to quantify the degree of additional disability resulting from the aggravation above the baseline level of disability. The examiner must provide a comprehensive rationale for each opinion provided. The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports are to be considered in formulating any opinion. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. APRIL MADDOX Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Zachery S.C. Luce, Associate 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.