Citation Nr: 21021840 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 14-31 159 DATE: April 14, 2021 REMANDED Entitlement to service connection for a right ankle condition is remanded. Entitlement to service connection for a right upper extremity condition, to include neuropathy is remanded. REASONS FOR REMAND The Veteran served on active duty from March 2001 to July 2001 and from January 2003 to December 2003. Evidence affiliated with the claims file also indicates that the Veteran served in the Reserve, from which he was discharged in April 2008. This matter again comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Roanoke, Virginia. The Board remanded this matter in April 2018. The Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference in January 2021; a transcript is of record. 1. Right Ankle Condition 2. Right Upper Extremity Condition to Include Neuropathy As a preliminary matter, the Board acknowledges that the Veteran served in the Army Reserve for an undisclosed period of time until his discharge effective April 2008. See April 2008 Letter from Department of the Army Headquarters. Though there are service treatment records and service personnel records associated with the claims file reflecting the Veteran’s education, performance, assignments, points, and awards, the precise dates of all periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA) are not available. On remand, the RO should confirm the Veteran’s periods of ACDUTRA and INACDUTRA. Furthermore, the Veteran’s service treatment records affiliated with his Reserve service should also be obtained and associated with the claims file. In November 2018, the Veteran was examined to determine the nature and etiologies of his current right ankle and right upper extremity disabilities. However, the Board finds that these examinations are inadequate. Although the examiners concluded that the Veteran’s conditions were less likely than not related to his active duty service, the examiners did not address the Veteran’s service medical records reflecting chronic complaints of right upper extremity pain or that he was diagnosed with “chronic pain in ankle” during service. See August 2003 Service Treatment Records; June 2002 Service Treatment Record. Because the VA examiners did not consider or address the Veteran’s relevant pertinent service treatment records, the Board finds that new opinions are to be obtained. Furthermore, after the issuances of the November 2018 and December 2018 VA opinions, the Veteran submitted lay statements, including his January 2021 hearing testimony and a January 2021 written statement by his spouse, regarding the onset and continuity of his symptomatology. See May 2019 Correspondence from Veteran; January 2021 Hearing Transcript; January 2021 Statement by Veteran’s Wife. Therefore, the Board finds that these statements should also be considered and addressed in the addendum opinions. Moreover, after the November 2018 examination, the Veteran’s VA medical records reflect that he visited a non-VA hospital facility for body aches, including shoulder pain. See December 2018 VA Advice Line Record and Addendum. Because the records from said non-VA hospital are not affiliated with the claims file, the Board finds that these records should be obtained on remand in addition to any and all updated VA treatment records. The matters are REMANDED for the following action: 1. The RO should determine the specific dates of when the Veteran served on ACDUTRA and/or INACDUTRA. In this regard, a report detailing the Veteran’s award of reserve retirement points will NOT represent compliance with this instruction. Rather, each and every date of ACDUTRA and INACDUTRA must be identified. Then, issue a memorandum for inclusion in the claims file detailing each period of verified active military service, whether on active duty, ACDUTRA, or INACDUTRA. Any and all outstanding service treatment records from the Veteran’s Reserve service should also be obtained and associated with the claims file. 2. The RO should request the Veteran to identify any and all outstanding and/or updated VA and/or private medical records, including from a visit to a non-VA facility in December 2018 for body aches including shoulder pain. Appropriate efforts must be made to obtain these records if he has adequately identified them and authorized their release (with respect to any private medical records). He should also be invited to submit these records himself. All actions to obtain the requested records should be documented in the claims file. If they cannot be located or no such records exist, the Veteran and his representative should be so notified in writing. 3. Then, forward the claims file to an appropriate clinician for an addendum opinion to determine the nature and etiology of the Veteran’s right ankle condition(s). The entire claims file, including a copy of this remand, must be made available to the clinician, who must note its review. If the clinician determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be obtained. (a) The clinician should identify any and all right ankle condition(s) attributable to the Veteran throughout the appellate period. (b) For each condition so identified, the clinician should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s condition manifested during, or is the result of, his active duty service, ACDUTRA, and/or INACDUTRA. In formulating his or her opinion, the clinician should consider and address all competent medical and lay evidence of record, including, but not limited to: (i) The Veteran’s service treatment records; (ii) The Veteran’s VA medical records; (iii) The Veteran’s private medical records, if obtained; and (iv) The Veteran’s and Veteran’s wife’s competent lay statements of record, including May 2019 Correspondence from the Veteran, the Veteran’s January 2021 hearing testimony, and the Veteran’s wife’s January 2021 written statement, regarding the Veteran’s first-hand experiences during service and the onset and continuity of his symptomatology. If the clinician determines that the Veteran’s right ankle condition(s) is/are less likely than not due to his active duty service, ACDUTRA, and/or INACDUTRA, the clinician should discuss what other factor(s) caused the disorder(s). A complete rationale must be provided for all opinions and conclusions reached. 4. Forward the claims file to an appropriate clinician for an addendum opinion to determine the nature and etiology of the Veteran’s right upper extremity condition(s). The entire claims file, including a copy of this remand, must be made available to the clinician, who must note its review. If the clinician determines that a new examination (or telehealth interview, etc., if an in-person examination is not feasible) would be beneficial, one is to be obtained. (a) The clinician should identify any and all right upper extremity condition(s) attributable to the Veteran throughout the appellate period. (b) For each condition so identified, the clinician should opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s condition manifested during, or is the result of, his active duty service, ACDUTRA, and/or INACDUTRA. In formulating his or her opinion, the clinician should consider and address all competent medical and lay evidence of record, including, but not limited to: (i) The Veteran’s service treatment records; (ii) The Veteran’s VA medical records; (iii) The Veteran’s private medical records, if obtained; and (iv) The Veteran’s competent lay statements of record, including May 2019 Correspondence from the Veteran and the Veteran’s January 2021 hearing testimony regarding his first-hand experiences during service and the onset and continuity of his symptomatology. If the clinician determines that the Veteran’s right upper extremity condition(s) is/are less likely than not due to his active duty service, ACDUTRA, and/or INACDUTRA, the clinician should discuss what other factor(s) caused the disorder(s). A complete rationale must be provided for all opinions and conclusions reached. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Seserman 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.