Citation Nr: 21023837 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 13-13 686 DATE: April 21, 2021 ORDER Entitlement to service connection for a right ankle disability is granted. Entitlement to service connection for a left ankle disability is granted. FINDING OF FACT Right and left ankle pain are presumed to be related to the Veteran’s service in Southwest Asia. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right ankle disability have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.317 (2020). 2. The criteria for entitlement to service connection for a left ankle disability have been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.317 (2020). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran had active military service from August 1985 to May 1988 and June 1988 to June 1992, to include service in Southwest Asia from October 1990 to April 1991. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from April 2011 rating decisions issued by the Department of Veteran Affairs (VA) Regional Office (RO). In connection with this appeal, the Veteran testified at a hearing before the undersigned Veterans Law Judge in August 2017. A transcript of that hearing has been associated with the claims file. This case was previously before the Board, most recently in November 2020, at which time the issue currently before the Board was remanded for additional development. The case has now been returned to the Board for further appellate action. Service Connection – Right and Left Ankle Disabilities The Veteran contends that he has right and left ankle paint hat began while he was ina active service, and has continued since that time. Service treatment records (STR’s) are silent for complaints of, treatment for, or a diagnosis of a right or left ankle disability while the Veteran was in service. Regardless, the Veteran has reported that he first experienced ankle pain during active service, and that the symptoms have continued since that time. Moreover, the Board finds the Veteran credible in that respect. Heuer v. Brown, 7 Vet. App. 379 (1995); Falzone v. Brown, 8 Vet. App. 398 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). A review of the post-service evidence of record shows that the Veteran has a history of reporting ankle pain since at least June 2011. At a March 2013 Gulf War general medical examination, the Veteran reported that he began having ankle pain with any exercise. Upon physical examination, the reflex and sensory examinations yielded normal results for the Veteran’s right and left ankles. There was no diagnosis of a right or left ankle disability made at that time. At a January 2018 VA examination, the examiner did not diagnose a chronic right or left ankle disability, and merely noted ankle strain. The Veteran had current symptoms of swelling, stiffness, numbness, and sharp pain. The examiner opined that the Veteran’s bilateral ankle disability 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 stated that the claims file was silent for any complaints, diagnosis, or treatment while the Veteran was in service. At an August 2018 VA examination, the examiner found that the Veteran did not have a current right or left ankle disability despite the Veteran’s reports of constant ankle pain. X-rays at that time were negative for any pathology to support a diagnosis of a chronic right or left ankle disability. The examiner opined that the claimed right and left ankle disabilities were less likely than not (less than 50 percent or greater probability) incurred in or caused by the claimed in-service injury, event, or illness. In so finding, the examiner noted that there was no documented in-service injury. At a January 2020 VA examination, the examiner did not make a diagnosis of a chronic right or left ankle disability, and diagnosed ankle strain. X-rays at that time were negative for any pathology to support a diagnosis of a chronic right or left ankle disability. In January 2021, an addendum medical opinion was sought. At that time, the VA examiner stated that the Veteran did not have a current right or left ankle disability. In sum, the Veteran had active service in Southwest Asia. He has reported that he has experienced right and left ankle pain since service. There is no pathology to render a diagnosis of a right or left ankle disability to account for the Veteran’s reported right and left ankle pain. Further, the Veteran has painful motion of both his right and left ankle sufficient to warrant a 10 percent rating for each. As such, the Veteran’s unexplained right and left ankle pain are presumed to be related to his service in Southwest Asia. 38 C.F.R. § 3.317. Accordingly, the Board finds that the evidence for and against the claims is at least in equipoise. Therefore, the benefit of the doubt must be resolved in favor of the Veteran, and entitlement to service connection for right and left ankle pain is warranted. 38 U.S.C. § 5107 (b) (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Ivan Franklin 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.