Citation Nr: 21026509 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 10-21 202 DATE: May 3, 2021 ORDER Service connection for a left ankle disability, to include achilles bone spur and lateral collateral ligament sprain (claimed as a left leg disability) is granted. REMANDED The issue of service connection for diabetes mellitus, type II (DM II), to include as secondary to service-connected disabilities is remanded. FINDING OF FACT The Veteran's left ankle disability is related to the left ankle injury sustained during service. CONCLUSION OF LAW The criteria to establish service connection for a left ankle disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1979 to August 1983, and from January to May 1991, with additional Reserve service. This matter come before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In the January 2019 decision, the Board denied service connection for a left leg disability, DM II, and hypertension. The Veteran appealed the claims to the United States Court of Appeals for Veterans Claims (Court). In a September 2019 Joint Motion for Partial Remand (JMPR), the parties requested that the Court vacate and remand the January 2019 Board decision. In April 2020, the Board remanded the claims for further development. In November 2020, the RO granted service connection for hypertension therefore, the claim is no longer before the Board. Service Connection for a Left Ankle Disability The Veteran contends that her left ankle disability was related to injury that occurred during a period of reserve service. The Board concludes that the Veteran has a current disability that is related to in-service injury to her left ankle. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The November 2017 and December 2020 VA ankle examinations show the Veteran has current diagnoses of achilles bone spur and lateral collateral ligament sprain. During service, the Veteran was seen for an incident where she twisted her ankle after tripping over some cables. There was swelling over her left lateral malleolus and her anterior lateral collateral ligament was tender and swollen. The Veteran was diagnosed at that time with a strain and/or sprain. Thus, the question becomes whether the current disability is related to service. On this question there are probative opinions in favor of and against the claim. The evidence against the claim includes the November 2017 VA medical opinion. The examiner opined that the Veteran's left ankle disability was less likely than not related to exertional activity in service and it was less likely than not that the Veteran left ankle disability was caused or aggravated by a service-connected disability. The examiner reasoned that the one injury sustained to the left ankle during service was isolated and there was no evidence to support continuity or chronicity of the injury. The examiner further explained that the left ankle disability was not caused or aggravated by a service connected disability as service connection was not in effect for DM II and the Veteran's symptoms were not associated with diabetic neuropathy. The evidence in favor of the claim includes the December 2020 VA medical opinion. The examiner opined that the Veteran's left ankle disability was at least likely as not due to the left ankle service injury. The examiner based the opinion on examination of the Veteran, consideration of the Veteran's lay assertions indicating that she suffered injury to her left ankle during service from which the condition never improved and she continued to experience swelling and pain since the injury, and review of the record. Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current left ankle disability is related to service. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a left ankle disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND The issue of service connection for DM II, to include as secondary to service-connected disabilities is remanded. The matter is REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: There has not been substantial compliance with the Board's previous remand directives regarding the issue. Another remand is required. Stegall v. West, 11 Vet. App. 268, 271 (1998). In the April 2020 Board remand, the examiner was instructed to provide an opinion as to the Veteran's DM II on a secondary basis. The examiner was specifically instructed to provide a complete rationale for the opinion rendered. Review of the subsequent August 2020 VA medical opinion reveals that this was not accomplished. The examiner provided a conclusory opinion without any rationale. Additionally, following this opinion the Veteran was granted service connection for hypertension and coronary artery disease (CAD). The Board finds an additional opinion is required to determine if any of the Veteran's service connected disabilities caused or aggravated the Veteran's DM II. 2. Obtain an addendum from an appropriate VA physician to determine the nature and etiology of the Veteran's DM II. If the examiner finds an examination is required one should be scheduled. The electronic file, including a copy of the Remand, must be reviewed by, the VA examiners. Based upon a review of the relevant evidence of record, history provided by the Veteran, and sound medical principles, the VA examiner should provide the following opinion: The examiner should opine if the Veteran's DM II is proximately due to or aggravated (e.g. worsened, and if so, to what degree) by the Veteran's service-connected disabilities? The examiner is advised: He/she must fully explain the opinion. A summary conclusion is not sufficient under the law and the opinion will be returned for further clarification. The examiner must review the entire record in conjunction with rendering the requested opinions. IN ADDITION TO ANY RECORDS THAT ARE GENERATED BECAUSE OF THIS REMAND, the VA examiner's attention is drawn to the following: *Service connection is in effect for CAD, gastroduodenitis, major depressive disorder, and hypertension. 3. After completing the requested actions, and any additional actions deemed warranted, readjudicate the claim on appeal. If the benefit sought on appeal remains denied, the Veteran and her representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. McDuffie, 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.