Citation Nr: 21026668 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 14-39 108 DATE: May 3, 2021 REMANDED Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1999 to January 2005. This matter comes before the Board of Veterans' Appeals (Board) from a September 2010 rating decision by the Agency of Original Jurisdiction (AOJ). The Board denied the instant claims in August 2018. The Veteran appealed to the U.S. Court of Appeals for Veterans Claims (Court). In an April 2020 Memorandum Decision, the Court vacated the Board's decision and remanded the appeal for proceedings consistent with its decision. In December 2020, the Board remanded the appeal for development of the record. It directed that an examination be conducted to determine the nature and etiology of the Veteran's right and left ankle disabilities. In February 2021, the Veteran was afforded a VA examination. The examiner opined that the Veteran's bilateral ankle disability "is less likely than not incurred in or caused by (the) ITS ONSET [sic] during service." See February 2021 VA examination report. The examiner acknowledged the idea that the Veteran is deemed competent as to history and symptoms and thus, the Veteran's statements should be given consideration in his opinion. However, the examiner ultimately concluded that "there are no records to support the claim and no records have been found that will confirm consultation or treatment relative to ankle condition during service, no nexus has been established." Id. Therefore, despite the acknowledgement that the Veteran is competent to report his history of an ankle injury and continued symptoms, it appears the examiner based his negative opinion predominantly on lack of evidence in the Veteran's record. This conclusion is not adequate for rating purposes. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Moreover, a medical opinion that ignores relevant evidence, including lay evidence, is inadequate because it fails to take into account the Veteran's medical history. See McKinney v. McDonald, 28 Vet. App. 15, 30 (2016); see also Monzingo v. Shinseki, 26 Vet. App. 97, 107 (2012) (concluding that a medical opinion based on an inaccurate factual premise, i.e., an incomplete medical history, has no probative value). Therefore, the Board finds that the February 2021 examiner's opinion is inadequate for adjudicative purposes and remand is required. The examiner was also asked to provide a secondary service connection opinion regarding the Veteran's bilateral knee disability. The examiner opined "that the current diagnosis of lateral collateral ligament strain is less likely than not related to the service-connected bilateral knee disabilities as there is no known causal relationship between the two conditions." See February 2021 VA examination report. The Board finds this statement to be conclusory and not supported by any rationale. As to the question of aggravation, the examiner stated that "Medical evidence is not sufficient to support a determination of a baseline level of severity. No medical evidence is found to confirm aggravation of condition by military service or any service connected condition." See February 2021 VA examination report. The examiner further added, "No records has [sic] been found that will confirm aggravation therefore it is less likely than not that the diagnosed collateral ligament strain is aggravated beyond its natural progression by the service connected bilateral knee disability." Id. Here again, the examiner based this opinion on lack of medical evidence or records, and failed to provide supporting rationale. Considering the above discussion, the Board has determined that an additional medical opinion is necessary. The matters are REMANDED for the following action: 1. Obtain any outstanding VA and/or private treatment records relevant to treatment the Veteran received for his bilateral ankle disability that are not already of record. All obtained records should be associated with the evidentiary record. If any identified records are not obtainable (or none exist), the Veteran and his representative should be notified, and the record clearly documented. 2. Thereafter, obtain an opinion from an appropriately qualified VA clinician to determine the nature and etiology of the Veteran's bilateral ankle disability. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the reviewing clinician. The opinions must include a notation that this record review took place. It is up to the discretion of the reviewing clinician whether a physical examination of the Veteran is needed to answer the questions below. The reviewing clinician should answer the following: (a.) Is it at least a likely as not that the Veteran's bilateral ankle disability was incurred in or is otherwise related to active service, to include the Veteran's reported ankle sprain in service and continued symptoms since? (b.) Is it at least as likely as not that the Veteran's bilateral ankle disability was proximately caused or aggravated by his service-connected bilateral knee disability? In rendering these opinions, the reviewing clinician is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the reviewing clinician rejects the Veteran's reports, he or she must provide an explanation for such rejection. The reviewing clinician is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If an opinion cannot be provided without resorting to mere speculation, the reviewing clinician must provide a complete explanation for why an opinion cannot be rendered. In so doing, the reviewing clinician must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that question. (Continued on the next page) 3. After the above has been completed to the extent possible, readjudicate the claims. If any benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case (SSOC), and return the case to the Board. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Katie Poe, 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.