Citation Nr: 21028397 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-03 101 DATE: May 11, 2021 REMANDED Entitlement to service connection for residuals of broken right ankle/foot is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1981 to June 1984. This case is before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office. In November 2018, the Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the electronic claims file. In March 2020, the Board remanded the matter for further development. Now the matter is returned to the Board. The Veteran is seeking service connection for residuals of right ankle/foot. He contends that his current condition is due to an in-service right ankle fracture. However, the Board finds that more development is necessary prior to final adjudication. The Veteran underwent VA examinations in March 2021 for his right ankle and right foot conditions. The March 2021 examiner reported that the Veteran has a current diagnosis of calcaneal heel spur of the right foot, but provided that he does not have a current right ankle diagnosis. However, the Board notes that the examiner noted the Veteran's competent report of experiencing burning pain in the right ankle daily, which requires him to get off his feet after standing for about 2 hours. In this regard, the Board finds that an addendum opinion is required to clarify the Veteran's current right ankle condition. In Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), United States Court of Appeals for the Federal Circuit held that a disability for VA compensation purposes exists when pain causes functional impairment even if there is no underlying diagnosis. Thus, pain alone resulting in functional impairment is in fact a disability, and should not be summarily discounted as a bar to benefits based on a finding of no current diagnosis. The March 2021 examiner stated that the Veteran does not have "significant functional impairment" as he only has to "get off his feet at times." As such, the Board finds that a remand is required to clarify the Veteran's current right ankle diagnosis, to include functional impairment due to right ankle pain. Further, the examiner provided that the Veteran's calcaneal heel spur of the right foot is unrelated to his claimed in-service injury because the toolbox landed on top of his foot. However, the Board finds this rationale conclusory and additional explanation on the etiology of the Veteran's calcaneal heel spur of the right foot should also be obtained in order to make a fully informed decision. Accordingly, the matter is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) must obtain an addendum opinion from the March 2021 VA examiner regarding the Veteran's service connection claim for residuals of broken right ankle/foot. If the March 2021 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. If the examiner determines that a new examination is necessary, the AOJ should schedule one for the Veteran. The examiner should review the Veteran's claims file and a copy of this REMAND order before rendering the requested addendum opinion. (a.) The examiner is asked to clarify the Veteran's current right ankle diagnosis. If no diagnosis is found, the examiner is asked to address the Veteran's functional impairment due to his right ankle pain. (b.) The examiner must opine whether the Veteran's current right ankle disability and/or functional impairment due to right ankle pain is at least as likely as not (50 percent or greater probability) related to his in-service injury or had its onset in service. (c.) The examiner must opine whether the Veteran's current right foot disability is at least as likely as not (50 percent or greater probability) related to his related to his in-service injury or had its onset in service. (d.) The examiner is advised that the Veteran is competent to report his symptoms and history and such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, the examiner must provide an explanation for such rejection. (e.) The examiner must provide a complete written rationale for any opinion offered. If it is not possible to provide an opinion without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner does not have the knowledge or training. 2. After completing the above actions and any other necessary development, the issue on appeal must be readjudicated. If the claim remains denied, a Supplemental Statement of the Case must be provided to the Veteran. After the Veteran has had an adequate opportunity to respond, the appeal must be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. E. Kim, 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.