Citation Nr: 21032075 Decision Date: 05/25/21 Archive Date: 05/25/21 DOCKET NO. 16-12 114 DATE: May 25, 2021 REMANDED Entitlement to service connection for a right ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the U.S. Marine Corps from December 2008 to December 2012. Initially, the Board notes that when this appeal was last before the Board in August 2019 the issues of entitlement to service connection for a bilateral knee, bilateral ankle, right shoulder, and low back disability were remanded for further development. In October 2020, however, the Agency of Original Jurisdiction (AOJ) granted service connection for left knee, right knee, left ankle, and lumbar spine disabilities. Service connection for a right shoulder disability was granted in January 2021. The Veteran has not expressed disagreement with the evaluations and/or effective dates assigned. As the benefits sought on appeal have been granted, these issues are no longer before the Board. The Veteran appeals the denial of service connection for a right ankle disability. In relation to his claim, the Veteran was afforded a VA examination in February 2020. During the examination, the Veteran reported that his ankle condition started in 2009 and it progressed over time. The VA examiner, however, found that there was no objective evidence to render a diagnosis related to the claimed right ankle condition at that time. Although there was no evidence of pain noted on examination, the record shows that the Veteran has consistently reported bilateral ankle pain and functional limitations resulting therefrom. Furthermore, during the December 2012 VA examination, the Veteran was noted to have a diagnosis of bilateral ankle sprain resolved in 2010. The Veteran reported occasional bilateral ankle pain with prolonged standing during this examination. It is also noted that the Veteran was fitted for right ankle support in June 2016. The Board notes that a Veteran may be service-connected for pain with functional impairment. See Saunders v. Wilkie, 886 F.3d 1356 (2018). Accordingly, a remand is warranted to afford the Veteran an opportunity to undergo a new examination to ascertain the nature and etiology of his right ankle pain, to include determining whether the pain amounts to functional impairment such that it is considered a disability. Id. The matters are REMANDED for the following action: 1. Associate with the claims folder updated treatment records. 2. Schedule the Veteran for a VA examination to determine the nature and etiology of his right ankle pain. The examiner must be provided access to the Veteran's electronic claims file. After review of the record, the examiner is requested to provide an opinion as to whether it is at least as likely as not that a right ankle disorder had its onset in service or is attributable to service, including as a result of lifting heavy objects weighing from 60 to 120 pounds while deployed, as a result of trauma from his January 2012 motor vehicle accident and/or the general rigors of military service. If no diagnosis is able to be assigned, the examiner must discuss the impact of the right ankle pain upon the Veteran's functional impairment of earning capacity. In this regard, it is important to note that functional impairment of earning capacity is ultimately a determination for adjudicators to make, however, information and impressions from the VA examiner will be helpful to adjudicators in understanding the effects of the Veteran's right ankle pain. The examiner should take into account that the Veteran was fitted for right ankle support in June 2016. In so doing, the examiner should explain whether there is any medical reason to accept or reject the Veteran's belief that his current disorder is related to service, including why his December 2012 report of bilateral ankle pain and pain with prolonged standing does not represent the onset of a chronic orthopedic disorder during service. In doing so, the examiner should also consider the following: service treatment records which show treatment for a right ankle injury in August 2009 from playing soccer which also reported a history of untreated right ankle trauma during bootcamp; complaints of ankle pain following a motor vehicle accident in January 2012; the Veteran's description of bilateral ankle pain/laxity on his July 2012 pre-discharge compensation claim; the Veteran's claim that his current conditions are a direct result from the January 2012 accident; and his claims that his gradual decline in performing physical training tests was due to his orthopedic disorders. A complete rationale for any opinion should be provided. The examiner must not rely solely on the absence of a diagnosis or symptom in service as the basis for a negative opinion. It is also noted that the mere passage of time without treatment is not a sufficient basis for finding that no relationship between a current disability and service exists. Any opinion should be reconciled with the service treatment and personnel records, any post-service diagnoses, lay statements, and testimony of the Veteran. If the lay evidence is rejected, an explanation must be provided. If an opinion cannot be made without resort to speculation, please state so and include an explanation for that conclusion. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.S. Willie 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.