Citation Nr: 21039890 Decision Date: 07/01/21 Archive Date: 07/01/21 DOCKET NO. 16-46 791 DATE: July 1, 2021 REMANDED Entitlement to service connection for left ankle sprain is remanded. REASONS FOR REMAND The appellant had active service in the Army from October 1986 to September 1987. She also served in the Ohio National Guard from 1988 to February 2009. This matter comes before the Board of Veterans' Appeals (Board) on appeal from the April 2013 rating decision. In September 2019, the Board denied the service connection claims for left ankle disability and headache disability. The Veteran appealed the September 2019 Board decision to the United States Court of Appeals for Veterans Claims (Court). In November 2020, the Court issued a Memorandum Decision, finding that the Board provided inadequate reasons and bases for determining that the appellant's two-week National Guard training in question did not constitute ACDUTRA per regulation. The Court further noted that the July 2004 document shows an ankle injury during ACDUTRA but that it was not incurred in the line of duty. Accordingly, the Court set aside the denial of the service connection claim for left ankle disability and remanded the claim for readjudication. The remainder of the appeal was dismissed. The Veteran asserts she injured her left ankle while dismounting from a large vehicle during National Guard annual training in July 2004, and that she continues to have sharp pains in her ankle. See November 2011 Statement in Support of Claim and September 2016 VA Form 9. As an initial matter, the Veteran has been diagnosed with a left ankle sprain. See May 2012 VA Examination Report. In a July 2004 statement of medical examination and duty status completed by her unit commander, it was noted that the Veteran was on ACDUTRA for the period from July 10, 2004 to July 24, 2004, and during that period of ACDUTRA she injured her left ankle on July 15, 2004 while training at Camp Grayling. While that information is clear, the line of duty determination is not. In Question 11.d. on the same form, the box was checked indicating the injury was not incurred in the line of duty, with no accompanying explanation; in response to question 15, details of the accident or history of disease, it noted, "How...training hurt ankle L ankle strain vs. arthritis, Where...Camp Grayling, When...20040715;" and question 32, injury considered to have been incurred in line of duty, the box for "no" was checked and the box for "yes" was checked and circled. Nonetheless, in consideration of the evidence, to include the Veteran's lay statements regarding the onset of the injury and the statement of medical examination and duty status, there is sufficient evidence which to determine the injury was sustained during a period of ACDUTRA. Specifically, it appears that the circled "yes" was to correct the checked box for "no" as to whether the injury incurred in the line of duty. Nevertheless, the Board finds that a remand is necessary to help determine the likely etiology of the currently diagnosed left ankle disability. The Veteran was provided a VA examination in May 2012. In the corresponding medical opinion, the examiner opined the ankle injury was less likely related to one problem in the 1980s but rather was natural age progression. The Board finds the opinion to be inadequate. First, the examiner specifically refers to an injury in the 1980s despite the Veteran's contention which specifically referred to her injury in July 2004. Reonal v. Brown, 5 Vet. App. 458, 461 (1993). Next, the examiner found the current disability was the result of natural age progression but failed to explain why such was more likely. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Accordingly, an adequate examination is necessary prior to deciding the claim on the merits. The matters are REMANDED for the following action: 1. Provide the Veteran with a VA examination and medical opinion to help determine the nature and etiology of her left ankle disability, to include left ankle sprain. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. After a review of the claims file and examination of the Veteran, the examiner is asked to respond to the following: (a) Elicit from the Veteran the history of all signs and symptoms associated with the claimed left ankle disability during the 2004 period of ACDUTRA and since that time. (b) Identify all current (diagnosed from date of claim in October 2011) left ankle disabilities shown, to include left ankle sprain. All necessary diagnostic studies and tests should be performed. (c) For each current left ankle disability, to include left ankle sprain, provide an opinion as to whether it at least as likely as not (50 percent or higher probability) had its onset during service, specifically the July 2004 event where the Veteran injured her ankle stepping off of a large vehicle. In so doing, the examiner is asked to address the Veteran's treatment in service, including (i) her July 2004 Statement of Medical Examination and Duty Status regarding the onset of her pain and diagnosis of left ankle strain versus arthritis; (ii) her September 2005 diagnosis of left ankle synovitis, tenosynovitis, and tarsal tunnel syndrome; and (iii) her lay statements within the November 2011 Statement in Support of Claim and September 2016 VA Form 9 regarding the onset and symptomatology. A complete rationale should be provided for all opinions. 2. Thereafter, readjudicate the remanded claim. A. Yaffe Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Moldawer, 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.