Citation Nr: 21040575
Decision Date: 07/06/21	Archive Date: 07/06/21

DOCKET NO. 17-05 148
DATE: July 6, 2021

REMANDED

Entitlement to service connection for a right ankle disability is remanded.

REASONS FOR REMAND

The Veteran served on active duty from July 2009 to April 2013, with additional service in the Marine Corps Reserves.

At an April 2021 Board hearing, the Veteran testified that during service he injured his ankle "many times" during physical training and on hikes, but did not seek treatment at the time, but would "take it a little lighter that day." He testified that as service progressed, the right ankle got worse. Shortly after service he "ended up in the ER when [his ankle] kind of turned over real bad." The Veteran testified that he was told at the time that his ankle complaints were "likely" related to service.

A September 2014 record from Perry Memorial Hospital details the Veteran's complaints of right ankle pain after a fall and he "stepped down wrong." An x-ray report showed bone density that "may be from previous trauma." 

The claim is remanded to obtain a medical opinion. 38 C.F.R. § 3.159 (c)(4). The competently testified to ankle problems during service, without documented treatment, and the September 2014 medical record refers to a possible relationship to "previous trauma." 

The matters are REMANDED for the following action:

1. Ask the Veteran to identify any providers (both VA or private) who treated him for right ankle complaints since service. Take all appropriate action to obtain all identified records.

2. After completion of the above, schedule the Veteran for an examiner with an appropriate clinician to determine the nature and likely etiology the right ankle disability. Copies of all pertinent records must be made available to the examiner. 

The examiner is asked to answer the following questions:

(a) Identify any diagnosed right ankle disability. 

(b) Is it at least as likely as not that any diagnosed right ankle disability was incurred in or is otherwise related to service?  In answering this question, the examiner must specifically consider the following: (i) the Veteran's testimony that during service he suffered ankle injuries during physical training and on hikes, but self-treated and (ii) the September 2014 x-ray from Perry Memorial Hospital noting "may be from previous trauma." 

A complete rationale must be provided for all opinions. If the examiner cannot provide an opinion without resort to speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge; the examiner's own expertise, or; whether additional facts are required and note what, if any, additional evidence would permit such an opinion to be made.

 

 

M.E. Larkin

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	S.E. Bresler, 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.