Citation Nr: 21042401 Decision Date: 07/13/21 Archive Date: 07/13/21 DOCKET NO. 16-03 230 DATE: July 13, 2021 REMANDED Entitlement to service connection for a right ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from December 1990 to August 1994. Also, he had active duty for training from January 1985 to May 1985. This matter comes before the Board of Veterans' Appeals ("Board") on appeal from a June 2012 rating decision of the Department of Veterans Affairs ("VA") Regional Office ("RO"). The Board remanded this matter in September 2020 and directed the RO to obtain an addendum VA medical opinion on the nature and etiology of the Veteran's right ankle disability. Consequently, the RO obtained a medical opinion in October 2020. However, the Board finds the October 2020 opinion inadequate for deciding the issue on appeal. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). Regrettably, the Board finds that further remand is necessary in this matter. Entitlement to service connection for a right ankle disability is remanded. The Veteran contends that his right ankle disability is related to military service. Specifically, in the November 2015 VA form 9 the Veteran asserted that he injured his right ankle in service and was treated by a medic in Germany in 1992. He reportedly was seen at the aid station in Germany on at least two occasions, where his ankle was wrapped, and the Veteran was placed on a profile. He further asserted that he was seen again in 1995 for his ankle when it started causing him pain, as it does now. In the September 2020 remand, the Board found the Veteran competent to attest factual matters of which he had first-hand knowledge, including observable symptomatology. Hence, the Board directed the RO to obtain an addendum opinion on the nature and etiology of his right ankle disability and advised the examiner to address the Veteran's contentions regarding the claimed in-service injury. Pursuant to the September 2020 Board's remand, a medical opinion was obtained in October 2020, in which the examiner noted a right ankle sprain and opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As a rationale, the examiner stated that no service treatment records were found to address the right ankle condition, including the October 1993 exit examination. The examiner noted that the exit examination was very detailed regarding self-reported symptoms, and it is unlikely that the Veteran would not mention right ankle issues. The examiner stated that the records are silent for right ankle issue and first indication of this issue was in 2010. Also, the examiner noted that the Veteran's June 2012 right ankle Xray and MRI in 2015 were normal. If the Veteran had right ankle condition/instability since 1992, the MRI in 2015 would show chronic changes. Therefore, the examiner concluded that it was less likely than not that the right ankle condition was incurred in service. The Board finds the above October 2020 VA medical opinion inadequate because it is based on wrong factual premise. The examiner found that the first indication of right ankle issue was in 2010, however, the Board notes that a VA examiner in May 1995 noted the complaints of right ankle pain and made findings of lateral instability on examination. Therefore, a remand is warranted to obtain an addendum medical opinion for addressing this important medical record. Additionally, the Board notes that there are no treatment records in the claims file from May 1995 to August 2009. Therefore, RO should try to obtain any outstanding VA and private treatment records for this time period and request the Veteran to assist VA in locating these records, if possible. The matter is REMANDED for the following action: 1. Obtain any outstanding VA and private treatment records, specifically records from May 1995 to August 2009. Request the Veteran to assist VA with locating these records, if possible. Associate these records with the claims file. 2. Forward the claims file, and a copy of this remand to the examiner who rendered the October 2020 medical opinion, or to an appropriate clinician if the October 2020 examiner is unavailable, to obtain an addendum opinion on the nature and etiology of the Veteran's right ankle disability. Further in-person examination is left to the discretion of the clinician providing the opinion. If the clinician deems such examination is necessary, then an examination should be scheduled. 3. After reviewing the claims file and copy of this remand, the examiner should provide an opinion as to whether it is at least as likely as not that the Veteran's right ankle disability had its onset during his period of active service, or related to an in-service injury, event, or disease, including the claimed right ankle injury during service in 1992. In providing the above opinion, the examiner is advised to address the Veteran's contentions and VA medical record associated with the claims file with entries dated: (i) 05/23/1995, titled "VA Examination," which contains a notation of right ankle pain and findings of lateral instability by the examiner during a May 1995 VA examination; (ii) 11/30/2015, titled "Congressionals," page number 2 and 3, which includes VA From 9 containing the Veteran's statement regarding the ankle injury during 1992 service in Germany. A complete rationale for the opinion rendered must be provided. If the examiner is unable to provide an opinion without resorting to mere speculation, then the examiner must state this and provide any information needed to make an opinion, if possible. 4. Thereafter, readjudicate the claim on appeal. If the benefit sought remains denied, issue the Veteran and his representative a supplemental statement of the case and provide a reasonable opportunity to respond before returning the matter to the Board for further appellate review. MICHAEL MARTIN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tariq, Nadeem, 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.