ANKLE IMPAIRMENT OF

Summary

The Veteran served from July 1998 to July 2002 and December 2005 to July 2013. The Veteran appealed a March 2021 rating decision, seeking an increased rating for his service-connected left ankle disability and service connection for headaches secondary to his service-connected PTSD with alcohol use disorder. The Board granted a 20 percent increased rating for the left ankle disability, effective September 16, 2018. The Board found that during the rating period, the Veteran's left ankle had limited range of motion (dorsiflexion to 5 degrees, plantar flexion to 10 degrees) with pain, instability, and functional loss, warranting the higher rating under DC 5271. The Board denied higher ratings for ankylosis or other ankle-related diagnostic codes, as the evidence did not support immobility or fixation. For the headache claim, the Board granted service connection for tension headaches secondary to PTSD with alcohol use disorder, applying the benefit of the doubt doctrine. While a VA examiner opined the headaches were not related to PTSD, the Board found the Veteran's credible testimony regarding stress-triggered headaches, consistent with his service-connected conditions, outweighed the examiner's opinion, especially since the examiner failed to address the Veteran's detailed statement and the potential link to stress or blood pressure elevations.

Rationale

Limited range of motion with pain; Instability and functional loss; Warrants higher rating under DC 5271

Full Decision Text

Citation Nr: A26036912
Decision Date: 04/21/26	Archive Date: 04/21/26

DOCKET NO. 210901-182820
DATE: April 21, 2026

ORDER

A 20 percent increased rating for the Veteran's service-connected left ankle disability is granted, effective September 16, 2018.

Service connection for a headache disorder secondary to service-connected posttraumatic stress disorder ("PTSD") with alcohol use disorder is granted.

FINDINGS OF FACT

1. Since September 16, 2018, the Veteran's service-connected left ankle disability manifested with dorsiflexion to 5 degrees, plantar flexion to 10 degrees, painful motion, painful weightbearing, instability, and swelling. 

2. Resolving reasonable doubt in the Veteran's favor, his current tension headaches are caused by his service-connected PTSD with alcohol use disorder.

CONCLUSIONS OF LAW

1. The criteria for a 20 percent rating for the Veteran's service-connected left ankle disability were met, effective September 16, 2018. 38 U.S.C. §§ 1155, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1-4.7, 4.10, 4.14, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code ("DC") 5271.

2. The criteria to establish service connection for a headache disorder secondary to service-connected PTSD with alcohol use disorder have been approximated. 38 U.S.C. §§ 1101, 1131, 5107(b); 38 C.F.R. §§ 3.303, 3.304, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service from July 1998 to July 2002 and December 2005 to July 2013.

This matter is on appeal from a March 2021 rating decision by a VA Regional Office ("RO"). The Veteran filed a timely notice of disagreement (VA Form 10182 or "NOD") and selected the hearing docket. In March 2025, the Veteran clearly and unambiguously withdrew his hearing request. 

Under these circumstances, the Board may only consider the evidence of record at the time of the March 2021 decision on appeal and evidence received within 90 days of the hearing withdrawal (i.e., within 90 days of March 4, 2025). The Board cannot consider (1) evidence submitted during the period after the RO issued the decision on appeal and before March 4, 2025, or (2) evidence submitted more than 90 days after March 4, 2025. 38 C.F.R. § 20.704(e).

If evidence was associated with the claim file during a period when additional evidence was not allowed, the Board did not consider it in its decision. If the Veteran would like VA to consider any evidence that was added to the claims file that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision considering the new evidence in addition to the evidence previously considered. Specific instructions for filing a Supplemental Claim are included with this decision.   

INCREASED RATINGS

VA assigns disability ratings by applying criteria in its Schedule for Rating Disabilities ("the Rating Schedule"). Ratings are based on the average impairment of earning capacity. Individual disabilities are assigned separate diagnostic codes. See 38 U.S.C. § 1155; 38 C.F.R. § 4.1. Where there is a question of which two evaluations should be applied, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. See 38 C.F.R. § 4.7.

In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims).

In addition to applying the Rating Schedule,
 be assigned. See 38 C.F.R. § 4.7.

In disability rating cases, VA assesses the level of disability from the initial grant of service connection or a year prior to the date of application for an increased rating and determines whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as "staged ratings." See Fenderson v. West, 12 Vet. App. 119, 126 (1999); see also Hart v. Mansfield, 21 Vet. App. 505, 509-10 (2007) (holding that staged ratings may be warranted in increased rating claims).

In addition to applying the Rating Schedule, VA may assign a higher disability rating when the evidence demonstrates functional loss due to limited or excessive movement, pain, weakness, excessive fatigability, or incoordination, to include during flareups and with repeated use, if those factors are not considered in the rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995); Burton v. Shinseki, 25 Vet. App. 1 (2011).

VA will assign a higher disability rating when the evidence supports the claim, or when the evidence for and against the claim is approximately balanced. When the evidence is approximately balanced, VA will resolve reasonable doubt in the Veteran's favor. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch v. McDonough, 999 F.3rd 1391 (2021).

A 20 percent increased rating for the Veteran's service-connected left ankle disability is granted, effective September 16, 2018.

For purposes of evaluating the Veteran's left ankle disability, the rating period begins September 16, 2019, the date VA received his increased rating claim. 38 U.S.C. § 5110 (a); 38 C.F.R. § 3.400 (o). The rating period closed March 9, 2021, the date the Veteran was notified of the decision on appeal. 

Additionally, an increased rating may be assigned up to one year before the date of claim (i.e., one year before September 16, 2019) if it is factually ascertainable that the disability increased during that period. See 38 U.S.C. § 5110; Gaston v. Shinseki, 605 F. 3d 979, 983 (Fed. Cir. 2010).

During the rating period, the Veteran's left ankle disability was rated 10 percent under DC 5271, which provides:

A 10 percent rating for "moderate" limitation of motion of the ankle (less than 15 degrees dorsiflexion or less than 30 degrees plantar flexion) 

A 20 percent rating for "marked" limitation of motion of the ankle (less than 5 degrees dorsiflexion or less than 10 degrees plantar flexion)

38 C.F.R. § 4.71a, DC 5271.

The average normal range of motion of the ankle is dorsiflexion from 0 to 20 degrees and plantar flexion from 0 to 45 degrees. 38 C.F.R. § 4.71, Plate II.

"Ankylosis" is immobility and consolidation of a joint due to disease, injury, surgical procedure. Lewis v. Derwinski, 3 Vet. App. 259 (1992); see also Chavis v. McDonough, 34 Vet. App. 1 (2021), above ("ankylosis is, in essence, a complete limitation of motion.") Even when ankylosis is not present, VA may assign a disability rating based on ankylosis if there is functional loss equivalent to ankylosis. Id. at 11.

At a May 2018 VA examination (before the rating period), the Veteran endorsed "daily" left ankle pain that caused difficulty with prolonged standing/walking. He reported constantly using an ankle brace and custom insoles. On range of motion ("ROM") testing, the Veteran had left ankle dorsiflexion to 5 degrees and plantar flexion to 10 degrees, both with pain. A VA clinician opined there was evidence of painful weightbearing, tenderness to palpation, and functional loss due to limited ROM. Joint stability testing showed left ankle instability. The VA clinician opined that the Veteran did not have ankylosis in either ankle.

In September 2019, the Veteran asserted that his left ankle "worsened significantly," and endorsed limited/painful movement,
), the Veteran endorsed "daily" left ankle pain that caused difficulty with prolonged standing/walking. He reported constantly using an ankle brace and custom insoles. On range of motion ("ROM") testing, the Veteran had left ankle dorsiflexion to 5 degrees and plantar flexion to 10 degrees, both with pain. A VA clinician opined there was evidence of painful weightbearing, tenderness to palpation, and functional loss due to limited ROM. Joint stability testing showed left ankle instability. The VA clinician opined that the Veteran did not have ankylosis in either ankle.

In September 2019, the Veteran asserted that his left ankle "worsened significantly," and endorsed limited/painful movement, swelling, limping, instability, "giving out," and "rolling." He further reported missing work due to left ankle pain/limited mobility. See Statement in Support of Claim ("VA 21-4138"), received September 16, 2019.

At an October 2019 VA examination, the Veteran had left ankle dorsiflexion to 10 degrees and plantar flexion to 25 degrees, both with pain. A VA clinician opined that the Veteran's painful ROM did not cause functional loss. The clinician opined that the Veteran's ROM would not be additionally limited after repeated use over time. The clinician did not record the Veteran's description of his left ankle symptoms/functional loss.

The Veteran's VA treatment records during the appeal show limited motion and functional loss of the left ankle consistent with the May 2018 VA examination and his September 2019 statement.  

During the appeal, the Veteran had left ankle dorsiflexion to 5 degrees and plantar flexion to 10 degrees, which would normally warrant a 10 percent rating under DC 5271. See 38 C.F.R. § 4.71a. However, given the Veteran's painful ROM, painful weightbearing, instability, limp, and swelling, the next higher rating (20 percent) is warranted. See 38 C.F.R. § 4.59; DeLuca, above. 20 percent is the highest rating allowed under DC 5271.

The evidence weighs heavily against assigning separate and/or higher ratings based on the other DCs applicable to the ankle. 

The Veteran's left ankle disability did not manifest with ankylosis (DC 5270), ankylosis of the subastragalar or tarsal joint (DC 5272), malunion of the os calcis or astragalus (DC 5273) or astragalectomy (DC 5274). See 38 C.F.R. § 4.71a.

The evidence weighs heavily against finding ankylosis of the left ankle or its functional equivalent. While the Veteran reports painful movement, instability, and limited ROM, he has not contended, nor does the record reflect, that his left ankle is immobile or "fixed." Even considering the Veteran's painful weightbearing, he retained motion in his left ankle. See Chavis, above.

For the reasons above, a 20 percent rating is granted, effective September 19, 2018 (one year before the date of claim). This is the earliest effective date allowed by law. See 38 U.S.C. § 5110; Gaston, above.

SERVICE CONNECTION

VA grants service connection for disabilities resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). "Direct" service connection requires: (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus (a causal link) between the current disability and the disease or injury incurred or aggravated during service. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge may still be service connected if the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994).

A veteran may establish service connection on a "secondary" basis for a non- service-connected disability that was caused by a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C
 1163, 1167 (Fed. Cir. 2004)). Disorders diagnosed after discharge may still be service connected if the evidence establishes that the disorder was incurred in service. 38 C.F.R. § 3.303 (d); see Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994).

A veteran may establish service connection on a "secondary" basis for a non- service-connected disability that was caused by a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Additional disability resulting from the aggravation of a nonservice-connected condition by a service-connected condition is also compensable under 38 C.F.R. § 3.310 (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). 

In deciding claims, the Board evaluates the entire record on appeal. 38 U.S.C. § 7104 (a). When the evidence fully supports the claim, it will be granted. When the evidence for and against the claim is approximately balanced, the Board resolves any reasonable doubt in the Veteran's favor and grant the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Lynch, above.

Service connection for a headache disorder secondary to service-connected PTSD with alcohol use disorder is granted.

The Veteran has been diagnosed with "tension headaches" and contends the condition was caused by his service-connected PTSD with alcohol use disorder. 

The claim will be granted based on the benefit of the doubt doctrine. 

In December 2018, the Veteran endorsed headaches associated with alcohol use and his blood pressure medication. He also endorsed anxiety, hypervigilance, and elevated heartrate in crowds and public spaces. See December 8, 2018 "VA Mental Health E&M Note."

In September 2019, the Veteran endorsed "daily throbbing migraines" triggered by stress, anxiety, and being in public places. He reported that, twice per month, these headaches "...knock me out of commission to the point that I am totally incapacitated and bedridden." The Veteran further reported taking breaks at work due to migraines, which lasted approximately 30 minutes. See Statement in Support of Claim ("VA 21-4138"), received September 16, 2019.

At an October 2019 VA headaches examination, the Veteran endorsed headaches with light and sound sensitivity that lasted approximately 1-2 hours. He stated these headaches began approximately two years earlier. A VA clinician opined that the Veteran had not been diagnosed with a "chronic type of headaches" such as migraines, and that his unspecified headaches were likely caused by "stress" or sudden blood pressure elevations. The clinician opined that the Veteran's headaches were not caused by or related to his PTSD. However, the clinician did not explain his conclusion or address the Veteran's September 2019 statement (above).

The Veteran credibly and competently reports headaches triggered by stress, anxiety, and alcohol use (all documented symptoms of his service-connected psychiatric disorder), and the October 2019 VA examiner opined that his headaches are caused by "stress" or sudden blood pressure elevations. 

The Board will resolve the reasonable doubt regarding the cause of the Veteran's headaches in his favor and grant service connection for a headache disorder secondary to service-connected PTSD with alcohol use disorder. See Lynch, above.

 

 

L. M. BARNARD

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	B. Hiaasen

The Board's action is only binding on this case. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.