ANKLE IMPAIRMENT OF

MICHAEL LANE · 2026 · Case ID: A26038607

MIXED

Summary

The veteran, who served in the Navy from March 2021 to March 2024, appeals the denial of service connection for multiple conditions, including right ankle, right thumb, right shoulder, left upper extremity nerve condition (CTS), dizziness, hyperhidrosis, GERD, chronic sinusitis, and an acquired psychiatric disorder (depression and anxiety). The Board reviewed the January 2025 decision, which applied the Appeals Modernization Act. The veteran submitted a Direct Review election. The Board noted that favorable findings were made during the appeal period regarding a qualifying in-service event for the right ankle, GERD, back, and shoulders, making the Board bound by these findings. However, the Board ultimately denied service connection for all appealed conditions. Recent VA examinations in December 2024 found no medically objective evidence or functional impairment to support current diagnoses for these conditions. The Board referenced Saunders v. Wilkie regarding pain without diagnosis causing functional impairment, but found the examiner did not adequately address this for the remanded conditions. The Board also acknowledged McClain v. Nicholson regarding chronic disabilities, but found no current evidence of the claimed conditions. The Board considered the veteran's lay testimony but found it lacked probative value on medical etiology. The Board denied all claims due to the absence of a current disability or objective evidence supporting the claimed conditions. The case was remanded for further development regarding the left shoulder, back, sciatica, and shin splints, as the VA examiner did not adequately address the veteran's reported pain and functional limitations in relation to potential diagnoses under Saunders.

Rationale

No current diagnosis found; No objective evidence of functional impairment; Evidence persuasively against service connection

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250113-508333

Full Decision Text

Citation Nr: A26038607
Decision Date: 04/24/26 Archive Date: 04/24/26

DOCKET NO. 250113-508333
DATE: April 24, 2026

ORDER

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

Entitlement to service connection for a right thumb disability is denied.

Entitlement to service connection for a right shoulder disability is denied.

Entitlement to service connection for left upper extremity nerve condition to include carpal tunnel syndrome (CTS) is denied.

Entitlement to service connection for dizziness is denied.

Entitlement to service connection for hyperhidrosis (excessive sweating) is denied.

Entitlement to service connection for chronic sinusitis is denied.

Entitlement to service connection for gastrointestinal reflux disease (GERD) is denied.

Entitlement to service connection for an acquired psychiatric disorder to include depression and anxiety, is denied.

REMANDED

Entitlement to service connection for a left shoulder disability is remanded.

Entitlement to service connection for a back disability is remanded.

Entitlement to service connection for sciatica is remanded.

Entitlement to service connection for right shin splints is remanded.

Entitlement to service connection for left shin splints is remanded.

FINDINGS OF FACT

1. The evidence is persuasively against a finding that the Veteran has any current residuals or functional impairment related to a right ankle disability during the pendency of the appeal.

2. The evidence is persuasively against a finding that the Veteran has any current residuals or functional impairment related to a right thumb disability during the pendency of the appeal.

3. The evidence is persuasively against a finding that the Veteran has any current residuals or functional impairment related to a right shoulder disability during the pendency of the appeal.

4. The evidence is persuasively against a finding that the Veteran has any current residuals or functional impairment related to a left upper extremity nerve condition to include carpal tunnel syndrome (CTS) disability during the pendency of the appeal.

5. The evidence is persuasively against a finding that the Veteran has any current residuals or functional impairment related to dizziness during the pendency of the appeal.

6. The evidence is persuasively against a finding that the Veteran has any current residuals or functional impairment related to hyperhidrosis (excessive sweating) during the pendency of the appeal.

7. The evidence is persuasively against a finding that the Veteran has any current residuals or functional impairment related to a chronic sinusitis during the pendency of the appeal.

8. The evidence is persuasively against a finding that the Veteran has any current residuals or functional impairment related to a gastrointestinal reflux disease (GERD) during the pendency of the appeal.

9. The evidence is persuasively against a finding that the Veteran has any current residuals or functional impairment related to an acquired psychiatric disorder during the pendency of the appeal.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a right ankle disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

2. The criteria for entitlement to service connection for a right thumb disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

3. The criteria for entitlement to service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

4. The criteria for entitlement to service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

5. The criteria for entitlement to service connection for a left upper extremity nerve condition to include carpal tunnel syndrome (CTS) have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

6. The criteria for entitlement to service connection for dizziness have not been met. 38 U.S
1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

6. The criteria for entitlement to service connection for dizziness have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

7. The criteria for entitlement to service connection for hyperhidrosis (excessive sweating) have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

8. The criteria for entitlement to service connection for chronic sinusitis have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

9. The criteria for entitlement to service connection for GERD have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

10. The criteria for entitlement to service connection for an acquired psychiatric disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 5107(b); 38 C.F.R. §§ 3.102, 3.303(b), 3.307, 3.309(a).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served in active-duty service with the Navy from March 2021 to March 2024.

The rating decision on appeal was issued in January 2025; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

The Veteran submitted a January 2025 10182 form selecting the Direct Review option.

The Board notes that a claim for a disability includes any disability that may reasonably be encompassed by the claimant's description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009).

The Veteran has submitted claims for service connection for a low back, mid back, and other back related disabilities; as well as claims for depression, and anxiety. As such, the Board has recharacterized these issues as entitlement to service connection for a back disability and acquired psychiatric disorder.

The Board next notes that during the pendency of the appeal favorable findings were made to include finding new and relevant evidence had been received to readjudicate the above claims; finding the Veteran with qualifying inservice event relating to the right ankle, GERD, back, and shoulders. As such, the Board is bound by the favorable findings. AMA, Pub. L. No. 115-55, § 5104A, 131 Stat. 1105, 1106-07.

Service Connection

Service connection is granted on a direct basis when there is competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d).

The Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Board determinations with respect to the weight
the current disability and the in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d).

The Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Board determinations with respect to the weight and credibility of evidence are factual determinations going to the probative value of the evidence. Layno v. Brown, 6 Vet. App. 465, 469 (1994).

In relevant part, 38 U.S.C. § 1154 (a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability. Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional." Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009).

When a claimant seeks benefits and the evidence is in relative equipoise, the claimant prevails. 38 U.S.C. § 5107 (b); see Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 C.F.R. § 3.102. The evidence must be persuasively against the claim for benefits to be denied. See Alemany v. Brown, 9 Vet. App. 518 (1996).

Right ankle; right thumb; right shoulder; left upper extremity nerve condition to include carpal tunnel syndrome (CTS); dizziness; hyperhidrosis; GERD; chronic sinusitis; acquired psychiatric disorder

Review of the record shows in a September 2024 VA examination for mental disorders, the Veteran reported mental health issues during service but described them as "...none that were noted but I had some out of fear...behind closed doors...problems internally with relationships and family..."

The examiner found the record did not show any medical evidence of anxiety or depression as claimed by the Veteran; the examiner found no medically objective evidence of current treatment or symptoms documented by the Veteran to make a mental disorder diagnosis.

In a December 2024 VA examination for the ankle, the Veteran reported an injury to the right ankle in service; the Veteran described feeling unstable while standing on uneven ground but did not report functional impairment or loss from the right ankle. The Veteran demonstrated full range of motion with no evidence of pain.

The examiner did not find the Veteran with a diagnosis for the right ankle and finding no objective evidence to support a right ankle diagnosis.

In a December 2024 VA examination for the right shoulder, the Veteran reported that their right shoulder was stable and demonstrated full range of motion (ROM) with no reported functional impairment attributable to the right shoulder.

The examiner found no objective evidence to support a diagnosis for the right shoulder.

In a December 2024 VA examination addressing the right thumb, left upper extremity nerve condition, and hyperhidrosis, the Veteran demonstrated intermittent pain to the left upper extremity. The Veteran reported "sweating randomly" and pain and fatigue of the left wrist when driving their motorcycle.

The examiner found no evidence of nerve involvement or functional impairment resulting from the Veteran's reported symptoms.

The Veteran remarked that concerning the upper extremity nerve condition to include CTS, they "[wanted] to find out if [the Veteran] has it" and for hyperhidrosis they "read about it" and therefore also wanted to see if they had this condition.

The examiner found no objective medical evidence to support a diagnosis for the right thumb, left upper extremity nerve condition, and hyperhidrosis.

In a December 2024 VA examination for GERD, the examiner found the evidence and examination findings did not result in functional impairment or met the criteria for a diagnosis for GERD.

In a December 2024 VA
when driving their motorcycle.

The examiner found no evidence of nerve involvement or functional impairment resulting from the Veteran's reported symptoms.

The examiner found no objective medical evidence to support a diagnosis for the right thumb, left upper extremity nerve condition, and hyperhidrosis.

In a December 2024 VA examination for GERD, the examiner found the evidence and examination findings did not result in functional impairment or met the criteria for a diagnosis for GERD.

In a December 2024 VA examination for sinusitis, the examiner found the evidence and examination findings did not result in functional impairment or met the criteria for a diagnosis for chronic sinusitis.

In a December 2024 VA examination for ear condition, the Veteran reported feeling unstable "like on sea legs"; however, the examiner found the evidence and examination findings did not result in functional impairment or met the criteria for a diagnosis for dizziness.

In December 2024 the Veteran declared that there was no more information to submit in support of their claim and appeal.

After review of the record, the Board finds the evidence is persuasively against a finding for service connection for the right ankle; right thumb; right shoulder; left upper extremity nerve condition to include carpal tunnel syndrome (CTS); dizziness; hyperhidrosis; GERD; chronic sinusitis; and acquired psychiatric disorder.

As addressed above, the most recent VA examinations held in December 2024 did not find any medically objective evidence or findings to support a current diagnosis relating to the right ankle; right thumb; right shoulder; left upper extremity nerve condition to include carpal tunnel syndrome (CTS); dizziness; hyperhidrosis; GERD; chronic sinusitis; and acquired psychiatric disorder.

The Board notes the Federal Circuit's holding in Saunders v. Wilkie, which stated that even in the absence of a presently diagnosed condition, pain can cause functional impairment, and that in that situation, "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability. " Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). However, the examiner in the most recent VA examinations did not find any functional impairment from the Veteran's claimed condition, and the Veteran has not identified any pain specifically relating to the above issues and how it would have resulted in functional impairment.

As such, the Board finds the evidence of record does not show any medically objective or competent evidence to show the Veteran has any current diagnosis or residuals relating to right ankle; right thumb; right shoulder; left upper extremity nerve condition to include carpal tunnel syndrome (CTS); dizziness; hyperhidrosis; GERD; chronic sinusitis; and acquired psychiatric disorder.

The Board acknowledges that presence of a chronic disability at any time during the claim process can justify a grant of service connection, even where the most recent diagnosis is negative. McClain v. Nicholson, 21 Vet. App. 319 (2007). However, because there was no actual disability diagnosed at any time since the claim was filed or contemporary to the filing of the claim, and there remains no current evidence of the claimed disabilities, no valid claim for service connection for right ankle; right thumb; right shoulder; left upper extremity nerve condition to include carpal tunnel syndrome (CTS); dizziness; hyperhidrosis; GERD; chronic sinusitis; and acquired psychiatric disorder.

The Board has considered the Veteran's statements and testimony regarding their claimed issues. While the Veteran is competent to report observable symptomatology, the Veteran lacks the medical training and expertise necessary to provide a probative opinion on the medically complex issue such as the nature and etiology of the claimed right ankle; right thumb; right shoulder; left upper extremity nerve condition to include carpal tunnel syndrome (CTS); dizziness; hyperhidrosis; GERD; chronic sinusitis; and acquired psychiatric disorder. See Layno v. Brown, 6 Vet. App. 465 (1994), Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007).

The existence of a current disability is the cornerstone of a claim for a VA disability compensation. Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997).

With the absence of a current disability for right ankle; right thumb; right shoulder; left upper extremity nerve condition to include carpal tunnel syndrome (CTS); dizziness; hyperhidrosis; GERD; chronic sinusitis; and acquired psychiatric disorder during the current appeal period, the analysis ends, and the claim for service connection for right ankle; right thumb; right shoulder; left upper extremity nerve condition to include carpal tunnel syndrome (CTS); dizziness; hyperhidrosis; GERD; chronic sinusitis; and acquired psychiatric disorder, whether on a direct or secondary basis, cannot be granted. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).

The Board has considered the applicability of the benefit of the doubt doctrine. However, as the evidence is persuasively against the claim, that doctrine is not applicable. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert, 1 Vet. App. at 53-56.

REASONS FOR REMAND

The Board finds remand is warranted for development.

Left shoulder, back, sciatica, right and left shin splints

As addressed above, in the absence of a presently diagnosed condition, pain can cause functional impairment, and that in that situation, "pain alone, without an accompanying diagnosis of a present disease, can qualify as a disability. " Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018).

In a December 2024 VA examination for the shoulder, the Veteran reported symptoms to include pain and flareups in the left shoulder that stated that they limited carrying or use of the left arm to lift or perform other tasks to avoid aggravating it.

In a December 2024 VA examination for the back, although the Veteran demonstrated full range of motion with no documented pain, the Veteran also reported symptoms of discomfort and "sore muscles" and that they would limit their sitting and avoid taking any flights of stairs.

In a December 2024 VA examination, the Veteran reported symptoms of localized pain in their shins and caused them to limit recreational activities to include being unable to run, hike, or take long walks.

The December 2024 examiner did not find the Veteran with a diagnosis for a left shoulder, back, or right and left shin splints; however, the examiner does not address the Veteran's statements and report of functional impairment as to whether this could support a diagnosis under Saunders.

As such, the Board finds remand is warranted to obtain an adequate opinion.

As the decision on the Veteran's claimed back disability may impact the decision on entitlement to service connection for sciatica, the issues are intertwined and are also remanded.

The matters are REMANDED for the following action:

Return the claims file to the VA examiner who provided the December 2024 medical opinions on the Veteran's left shoulder, back, or right and left shin splints. The record and a copy of this remand must be made available to the examiner.

If the examiner determines that an examination of the Veteran is necessary to provide the requested opinion with rationale, then such examination should be scheduled. If the examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional.

The examiner must review the entire claims file, to include a copy of this remand, in conjunction with the examination. Based on this review of the record, and examination if provided, the examiner should provide opinions that respond to the following:

(a.) Please identify all current disabilities applicable to the Veteran's claims for the left shoulder, back, sciatica or right and left shin splints. "Current" is defined as any condition identified since the filing of the claim (or approximate thereto) to the present. "Disability" includes any diagnosable conditions as well as pain or symptoms that are not diagnosable but, nonetheless, cause functional impairment.

(b.) All diagnostic findings must be reconciled with conflicting evidence in the record. If a previously documented diagnosis is deemed incorrect or obsolete (i.e., subsumed by a more appropriate diagnosis), the examiner must explain why.

(c.) Is it as likely as not (i.e., a 50 percent or greater probability) that the Veteran's left shoulder disability is related to the Veteran's service?

(d.) Is it as likely
or right and left shin splints. "Current" is defined as any condition identified since the filing of the claim (or approximate thereto) to the present. "Disability" includes any diagnosable conditions as well as pain or symptoms that are not diagnosable but, nonetheless, cause functional impairment.

(c.) Is it as likely as not (i.e., a 50 percent or greater probability) that the Veteran's left shoulder disability is related to the Veteran's service?

(d.) Is it as likely as not (i.e., a 50 percent or greater probability) that the Veteran's back disability is related to the Veteran's service?

(e.) Is it as likely as not (i.e., a 50 percent or greater probability) that the Veteran's sciatica is related to the Veteran's service?

(f.) Is it as likely as not (i.e., a 50 percent or greater probability) that the Veteran's right shin splints is related to the Veteran's service?

(g.) Is it as likely as not (i.e., a 50 percent or greater probability) that the Veteran's left shin splints is related to the Veteran's service?

(h.) The examiner is also advised that the Veteran is competent to report in-service events and treatment, and the Veteran's symptoms and history, and such reports and assertions to include the Veteran's testimony and statements must be specifically acknowledged and considered in formulating any opinions.

(i.) If the examiner rejects the Veteran's reports, the examiner must provide a reason for doing so. In doing so, the examiner should reconcile any contrary medical evidence of record.

(j.) The examiner should provide a complete rationale for any opinions provided, and if the examiner is unable to provide any opinion request, then the examiner should state so and why.

MICHAEL LANE

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Yang, Jonathan

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.

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