ANKLE IMPAIRMENT OF

G. E. WILKERSON · 2026 · Case ID: A26039175

DENIED

Summary

The veteran, who served honorably in the United States Army from October 1976 to October 1979, appeals the denial of service connection for a right ankle disability, a right leg disability, and a right tibia fracture. The veteran claimed these conditions stemmed from a basketball injury in service in 1978, where he allegedly broke his right ankle and injured his right leg. The Board found that the first requirement for service connection, a current disability, was met, noting diagnoses of right tibia fracture, right ankle degenerative arthritis, and osteochondral defect from VA examinations. However, service treatment records were unavailable due to a government records loss. The Veteran testified at a hearing, providing details about the in-service injury and subsequent treatment, and his spouse submitted a statement corroborating his ankle and leg problems. The Board found the Veteran's testimony and lay statements, while competent, were outweighed by other evidence. Specifically, the Board found the November 2020 VA examiner's opinion more probative than a private opinion from Dr. R. The VA examiner noted the lack of contemporaneous service treatment records documenting the alleged ankle fracture and suggested that the degenerative arthritis and osteochondral defect were more likely due to aging, given the 41-year gap between the alleged injury and the first reported symptoms. The Board concluded that the persuasive weight of the evidence indicated the claimed disabilities manifested many years post-service and were unrelated to service. Therefore, service connection for all three conditions was denied.

Rationale

No contemporaneous service treatment records documenting right ankle fracture; Degenerative arthritis and osteochondral defect likely due to aging; VA examiner's opinion outweighed private opinion

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210501-156482

Full Decision Text

Citation Nr: A26039175
Decision Date: 04/27/26 Archive Date: 04/27/26

DOCKET NO. 210501-156482
DATE: April 27, 2026

ORDER

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

Entitlement to service connection for right leg disability is denied.

Entitlement to service connection for right tibia fracture is denied.

FINDINGS OF FACT

1. The evidence of record persuasively weighs against finding that the Veteran's right ankle disability onset during active service or is otherwise related to an in-service injury or disease.

2. The evidence of record persuasively weighs against finding that right leg disability onset during active service or is otherwise related to an in-service injury or disease.

3. The evidence of record persuasively weighs against finding that a right tibia fracture onset during active service or is otherwise related to an in-service injury or disease.

CONCLUSIONS OF LAW

1. The criteria for service connection for right ankle disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for right leg disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

3. The criteria for service connection for right tibia fracture have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served honorably on active duty in the United States Army from October 1976 to October 1979.

The rating decision on appeal was issued in April 2021 and constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In January 2021, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of a November 2020 decision. In April 2021, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior November 2020 decision.

In May 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held on February 202, 2025.

Therefore, the Board may only consider the evidence of record at the time of the November 2020 agency of AOJ decision, which was subsequently subject to higher-level review, as well as any evidence submitted by the Veteran or representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted 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 on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

In the November 2020 rating decision, the AOJ determined that new and relevant evidence had been received to readjudicate the previously denied claims. This is a favorable finding, and the Board will proceed to adjudicate the claims on the merits.

Service Connection

Service connection will be granted if it is shown that the Veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation during active service of a preexisting injury or disease. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F
claims. This is a favorable finding, and the Board will proceed to adjudicate the claims on the merits.

Service Connection

To establish service connection, there must be a competent diagnosis of a current disability; medical or, in certain cases, lay evidence of in-service occurrence or aggravation of a disease or injury; and competent evidence of a nexus between an in-service injury or disease and the current disability. Hickson v. West, 12 Vet. App. 247, 252; see Jandreau v. Nicholson, 492 F.3d 1372.

Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1).

Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau, 492 F.3d 1372.

In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is "nearly equal" or in approximate balance, with the Veteran prevailing in either event, or whether most of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Lynch v. McDonough, 21 F.4th 776.

1. Service connection for a right ankle disability

2. Service connection for a right leg disability

3. Service connection for a tibia fracture

The Veteran contends that he has disabilities of the right knee, leg, and ankle stemming from injury in service. He asserts that he fell in service playing basketball while stationed in Hawaii and injured his right leg, breaking his right ankle.

At the outset, the Board notes that the record reflects Veteran has diagnoses of right tibia fracture, right ankle degenerative arthritis, and osteochondral defect, as found on November 2020 VA ankle, knee and lower leg examinations. Therefore, the first requirement for service connection, current disabilities of the knee/ankle/leg satisfied.

As to an in-service event the claims file contains July 2004 VA memo that formally finds that the Veteran's service medical records are unavailable. His service treatment records (STR) only contain his service entrance examination and report of medical history dated September 8, 1976.

The memorandum indicated that all procedures to obtain the service records for the Veteran had been correctly followed. All efforts to obtain the needed military information have been exhausted; further, attempts are futile and that, based on these facts, the record is not available.

The Court of Appeals for Veterans Claims has held that in cases where records once in the hands of the government are lost, the Board has a heightened obligation to explain its findings and conclusions and to consider carefully the benefit-of-the-doubt rule where applicable. See O'Hare v. Derwinski, 1 Vet. App. 365, 367 (1991).

The Veteran was informed of the unavailability of his service treatment records by letter dated July 9, 2004, and was asked to submit any records he had in his possession or provide information as to their location. The Veteran did not respond. The STR are unavailable at the time of this decision.

At the February 2025 Board hearing, the Veteran reported additional details regarding his in-service injuries. He indicated that in 1978, while playing basketball when stationed at Schofield Barracks in Hawaii, he injured his right leg, and that he fractured his right ankle. The Veteran testified to receiving medical treatment at that time, and said his leg was placed in a cast for 8 weeks
. 365, 367 (1991).

Post-service records include an October 1982 report statement in support of claim regarding vocational benefits. On that form, the Veteran did not fill out any response to the question of whether he had disabilities that limited the type of work he could perform.

The Veteran first submitted his claim for "right leg injury (knee down to ankle)" in December 2003, more than 24 years after service. In his statement of January 2004, the Veteran says he was treated by his own doctor for right knee pain that came and went over the years. He stated that, since December 1980 he went to his doctor on two occasions and was treated with medication and released though medical records from this provider were not available.

VA treatment records from 2003 reflect that the Veteran reported left knee pain, but he did not describe any pain or injury related to the right knee, leg, or ankle. He stated that he broke a leg in service, though he did not recall which leg.

Social Security Administration Records include a March 2004 disability determination report noting complaints of pain in both knees. He stated that his injured his right knee in active duty and since then, his left knee also began to act up. He was assessed with possible degenerative joint disease of the right knee.

However, an X-ray of the right knee from March 2004 revealed no abnormalities.

In April 2004, the Veteran's spouse submitted a statement noting that she had been married to the Veteran since March 1979, and that he had problems with his ankle and upper right leg in service. He went to his family doctor after discharge from service.

Social Security Administration Records also include a November 2004 disability evaluation, which documents complaints of chronic low back pain for 10 years, that occasionally radiated to right leg, but no other abnormalities. His past history was unremarkable except for a left ankle injury in the Army in 1978.

Treatment records from Scotland Memorial Hospital from March 2011 reflect that the Veteran was seen for complaint of right knee pain and injury stemming from a fall onto a hard surface. The onset of symptoms was noted as occurring just prior to presentation. Fracture of the fabella was found on X-ray and he was assessed with tibia fracture.

On VA treatment in September 2012, the Veteran reported an 18-month history of right knee pain, which was described as a fractured tibia. He described chronic pain in the right leg and knee.

At the hearing, the Veteran stated that two fellow soldiers from his battalion submitted statements about his right leg injury in service. However, review of the claims file finds these August 2014, statements are certifications with the same date, in at least similar if not the same handwriting as a statement from the Veteran of the same date, with the same exact wording and misspelling "that the information is true to [the] best of my knowledge and beleif [sic]." Neither certification is accompanied by a statement from either of the lay witnesses.

In February 2015 deferred rating, the Veteran was informed that his two buddy statements were deficient, and that a Beneficiary Identification Records Locator Subsystem (BIRLS) search did not find the two witnesses. He was advised to provide actual statements the purported witnesses, or information that would allow VA to verify their having served at Schofield Barracks with the Veteran. To date, the Veteran has not provided any additional information for the two buddy statement submissions.

On VA treatment in April 2017, the Veteran reported chronic pain from his ankle up his knee on the right.

A September 2018 report from Scotland Memorial Hospital reflects that the Veteran was seen for complaint of right knee pain after slipping getting into a car a few days prior. He was assessed with right knee pain.

A February 2019 VA urgent care report reflects that that the Veteran was seen for a right ankle sprain, with an onset of symptoms the previous night. He denied any obvious injuries.

A January 2020 VA treatment report
, or information that would allow VA to verify their having served at Schofield Barracks with the Veteran. To date, the Veteran has not provided any additional information for the two buddy statement submissions.

On VA treatment in April 2017, the Veteran reported chronic pain from his ankle up his knee on the right.

A February 2019 VA urgent care report reflects that that the Veteran was seen for a right ankle sprain, with an onset of symptoms the previous night. He denied any obvious injuries.

A January 2020 VA treatment report notes that the Veteran reported a history of right ankle fracture in 1978, treated with a cast.

An X-ray of the ankle from October 2020 indicated small osteochondral lesion at the lateral dome of the talus. The treating physician, Dr. R., indicated that the "osteochondral defect was from ankle trauma."

In October 2020, the Veteran submitted a statement from Dr. R., who noted that the Veteran did a lot of standing and carrying of equipment while working as a food service specialist in the Army. During his time in the Army, the Veteran did not always have the luxury of working on a smooth service [sic]; especially when working in a deployment-style kitchen to simulate war. After speaking with the Veteran and reviewing the documents from VA, Dr. K.R. opined that his right leg conditions were at least as likely as not caused by his military service. Dr. R. noted the following disabilities impacting the right leg: osteochondral injury right, tibia fracture (claimed as right knee injury), right leg injury, and broke right ankle.

On VA ankle examination in November 2020, the Veteran reported that he fractured his right ankle while playing basketball in service in 1978. He went to the medic and was placed in a cast for 8 weeks. After interview, examination, and review of the record, the examiner diagnosed degenerative arthritis of the right ankle and osteochondral defect.

On VA knee examination also in November 2020, the Veteran also reported that he fell on his right knee when he fractured his right ankle during the basketball game. After interview, examination, and review of the record, the examiner diagnosed right tibia fracture.

November 2020 VA examiner opined that the Veteran's right leg disabilities, including disabilities of the knee ankle, are less likely than not related to active duty service. With respect to the claimed right ankle disability, the examiner pointed out that there is no medical record to indicate that the Veteran sustained any right ankle fracture during service. Medical record dated February 2019 noted Veteran complaining of right ankle pain that only started last night and was diagnosed with an ankle sprain. The VA examiner also pointed out that osteochondral defects and degenerative arthritis occur commonly as a result of aging. Given the fact that Veteran has not sought medical care nor complained of any right ankle pain from his claimed injury in 1978 until 41 years later in 2019, it is more likely that Veteran's current ankle pain was due to aging.

With respect to the Veteran's tibia fracture, the November 2020 VA examiner pointed out that there is no evidence that Veteran sustained any right knee fracture during service. Medical record dated March 2011 from Scotland Memorial Hospital noted Veteran sustaining a right tibial plateau fracture. Therefore, the knee fracture more likely than not occurred in 2011 after service and not in service in 1978.

Given the unavailability of service treatment records and the Veteran's mostly consistent report of injury to the right leg requiring treatment to the right ankle and/or knee during service (though some details regarding the nature and joint affected have not been consistent), the Board resolves reasonable doubt in the Veteran's favor and finds that an in-service event occurred. The remaining question is whether the claimed disabilities of the right leg/knee/ankle onset in or are otherwise related to service.

There are competing opinions of record as to likely etiology of the disabilities involving the right lower extremity-the opinion of VA physician Dr. R., which found a link between the Veteran's current disabilities and service, and that of the November 2020 VA examiner, which is against the claims.

It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence
disabilities involving the right lower extremity-the opinion of VA physician Dr. R., which found a link between the Veteran's current disabilities and service, and that of the November 2020 VA examiner, which is against the claims.

It is the responsibility of the Board to assess the credibility and weight to be given the evidence. See Hayes v. Brown, 5 Vet. App. 60, 69-70 (1993) (citing Wood v. Derwinski, 1 Vet. App. 190, 192-93 (1992)). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion the physician reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. See Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993).

When reviewing such medical opinions, the Board may appropriately favor the opinion of one competent medical authority over another. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). However, the Board may not reject medical opinions based on its own medical judgment. Obert v. Brown, 5 Vet. App. 30 (1993); see also Colvin v. Derwinski, 1 Vet. App. 171 (1991). In assessing medical opinions, the failure of the physician to provide a basis for his opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). A medical opinion may not be discounted solely because the examiner did not review the claims file. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008).

In this case, the Board finds the November 2020 VA examiner's opinion most probative. In this regard, the Board observes that the VA examiner reviewed the entire claims file, including the prior private and VA treatment records. The VA examiner's opinion is consistent with the medical evidence of record, which does not document right knee, leg, or ankle complaints for many years after service. Although the Veteran's representative indicated that the examiner relied on the lack of service treatment records, the Board points out that the examiner discussed post-service evidence and other rationale; the Board finds this opinion adequate for adjudication purposes.

On the other hand, Dr. R.'s opinions were not supported by any rationale or explanation as to why the Veteran's duties as a cook led to the current disabilities, or provide any rationale or basis for finding that the Veteran's right ankle disability was related to an in-service injury. She noted that she reviewed "documents" from the Veteran, but did not specify what those documents were. Accordingly, the Board assigns this opinion minimal probative value, and finds that it outweighed by the opinion of the 2020 VA examiner.

Accordingly, the most probative opinion of record does not support the claims.

To the extent that the Veteran advances his own interpretation of his medical condition indicating that his right knee, leg, and ankle disabilities began in service related to the basketball injury therein, the Board acknowledges that lay witnesses may, in some circumstances, opine on questions of diagnosis and etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) (Board's categorical statement that "a valid medical opinion" was required to establish nexus, and that a layperson was "not competent" to provide testimony as to nexus because she was a layperson, conflicts with Jandreau).

The Board has considered the Veteran's and lay witness statements regarding his injuries in service and continuing knee pain since then. The Veteran and his spouse are competent to testify to observations and symptoms; however, this testimony must be weighed against the other evidence of record. The Board notes that while the Veteran reported symptoms since service, the first notations of right knee symptoms of record are from 2004, and ankle symptoms in 2017-with specific notation of injury and symptoms impacting the right ankle in 2019, many years after discharge from service. On several of these occasions of treatment, the Veteran reported more recent onset of symptoms, and he has not been consistent regarding the nature and continuous nature of his symptoms when seeking treatment. Accordingly, the Board finds these statements outweighed by the other evidence of record.

Moreover, on the question as to
knee pain since then. The Veteran and his spouse are competent to testify to observations and symptoms; however, this testimony must be weighed against the other evidence of record. The Board notes that while the Veteran reported symptoms since service, the first notations of right knee symptoms of record are from 2004, and ankle symptoms in 2017-with specific notation of injury and symptoms impacting the right ankle in 2019, many years after discharge from service. On several of these occasions of treatment, the Veteran reported more recent onset of symptoms, and he has not been consistent regarding the nature and continuous nature of his symptoms when seeking treatment. Accordingly, the Board finds these statements outweighed by the other evidence of record.

Moreover, on the question as to whether a current knee disability had its onset in service, or within one year of discharge, or is otherwise related to service, the specific, reasoned opinion of the 2020 VA examiner is of greater probative weight than the more general assertions of the Veteran, even assuming the Veteran's competence to opine on this medical question.

Thus, based upon the cumulative record, the Board concludes that the persuasive weight of the evidence shows that the claimed right knee, leg, and ankle disabilities, including tibia fracture, first manifest many years post service, and was unrelated to service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.303, 3.307, 3.309.

The evidence at this time weighs persuasively against the claims for service connection for right ankle, right leg, and right tibia fracture disabilities. The benefit of the doubt doctrine is therefore not for application. Lynch, 21 F.4th at 781-2.

G. E. Wilkerson

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J. Black

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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