Citation Nr: 1325863 Decision Date: 08/15/13 Archive Date: 08/26/13 DOCKET NO. 11-26 244 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Indianapolis, Indiana THE ISSUE Entitlement to an increased rating in excess of 10 percent for residuals of a left leg contusion. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD S. Finn, Counsel INTRODUCTION The Veteran served on active duty from February 1968 to January 1970, during the Vietnam Era. This appeal to the Board of Veterans' Appeals (Board) is from a March 2010 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Indianapolis, Indiana. In an August 2011 written statement the Veteran filed a claim for service connection for lupus, to include as a result of Agent Orange exposure. This matter is referred to the RO for appropriate action. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required. REMAND The Veteran reported that his residuals of his left leg contusion have worsened. Specifically, the representative stated that "[i]t appears that this Veteran's left leg contusion may now affect his muscle tissue." (See December 2011 VA Form 646). The Veteran was last examined in February 2010. Although the VA examiner stated that the Veteran residuals consisted of pain, itching, cramping, swelling, muscle cramps, numbness, and jerking, there is no evidence of any evaluation as to whether his complaints represent a separately diagnosable muscle injury. The Veteran has also complained of stinging, discoloration, and hair loss of the left leg. Absent information regarding the Veteran's left leg muscles, the Board concludes that it cannot adequately rate his service-connected left leg disability, and a remand is necessary to obtain a new examination. See 38 C.F.R. § 4.70 (2012); Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). (Once VA undertakes the effort to provide an examination when developing a service-connection claim, even if not statutorily obligated to do so, it must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided). As such, the Board has no discretion and must again remand this claim. Therefore, additional development is warranted to obtain a new VA examination and to obtain the Veteran's most current VA medical records, pursuant to 38 C.F.R. §3.159(c) (2). Accordingly, the case is REMANDED for the following action: 1. Make arrangements to obtain the Veteran's complete treatment records or scan them into Virtual VA from the Danville VA treatment facility, dated since July 2011. 2. Then, the Veteran should be afforded an appropriate VA examination(s) for the purpose of determining the current severity of his service-connected residuals of his left leg contusion. The claims file should be made available to and reviewed by the examiner. Any indicated diagnostic tests and studies must be accomplished. The examiner(s) should identify all current manifestations of the Veteran's service-connected residuals of a left leg contusion, to include any muscle, orthopedic, neurological, and/or skin residuals. In particular, the Veteran has complained of pain, itching, muscle cramping, swelling, numbness, jerking, stinging, discoloration, and hair loss of the left leg. The examiner(s) should determine whether these symptoms/findings are manifestations of the service-connected left leg contusion, and if so, discuss the severity of those manifestations. The examiner(s) must document any limitation of motion of the left leg (knee and/or ankle). Whether there is any pain, weakened movement, excess fatigability or incoordination on movement should be noted, and whether there is likely to be additional range of motion loss due to any of the following should be addressed: (1) pain on use, including during any flare-ups; (2) weakened movement; (3) excess fatigability; or (4) incoordination. The examiner(s) is asked to describe whether pain significantly limits functional ability during flare-ups or when the left knee or left ankle is used repeatedly. All limitation of function must be identified. If there is no pain, no limitation of motion and/or no limitation of function, such facts must be noted in the report. The examiner(s) should specifically discuss the severity of any muscle impairment, including identifying any affected Muscle Groups. The examiner(s) should also describe in detail any associated skin manifestations. Finally, the examiner(s) should state whether there are any neurological residuals associated with the Veteran's service-connected left leg disability and identify any nerves involved. If so, the examiner(s) should also specifically discuss the extent, if any, of paralysis of the nerves involved (mild, moderate, moderately severe, severe, or complete). A complete rationale should be given for all opinions and conclusions expressed in a typewritten report. 3. Next, review the medical opinion(s) obtained above to ensure that the remand directives have been accomplished. If all questions posed are not answered or sufficiently answered, return the case to the examiner(s) for completion of the inquiry. 4. Finally, readjudicate the claim on appeal. If the benefit sought on appeal remain denied, issue the Veteran a Supplemental Statement of the Case and allow for a reasonable period to respond. The Veteran has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ P.M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2012).