Citation Nr: 18140338 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 13-29 625 DATE: October 2, 2018 REMANDED Entitlement to a rating in excess of 10 percent for a left ankle disability is remanded. Entitlement to a rating in excess of 10 percent for a right ankle disability is remanded. REASONS FOR REMAND The Veteran had active duty service from September 2005 to October 2006. These matters come before the Board of Veterans’ Appeals (Board) from an October 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which, in pertinent part, continued the 10 percent disability ratings for the Veteran’s service-connected right and left ankle sprains (ankle disability). The Veteran testified before the undersigned Veterans Law Judge (VLJ) in February 2017. A copy of the transcript has been reviewed and associated with the claims file. These matters were before the Board in May and October 2017, on which occasions they were remanded for additional evidentiary development. 1. Entitlement to a rating in excess of 10 percent for a left ankle disability is remanded; 2. Entitlement to a rating in excess of 10 percent for a right ankle disability is remanded. Pursuant to the Board’s October 2017 remand instructions, a VA examination was performed in April 2018. While range of motion testing results were provided, the results of active, passive, weight-bearing, and nonweight-bearing tests were not delineated or recorded pursuant to the remand instructions and required by VA regulations and case law. See 38 C.F.R. § 4.59; Correia v. McDonald, 28 Vet. App. 158 (2016). On remand, an additional examination must be provided and the examiner must test and record the results of range of motion testing of both ankles in active motion, passive motion, in weight-bearing, and nonweight-bearing positions. The matters are REMANDED for the following actions: 1. Obtain and associate with the claims file the Veteran’s updated VA treatment records from February 2017 to the present. 2. After completion of # 1, schedule the Veteran for a VA examination to determine the nature and severity of his right and left ankle disabilities. The claims file, including this remand, should be reviewed by the examiner to become familiar with the Veteran’s pertinent medical history and such review should be noted in the examination report. Complete range of motion testing should be accomplished and the examiner should note the point at which there is pain on motion, if any. Specifically, active and passive range of motion testing, as well as weight-bearing and non-weight-bearing testing must be conducted and recorded for both the right and left ankles. If possible, the examiner should indicate how far back (i.e., one year, two years, etc.) these results would apply. The examiner should describe the severity of such limitation of motion (i.e., moderate or marked). The examiner should also note any additional loss of function with repetition due to factors such as pain, weakness, fatigability, and pain on movement. The extent of additional limitation should be expressed in degrees. The examiner is advised that the Veteran has reported flare-ups throughout the pertinent time of this appeal and he or she must express an opinion on whether the flare-ups are associated with additional functional loss. If so, he or she should estimate the degree of lost motion during such flare-ups. The examiner may indicate the degree of confidence that they place on their estimate, on a scale of 1 to 5, with 1 being least confident and 5 being most confident. The examiner must attempt to elicit information from the record and the Veteran regarding the severity, frequency, duration, or functional loss manifestations during flare-ups before determining that an estimate of motion loss in terms of degrees cannot be given. Any inability to furnish such an estimate must be predicated on a lack of medical knowledge among the medical community at large and not the insufficient knowledge of the examiner. Further, the examiner should note the presence, or absence, of (i) ankylosis of the right and/or left ankle, including whether ankylosis of the ankle in plantar flexion is less than 30 degrees, between 30 degrees and 40 degrees, or more than 40 degrees, or whether ankylosis of the ankle in dorsiflexion is between 0 degrees and 10 degrees, or at more than 10 degrees or with abduction, adduction, inversion, or eversion deformity; (ii) ankylosis of the subastragalar or tarsal joint, noting poor or good weight-bearing position; (iii) malunion of the os calcis or astragalus, noting marked or moderate deformity; and (iv) astragalectomy. The examiner is also to provide an opinion as to whether the right and/or left ankle disability causes loss or permanent loss of use of the right and/or left foot. The examiner must provide a rationale for all opinions provided. If an opinion cannot be made without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD S. Hurley, Associate Counsel