Citation Nr: 18156781 Decision Date: 12/11/18 Archive Date: 12/10/18 DOCKET NO. 14-20 132A DATE: December 11, 2018 REMANDED Entitlement to an initial rating in excess of 10 percent for service-connected left ankle tendonitis is remanded. Entitlement to an initial rating in excess of 10 percent for service-connected status post fracture right ankle tendonitis is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1994 to February 1997. The Veteran also had additional service in the Army National Guard. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In July 2018, the Veteran testified at a Board hearing. The transcript is of record. 1. Entitlement to an initial rating in excess of 10 percent for service-connected left ankle tendonitis and right ankle tendonitis is remanded. The Veteran last underwent a VA examination in September 2011 for a bilateral ankle condition. In January 2012, the Veteran was granted a 10 percent evaluation for both ankle conditions. At the July 2018 Board hearing, the Veteran testified that her ankle symptoms have increased since her last VA examination. While the mere passage of time since the last VA examination does not, in and of itself, warrant additional development, the Board finds that the examination is too remote to be considered a contemporaneous medical examination sufficient to ascertain the current level of disability. See Green v. Derwinski, 1 Vet. App. 121, 124 (1991); Caffrey v. Brown, 6 Vet. App. 377 (1994); Palczewski v. Nicholson, 21 Vet. App. 174 (2007). Additionally, in Correia v. McDonald, 28 Vet. App. 158, 169-70 (2016) the Court held that adequate examination reports must include joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Based on the contention that her symptoms worsened, the Veteran should be afforded a contemporaneous VA examination which includes such findings and properly assesses the current level of the Veteran’s service-connected disabilities. The matters are REMANDED for the following action: 1. Undertake appropriate development to obtain, and associate with the record to the extent possible, any outstanding private or VA treatment records relating to the remanded issue. All efforts to obtain such records should be documented in the record. 2. Schedule the Veteran for an examination as to the current severity of her left and right ankle disability. To the extent possible, the examiner should identify any symptoms and functional impairments due to both the left and right ankle disability. Likewise, the examiner should discuss the effect of the left and right ankle disability on any occupational functioning and activities of daily living. Joint testing for pain on both active and passive motion, in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint should be performed. The examiner must determine whether pain, weakness, fatigability, or incoordination significantly limits functional ability with repeated use over a period of time. The examiner should also describe, to the extent feasible, such functional limits in terms of additional degrees of limitation of motion. If such a description is not feasible, this should be explained. The examiner must attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. It is not sufficient to state only that all such information would be subjective and therefore of no value in estimating functional loss. (Continued on the next page)   If it is not possible to provide a specific measurement or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), in the record (additional facts are required), or in the examiner (does not have the knowledge or training). G. A. WASIK Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Smith, Associate Counsel