Citation Nr: 20005171 Decision Date: 01/22/20 Archive Date: 01/22/20 DOCKET NO. 18-18 138 DATE: January 22, 2020 REMANDED Entitlement to an evaluation in excess of 10 percent for a right ankle sprain status post Achilles tendon repair is remanded. REASONS FOR REMAND This case comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Board notes that the Veteran’s appeal had also included the issue of entitlement to service connection for sleep apnea. However, the Veteran did not submit a substantive appeal for that issue following the issuance of the October 2019 statement of the case (SOC). Therefore, that issue no longer remains in appellate status, and no further consideration is required. Upon review, the Board finds that additional development is needed prior to adjudication of the claim. The Veteran was most recently provided a VA examination in March 2017 in connection with his claim. During the examination, the Veteran reported that he did not have flare-ups and that he had difficulty with running, heavy lifting, and walking and standing for more than 45 minutes. However, in an August 2017 notice of disagreement, the Veteran indicated that he experienced daily flare-ups, could not exercise, and is unable to sit in a vehicle longer than 30 minutes. His statements suggest that his disability may have worsened since the last VA examination. VA’s General Counsel has indicated that, when a claimant asserts that the severity of a disability has increased since the most recent rating examination, an additional examination is appropriate. VAOPGCPREC 11-95 (April 7, 1995); see also Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994). Therefore, the Board finds that an additional VA examination is needed to ascertain the current severity and manifestations of his service-connected right ankle disability. The matter is REMANDED for the following actions: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his right ankle. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file The AOJ should also obtain any outstanding VA medical records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to ascertain the current severity and manifestations of his service-connected right ankle disability. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file. It should be noted that the Veteran is competent to attest to factual matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should state this with a fully reasoned explanation. The examiner should report all signs and symptoms necessary for rating the Veteran’s service-connected right ankle disability. In particular, he or she should provide the range of motion in degrees and test the Veteran’s range of motion in active motion, passive motion, weight-bearing, and nonweight-bearing for both the right and left ankles. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain so in the report. The examiner should further address whether there is any ankylosis; malunion of the os calcis or astragalus; or, evidence of an astragalectomy. The presence of objective evidence of pain, excess fatigability, incoordination and weakness should also be noted, as should any additional disability (including additional limitation of motion) due to these factors. The examiner should further discuss any additional functional impairment that occurs during flare-ups, including any additional limitation of motion. To the extent possible, he or she should address the frequency, duration, characteristics, and severity of flare-ups (through an examination, review of the medical records, and/or history provided by the Veteran). If the examination is not provided during a flare-up, and the examiner cannot otherwise opine as to functional loss, he or she must provide an explanation. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history [,]” 38 C.F.R. § 4.1, copies of all pertinent records in the Veteran’s claims file, or in the alternative, the claim file, must be made available to the examiner for review. 3. The AOJ should conduct any other development as may be indicated. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. J. Williams, Associate Counsel 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.