Citation Nr: 20006955 Decision Date: 01/28/20 Archive Date: 01/28/20 DOCKET NO. 17-27 947 DATE: January 28, 2020 REMANDED Entitlement to an initial compensable rating for right calf muscle disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1990 to August 1994 and from October 2008 to October 2010. In January 2020, the Veteran testified in front of the undersigned Veterans Law Judge. This decision is being made under the “one-touch” program. A transcript of the hearing will be associated with the claims file at a later time. 1. Right calf muscle A remand is warranted for a new VA examination pertaining to the Veteran’s initial rating for his service-connected right calf muscle. The Veteran was last afforded a VA examination in November 2016 during which he endorsed increased calf swelling associated with running. See November 2016 VA Muscle Injuries Disability Benefits Questionnaire. However, at the January 2020 Board hearing, the Veteran reported additional symptoms including his right calf muscle tightening while sleeping and when he is walking. He further reported that he had to stop walking to release the tension. Therefore, because there is evidence that his disability may have increased in severity since the November 2016 VA examination, the Board finds that a remand is necessary to afford the Veteran a contemporaneous VA examination to address the current nature and severity of his right calf muscle disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The matters are REMANDED for the following action: 1. Obtain copies of records pertaining to any relevant VA and/or private treatment (not already in the claims file) that the Veteran has received since May 2017 following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained, if any, should be associated with the record. 2. After the foregoing development, schedule a VA examination by a VA examiner by an appropriate clinician to determine the current nature and severity of his service-connected right calf muscle strain. The record, to include a complete copy of this remand, must be made available to the examiner, and all indicated tests and studies should be undertaken. Thereafter, the examiner should address the following inquiries: (a.) The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability and all relevant muscle groups, to include under the Group XI Function under Diagnostic Code 5311 rating criteria. (b.) Identify the nature and severity of all manifestations of the Veteran’s right calf muscle disability. In doing so, the examiner should consider the Veteran’s reports of worsening pain, swelling, when walking and sleeping. The examiner should also indicate whether such muscle disability results in neurologic impairment and, if so, identify the affected nerve and the severity of such impairment. (c.) The examiner is also asked to illicit information from the Veteran and provide an explanation of his right calf muscle symptoms from going up steps and running. (d.) 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. The examiner(s) must provide a complete explanation for his or her opinion(s), based on his or her clinical experience, medical expertise, and established principles. A rationale for all opinions expressed should be provided in the examination report. If medical literature is relied upon in rendering any opinion(s), the VA examiner should identify and specifically cite each reference material utilized. If the VA examiner(s) is/are unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. 3. THE AOJ MUST REVIEW THE CLAIMS FILE AND ENSURE THAT THE FOREGOING DEVELOPMENT ACTION HAS BEEN COMPLETED IN FULL. IF ANY DEVELOPMENT IS INCOMPLETE, APPROPRIATE CORRECTIVE ACTION MUST BE IMPLEMENTED. IF ANY REPORT DOES NOT INCLUDE ADEQUATE RESPONSES TO THE SPECIFIC OPINIONS REQUESTED, IT MUST BE RETURNED TO THE PROVIDING EXAMINER FOR CORRECTIVE ACTION. YVETTE R. WHITE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Gunella Lilly, 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.