Citation Nr: 20009878 Decision Date: 02/05/20 Archive Date: 02/05/20 DOCKET NO. 19-18 090 DATE: February 5, 2020 REMANDED Entitlement to an initial rating in excess of 10 percent for healed right ankle fracture is remanded. REASONS FOR REMAND The Veteran had active service from March 1981 to January 1989 This matter comes before the Board of Veterans Appeals (Board) on appeal from a rating decision issued in April 2019 by a Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to an Initial Rating in Excess of 10 Percent for Healed Right Ankle Fracture is Remanded. The Veteran seeks an initial rating in excess of 10 percent for healed right ankle fracture. He specifies suffering from increased pain resulting in decreased range of motion and instability in his right ankle which has impacted his employment as a truck driver. He also contends that the injury to his right ankle has caused his right foot to be offset pointing outward which has affected the alignment of his body causing pain and discomfort down the right side of his body. See June 2019 Substantive Appeal. The Veteran’s right ankle disorder was last examined by the VA in June 2016. However, this examination report does not include all the required testing pursuant to Correia v. McDonald, 28 Vet. App. 158, 166 (2016) and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The June 2016 VA examination does not note if the range of motion measurements for the right ankle are active, passive, weight-bearing or not weight-bearing. Correia v. McDonald, 28 Vet. App. 158 (2016). There is no indication the examiner attempted to illicit sufficient information from the Veteran to discuss additional functional loss after repeated use or during a flare up. Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). Given the Veteran’s assertions that his right ankle disorder has worsened since the June 2016 VA examination and the lack of evidence to ascertain the current severity of his right ankle disorder, a remand is appropriate. The matters are REMANDED for the following action: 1. Obtain all outstanding treatment medical records and associate with the claims file. 2. Schedule the Veteran for an examination of the current severity of his service-connected right ankle disorder. All indicated studies should be completed, including range of motion testing. All findings must be fully reported. Findings of the opposite (left) ankle must also be included, unless the examiner states that the ankle is damaged (abnormal). (a) The examiner must address the Veteran’s complaints of instability and test his active motion, passive motion, and pain with weight-bearing and without weight-bearing. (b) The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. (c) The examiner is asked to describe whether pain significantly limits functional ability during flares, and if so, the examiner must estimate range of motion during flares. If the examination does not take place during a period of flare-up, the examiner should glean information regarding the flares’ severity, frequency, duration, and functional loss manifestations from the Veteran, medical records, and other available sources. Efforts to obtain such information must be documented. If there is no pain and/or no limitation of function, such facts must be noted in the report. (d) The examiner is asked to explain whether pain from the Veteran’s right ankle accounts for limitation in range of motion of his right leg, hip, knee and back. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Smith, 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.