Citation Nr: 20023398 Decision Date: 04/06/20 Archive Date: 04/06/20 DOCKET NO. 17-64 869 DATE: April 6, 2020 REMANDED Entitlement to a rating in excess of 20 percent for a left ankle disability is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from September 1978 until September 1998. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2015 Department of Veterans Affairs (VA) rating decision, which in pertinent part granted service connection for a left ankle disability rated 20 percent, effective January 20, 2015. [Temporary total (100 percent) ratings were assigned for the left ankle from January 20, 2015 to March 1, 2015: from August 6, 2015 to December 1, 2015; and from January 17, 2019 to March 1, 2020 (for convalescence following surgery under 38 C.F.R. § 4.30, and under 38 C.F.R. § 4.71a, Code 5056 for a 1 year period following total ankle replacement following a convalescence period). Accordingly, those periods are not for consideration herein.] Entitlement to a rating in excess of 20 percent for a left ankle disability The Veteran contends that he has chronic residuals of left total ankle consisting of severe pain and weakness, warranting a 40 percent rating. A review of his record found that in January 2020 (prior to expiration of the period during which the ankle was rated totally disabling) he underwent another left ankle surgical procedure (tendon debridement). The agency of original jurisdiction (AOJ) has not readjudicated the claim considering the January 2020 surgery (and its effects). The Board observes that the need for further surgical intervention suggests impairment of greater severity than reflected by a minimum post total ankle replacement 20 percent rating. Further development to ascertain the current status of the disability, followed by AOJ readjudication of this claim that encompasses the January 2020 surgery and its effects is necessary. Accordingly, the matter is REMANDED for the following: 1. Secure for the record complete updated (to the present, any not already in the claims file) records of VA evaluations and treatment the Veteran has received for his left ankle. 2. Then arrange for an orthopedic examination of the Veteran to assess the current severity of his left ankle disability. The Veteran’s claims file must be reviewed by the examiner. All indicated studies should be completed, and all pertinent findings should be described in detail. The examiner should have available for review the criteria in 38 C.F.R. § 4.71a, Codes 5056, 5270-5274 and the findings should be sufficient to allow for application of all criteria therein. The examiner should: (a) Describe in detail all symptoms and functional impairment associated with the Veteran’s left ankle disability. Studies conducted should include range of motion studies of the ankle, to include testing for pain on both active and passive motion, and in weight-bearing and non-weight bearing. The examiner should note whether or not the ankle is ankylosed (and if so, the position of ankylosis). If any testing necessary cannot be completed, the examiner should explain why that is so. The examiner should note whether the findings are affected by such factors as pain, use, periods of exacerbation, etc., and should describe in detail any additional degree of disability resulting from such factors. (b) Indicate whether the Veteran’s post-total replacement left ankle disability is manifested by chronic residuals of severe painful motion or weakness, or an intermediate degree of residual weakness, pain or limitation of motion (if intermediate specify the degree). (c) Identify the extent of convalescence that was required following the January 2020 ankle (tendon) surgery. All opinions should include rationale. GEORGE R. SENYK Veterans Law Judge Board of Veterans’ Appeals Law Clerk for the Board Norman R. McNeal 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.