Citation Nr: 21003965 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 14-35 262A DATE: January 25, 2021 REMANDED Entitlement to rating in excess of 20 percent for left ankle sprain is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Marine Corps from July 1982 to August 2003. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a December 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office in St. Petersburg, Florida. The Board issued a May 2018 decision remanding the case for additional development including a medical examination. The agency of original jurisdiction (AOJ) issued a March 2019, November 2019 and December 2020 rating decision and the case was returned to the Board for adjudication. 1. Entitlement to rating in excess of 20 percent for left ankle sprain is remanded. The Veteran claims that he should be entitled to a higher rating for his service-connected left ankle disability because his condition has worsened requiring multiple surgeries. The Board remanded the case in May 2018 for additional development including a medical examination. The Board directives required any outstanding private medical treatment records to be obtained, that the Veteran be afforded a new VA examination to determine the severity of his left ankle disability, and lastly, that the claim be readjudicated to include the Veteran’s January 2010, June 2017 and February 2018 left ankle surgeries. During a January 2019 VA examination, the examiner stated the left ankle could not be tested because the Veteran had recently undergone an additional left ankle surgery and currently had a halo fixation. As this examination was inadequate, in August 2020 the Veteran was afforded an additional VA examination for his left ankle disability. The August 2020 VA examiner made a note of the Veteran’s multiple surgeries in the medical history section; however, he only discussed the Veteran’s January 2010 surgery for a total ankle joint replacement, and failed to discuss the Veteran’s additional surgeries in November 2008, June 2017, and February 2018. The Veteran also reported leg shortening and left foot drop as a result of the surgeries during the exam; however, his leg lengths were not measured nor was a neurological examination conducted to enable consideration of analogous ratings under 38 C.F.R. §§ 4.71a and 4.124a. See also November 2020 correspondence. Therefore, the Board finds an additional examination is warranted before the claim can be adjudicated on its merits. In addition, the Board remanded the case in May 2018 and to date, the agency of original jurisdiction has not issued a supplemental statement of case (SSOC) as required after a Board remand. 38 C.F.R. § 19.31(c). On remand, the AOJ must issue an SSOC that considers the additional evidence of record received since the May 2018 Board remand. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the current severity of the service-connected left ankle sprain residuals. The examiner must provide measurements of the length of the Veteran’s legs to assess his reported of leg shortening. The examiner must also provide a neurological examination. The examiner should also provide an opinion discussing whether the Veteran’s left ankle disability resulted in neurological complications or leg length shortening after any of his November 2008, January 2010, June 2017, February 2018, February 2019, September 2019, and June 2020 surgeries. The claims file must be made available for review, and the examination report should reflect that such review occurred. The examiner is reminded that a medical opinion based solely on the absence of documentation in the record or that does not address the Veteran’s reports of symptoms and history is inadequate. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed should be provided as the Board is precluded from making medical findings. A discussion of the facts and the medical principles involved will be of considerable assistance to the Board, including citation to any supporting medical treatises. 2. Review all the evidence received since the May 2018 Board remand. If the claim is not fully granted, a supplemental statement of case should be issued regarding the claim for increased rating for left ankle (Continued on the next page)   disability and the case then returned to the Board for further appellate consideration. J. B. FREEMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Aubee, 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.