Citation Nr: 21067791 Decision Date: 11/05/21 Archive Date: 11/05/21 DOCKET NO. 16-32 617 DATE: November 5, 2021 REMANDED Entitlement to a disability rating in excess of 10 percent for residuals of a right fibula fracture is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from April 1964 to April 1967. During his period of service, he earned the National Defense Service Medal and Marksman Badge (Rifle). This matter was previously before the Board in April 2020 and March 2021, at which time it was remanded for further development. Entitlement to a higher rating for residuals of a right fibula fracture Pursuant to the Board's March 2021 remand, the Veteran was afforded a new VA examination in August 2021. The Veteran reported pain when standing or walking and has to sit to get some comfort. If he is unable to get off his leg, the pain will take him to the ground. This restricts or limits his outings. The pain also wakes him up sometimes. He also experienced numbness in his leg. Weakness causes him to hold onto things to prevent falling. He loses circulation in the leg and has to rub it to get circulation back. The examiner noted normal range of motion in the right knee. The examiner indicated that the Veteran did not suffer from flareups and documented that there was no evidence of additional loss of function or range of motion after three repetitions. The examiner also noted there was no pain with weight bearing, non-weight bearing, and with active and passive motion. However, the examiner failed to provide the range of motion testing expressed in degrees for active and passive motion, and with weightbearing and non-weightbearing in accordance with Correia v. McDonald, 28 Vet. App. 158 (2016). The examiner also failed to include any comparisons with the Veteran's paired joints. Lastly, although the August 2021 examiner stated that the Veteran did not report flareups of the knee and further indicated there was no pain noted on the examination, as well as normal range of motion in the right knee, the findings of the August 2021 examination are in contrast with the findings of prior examinations of record that document abnormal range of motion and pain in the right knee. However, this inconsistency was not addressed or explained by the August 2021 VA examiner. Accordingly, a remand is warranted in order to obtain an adequate examination to assess the current severity of his service-connected residuals of a right fibula fracture. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination with the appropriate examiner to determine the current severity and manifestations of his service-connected residuals of a right fibula fracture. The claims folder must be made available to the examiner for review in connection with the examination. The examination report must reflect that such a review was conducted. (a.) The examiner should identify any symptoms that the Veteran currently manifests or has manifested that are attributable to his service-connected residuals of a right fibula fracture. (b.) The examiner should test the Veteran's range of motion in active motion, passive motion, weight bearing, and non-weight bearing. 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. (c.) The examiner must further comment as to whether there is any pain, weakened movement, excess fatigability, or incoordination on movement, and the degree to which any additional range of motion is lost due to any of the following should be addressed: (1) pain on use, including during flare-ups; (2) weakened movement; (3) excess fatigability; or (4) incoordination. (d.) If the Veteran reports flare-ups, the examiner should record the Veteran's reports of limitation of motion during these episodes and opine whether the disability shown on examination is consistent with the Veteran's reports. If the examination does not take place during a flare, the examiner must 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. (e.) The examiner is asked to describe whether pain significantly limits functional ability during flare-ups and after repeated use over time. All limitation of function must be identified. If there is no pain and/or no limitation of function, such facts must be noted in the report. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Tracy O. Joseph, 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.