Citation Nr: 21071698 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 17-52 243 DATE: December 1, 2021 REMANDED Entitlement to an initial rating in excess of 10 percent for right ankle posterior tibialis and flexor hallucis longus tenosynovitis and deep deltoid ligament partial tear residuals is remanded. REASONS FOR REMAND The Veteran had active service from December 2006 to March 2016. He served in Southwest Asia. Entitlement to an initial rating in excess of 10 percent for right ankle posterior tibialis and flexor hallucis longus tenosynovitis and deep deltoid ligament partial tear residuals is remanded. In its November 2019 Remand instructions, the Board of Veterans' Appeals (Board) requested that the Veteran be scheduled for further Department of Veterans Affairs (VA) ankle evaluation conducted by a physician. The examiner was directed to "report, in degrees, the point at which pain is demonstrated, and whether any limitation of motion is moderate or marked" and "with regard to range of motion testing, the examiner should report at what point (in degrees) pain is elicited as well as whether there is any other functional loss due to weakened movement, excess fatigability or incoordination." The report of a December 2019 ankle examination conducted for VA states that the examiner was a physician assistant. On examination of the right ankle, the Veteran exhibited a range of motion of dorsiflexion of 0 to 15 degrees with pain and plantar flexion of 0 to 45 degrees with pain. The physician assistant did not note the degree at which the Veteran exhibited pain. The report of a June 2020 ankle examination conducted for VA states that the examiner was a physician. On examination of the right ankle, the Veteran exhibited a range of motion of dorsiflexion of 0 to 5 degrees and plantar flexion of 0 to 30 degrees with pain. The examiner commented that "the current diagnoses of chronic sprain/ strain of the medial and lateral ligaments of the right ankle are a progression of the original diagnosis in that this has become a chronic pain issue with impaired mobility rather than a tenosynovitis." The physician did not note the degree at which the Veteran exhibited pain. Neither the December 2019 ankle examination report nor the June 2002 ankle examination complied with the Board's remand instructions. The Agency of Original Jurisdiction's compliance with the Board's remand instructions is neither optional nor discretionary. Stegall v. West, 11 Vet. App. 268 (1998). Clinical documentation dated after June 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated the service connected right ankle disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after June 2021. 3. Schedule the Veteran for a VA ankle examination to assist in determining the current severity of service connected right ankle disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for weight bearing and nonweight-bearing and passive and active motion of the right ankle. The degree of range of motion at which pain is exhibited should be specifically reported. (b) State whether there is any additional loss of right ankle function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. (c) State whether there is ankylosis of the right ankle. J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K.R. Kardian, 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.