Citation Nr: 21073287 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 18-04 174 DATE: December 8, 2021 REMANDED Entitlement to a rating in excess of 10 percent for residuals of left foot tarsal bone fracture is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from May 2000 to November 2000, January 2009 to December 2009 and February 2010 to March 2011. In September 2021, the Veteran testified at a Board hearing. The transcript is of record. 1. Entitlement to an increased rating for residuals of left foot tarsal bone fracture The Board finds that additional evidentiary development is necessary. VA has a duty to make reasonable efforts to assist Veterans in securing evidence necessary to substantiate their claim. 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159(c) (2017). The evidence of record indicates that there may be outstanding relevant private and/or VA treatment records. The Veteran indicated that there are medical treatments in her medical folder that may help her claim in an October 2015 statement and testified at the hearing that she had an appointment pending with a private orthopedist for her foot condition. Therefore, a remand is required to allow VA to obtain any outstanding medical records. Additionally, the Veteran last underwent a VA examination for her foot in April 2017. The VA has a duty to provide the Veteran with a thorough and contemporaneous medical examination. The Board also notes that the lay evidence indicates a possible worsening of symptoms as she reported difficulty with putting pressure on her foot, tingling sensations, and loss of motion. For these reasons, the Veteran must be afforded a new VA examination to determine the functional and occupational impact of her service-connected foot condition. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159; see also Green v. Derwinski, 1 Vet. App. 121, 124 (1991). The matters are REMANDED for the following action: 1. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. 2. Contact the Veteran and afford her the opportunity to identify by name, address and dates of treatment or examination any relevant medical records. Subsequently, and after securing the proper authorizations where necessary, make arrangements to obtain all the records of treatment or examination from all the sources listed by the Veteran which are not already on file. All information obtained must be made part of the file. All attempts to secure this evidence must be documented in the claims file. If, after making reasonable efforts, the records cannot be obtained, notify the Veteran and her representative and (a) identify the specific records that cannot be obtained; (b) briefly explain the efforts made to obtain those records; and (c) describe any further action to be taken with respect to the claim. The Veteran must then be given an opportunity to respond. 3. After the above development is completed, schedule the Veteran for a VA medical examination to determine the current severity of her service-connected left foot. The electronic claims file must be reviewed in conjunction with the examination. All necessary testing must be conducted. 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 why that is so. The examiner must describe whether pain, weakness, fatigue and/or incoordination significantly limits functional ability during flares or repetitive use, and if so, the examiner must estimate range of motion during flares or repetitive use. If the examination does not take place during a flare or repetitive testing cannot be performed, the examiner should have the Veteran describe and/or demonstrate the extent of motion loss during flares or repetitive use and provide the extent of motion loss described in terms of degrees. If there is no pain and/or no limitation of function, such facts must be noted in the report. The examiner should comment as to whether there is any medical reason to accept or reject the Veteran's description of reduced range of motion during flares or repetitive use. The examiner must also provide an assessment of the Veteran's functional limitations due to her left foot condition as it may relate to her ability to function in a work setting and to perform work tasks. However, the examiner should refrain from commenting on the Veteran's employability. A complete rationale for all medical opinions is required. The examiner should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge, or literature, etc., relied upon in reaching the conclusion(s). If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 4. Finally, readjudicate the appeal. If the benefit sought on appeal remains denied, issue a supplemental statement of the case, and return the case to the Board. G. A. WASIK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. A. Prinsen 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.