Citation Nr: 21075814 Decision Date: 12/21/21 Archive Date: 12/21/21 DOCKET NO. 19-22 501 DATE: December 21, 2021 REMANDED Entitlement to specially adapted housing is remanded. Entitlement to special home adaptation is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1972 to September 1974. The Veteran and his wife testified before the undersigned Veterans Law Judge at a December 2021 Board hearing. This matter is on appeal from an October 2017 rating decision. The Veteran is currently seeking entitlement to specially adapted housing and special home adaptation due to his overall service-connected disabilities. At his December 2021 Board hearing, he testified that his mobility has been significantly impaired because of his back and knees. Because of his more recent back surgery, he requires an update to his bathroom. He is unable to move around without the use of braces, canes, and a walker. He is unable to engage in physical activities after having 3 back surgeries and 5 knee surgeries. His disabilities have been worsening and now experiences foot drop, which increases the incidence of falling. He is unable to get out of the bathroom or step out of the bathtub. His bathroom is very small, which does not allow any maneuvering with his walker. Without it, he fears falling. His left knee disability prevents him from prolonged standing and has even fallen several times before. The Veteran's wife testified that her husband's testimony covered all his complications and stated that she is mostly worried about him falling as he has done so in the past. He is currently service connected for left knee chondromalacia, status post total knee arthoplasty at 60 percent, degenerative disc disease of the spine with bilateral for minimal encroachment with radiculopathy to the bilateral lower extremities at 40 percent, tinea pedis at 10 percent, a left ankle strain at 10 percent, and bilateral flat feet at a noncompensable rating. Based on a May 2017 VA examination for his back disability, the Veteran underwent a right sided decompressive laminectomy of L4-5 and L5-S1 discectomy in December 2016. Surgery was done for an L4-5 stenosis and L5-S1 disc herniation. He stated that he had bilateral lower extremity radiculopathy prior to the surgery more pronounced on the right, which did not improve after the surgery. A repeat L-spine MRI was done in March 2017 which showed paracentral disc extrusion at the L5-S1 with cephalad migration. He demonstrated an abnormal range of motion due to pain. Further examination revealed normal muscle strength with a score of 5 out of 5 in bilateral hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extensions. There was no evidence of muscle atrophy. A reflex examination revealed hypoactive results with a score of 1+ in the bilateral knee and ankle. A sensory examination noted decreased sensation in the ankles and foot/toes. The examiner found that the Veteran demonstrated mild radiculopathy in the right and left leg. In regard to functional impact, the examiner stated that the Veteran's condition would limit any type of job. In a VA physical therapy consult dating May 2017, the Veteran reported that he needed a walker. He was protective of his back due to his abnormal range of motion. He was able to balance in sitting and was able to self-stabilize in standing with the use of a walker. He was educated on a walking program protocol. The physician noted that the Veteran had a low risk of falling but should use a walker to assist with gait. In May 2019, the Veteran filed an increased rating for his back disability due to worsening symptoms. See March 2019 VA 21-526EZ Fully Developed Claim. In a July 2018 VA outpatient note, the Veteran's physician noted a clinical diagnosis of foot drop. September 2018 and March 2019 orthopedic surgery notes indicated that the Veteran complained of weakness in the right foot and dropfoot. He wears an AFO (ankle foot orthosis) in the right side. In a March 2019 VA podiatry note, the Veteran presented for diabetic foot care and complained of numbness in both feet. A neurological examination revealed that vibratory sensation was intact but there was monofilament decrease in his digits. The Veteran was afforded another VA examination in August 2019. There, he complained of lower back pain that radiates into his lower bilateral extremities with numbness and tingling. He was unable to stand during flareups. He complained of an inability to walk long distances or stand for a prolonged period on time. A muscle strength test revealed full strength with scores of 5 out of 5 in bilateral hip flexion, knee extension, ankle plantar flexion, ankle dorsiflexion, and great toe extension. There was no evidence of muscle atrophy. A reflex examination showed hypoactive results in the right knee and right ankle. Reflexes were normal in the left knee and ankle. A sensory examination showed normal results in the bilateral upper anterior thigh, knees, ankles, and feet. The examiner found that the Veteran demonstrated a moderate level of radiculopathy in both legs. The Veteran reported the regular use of a brace and a walker. The record suggests that the Veteran's service-connected back disability has worsened over the course of his appeal. His August 2019 VA examination showed that his radiculopathy of the lower extremities is to a moderate degree, but that he retained full muscle strength in the bilateral lower extremities, which include bilateral hip flexion, knee extension, and ankle movement. He uses a cane and a walker on a regular basis but not constantly. While his medical records undoubtedly show difficulties with mobility, it does not show that his low back disorder and his left knee condition result in a disability that equate to the loss or loss of use of his lower extremities. However, the Board notes that with his more December 2021 Board hearing testimony, the Veteran indicates he is now unable to walk or stand without the assistance of a walker or a cane, with incidences of falling. He requires the use of a walker or cane constantly. More importantly, he has reported drop foot in the right side, making it more difficult for him to walk. These lay statements strongly suggests that his condition had worsened and that his radiculopathy of the lower extremities may now have increased to a severe level. Therefore, the Board finds that the current medical evidence of record is inadequate to address the questions on appeal as they depict a disability picture that may be less severe than the Veteran claims. Thus, a remand is warranted to obtain a medical opinion. The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Then, schedule the Veteran for an examination by an appropriate clinician to determine the severity of his service-connected disabilities and the impact of his disabilities upon his activities of daily living for the purpose of determining his eligibility for specially adapted housing or a special home adaptation grant. The examiner must determine whether it is at least as likely as not (50 percent probability or greater) that the Veteran's service-connected disabilities, (which include his low back disorder, left knee disability, and left ankle disability) alone, are of such severity as to preclude him from ambulating without the use of an ambulatory device. The examiner should provide a full description of the Veteran's service-connected disabilities (including the reported right foot drop) and indicate the extent to which these disabilities result in loss of use of the lower extremities; preclude locomotion without the aids of braces, crutches, canes, or a wheelchair; and/or affect the functions of balance and propulsion. Specifically, the examiner should attempt to elicit information regarding the severity, frequency, and duration of any flare-ups of the Veteran's service-connected disabilities, and the degree of functional loss during flare-ups. The examiner should consider what ambulatory aids the Veteran uses, and with what frequency? How far, if at all, is the Veteran able to walk independently? Does the Veteran use ambulatory devices inside his home, and if so, what type and how frequently? A complete rationale must be provided for the opinion offered. Tiffany Dawson Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Yeh, 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.