Citation Nr: 21010028 Decision Date: 02/23/21 Archive Date: 02/23/21 DOCKET NO. 10-35 440 DATE: February 23, 2021 REMANDED Entitlement to a rating in excess of 10 percent for service-connected sprain injury of the left ankle with chronic lateral instability and degenerative changes (left ankle disability) is remanded. Entitlement to a total disability rating based on individual unemployability (TDIU) due to service-connected disabilities is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1979 to May 1985. The Veteran testified before the Board at a March 2018 videoconference hearing. A transcript has been associated with the claims file. The most recent VA examination assessing the nature and severity of the Veteran’s service-connected left ankle disability was in July 2020. Subsequently, a November 2020 VA treatment record noted the Veteran’s report of worsening left ankle pain in his arch, as well as worsening pain in the morning. See November 2020 VA Pain Procedure Note. The Board also notes that he rated his pain a nine out of ten, higher than the level of pain reported during the July 2020 VA examination. See November 2020 VA Primary Care Nursing Note; July 2020 VA Examination Report. Given evidence of potential worsening, the Board finds that a more contemporaneous examination is needed to fully and fairly evaluate the Veteran’s claim for an increased rating for his service-connected left ankle disability. As noted in the November 2020 remand, the Veteran’s claim for a TDIU is inextricably intertwined with his other claim on appeal. See Parker v. Brown, 7 Vet. App. 116 (1994); Harris v. Derwinski, 1 Vet. App. 180, 183 (1991). As such, the Board will defer consideration of entitlement to a TDIU issue at this time. On remand, the AOJ should associate with the record any outstanding VA treatment records that are not currently associated with the claims file. Additionally, the Veteran should be given the opportunity to identify any outstanding pertinent evidence. The matters are REMANDED for the following action: 1. Obtain the Veteran’s VA treatment records for the period from November 2020 to the present. 2. Schedule the Veteran for an appropriate VA examination by a competent medical professional to determine the current nature and severity of his service-connected left ankle disability. The entire record must be made available to, and be reviewed by the examiner. The examiner should take a history from the Veteran as to the progression of his service-connected left ankle disability. The examiner must address each of the following: a) The examiner should describe all symptoms associated with the Veteran’s service-connected left ankle disability. d) The examiner should ask the Veteran to report any range of motion loss during flare-ups or following repeated use. Even if the Veteran is not experiencing a flare-up at the time of the examination, the examiner must elicit relevant information as to flare ups and ask him to describe the additional functional loss, if any, he suffers during flare-ups or following repeated use. The examiner should then estimate the functional loss, including loss of range of motion, due to flare-ups or following repeated use based on all the evidence of record—including the Veteran’s lay statements. All examination findings/testing results, along with a complete, clearly-stated rationale for any opinion offered, must be provided. 3. Thereafter, and after any further development deemed necessary, the issues on appeal should be readjudicated. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board James R. Springer, 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.