Citation Nr: 21014482
Decision Date: 03/12/21	Archive Date: 03/12/21

DOCKET NO. 16-32 617
DATE: March 12, 2021

REMANDED

Entitlement to a rating in excess of 10 percent disabling for service-connected residuals of a right fibula fracture is remanded.

REASONS FOR REMAND

The Veteran served on active duty from April 1964 to April 1967.

This appeal was previously before the Board in April 2020, at which time it was remanded for further development.  Unfortunately, another remand is required.

Entitlement to a rating in excess of 10 percent disabling for service-connected residuals of a right fibula fracture is remanded.

Records of VA care dated in February 2020 show that the Veteran was provided an x-ray of his right knee to help assess the severity of his service-connected right fibula fracture residuals.  A radiology report discussing the results of the x-ray has not been associated with the claims file.  Importantly, when the Veteran appeared for his subsequent August 2020 knee examination, the examiner responded “No” to the questions of whether imaging studies of the knee had been performed and whether the results were available.  As the evidence of record demonstrates that imaging studies were performed in the months prior to the August 2020 examination, as ordered by VA on February 7, 2020, it appears the examiner did not have a complete record to review at the time of the August 2020 knee examination.  As the Veteran’s service-connected disability specifically involves fracture residuals, such x-ray results may contain information that is relevant to the assignment of an appropriate disability rating.  

On remand, efforts should be taken to obtain the February 2020 VA x-ray results.  The results should then be assessed by a clinician with appropriate expertise, and it should be determined whether the August 2020 examination results are accurate in light of the x-ray results.   If the reviewing clinician believes that the x-ray results call into question the accuracy of the August 2020 examination results, or if the February 2020 x-ray results simply cannot be found, the Veteran should be scheduled for another right knee examination.

The matters are REMANDED for the following action:

1. Obtain the Veteran’s VA treatment records for the period from February 2020 to the present, including any radiology reports for x-rays of the right knee ordered in February 2020.  See a February 7, 2020 VA treatment report indicating that x-rays of the right knee were ordered on that day.  All attempts to obtain these records should be documented in the claims file.  

2.  If the Veteran’s right knee x-ray results are found, they should be reviewed by a clinician with appropriate expertise, and it should be determined by that clinician whether the August 2020 right knee examination results are accurate, given the findings on x-ray.   Importantly, if the reviewing clinician believes that the x-ray results call into question the accuracy of the August 2020 examination results, or if the x-ray results ordered on February 7, 2020 simply cannot be found, the Veteran should be scheduled for another right knee examination, with new x-rays taken (with the consent of the Veteran) if x-ray results from February 2020 are not otherwise of record.

3.  After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal.

 

 

V. Chiappetta

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	L. Bristow Williams, 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.