Citation Nr: 21015007 Decision Date: 03/16/21 Archive Date: 03/16/21 DOCKET NO. 15-19 207 DATE: March 16, 2021 REMANDED Entitlement to a rating in excess of 20 percent for left ankle posttraumatic arthritis and Achilles tendinopathy (hereinafter left ankle disability) is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1978 to September 1991. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2018, the Board remanded the appeal for additional development. The Board regrets the additional delay in adjudication, but finds this issue must be remanded for a new examination. The Veteran underwent a VA ankle examination in August 2019, but subsequently submitted a July 2020 VA treatment record that indicates the left ankle disability increased in severity after the examination. See Snuffer v. Gober, 10 Vet. App. 400 (1997) (holding that the Veteran is entitled to a new VA examination where there is evidence that the condition has worsened since the last examination). The July 2020 VA treatment record notes that the Veteran had a new complaint of “worsening burning then weakness in the ankles, feet, and legs with them giving away beneath him at the end of the day.” See July 2020 Neurology Consult. Furthermore, the Veteran described a burning sharp pain in the ankles, indicating neuropathy and peripheral nerve disease. See id. Accordingly, remanding for a new examination is the only way to obtain the evidence needed to properly evaluate the service-connected left ankle disability. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records relating to treatment for the Veteran’s service-connected left ankle disability. Contact the Veteran and ask him to identify whether there are any outstanding private medical records reflecting treatment for his left ankle disability. If such records are identified, then obtain those records and associate them with the electronic claims file. If possible, the Veteran is encouraged to obtain and submit these records himself in order to avoid any additional delays. 2. Schedule the Veteran for a VA examination with a suitably qualified medical professional to address the severity of his left ankle disability. The claims file should be made available and reviewed by the examiner in conjunction with conducting the examination. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. After a review of the claims file, any needed testing, and an examination of the Veteran, the examiner should provide answers to the following questions regarding the Veteran’s left ankle disability: (a) The examiner should identify all left ankle pathologies found to be present during the pendency of the appeal, including potential peripheral neuropathy. (b) The examiner should conduct all indicated tests and studies, to include range of motion studies. Full range of motion testing must be performed where possible. The joints involved should be tested in both active and passive motion, and in weight-bearing and non-weight-bearing. 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. (c) The examiner should describe any pain, weakened movement, excess fatigability, instability of station, and incoordination present. (d) The examiner should also state whether the examination is taking place during a period of flare-up. (e) If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms, and/or after repeated use over time. (f) Based on the Veteran’s lay statements and the other evidence of record, the examiner should provide an opinion estimating any additional degrees of limited dorsiflexion and plantar flexion caused by functional loss during a flare-up and after repeated use over time. (g) If the examiner cannot estimate the degrees of additional range of motion loss in the left ankle dorsiflexion and plantar flexion during flare-ups and/or after repetitive use without resorting to speculation, the examiner should 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). (h) The examiner should also state the nature, extent, and severity of any left ankle instability. (Continued on the next page)   In providing the opinions, the examiner should consider the Veteran’s competent lay statements regarding observable symptomatology, including instability. The examination report must include a complete rationale for all opinions expressed. John J. Crowley Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Laura Cochran, 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.