Citation Nr: 21015733
Decision Date: 03/18/21	Archive Date: 03/18/21

DOCKET NO. 13-32 313
DATE: March 18, 2021

REMANDED

Entitlement to a rating in excess of 10 percent for a left ankle and calcaneal spur disability is remanded.

REASONS FOR REMAND

Left ankle instability and the constant use of braces for left ankle instability was noted in the January 2013 and February 2018 VA examination reports.  However, the examiners did not provide an assessment of the severity of left ankle instability.  In addition, the Board finds that the disability has been rated together with a calcaneal spur disability.  Consideration is needed as to whether separate ratings may be warranted for limitation of motion of the foot and limitation of motion of the ankle.  When VA provides an examination or obtains an opinion, the examination or opinion must be adequate.  Barr v. Nicholson, 21 Vet. App. 303 (2007).  Therefore, remand is necessary for a medical opinion regarding left ankle instability and differentiating any symptomatology of the left foot and left ankle.  

The matter is REMANDED for the following action:

1. After obtaining any necessary releases, obtain all relevant VA and private treatment records not already associated with the claims file.  All attempts to locate records must be documented in the claims file.

2. Schedule the Veteran for a VA ankle examination and a VA foot examination of the left ankle and foot disability.  The examiner should review the claims file.  The examiner should record in detail all symptoms of a service-connected left ankle disability to include ankle instability, and whether it is slight, moderate, or severe.  The examiner should provide ranges of motion of both feet and both ankles for passive motion, active motion, weight-bearing motion, and nonweight-bearing motion.  The examiner should specifically state whether there is any limitation of motion of the left ankle or of the left foot, to include as due to painful motion, excess motion, weakened motion, incoordination, fatigability, or on flare up.  The examiner should describe all limitation of function of the left foot due to the left calcaneal spur and should characterize any disability of the left foot as mild, moderate, moderately severe, or severe.  The examiner should describe all limitation of function of the left ankle due to the left ankle degenerative joint disease.  A clearly stated rationale with references to the record and diagnostic tests should be provided.

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3. Then, readjudicate the claim, including consideration of whether separate ratings should be applied for left ankle and left foot disability.  If any decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response.  Then, return the case to the Board.

 

 

Harvey P. Roberts

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	E.O., 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.