Citation Nr: 21015939 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 17-39 082 DATE: March 18, 2021 REMANDED 1. Entitlement to an initial rating in excess of 10 percent for a low back disability is remanded. 2. Entitlement to an initial rating in excess of 10 percent for a right ankle disability is remanded. 3. Entitlement to an initial rating in excess of 10 percent for right leg shin splints is remanded. 4. Entitlement to an initial rating in excess of 10 percent for left leg shin splints is remanded. 5. Entitlement to a total disability rating based on individual unemployability due to service-connected disability (TDIU) is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty in the U.S. Army from April 1992 to September 1999. These matters are before the Board of Veterans’ Appeals (Board) on appeal from a July 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In January 2021, a remote video conference hearing was held before the undersigned; a transcript is in the record. 1. 2. 3. 4. Entitlement to a rating in excess of 10 percent for a low back disability, entitlement to a rating in excess of 10 percent for a right ankle disability, entitlement to a rating in excess of 10 percent for right leg shin splints, and entitlement to a rating in excess of 10 percent for left leg shin splints are remanded. The Board finds that further development of the record is necessary for proper adjudication of these claims. Initially, treatment records (including up to date records from the Portland VAMC) pertaining to the above service-connected disabilities appear to be outstanding (not all available records have been secured). All records of treatment he has received for the service-connected disabilities are pertinent evidence in determining the ratings warranted (as they would reflect worsening, and when it occurred). Furthermore, at the time of the January 2021 video conference hearing, the Veteran expressed that he would be seeking emergency department care for his back following the completion of the hearing, and reported that he had been experiencing significant back pain for a week. See Video Conference Hearing pg. 3. Records of such recent emergency department treatment of the Veteran’s service-connected back disability should also be sought. At the January 2021 video conference hearing, the Veteran and his representative testified that the Veteran’s above service-connected disabilities had increased in severity since he was last examined in January 2017. Considering the allegation of worsening, and the duration of interval since the last examinations were conducted, contemporaneous examinations to assess the disabilities are necessary. 5. Entitlement to TDIU is remanded. The claim of TDIU has been raised by the record. See January 2021 Video Conference Hearing pg. 8. The Veteran’s current combined rating is 60 percent for his service-connected disabilities. Currently, the Veteran’s service-connected disabilities do not meet the schedular criteria for TDIU. See 38 C.F.R. § 4.16. The claim for TDIU is therefore inextricably intertwined with the above increased rating claims above, and consideration of the claim must be deferred pending resolution of the above increased rating claims. In March 2020, the Veteran was found eligible for VA Vocational Rehabilitation benefits but he did not pursue his claim at that time. A check on whether he reinitiated the claim is necessary as any vocational benefits or experience may be relevant to employability. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all providers (VA and private) of evaluations and treatment he has received for his service-connected (1) low back, (2) right ankle, (3) right shin splints, and (4) left shin splints (records of which are not already in the claims file), and to submit authorizations for VA to obtain complete pertinent clinical records from all private providers identified. Secure all such records from all providers identified (specifically including any VA evaluation or treatment records he identifies that are not already in the record). 2. Request any information on whether the Veteran was granted any Vocational Rehabilitation benefits after March 2020 and associate any records received with the claims file. 3. Arrange for an orthopedic examination of the Veteran to assess the current severity of his service-connected (1) low back, (2) right ankle, (3) right shin splints, and (4) left shin splints. The Veteran’s record must be reviewed by the examiner. All necessary studies must be completed, and must include range-of-motion studies in weight-bearing and non-weight-bearing (with notation of any additional functional limitations due to such factors such as weakness, pain, incoordination, flare-ups and fatigue). All pertinent findings including related functional limitations and impact on employment must be described in detail. 4. Then, review the expanded record, arrange for any further development indicated, and adjudicate the claim for TDIU considering the determinations made on the above increased rating claims. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Staskowski, 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.