Citation Nr: 21025777 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 18-08 129 DATE: April 29, 2021 REMANDED Entitlement to an initial rating in excess of 30 percent for a left foot disability is remanded. REFERRED The issue of entitlement to service connection for left leg lower muscle group disability, to include as secondary to service-connected left foot disability, has been raised by the record and is referred to the Agency of Original Jurisdiction (AOJ) for adjudication. REASONS FOR REMAND The Veteran served active duty in the United States Army from April 2003 to May 2003 and from May 2010 to June 2015. In December 2020, the Veteran testified before the undersigned Veterans Law Judge at a Virtual hearing. A copy of the transcript has been associated with the claims file. The Board notes that the Veteran asserted that a separate rating for left leg muscle group disability is warranted as part of a claim for an increased rating for service-connected left foot disability. The Board notes that, as the Veteran has asserted that the muscle group injury arose over time, it is not part and parcel of the left foot injury itself; rather, the issue is more appropriately classified as a claim secondary to the service-connected left foot disability. Therefore, the claim for service connection for left leg muscle group is referred to the AOJ for appropriate action. 1. An initial rating in excess of 30 percent for a left foot disability is remanded. The Veteran contends that his left foot disability is such that a rating in excess of 30 percent is warranted, to include separate ratings for left foot limitation of motion, left ankle limitation of motion, and neurological symptoms of the left foot disability. The Veteran’s last VA examination for his left foot disability was in December 2017. When available evidence is too old for an adequate evaluation of the Veteran’s current condition, VA’s duty to assist includes providing a new examination. Weggenmann v. Brown, 5 Vet. App. 281 (1993). The Board finds that the December 2017 examination is remote, and the examination does not include testing for neurological findings. Moreover, there is insufficient medical evidence on file from which the Board can accurately determine the current severity of the Veteran’s service-connected left foot disability. Clarification is also needed to determine if the Veteran’s left ankle symptoms arise from the same left foot disability such that a separate rating would be warranted. Therefore, a remand is necessary. The matters are REMANDED for the following action: Schedule the Veteran with an appropriate examiner to determine the current severity of the Veteran’s service-connected left foot disability. The claims file must be made available to and reviewed by the examiner for the pertinent medical and other history. All necessary diagnostic testing and evaluation should be performed, and all findings set forth in detail, utilizing the most up-to-date Disability Benefits Questionnaire. a. The examiner should provide all information required for rating purposes, to specifically include range of motion of each foot in active motion, passive motion, weight-bearing, and non-weight-bearing. Further, the examiner must indicate if movement is limited by pain, and if so, at what point. The examiner is requested, to the extent possible, to provide estimates of range of motion if the Veteran asserts that he is unable to perform range of motion testing due to pain. 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. The examiner must report whether there is a lack of normal endurance or functional loss due to pain and pain on use, including that experienced during flare ups; whether there is weakened movement, excess fatigability, incoordination; and the effects of the service-connected disability on the Veteran’s ordinary activity, including his ability to work. The examiner should also ask the Veteran to identify the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment resulting from flare-ups. The examiner should identify the extent of the Veteran's functional loss during flare-ups and offer range of motion estimates based on that information. If the examiner cannot provide the above-requested opinion without resorting to speculation, he or she should state whether all procurable medical evidence had been considered, to specifically include the Veteran’s description as to the severity, frequency, duration of the flare-ups and his description as to the extent of functional loss during a flare-up and after repetitive use over time; whether the inability is due to the limits of medical community or the limits of the examiner's medical knowledge; and whether there is additional evidence, which if obtained, would permit the opinion to be provided. b. In making a determination of the current severity of the Veteran’s left foot disability, the examiner is asked to determine all neurological deficits of the foot. c. The examiner is also asked to determine if the Veteran’s left ankle symptoms arise from the same in-service left foot injury. If so, the examiner is asked to determine the current severity of the Veteran’s left ankle symptoms. If the examiner determines that the Veteran’s left ankle symptoms did not arise from the same left foot disability, the examiner is asked to determine whether it at least as likely as not that the Veteran’s left ankle disability is otherwise due to, caused by, or the result of his period of active duty service. JENNIFER HWA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Ford 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.