Citation Nr: 21041671
Decision Date: 07/09/21	Archive Date: 07/09/21

DOCKET NO. 16-45 580
DATE: July 9, 2021

REMANDED

Entitlement to a rating in excess of 10 percent for an impairment of the right tibia and fibula (right leg disability) is remanded.

Entitlement to a rating in excess of 50 percent for posttraumatic stress disorder (PTSD) is remanded.

REASONS FOR REMAND

The Veteran had active service in the United States Army from February 1997 to August 1999.

In November 2018, the Board denied the increased rating claims, which the Veteran appealed to the United States Court of Appeals for Veterans Claims ("CAVC" or "the Court").  In October 2020, the Court vacated the Board's decision, and remanded the claims to the Board for action consistent with its decision.

Regarding the Veteran's right leg disability, she was last afforded a VA examination in December 2015.  The VA examiner reported that the Veteran's right leg disability was asymptomatic and had no impact on her ability to perform any type of occupational task.  In September 2016, the Veteran reported that her right lower extremity disability pain prevented her from performing normal activities and affected her ability to work.  Pain and its associated functional impairment are symptoms that the Veteran is competent to report.  As such, a remand in necessary to afford the Veteran a new examination to evaluate the current severity of her right leg disability and to consider any functional impairment due to pain.

Regarding the Veteran's PTSD, the Veteran was last afforded a VA examination in February 2016.  The examiner indicated that the Veteran's PTSD resulted in occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks, although generally functioning satisfactorily, with normal routine behavior, self-care, and conversation.  In September 2016, the Veteran reported that her PTSD symptoms resulted in difficulty with work and relationships, which indicated a worsening of her symptoms.  As such, a remand is necessary to afford the Veteran a new examination to evaluate the current nature and severity of her PTSD. 

Accordingly, in compliance with the Court's decision, VA examinations are necessary to adjudicate the Veteran's increased rating claims.

The matters are REMANDED for the following actions:

1. With any necessary identification of sources by the Veteran, obtain all outstanding VA and/or private medical records that pertain to the Veteran's right leg disability and PTSD.

2. Then, schedule the Veteran for a VA examination to determine the current severity of her right leg disability.  The examiner should use the appropriate DBQ template and record all relevant findings.  The examiner should ensure to the extent possible, consistent with 38 C.F.R. § 4.59, that the report includes the results of active and passive motion, in addition to the results following repetitive motion testing.  If it is not possible to complete any of the range of motion testing described above, it should be explained.  The examiner must consider the lay statements of the Veteran regarding her symptoms and its effects on her social and occupational functioning.

3. Schedule the Veteran for a VA examination to assess the current severity of her PTSD according to all applicable criteria.  The examiner must consider the lay statements of the Veteran regarding her PTSD symptoms and its effects on her social and occupational functioning.

Both examiners should keep in mind that the Veteran is competent to report her symptoms and history.  Such reports, including those of continuity of symptomatology and functional limitations, must be acknowledged and considered in formulating any opinion. Should an examiner reject the Veteran's reports, she/he must provide an explanation for such rejection.  

 

 

B.J. Komins

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	T. Berryman, 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.