Citation Nr: 22014371
Decision Date: 03/12/22	Archive Date: 03/12/22

DOCKET NO. 11-31 389
DATE: March 12, 2022

REMANDED

Entitlement to a rating in excess of 10 percent for a lumbosacral spine disability is remanded.

Entitlement to a rating in excess of 10 percent for left foot reflex sympathetic dystrophy with hammertoes (left foot disability) is remanded.

REASONS FOR REMAND

The Veteran had active service from January 2006 to April 2008.

This case is before the Board of Veterans' Appeals (Board) on appeal from a December 2010 Department of Veterans Affairs (VA) rating decision.

In March 2021, the Board denied the claims, and the Veteran appealed to the United States Court of Appeals for Veterans Claims (Veterans Court).  In October 2021, the Veterans Court issued an order that vacated the Board decision and remanded the claim for compliance with a Joint Motion for Remand (JMR).

Regarding the Veteran's increased rating claim for a lumbosacral spine disability, she was last provided a VA examination in October 2019.  The examiner indicated that the Veteran's lumbosacral spine disability did not result in an abnormal spinal contour.  In December 2020, the Veteran submitted a July 2020 lumbar spine MRI that showed an exaggerated lumbar lordosis, which indicated a worsening of her lumbosacral spine disability.

Regarding the Veteran's increased rating claim for a left foot disability, she was last provided a VA examination in October 2020.  The examiner found that the Veteran's left foot disability did not affect muscle strength or reflexes and had not resulted in muscle atrophy.  However, the medical records show that her left foot disability resulted in pain that caused her to limp, that she experienced temperature and color changes in her left foot, and that she was prescribed orthotics and a cane due to her left foot pain.  The October 2020 VA examiner indicated that the Veteran did not use any assistive device, including a brace or cane.

Accordingly, a remand is necessary in order to provide the Veteran new VA examinations for her lumbosacral spine disability and left foot disability.

The matters are REMANDED for the following action:

1. Obtain all outstanding VA and/or private medical records that pertain to the Veteran's lumbosacral spine disability and left foot disability.

2. Then, schedule the Veteran for a VA examination to determine the current severity of her service-connected lumbosacral spine disability.  In so doing, the examiner should ensure to the extent possible, consistent with 38 C.F.R. § 4.59, that the report include 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.

Furthermore, the examiner should opine as to whether any thoracolumbar spine limitation of motion qualifies as "functional ankylosis."

Finally, the examiner should specifically address the July 2020 lumbar spine MRI that showed an exaggerated lumbar lordosis and whether this results in an abnormal spinal contour.   The examiner should also address the Veteran's lay statements regarding the severity of her lumbosacral spine disability.

3. Schedule the Veteran for a VA examination to determine the current severity of her service-connected left foot disability.  The examiner should assess the severity and any functional impairment resulting from the Veteran's left foot disability, both neurological and musculoskeletal.

Finally, the examiner should specifically address the Veteran's medical records showing that the Veteran's left foot disability resulted in pain that caused her to limp, that she experienced temperature and color changes in her left foot, and that she was prescribed orthotics and a cane due to her left foot pain.  The examiner should also address the Veteran's lay statements regarding the severity of her left foot disability.

 

 

VICTORIA MOSHIASHWILI

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.