Citation Nr: 22018334 Decision Date: 03/29/22 Archive Date: 03/28/22 DOCKET NO. 19-17 581 DATE: March 29, 2022 REMANDED Entitlement to an initial rating in excess of 10 percent for right foot status post stress fracture is remanded. Entitlement to an initial rating in excess of 10 percent for left foot status post stress fracture is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1993 to January 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in April 2018 by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2021, the Veteran and his spouse testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. At such time, the Veteran waived Agency of Original Jurisdiction (AOJ) consideration of the evidence associated with the record since the issuance of the May 2019 statement of the case. 38 C.F.R. § 20.1305(c). 1. Entitlement to an initial rating in excess of 10 percent for right foot status post stress fracture. 2. Entitlement to an initial rating in excess of 10 percent for left foot status post stress fracture. The Board finds that a remand is necessary in order to afford the Veteran a contemporaneous VA examination so as to determine the current nature and severity of his bilateral foot disabilities. In this regard, the Board observes that he was last examined by VA in April 2018, at which time such were assessed as moderately disabling; however, updated treatment records and the testimony offered at the November 2021 Board hearing suggest increased and additional symptomatology. Specifically, June 2018 X-ray revealed bilateral calcaneal spurs and osteoarthritis in the right first metatarsophalangeal (MTP) joint, and a September 2018 private treatment record reflects an assessment of metatarsalgia of the bilateral feet. Moreover, at the November 2021 Board hearing, the Veteran testified that his bilateral foot disabilities had worsened since the April 2018 VA examination as such resulted in deformities, bone spurs, and arthritis as well as an increase in flare-ups that resulted in incapacitating episodes where he is not able to be on his feet, which resulted in further limitations in his occupation and daily life. Thus, as the evidence suggests that the Veteran's bilateral foot symptomatology may have increased in severity since the April 2018 VA examination, a remand is necessary in order to schedule him for an appropriate VA examination in order to assess the current nature and severity of such service-connected disabilities. See Snuffer v. Gober, 10 Vet. App. 400 (1997); Caffrey v. Brown, 6 Vet. App. 377 (1994); VAOPGCPREC 11-95 (1995). The Board also finds that a remand is necessary in order to obtain all outstanding relevant treatment records. In this regard, at the November 2021 Board hearing, the Veteran testified to receiving treatment for his bilateral foot disabilities through VA's Veteran's Choice program. In this regard, the Board notes the Veteran's VA treatment records on file reflect that various documents have been scanned into VistA Imaging, but such are not of record. Thus, on remand, all outstanding relevant treatment records that have been scanned into VistA Imaging should be associated with the file and the Veteran should also be given an opportunity to submit, or authorize VA to obtain, any outstanding private treatment records for consideration in his appeal. The matters are REMANDED for the following actions: 1. All outstanding relevant treatment records that have been scanned into VistA Imaging should be associated with the file and the Veteran should also be given an opportunity to submit, or authorize VA to obtain, any outstanding relevant private treatment records. In this regard, after obtaining authorization from the Veteran, any make at least two (2) attempts to obtain records from any identified sources. If any such records are unavailable, inform the Veteran and afford him an opportunity to submit any copies in his possession. 2. Afford the Veteran an appropriate VA examination to determine the current nature severity of his service-connected bilateral foot disabilities. The record, to include a copy of this Remand, must be made available to the examiner. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail. The examiner should describe the nature and severity of all manifestations of the Veteran's right and left foot status post stress fractures. The examiner should record the range of motion of the bilateral feet observed on clinical evaluation. If there is evidence of pain on motion, the examiner should indicate the degree of range of motion at which such pain begins, and whether such pain on movement, as well as weakness, excess fatigability, or incoordination, results in any loss of range of motion. The examiner should record the results of range of motion testing for pain on both active and passive motion, on weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. 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. It is also imperative that the examiner comment on the functional limitations caused by flare-ups, repetitive use, and repeated use over time. In this regard, the examiner should indicate whether, and to what extent, the Veteran's range of motion is additionally limited during flare-ups, on repetitive use, and on repeated use over time expressed, if possible, in terms of degrees, or explain why such details cannot be feasibly provided. If the Veteran endorses experiencing flare-ups of his feet, the examiner must obtain information regarding the frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups. Then, if the examination is not being conducted during a flare-up, the examiner should provide an opinion based on estimates derived from the information above as to the additional loss of range of motion that may be present during a flare-up. If the examiner cannot provide an opinion as to additional loss of motion during a flare-up without resorting to mere speculation, the examiner must make clear that s/he has considered all procurable data (i.e., the information regarding frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups elicited from the Veteran), but any member of the medical community at large could not provide such an opinion without resorting to speculation. The examiner should offer an opinion as to whether any right and/or left foot disorders that have been present at any time since February 2018, even if such are asymptomatic or resolved, to include bilateral calcaneal spurs and osteoarthritis in the right first MTP as shown in a June 2018 X-ray and bilateral metatarsalgia as shown in a September 2018 private treatment record, are at least as likely as not part and parcel of the Veteran's service-connected right and left foot status post stress fractures, or caused or aggravated by such disabilities. The examiner should also comment upon the functional impairment resulting from the Veteran's right and left foot status post stress fractures. A rationale for any opinion offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Dawn A. Leung, 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.