Citation Nr: 25005697 Decision Date: 04/25/25 Archive Date: 04/25/25 DOCKET NO. 18-55 516 DATE: April 25, 2025 REMANDED Entitlement to a disability rating in excess of 10 percent for left ankle disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from June 1988 to June 1992. This matter originally came before the Board of Veterans' Appeals (Board) on appeal from a September 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In December 2023, the Board issued a decision denying an increased rating for the Veteran's service-connected left ankle disability. The Veteran appealed the matter to the Court of Appeals for Veterans Claims (Court), which vacated the December 2023 Board decision, pursuant to a September 2024 Joint Motion for Remand (JMR). The Court remanded the matter for action consistent with the terms of the JMR. In October 2024, the Board remanded the matter to ensure compliance with the September 2024 JMR. Unfortunately, while the Board sincerely regrets the additional delay, the Board finds that the matter must again be remanded in order to ensure that the Veteran is afforded an adequate VA ankle examination. Entitlement to a disability rating in excess of 10 percent for left ankle disability is remanded. In the October 2024 remand, the Board directed the AOJ to schedule the Veteran for a VA examination to determine the nature and severity of her service-connected left ankle disability. See October 2024 BVA Decision, p. 6. In December 2024, the Veteran underwent a new VA ankle conditions examination in which she was diagnosed with left ankle sprain and tibiotalar osteoarthritis. See December 2024 C&P Examination, p. 2. However, this examination contains multiple inadequacies. First, the examiner did not provide any response when asked to document the Veteran's description of functional loss or functional impairment in her own words. Id. at 3. Next, the examiner stated that the Veteran did not report or have a history of instability of the ankle, which is in conflict with the findings of the September 2023 VA ankle examination of record. Id.; see also September 2023 C&P Examination, p. 3. These findings are of particular importance, as the rating criteria for ankle instability prior to February 7, 2021 allowed for a 20 percent rating for a moderate ankle disability associated with malunion of the tibia and fibula and a 30 percent rating for a marked level of such disability. See 38 C.F.R. § 4.71a, DC 5262 (2020). The Board notes that the criteria prior to February 7, 2021 are available to the Veteran as the period on appeal predates changes to ankle rating regulations. Next, regarding flare-ups, the examiner did not cite and discuss the evidence relied upon in providing estimations of range of motion. See December 2024 C&P Examination, p. 6. Due to the above issues, the Board must find that the December 2024 VA ankle examination is inadequate for adjudication purposes. Accordingly, the claim must be remanded in order to obtain an adequate examination and opinion. See Barr v. Nicholson, 21 Vet. App. 303, 312 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate). The matter is REMANDED for the following action: Schedule the Veteran for a VA examination to determine the nature and severity of her service-connected left ankle disability. The claims folder and this remand must be made available to the examiner for review, and the examination report must reflect that such a review was undertaken. The examiner is to specifically test the range of motion in active motion, passive motion, weight-bearing, and non-weightbearing, for the joint in question and any paired joint. See Correia v. McDonald,28 Vet. App. 158, 170 (2016). (Continued on the next page) The examiner should detail range of motion measurements, to include the degree at which the Veteran experiences pain, any additional impact caused by motion such as weakness and fatigability, incoordination, or swelling. The examiner is to note a full and complete history of the Veteran's symptoms, to include symptoms associated with any flare-ups. Provide an opinion as to additional functional loss during flare-ups of the musculoskeletal disability, pursuant to DeLuca v. Brown, 8 Vet. App. 202 (1995). Should the examiner state that he or she is unable to offer such an opinion without resorting to speculation based on the fact that the examination was not performed during a flare up, the examiner is directed to ascertain information as to the frequency, duration, characteristics, severity, or functional loss. Sharp v. Shulkin, 29 Vet. App. 26 (2017). John R. Doolittle, II Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Watkins, 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.