Citation Nr: 18132340
Decision Date: 09/06/18	Archive Date: 09/06/18

DOCKET NO. 11-13 885
DATE:	September 6, 2018
REMANDED
Entitlement to an initial compensable rating for left ankle strain, and to a rating in excess of 10 percent from February 10, 2011, is remanded.
Entitlement to an initial compensable rating for osteochondritis dissecan, right talus (previously diagnosed as right ankle strain), and to a rating in excess of 10 percent from February 2, 2010, is remanded.
Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the right knee is remanded.
REASONS FOR REMAND
The Veteran served on active duty from May 1984 to December 1984.
1. Entitlement to an initial compensable rating for left ankle strain, and to a rating in excess of 10 percent from February 10, 2011, is remanded.
2. Entitlement to an initial compensable rating for osteochondritis dissecan, right talus (previously diagnosed as right ankle strain), and to a rating in excess of 10 percent from February 2, 2010, is remanded.
3. Entitlement to an initial rating in excess of 10 percent for degenerative arthritis of the right knee is remanded.
During the February 2018 Board hearing, the Veteran testified that his service-connected knee and ankle disability has worsened since his January 2017 VA examination due to a June 2017 injury.  Accordingly, remand is appropriate for a new VA examination to address the current nature and severity of the Veteran’s disability.
During the February 2018 Board hearing, the Veteran also reported that he was currently in physical therapy and that he was treated at Emory through the VA contract care system.  See Hearing Tr., p. 6.  The Veteran submitted December 2017 treatment records from Emory.  While this matter is on remand, outstanding treatment records should be obtained, including VA treatment records from May 2017 to the present, to include physical therapy treatment and treatment at Emory or other non-VA providers contracted through the VA.  Any additional treatment records that were scanned into Vista Imaging and are part of the Veteran’s VA medical file but are not in the Veteran’s claims file should be added to the record.
On remand, the Veteran’s representative should be afforded the opportunity to submit a VA Form 646, Statement of Accredited Representative in Appealed Case, in support of the Veteran’s claims.
In addition, the Veteran reported muscle damage and instability relating to his knee disability during the February 2018 Board hearing.  Accordingly, when readjudicating the matter, the Regional Office should consider whether separate compensable ratings are warranted for such symptomatology.
The matters are REMANDED for the following action:
1. Obtain outstanding VA treatment records, including VA treatment records from May 2017 to the present, to include physical therapy treatment and treatment at Emory or other non-VA providers contracted through the VA.  Any additional treatment records that were scanned into Vista Imaging and are part of the Veteran’s VA medical file but are not in the Veteran’s claims file should be added to the record.
2. After obtaining outstanding treatment records, schedule the Veteran for an examination of the current severity of his service-connected right knee, left ankle, and right ankle disability.  The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing.  The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups.  To the extent possible, the examiner should identify any symptoms and functional impairments due to the Veteran’s service-connected disability alone and discuss the effect of the Veteran’s service-connected disability on any occupational functioning and activities of daily living.  If it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training).
The examiner should consider and evaluate the Veteran’s reports regarding muscle damage and instability relating to his right knee.
3. After completing the above development, request that the Veteran’s representative provide a VA Form 646 or its equivalent addressing the issues on appeal.
4. Thereafter, readjudicate the claims, including consideration of whether separate compensable ratings are warranted for muscle damage and instability relating to the Veteran’s knee disability.  If the benefits sought on appeal remain denied, the Veteran and his representative should be furnished a supplemental statement of the case and given the opportunity to respond thereto.
 
MARJORIE A. AUER
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	A. Purcell, Associate Counsel

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