Citation Nr: 18141669 Decision Date: 10/11/18 Archive Date: 10/11/18 DOCKET NO. 13-16 410 DATE: October 11, 2018 REMANDED Entitlement to a rating in excess of 10 percent for thoracic strain with degenerative changes is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1987 to August 1994. This matter comes before the Board of Veterans Appeals (Board) on appeal from a rating decision issued in June 2012 by a Department of Veterans Affairs (VA) Regional Office. In February 2017, the Board remanded the instant claim, as well as a claim for service connection for chronic headaches, for additional development. While on remand, service connection for chronic headaches was granted in a July 2017 rating decision. As such claim has been granted in full, it is no longer before the Board. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The remaining claim now returns for further appellate review. Entitlement to a rating in excess of 10 percent for thoracic strain with degenerative changes. During the course of the appeal, the Veteran was afforded VA examination in April 2011, July 2013, and April 2017 in order to assess the nature and severity of his service-connected thoracic spine disability. At the most recent VA examination, the examiner recorded the range of the Veteran’s thoracolumbar spine motion, noted that there was pain on weight bearing, and stated that the documented objective findings regarding the absence or presence of pain hold for both passive and active range of motion, and both weight bearing and non-weight bearing. However, the examiner did not include joint testing for pain on both active and passive motion, or in weight-bearing and nonweight-bearing in accordance with Correia v. McDonald, 28 Vet. App. 158 (2016). Furthermore, such range of motion testing was not conducted at the prior VA examinations. Therefore, a remand is necessary in order to afford the Veteran another VA examination that includes such range of motion testing, and a retrospective opinion concerning the findings at the prior examinations in accordance with Correia, supra, and Sharp v. Shulkin, 29 Vet. App. 26 (2017). The matter is REMANDED for the following action: 1. Afford the Veteran should be afforded an appropriate VA examination to determine the current nature and severity of his service-connected thoracic spine disability. All indicated tests and studies should be undertaken. The record, including a complete copy of this remand, must be made available for review in connection with the examination. (A) The examiner should identify the current nature and severity of all manifestations of the Veteran’s thoracic spine disability. (B) The examiner should record the range of motion of the thoracolumbar spine observed on clinical evaluation in terms of degrees for all planes. 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, and on weight-bearing and nonweight-bearing. 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. (C) The examiner is also requested to review the VA examinations containing range of motion findings pertinent to the Veteran’s thoracic spine disability conducted in April 2011, July 2013, and April 2017. In this regard, the examiner is requested to offer an opinion as to the range of motion findings for pain on both active and passive motion, and on weight-bearing and nonweight-bearing. If the examiner is unable to do so, he or she should explain why. (D) It is also imperative that the examiner comment on the functional limitations caused by flare-ups and repetitive use. In this regard, the examiner should indicate whether, and to what extent, the Veteran’s range of motion is additionally limited during flare-ups or on repetitive use, expressed, if possible, in terms of degrees, or explain why such details cannot be feasibly provided. (E) If the Veteran endorses experiencing flare-ups of his thoracic spine, but the examination is not being conducted during a flare-up, the examiner must obtain information regarding the frequency, duration, characteristics, severity, and/or functional loss related to such flare-ups. Then, 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. (F) The examiner should review the April 2011, July 2013, and April 2017 VA examinations and provide an opinion, based on estimates derived from the information as documented in such reports, 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. (G) The examiner is requested to indicate whether intervertebral disc syndrome related to the Veteran’s service-connected thoracic spine disability is present. If so, the examiner should the total duration of any incapacitating episodes over the past 12 months. The examiner is advised that an ‘incapacitating episode’ is defined as a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. (H) The examiner is also requested to indicate whether the Veteran’s thoracic spine disability results in any objective neurologic impairments and, if so, the nature and severity of such neurologic impairment. (I) The examiner should also comment upon the functional impairment resulting from the Veteran’s thoracic spine disability. A rationale for all opinions offered should be provided. A. JAEGER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Jimerfield, Associate Counsel