Citation Nr: 18150284 Decision Date: 11/14/18 Archive Date: 11/14/18 DOCKET NO. 12-13 725 DATE: November 14, 2018 ORDER Entitlement to service connection for left lower extremity disability is denied. Entitlement to service connection for right lower extremity disability is denied. Entitlement to an initial rating in excess of 30 percent prior to April 24, 2012, and in excess of 70 percent thereafter for chronic posttraumatic stress disorder (PTSD), previously rated as adjustment disorder with depressive features, is denied. REMANDED Entitlement to service connection for a bilateral shoulder disability is remanded. Entitlement to service connection for bilateral hand problems, claimed as circulatory problems is remanded. Entitlement to an increased rating in excess of 20 percent for thoracic muscle strain, lumbar muscle spasm is remanded. FINDINGS OF FACT 1. The evidence of record does not reflect that the Veteran currently has a bilateral lower extremity disability. 2. The Veteran’s PTSD has not, for the period prior to April 24, 2012, been manifested by occupational and social impairment with reduced reliability and productivity or with deficiencies in most areas. 3. The Veteran’s PTSD has not, at any time during the appeal period, been manifested by total occupational and social impairment with symptoms equivalent in severity, frequency, and duration to gross impairment in thought processes or communication, persistent delusions or hallucinations, grossly inappropriate behavior, persistent danger of hurting self or others; intermittent inability to perform activities of daily living, including maintenance of minimal personal hygiene), disorientation to time or place, memory loss for names of close relatives, own occupation, or own name. CONCLUSIONS OF LAW 1. The criteria for a bilateral lower extremity disability have not been met. 38 U.S.C. §§1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2017). 2. The criteria for an initial rating greater than 30 percent for PTSD have not been met for the time period prior to April 24, 2012. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.130, Diagnostic Code 9411 (2017). 3. The criteria for an evaluation in excess of 70 percent for PTSD have not been met from April 24, 2012. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.102, 3.321, 4.130, Diagnostic Code 9411 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 23, 2002 to November 26, 2002, from February 11, 2003 to May 21, 2003, and from August 2006 to November 2007. He also served in the Army National Guard. His decorations include the Combat Action Badge. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from January 2010 and May 2010 rating decisions of the Department of Veteran Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico and St. Petersburg Florida respectively. The RO in San Juan, Puerto Rico, currently has jurisdiction over the case. The claim was previously remanded by the Board in August 2016. Service Connection Service connection means that a disability resulting from disease or injury was incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical “nexus” requirement). Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004)); see 38 C.F.R. § 3.303(a). A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102 (providing, in pertinent part, that reasonable doubt will be resolved in favor of the claimant). When the evidence supports the claim or is in relative equipoise, the claim will be granted. See Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990); see also Wise v. Shinseki, 26 Vet. App. 517, 532 (2014). If the preponderance of the evidence weighs against the claim, it must be denied. See id.; Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Entitlement to service connection for bilateral lower extremity disability The Veteran contends that his bilateral lower extremity disability was caused as a residual of the IED explosion he experienced in service. See September 2010 NOD. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the Veteran does not have a current diagnosis of a left or right side lower extremity disability and has not had one at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303(a), (d). The requirement of a current disability is satisfied when a claimant has a disability at the time a claim for VA disability compensation is filed or during or contemporary to the pendency of that claim. McClain v. Nicholson, 21 Vet. App. 319 (2007). Although there is July 2009 physical profile of record for back and bilateral leg pain after the Veteran was seen for posttraumatic right dorsal hamstring hematoma and left calf pain, this apparently resolved. Neither VA treatment records nor private treatment records show any diagnosis or treatment of a lower extremity disability during the pendency of this claim, which was submitted in November 2009. Notably, the Veteran’s back and lower extremities were examined by VA in December 2007, November 2009, April 2012, and May 2013, and at no time were lower extremity abnormalities observed or diagnosed. The Veteran has not reported or described experiencing any recent lower extremity disability symptoms. While he believes he currently has a lower extremity disability, he is not competent to provide a diagnosis in this case. The issue is medically complex and requires specialized knowledge and experience. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007); see Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (reiterating the need for supporting medical evidence in claim for rheumatic heart disease). Finally, the Board is cognizant of the recent ruling in Saunders v. Wilkie, which found that pain alone can constitute a disability. 886 F.3d 1356, 1368 (Fed. Cir. 2018). However, in contrast with Saunders, the Veteran has not demonstrated that he has any pain in his lower extremities that results in functional impairment of earning capacity. As noted, the Veteran has not reported or described experiencing any recent lower extremity disability symptoms. As such, Saunders is not applicable to the case currently before the Board. Without a current disability, the Veteran is not entitled to service connection on any basis. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (“In the absence of proof of a present disability there can be no valid claim.”). In sum, the preponderance of the evidence is against the Veteran’s claim. Consequently, the benefit-of-the-doubt rule does not apply, and service connection for a bilateral lower extremity disorder is denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). 2. Entitlement to an initial rating in excess of 30 percent prior to April 24, 2012 and in excess of 70 percent thereafter for chronic post-traumatic stress disorder (PTSD) previously rated as adjustment disorder with depressive features For the reasons that follow, the Board concludes that a rating in excess of 30 percent prior to April 24, 2012 and in excess of 70 percent thereafter, is not warranted. VA has adopted a Schedule for Rating Disabilities to evaluate service-connected disabilities. See 38 U.S.C. § 1155; 38 C.F.R., Part IV. The basis of disability evaluations is the ability of the body as a whole, or of the psyche, or of a system or organ of the body to function under the ordinary conditions of daily life, including employment. 38 C.F.R. § 4.10 (2017). The percentage ratings in the Schedule for Rating Disabilities represent, as far as practicably can be determined, the average impairment in earning capacity resulting from service-connected diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1 (2017). Generally, the degree of disabilities specified are considered adequate to compensate for considerable loss of working time from exacerbation or illness proportionate to the severity of the several grades of disability. 38 C.F.R. § 4.1. Separate diagnostic codes identify the various disabilities and the criteria for specific ratings. If two disability evaluations are potentially applicable, the higher evaluation will be assigned to the disability picture that more nearly approximates the criteria required for that rating. 38 C.F.R. § 4.7 (2017). Otherwise, the lower rating will be assigned. Id. Any reasonable doubt regarding the degree of disability will be resolved in favor of the Veteran. 38 C.F.R. § 4.3. The schedule recognizes that disability from distinct injuries or diseases may overlap. See 38 C.F.R. § 4.14 (2017). However, the evaluation of the same disability or its manifestation under various diagnoses, which is known as pyramiding, is to be avoided. Id. In initial rating cases, VA must assess the level of disability from the date of initial application for service connection and determine whether the level of disability warrants the assignment of different disability ratings at different times over the course of the claim, a practice known as “staged ratings.” See Fenderson v. West, 12 Vet. App. 119, 126 (1999). The Veteran’s service-connected PTSD is currently evaluated as 30 percent disabling prior to April 24, 2012 and 70 percent thereafter, under 38 C.F.R. § 4.130, Diagnostic Code 9411, according to VA’s General Rating Formula for Mental Disorders. See 38 U.S.C. § 1155; 38 C.F.R. §§ 4.1. Under the General Rating Formula, as pertinent to the present appeal, a 30 percent rating is warranted for occupational and social impairment with occasional decrease in work efficiency and intermittent periods of inability to perform occupational tasks (although generally functioning satisfactorily, with routine behavior, self-care, and conversation normal), due to such symptoms as depressed mood, anxiety, suspiciousness, panic attacks (weekly or less often), chronic sleep impairment, and mild memory loss (such as forgetting names, directions, recent events). 38 C.F.R. § 4.130. A 50 percent rating is warranted where the disorder is manifested by occupational and social impairment with reduced reliability and productivity due to such symptoms as flattened affect; circumstantial, circumlocutory, or stereotyped speech; panic attacks (more than once a week); difficulty in understanding complex commands; impairment of short- and long-term memory (e.g., retention of only highly learned material, forgetting to complete tasks); impaired judgment; impaired abstract thinking; disturbances of motivation and mood; and difficulty in establishing and maintaining effective work and social relationships. 38 C.F.R. § 4.130, Diagnostic Code 9411. A 70 percent rating requires occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood, due to such symptoms as: suicidal ideation; obsessional rituals which interfere with routine activities; speech intermittently illogical, obscure, or irrelevant; near-continuous panic or depression affecting the ability to function independently, appropriately and effectively; impaired impulse control (such as unprovoked irritability with periods of violence); spatial disorientation; neglect of personal appearance and hygiene; difficulty in adapting to stressful circumstances (including work or a work like setting); and inability to establish and maintain effective relationships. Id. The maximum 100 percent rating requires total occupational and social impairment, due to such symptoms as: gross impairment in thought processes or communication; persistent delusions or hallucinations; grossly inappropriate behavior; persistent danger of hurting self or others; intermittent inability to perform activities of daily living (including maintenance of minimal personal hygiene); disorientation to time or place; and memory loss for names of close relatives, own occupation, or own name. Id. The symptoms associated with each evaluation under the General Rating Formula do not constitute an exhaustive list, but rather serve as examples of the type and degree of the symptoms, or their effects, that would justify a particular rating. See Mauerhan v. Principi, 16 Vet. App. 436, 442 (2002). Thus, the evidence considered in determining the appropriate evaluation of a psychiatric disorder is not restricted to the symptoms set forth in the General Rating Formula. See id. Rather, VA must consider all symptoms of a claimant’s condition that affect his or her occupational and social impairment, including, if applicable, those identified in the American Psychiatric Association’s DIAGNOSTIC AND STATISTICAL MANUAL FOR MENTAL DISORDERS (4th ed. 1994) (DSM-IV). Id. at 443. (The DSM-IV has been recently updated with a Fifth Edition (DSM-5), and VA has issued an interim final rule amending certain provisions in the regulations to reflect this update, including the Schedule for Rating Disabilities. 79 Fed. Reg. 45093. The amendments apply to applications that are received by VA or are pending before the agency of original jurisdiction on or after August 4, 2014. Id.). The United States Court of Appeals for the Federal Circuit (Federal Circuit) recently clarified that the General Rating Formula for Mental Disorders requires not only (1) sufficient symptoms of the kind listed in the percentage requirements, or others of similar severity, frequency or duration; but also (2) that those symptoms cause the level of occupational and social impairment specified in the regulation. See Vazquez-Claudio v. Shinseki, 713 F.3d 112, 118 (Fed. Cir. 2013). If the evidence demonstrates that the claimant’s psychiatric disorder produces symptoms and resulting occupational and social impairment equivalent to that set forth in the criteria for a given rating in the General Rating Formula, then the appropriate, equivalent rating will be assigned. Mauerhan, 16 Vet. App. at 443. In this regard, the Board must consider the frequency, severity, and duration of psychiatric symptoms, the length of remissions, and the Veteran’s capacity for adjustment during periods of remission. 38 C.F.R. § 4.126 (2017); Vazquez-Claudio v. Shinseki, 713 F.3d 112, 117 (Fed. Cir. 2013) (noting that the “frequency, severity, and duration” of a veteran’s symptoms “play an important role” in determining the disability level). While VA considers the level of social impairment, it shall not assign an evaluation based solely on social impairment. Id. Evaluating all the evidence of record, the Board finds that the frequency, severity, and duration of the Veteran’s reported PTSD symptomatology more closely approximates the criteria for a 30 percent rating prior to April 24, 2012 and a 70 percent rating thereafter. Specifically, prior to April 24, 2012, the VA psychiatric and mental health treatment records, as well as the September 2009 VA psychiatric examination report, indicate symptoms of irritability; anxiety; depression; sleeping difficulties; flashbacks, isolationist behavior, hyperarousal; and decreased concentration. See, e.g., November 2008 Psychiatry Note (nightmares, hyperarousal, isolationist nature), January 2009 Psychiatry Note (difficulties sleeping, nightmares, flashbacks, irritability); August 2009 Psychiatry Note (depression, feelings of hopelessness, difficulties sleeping, repetitive nightmares, flashbacks, irritability); September 2009 VA C&P Examination Report (moderate symptoms of poor sleep, sadness, depressed mood, nightmares, poor attention, irritability); September 2011 Psychiatry Note (nightmares, variable motivation, difficulty sleeping, lacks concentration). From April 24, 2012, the Veteran’s psychological symptoms were found to be productive of occupational and social impairment with deficiencies in most areas, such as work, school, family relations, judgment, thinking, or mood. See 38 C.F.R. § 4.130, DC 9411. Specifically, the Veteran was found to suffer from depressed mood; anxiety; chronic sleep impairment; flashbacks; nightmares; lack of concentration with memory lapses; irritability; disturbances in motivation and mood; difficulty maintaining effective work and social relationships; difficulty adapting to work and worklike settings; and an intermittent inability to maintain daily activities. See July 2011 SSA Record ( nightmares and hypervigilance); April 2012 VA C&P Examination Report (chronic sleep impairment, flashbacks, nightmares, lack of concentration with memory lapses, irritability, disturbances in motivation and mood, decrease in interest in pleasurable activities); May 2013 VA C&P Examination Report (difficulties falling asleep and hypervigilance); February 2014 VA C&P Examination Report (nightmares, irritability, difficulty sleeping, anger outbursts, isolation, avoidance of crowds, mild memory loss, anxiety, depressed mood, disturbances in motivation and mood); June 2015 Social Work Note (anger outbursts, easily irritable, ill-humored, intrusive thoughts, flashbacks, nightmares); November 2016 Mental Health Interdisciplinary Note (poor impulse control, intrusive thoughts, flashbacks, nightmares). The Veteran currently lives with his wife and daughter. See July 2011 SS Record; November 2016 Mental Health Interdisciplinary Note; September 2016 Psychiatry Note. The Veteran is not capable of handling his own finances or taking his medications. See April 2012 VA C&P Examination Report (noting that the Veteran’s wife manages his medications as he forgets to take them). The Veteran has also reported problems with crowds and engaging with the public. See April 2012 VA C&P Examination Report (describing feelings of anxiousness when standing in lines and heightened aggressiveness when in crowded noisy areas); February 2014 VA C&P Examination Report (reflecting Veteran has distant interpersonal relationships). Based on the Veteran’s latest examinations, his thought processes appeared rational and linear. See April 2012 VA C&P Examination Report; February 2014 C&P Examination Report; July 2015 Social Work Group Note; March 2016 Social Work Group Note; October 2016 Social Work Group Counseling Note; November 2016 Social Work Group. There were no indications of delusions or hallucinations. Id. Problems were noted with his memory and judgement but the Veteran was alert and oriented to time, place, and person. Id. Over all the examiners found the Veteran’s hygiene and grooming to be normal. See May 2013 VA C&P Examination Report; February 2014 VA C&P Examination Report; May 201 Mental Health Nursing Outpatient Note; November 2016 Health Interdisciplinary Note. Although there have been some fluctuations in severity of the Veteran’s symptoms over the course of this appeal, the preponderance of the evidence shows that they have not met or approximated the criteria for a rating higher than 70 percent under the General Rating Formula at any point during the pendency of this claim, for the reasons explained above. See 38 C.F.R. § 4.126; Vazquez-Claudio, 713 F.3d at 117. In order to warrant a 100-percent rating, the Veteran’s PTSD symptoms must not only produce total occupational and social impairment, but must also be equivalent in severity, frequency, and duration to the symptoms corresponding to a 100-percent rating. See Vazques-Claudio, 713 F.3d at 116-17. In other words, the Veteran’s symptoms in and of themselves must be equivalent in severity, frequency, and duration to the symptoms listed for a 100 percent rating in order for this evaluation to apply; they cannot be bootstrapped into such equivalency by means of the functional impairment they allegedly cause. See id. (rejecting the interpretation that symptoms corresponding to a 30-percent rating would warrant a 70 percent rating merely because it was found that they cause deficiencies in most areas). Here, not only is there an absence of any of the symptoms associated with a 100 percent rating, but the clinical findings consistently show that the Veteran’s thought processes and communication were normal; that he did not have persistent delusions or hallucinations; that he has generally been able to maintain normal personal hygiene standards; and that he was oriented times three. See 38 C.F.R. § 4.130, DC 9411. See also April 2012 VA C&P Examination Report; February 2014 VA C&P Examination Report; July 2015 Social Work Group Note; March 2016 Social Work Note; October 2016 Social Work Group Counseling Note; November 2016 Social Work Group. Further, the evidence reflects that the Veteran’s PTSD has not caused either total occupational or total social impairment, as he has maintained some social relationships, including with his wife and daughter; and has been noted to be cooperative and exhibiting normal communication by VA examiners and health care providers. See 38 C.F.R. § 4.130. Accordingly, the criteria for a 100 percent rating have not been satisfied or approximated during the pendency of this claim. See id. In this regard, the Veteran’s reported symptomatology, including specifically his anger outbursts and physical altercations, are contemplated by the rating criteria for a 70 percent rating, which include impaired impulse control, including periods of unprovoked violence. See 38 C.F.R. § 4.130. His irritability, anger, and violence thus do not amount to “grossly inappropriate behavior,” as required for a 100 percent rating. Grossly inappropriate behavior must necessarily be more severe than the unprovoked violence and impaired impulse control already contemplated by a 70 percent rating. The Veteran’s irritability and angry outbursts are thus not equivalent in severity to grossly inappropriate behavior. The Veteran also does not pose a persistent danger of hurting himself or others, as he has consistently denied suicidal ideation or homicidal ideation, let alone intent or plan. See April 2012 VA C&P Examination Report; February 2014 C&P Examination Report; July 2015 Social Work Group Note; March 2016 Social Work Group Note; October 2016 Social Work Group Counseling Note; November 2016 Social Work Group. See 38 C.F.R. § 4.130. Neither has the Veteran been found to be disoriented to time or place. Instead, he was consistently found to be oriented in all spheres. See Id. Therefore, he has not demonstrated psychiatric symptomatology equivalent in severity to disorientation to time or place, as contemplated by a 100 percent rating. See 38 C.F.R. § 4.130. Finally, although the Veteran has mild memory loss he is not shown to have memory loss for names of his close relatives, own occupation, or own name. See April 2012 VA C&P Examination Report; February 2014 C&P Examination Report. Thus, his memory loss is not equivalent in severity to the memory loss contemplated by a 100 percent rating. See 38 C.F.R. § 4.130. Because the Veteran’s symptoms, including nightmares, insomnia, flashbacks, hyper-vigilance, depression, anxiety, disturbances in motivation and mood, avoidance behaviors, concentration and memory problems, isolating behaviors, unprovoked irritability, and difficulty in establishing and maintaining effective work and social relationships, are not the same or equivalent in severity to the symptomology corresponding to a 100 percent rating, and as he has no other symptoms equivalent in severity to such symptomatology, the criteria for a 100 percent rating are not more nearly approximated at any point during the pendency of the claim. See id.; Vazques-Claudio, 713 F.3d at 116, 188. See also Hart, 21 Vet. App. at 509-10. REASONS FOR REMAND 1. Entitlement to service connection for a bilateral shoulder disability is remanded. The Veteran asserts that his left shoulder disability was caused as a residual of the IED explosion he sustained in service. See September 2010 NOD. The Veteran’s service treatment records (STRs) show that he was exposed to an IED blast during service. See October 2007 Health Assessment. Private treatment records show that the Veteran has received treatment for shoulder pain. April 2011 Psychiatry Note; April 2012 Primary Care Note (reflecting bilateral shoulder discomfort); January 2014 Report of Medical History; November 2016 Primary Care Note. Accordingly, the Board finds that a VA opinion as to the likelihood that the Veteran’s bilateral shoulder disability was caused by service, must be obtained in order to fulfill the VA’s duty to make reasonable efforts to assist the appellant in substantiating the claim. See 38 U.S.C.§ 5103A (a) (2012); 38 C.F.R. § 3.159 (c)(4)(i) (2017); accord DeLaRosa v. Peake, 515 F.3d 1319, 1321-22 (Fed. Cir. 2008). See also McLendon v. Nicholson, 20 Vet. App. 79 (2006) (noting that VA is obliged to provide an examination if there is insufficient competent medical evidence on file to decide the claim, when the record contains competent evidence of a current disability or persistent or recurrent symptoms of a disability, when evidence establishes that an event, injury, or disease occurred in service, and when there is an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the Veteran’s service or with another service-connected disability); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010) (indicating that, when determining whether a VA examination and opinion are required under 38 U.S.C. § 5103A (d)(2), the law requires competent evidence of a disability or persistent or recurrent symptoms of a disability, but does not require competent evidence of a nexus, only that the evidence suggests an association between the disability and service or a service-connected disability). 2. Entitlement to service connection for bilateral hand circulatory problems, claimed as circulatory problems is remanded. The Veteran asserts that his bilateral hand disability was caused as a residual of the IED explosion he sustained in service. See September 2010 NOD. The Veteran’s service treatment records (STRs) show that he was exposed to an IED blast during service. See October Health Assessment. Private treatment records show that the Veteran has sought treatment for his bilateral hand condition. See September 2008 Physical Medicine Rehab (reflecting the Veteran’s hands get numb at night); December 2008 Physical Medicine Rehab (reflecting hand numbness without neurological deficits); April 2009 Outpatient Attending Note (noting a complaint of hands swelling). Accordingly, the Board finds that a VA opinion as to the likelihood that the Veteran’s bilateral hand disability was caused by service, must be obtained in order to fulfill the VA’s duty to make reasonable efforts to assist the appellant in substantiating the claim. See 38 U.S.C.§ 5103A (a) (2012); 38 C.F.R. § 3.159 (c)(4)(i) (2017); accord DeLaRosa, 515 F.3d at 1321-22. 3. Entitlement to an increased rating in excess of 20 percent for thoracic muscle strain, lumbar muscle spasm is remanded. The U.S. Court of Appeals for Veterans Claims (Court) has issued a precedential decision holding that for VA examinations to be adequate for rating musculoskeletal disabilities, they must record range of motion testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of motion of the opposite undamaged joint. Correia v. McDonald, 28 Vet. App. 158, 169-70 (2016) (citing 38 C.F.R. § 4.59 (2017)). Furthermore, if the examiner is unable to conduct the required testing, or concludes that the required testing is not necessary, he or she must clearly explain why what that is so. Id. at 170. The May 2013 VA examination report of the Veteran’s back provides range of motion results, but does not specify the type of testing on which these results were based (i.e. active or passive, weight-bearing or non-weight bearing), or provide results for each type of test, as required under Correia. If only active range-of-motion testing was performed, and the other tests were deemed not necessary or possible, the examiner did not state this in the report. As this is a determination that requires medical judgment, the Board may not make its own independent finding on this issue. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Additionally, VA examiners are required to estimate the additional loss of range of motion during a flare-up based on all procurable information from the record, as well as the Veteran’s own statements. Sharp v. Shulkin, 29 Vet. App. 26 (2017). If an estimate cannot be provided without resort to speculation, it must be clear whether this is due to a lack of knowledge among the medical community at large, or insufficient knowledge of the specific examiner. Id. at 36. In this case, the May 2013 VA examination report does not provide the necessary information regarding flare-ups, as specified above. Although the examination was not performed during a flare-up at the time of the examination, it is not apparent why the examiner could not estimate additional functional loss based on the Veteran’s statements describing the flare-ups, or why the available information in the file was not sufficient to permit such an estimate. Accordingly, a new VA examination is necessary to allow the Board to decide the claim. Moreover, as the claim is being remanded any recent VA treatment records should be obtained. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c)(2). The matters are REMANDED for the following action: 1. Make arrangements to obtain the Veteran’s complete VA treatment records, dated from March 2018 forward. 2. Upon receipt of any additional records, schedule the Veteran for an appropriate VA examination to assist in determining the nature and current level of severity of his service-connected for thoracic muscle strain, lumbar muscle spasm. The Veteran’s claims file, including a copy of this REMAND, must be made available to and reviewed by the examiner in conjunction with the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. The examination should include any necessary diagnostic testing or evaluation, i.e. X-rays, etc. All pertinent symptomatology should be reported in detail. In particular, the examiner should test the range of motion using a goniometer in active motion, passive motion, weight-bearing, and non-weight bearing, for the back. See Correia v. McDonald, 28 Vet. App. 158 (2016). If the examiner is unable to conduct one or more of the above tests or finds that it is unnecessary, the examiner must provide an explanation. In any event, the type of test performed (i.e. active or passive, weightbearing or non-weight bearing), must be specified. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including: frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. Based on the Veteran’s lay statements and any additional relevant evidence of record, the examiner should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. To the extent possible, the examiner must express any functional loss in terms of additional degrees of limited motion. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). The examiner must provide a comprehensive report including complete rationales for all opinions. 3. Thereafter, schedule the Veteran for an appropriate VA examination, to determine the etiology of his bilateral shoulder disability and bilateral hand circulatory problems. The entire claims file and a copy of this REMAND must be made available to the examiner prior to the examination. The examiner must note in the examination report that the evidence in the claims file has been reviewed. The examination should include any diagnostic testing or evaluation deemed necessary by the examiner. After reviewing the file, obtaining a complete medical, social, and occupational history pertinent to the Veteran’s claimed conditions, and examining the Veteran, the examiner must render an opinion as to the following: (a) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s current bilateral shoulder disability had its clinical onset during active service or is related to any in-service event or injury, to include his exposure to an IED blast; and (b) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran has a bilateral hand circulatory disorder that had its clinical onset during active service or is related to any in-service event or injury, to include his exposure to an IED blast. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. The term “at least as likely as not” does not mean “within the realm of medical possibility.” Rather, it means that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor it as it is to find against it. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD L. Sinckler, Associate Counsel