Citation Nr: 18153533 Decision Date: 11/28/18 Archive Date: 11/27/18 DOCKET NO. 12-15 234 DATE: November 28, 2018 REMANDED Entitlement to an increased rating in excess of 10 percent for service-connected lumbosacral strain prior to August 6, 2009 and in excess of 20 percent thereafter is remanded. REASONS FOR REMAND The Veteran had active military service with the Army from May 2001 to October 2004. In May 2014, the Veteran testified in a Board videoconference hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript has been associated with the record. The issue was previously denied by the Board in an August 2017 decision. The Veteran appealed the denial to the United States Court of Appeals for Veterans Claims (Court) and after the filing of a Joint Motion for Remand (JMR), the Court remanded the matter in an April 2018 Order for further development consistent with the JMR.   1. Entitlement to an increased rating in excess of 10 percent for service-connected lumbosacral strain prior to August 6, 2009 and in excess of 20 percent thereafter is remanded. According to the March 2018 JMR, examination did not adequately consider the Veteran’s functional loss of the lumbar spine due to flare ups or the extent of any pain on motion as required under DeLuca v. Brown, 8 Vet. App. 202 (1995) and 38 C.F.R. §§ 4.40. The Veteran’s VA spine examinations conducted in July 2009 and May 2015 are inadequate in that the examiner noted that additional limitations due to flare-ups could not be determined without resort to speculation and the degree of functional loss with repetitive use was not discussed or provided. The Board also notes that VA examinations must comply with the language of 38 C.F.R. § 4.59 and test range of motion studies in both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. See Correia v. McDonald, 21 Vet. App. 158 (2016). The July 2009, May 2012, and May 2015 examinations do not contain passive range of motion measurements. Accordingly, the Veteran must be afforded new a spine examination that includes all of the necessary information and a thorough review of the symptomatology attributable to the Veteran’s spine disability The matter is REMANDED for the following actions: 1. Obtain all outstanding VA and/or private treatment records related to the Veteran’s outstanding claims. If any requested records are not available, the record should be annotated to reflect such and the Veteran notified. 2. Then, schedule the Veteran for VA spine examination to determine the severity of his service-connected lumbosacral strain. The Veteran’s entire claims file must be made available to and reviewed by the clinician in conjunction with the examination. All findings and diagnoses must be fully reported. The examination must be thorough and include all complaints, clinical findings, symptoms, and range of motion studies pertaining to the low back. Range of motion studies must include testing for pain in active motion and passive motion. The examiner should also discuss pain in weight-bearing and nonweight-bearing ranges of motion. If such are not applicable or possible to test, then the examiner should state such along with an explanation. The examiner must 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 lumbosacral strain alone and discuss the effect of the Veteran’s lumbosacral strain 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). . K. PARAKKAL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Williams, Counsel