Citation Nr: 18159848 Decision Date: 12/20/18 Archive Date: 12/20/18 DOCKET NO. 17-05 124 DATE: December 20, 2018 REMANDED Entitlement to an evaluation in excess of 10 percent for residuals of cervical spine strain with degenerative joint disease (DJD) is remanded. Entitlement to an evaluation in excess of 10 percent for right lower extremity (RLE) radiculopathy is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1986 to December 1991 in the United States Navy. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision issued by the Department of Veterans Affairs (VA). 1. Evaluation in excess of 10 percent for cervical spine disability is remanded. 2. Evaluation in excess of 10 percent for RLE radiculopathy is remanded. Issues 1-2. The Veteran contends that his neck and right leg symptoms are more severe than rated. In September 2013 correspondence, he reported numerous treatment for symptoms, and that he is unable to stand, sit, or walk for more than 20 minutes without severe pain. He complained of experiencing “spasms.” He reported taking continuous prescription medication and receiving injections to treat pain. He reported having some functional difficulties with activities of daily living such as toileting due to his pain. The Veteran further noted that his physician held him out of work indefinitely due to his disabilities. The Board finds that, to ensure that VA has met its duty to assist, remand is necessary. 38 C.F.R. § 3.159(c). First, in view of a 2016 decision of the Court of Appeals for Veterans Claims (Court), remand of the neck disability is necessary. In Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016), the Court held that to be adequate a VA examination of the joints must, wherever possible, include joint testing for pain on both active and passive motion, in weight bearing and non-weight bearing and, if possible, with range of motion measurements of the opposite undamaged joint. In this case, the most recent report of VA examination dated in 2013 does not reflect the necessary testing or findings. Therefore, remand is necessary for a new VA examination. Second, the Veteran’s recent statements suggest material worsening of his RLE radiculopathy since his last VA examination in 2013. Hence, reexamination is necessary. See 38 C.F.R. §§ 3.326, 3.327 (reexaminations will be requested whenever VA determines there is a need to verify the current severity of a disability, such as when the evidence indicates there has been a material change in a disability or that the current rating may be incorrect); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected RLE radiculopathy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran’s disability under the rating criteria. 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 RLE radiculopathy alone and discuss the effect of the Veteran’s RLE radiculopathy on any occupational functioning and activities of daily living. 2. Schedule the Veteran for an examination of the current severity of his cervical spine 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 cervical spine alone and discuss the effect of the Veteran’s neck 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). (Continued on the next page) 3. Readjudicate. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. A. Macek, Associate Counsel