Citation Nr: 18136232 Decision Date: 09/18/18 Archive Date: 09/18/18 DOCKET NO. 17-07 377 DATE: September 18, 2018 REMANDED Entitlement to an increased rating for a lumbar spine disability, evaluated as 10 percent disabling prior to January 26, 2016, and 20 percent disabling beginning January 26, 2016, is remanded. REASONS FOR REMAND The Veteran served on active duty from February 2003 to April 2004 and from May 2009 to June 2010. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2009 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Lumbar Spine Disability The Veteran contends that his service-connected lumbosacral strain is more disabling than currently evaluated. The Veteran was afforded VA examinations for his lumbar spine disability in April 2011 and March 2016. Subsequent to the VA examinations, the Court, in Correia v. McDonald, 28 Vet. App. 158 (2016), held that the final sentence of 38 C.F.R. 4.59 (2017) requires that VA examinations include joint testing for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint. Therefore, the Court’s holding in Correia establishes additional requirements that must be met prior to finding that a VA examination is adequate. A review of the claims file reveals that the previous VA examination reports did not address pain on both active and passive motion, and in weight-bearing and nonweight-bearing. In light of the fact that these examination reports do not fully satisfy the requirements of Correia and 38 C.F.R. 4.59, the Veteran should be afforded a new VA examination for his lumbar spine disability before a decision can be rendered on his claim. The matter is REMANDED for the following action: 1. Send a letter to the Veteran requesting that he identify all VA and non-VA health care providers. All attempts to secure this evidence must be documented in the claims file, and if, after making reasonable efforts to obtain named records, they are not able to be secured, provide Veteran and his representative the required notice and opportunity to respond. 2. After obtaining any outstanding treatment records, ensure that the Veteran is scheduled for an appropriate VA examination with a VA examiner who has not previously examined him. The examiner must review the claims file in conjunction with the examination. The examiner should describe the nature and severity of all manifestations of the Veteran’s lumbar spine disability, to include any associated neurological symptomatology. In this regard, the examiner should record the range of motion observed on clinical evaluation, in terms of degrees of extension and flexion. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree of flexion and/or extension at which such pain begins. The extent of any weakened movement, excess fatigability, and incoordination on use should also be described by the examiner. The examiner should assess the additional functional impairment due to weakened movement, excess fatigability, or incoordination in terms of the degree of additional range of motion loss. The examiner is reminded that he or she should specify the degree of additional functional loss/motion due to pain, to include during flare-ups, or state why it was not feasible to provide such information, as required for an adequate examination. In order to comply with the Court’s recent precedential decision in Correia v. McDonald, 28 Vet. App. 158 (2016), the examiner must test the range of motion in active motion, passive motion, 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. If the Veteran reports that he suffers flares of his back symptoms, and the examiner determines the Veteran is not currently suffering from a flare of any conditions, the examiner must also ascertain adequate information-i.e. frequency, duration, characteristics, severity, or functional loss-regarding flares by alternative means. The examiner must offer an estimate as to additional functional loss during flares regardless of whether the Veteran is undergoing a flare-up at the time. A complete rationale for all opinions expressed is required. If the examiner determines that a requested opinion cannot be rendered 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). Sharp v. Shulkin, 29 Vet. App. 26 (2017). The examiner must comment on the functional impairment caused by the Veteran’s lumbar spine disability. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. JAMES G. REINHART Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Norah Patrick, Associate Counsel