Citation Nr: 19118564 Decision Date: 03/14/19 Archive Date: 03/14/19 DOCKET NO. 15-42 053 DATE: March 14, 2019 REMANDED Entitlement to an initial rating in excess of 20 percent for degenerative arthritis of the spine is remanded. Entitlement to an initial rating in excess of 20 percent for arthritis of the right arm is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1992 to October 2000, June 2001 to July 2002, March 2003 to October 2003, and May 2009 to April 2011. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an August 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran submitted a VA Form 9 in October 2015 indicating that he wished to continue his appeal only as to the issues of the initial rating for right shoulder and lower back condition. Therefore, the appeal as to his claim for service connection for his right ankle disability was not perfected and therefore is not before the Board at this time. See Grantham v. Brown, 114 F.3d 1156, 1158-59 (Fed. Cir. 1997). 1. Entitlement to an initial rating in excess of 20 percent for degenerative arthritis of the spine is remanded The Veteran is seeking an increased initial rating for his service -connected degenerative arthritis of the spine disability. The Veteran underwent a VA examination in March 2013. During that examination the Veteran was diagnosed with degenerative arthritis of the spine. The examiner opined that the Veteran’s spine condition did impact his ability to work. The examiner further noted that the VA may request additional information, including examinations if necessary to complete review of the Veteran’s application. The Veteran contends, and the evidence suggests that his lower back condition has worsened since the March 2013 VA examination. Specifically, the Veteran asserts that in 2015, he spent approximately forty days where he was unable to move from his bed due to the severity of his lower back issues. See October 2015 VA Form 9. Additionally, the Veteran submitted medical records from private physician Dr. T.B. that demonstrated treatment for his lower back condition that included injections of Decadron and Toradol. Accordingly, the Veteran must be provided a new VA examination to determine the current severity of his lower back disability. See Snuffer v. Gober, 10 Vet. App. 400 (1997). Moreover, the Board notes that the March 2013 VA examination does not comply with the requirements in Correia v. McDonald, 28 Vet. App. 158 (2016). As such, the VA examination on remand should adequately address contain passive range of motion measurements. 2. Entitlement to an initial rating in excess of 20 percent for arthritis of the right arm is remanded. The Veteran is seeking an increased rating for his right shoulder disability. He contends that his March 2013 VA examination did not adequately address his right shoulder pain and the effects of pain on range of motion. See November 2015 VA Form-9. Further, the Veteran contends that since his March 2013 VA examination, his right shoulder pain has worsened. Therefore, as the Veteran’s most recent VA examination was six years ago, the Board finds that remand for VA examination to address the current severity of his right shoulder disability, to include consideration of the impacts of pain on range of motion, is warranted. See Correia v. McDonald, 28 Vet. App. 158 (2016). The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claim file. 2. Schedule the Veteran for a VA examination to identify the severity of his service-connected lower back and right shoulder disabilities. The Veteran’s claims file, to include a copy of this remand, must be made available to and be reviewed by the examiner. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. The examiner is asked to address the following for the Veteran’s lower back and right should disabilities: Testing for pain on both active and passive motion, in weight bearing and non-weight bearing. Functional loss after flare-ups and repeated use over time must be considered, and the examiner must consider all procurable and ascertainable data and describe the extent of any pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report functional impairment due to such factors in terms of additional degrees of limitation of motion. If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician’s Guide to estimate, “per [the] veteran,” what extent, if any, flare-ups and repeated use over time affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. C. TRUEBA Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Smith, Associate Counsel