Citation Nr: 21062444 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 17-61 806 DATE: October 7, 2021 REMANDED Entitlement to a rating in excess of 20 percent for degenerative arthritis of the cervical spine is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1973 to August 1974. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a November 2016 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. The Agency of Original Jurisdiction (AOJ) last adjudicated the issue on appeal in an October 2017 statement of the case. Since that time, additional records, including VA and private treatment records and a VA cervical spine examination, have been added to the claim file. A waiver of AOJ review was not submitted for those records. As this claim is being remanded anyway, the AOJ will have an opportunity to consider this additional evidence in the first instance. Entitlement to a rating in excess of 20 percent for degenerative arthritis of the cervical spine is remanded. VA examinations must include joint testing for active and passive motion in both weight-bearing and non-weight-bearing circumstances. Correia v. McDonald, 28 Vet. App. 158 (2016). In this case, the VA cervical spine examinations of record do not fully comport with the requirements of Correia. See, e.g., November 2016 and May 2021 VA examinations. Specifically, while noting pain in various ranges of motion, the examiners failed to indicate where pain began. Additionally, while these examinations noted no radiculopathy, the Veteran testified that he experiences tingling and numbness down his arms. His VA treatment records confirm complaints of numbness and tingling in his arms. Accordingly, remand is necessary for a new VA spine examination. The matter is REMANDED for the following action: 1. Obtain copies of any VA treatment records not already associated with the claim file. 2. Then, arrange for an orthopedic examination (or telehealth interview, review of the record, etc., if an in-person examination is not feasible) of the Veteran to assess the severity of his service-connected neck disability, to include a retrospective opinion to the extent possible. The examiner must review the entire record in conjunction with the examination and note such review was conducted. Pathology, symptoms (frequency and severity), and any associated impairment of function should be described in detail. (a) Range of motion measurements should be conducted in both active and passive motion, in both weight-bearing and non-weight-bearing for both the present time and the period from August 2016, if feasible. 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. (b) If feasible, the examiner must assess the additional functional impairment on repeated use or during flare-ups in terms of the degree of additional range of motion loss, using lay observations specifically elicited from the Veteran, to include the period from August 2016. If not feasible, the examiner must provide a detailed explanation and rationale for why such could not be accomplished. Specifically, if the medical professional cannot provide an opinion without resorting to mere speculation, he or she must provide a complete explanation for why an opinion cannot be rendered; a rationale based on the fact that the Veteran is not having a flare-up at the time of the examination will not be deemed adequate. (c) The examiner should address whether the Veteran's service-connected cervical spine disability has a neurological component and, if so, address the severity of such radiculopathy throughout the appeal period. In making this determination, the examiner's attention is directed to VA treatment records noting the Veteran's complaints of numbness and tingling in his arms and wrists, as well as his October 2021 Board testimony that he experiences tingling and numbness in his arms. 3. If upon completion of the above action the issue remains denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Matta, Counsel The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.