Citation Nr: 21066306 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 15-25 837 DATE: October 29, 2021 REMANDED Entitlement to service connection for recurrent cold injury residuals is remanded. Entitlement to a rating in excess of 10 percent prior to March 2, 2017, and in excess of 20 percent on and after March 2, 2017, for lumbar spine degenerative disc disease with spondylosis and degenerative joint disease is remanded. REASONS FOR REMAND The Veteran had active service from February 1987 to February 2010. He served in Iraq and Afghanistan. 1. Entitlement to service connection for recurrent cold injury residuals is remanded. The service treatment records state that the Veteran was seen for a cold weather injury. A December 1987 treatment record notes that the Veteran reported that he was "outside for several hours at a time while at Graf and at times feet became numb." He complained that his toes hurt at time and had been numb for three weeks. An impression of "possible chilblains" and "mild cold injury, resolving" was advanced. The report of an August 2021 Department of Veterans Affairs (VA) examination states that "there is no documentation of injury or ongoing treatment for an acute or chronic cold weather injuries condition while on active duty." The examiner concluded that "the condition claimed was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event, or illness." Given the VA nurse practitioner's failure to note or to otherwise address the documented in service cold injury, the examination report is of essentially no probative value. VA's duty to assist includes, in appropriate cases, the duty to conduct a thorough and contemporaneous medical examination which is accurate and fully descriptive. McLendon v. Nicholson, 20 Vet. App. 79 (2006); Green v. Derwinski, 1 Vet. App. 121, 124 (1991). When VA undertakes to obtain an evaluation, it must ensure that the evaluation is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that further VA cold injury evaluation is needed. Clinical documentation dated after June 2021 is not of record. VA should obtain all relevant VA and private treatment records which could potentially be helpful in resolving the Veteran's claims. Murphy v. Derwinski, 1 Vet. App. 78 (1990); Bell v. Derwinski, 2 Vet. App. 611 (1992). 2. Entitlement to a rating in excess of 10 percent prior to March 2, 2017, and in excess of 20 percent on and after March 2, 2017, for lumbar spine degenerative disc disease with spondylosis and degenerative joint disease is remanded. The report of an August 2021 VA examination states that the Veteran complained of progressively worsening lumbar spine pain which radiated to his feet. On examination of the lumbar spine, the Veteran exhibited a range of motion of forward flexion to 65 degrees, extension to 25 degrees, lateral flexion to 20 degrees, bilaterally, and lateral rotation to 20 degrees, bilaterally, with pain on all ranges of motion. The examiner stated that the pain associated with active motion of the spine "causes functional loss" and the service connected disability "impacts his ability to perform any type of occupational task" as "he cannot bend or pick up any heavy item." The nurse practitioner did not indicate the degree at which the Veteran experienced pain on motion of the lumbar spine. Given that deficiency, the Board finds that the functional loss associated with the service connected lumbar spine disability is unclear and the examination report is of limited probative value. Therefore, further VA spine evaluation is necessary. The matters are REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for each private healthcare provider who has treated any cold injury residuals and the service connected lumbar spine disability. Make two requests for the authorized records from all identified healthcare providers unless it is clear after the first request that a second request would be futile. 2. Obtain any VA treatment records not of record, to include those pertaining to treatment after June 2021. 3. Schedule the Veteran for a VA cold injury examination conducted by a medical doctor to assist in determining the current nature and severity of the claimed cold injury residuals. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Diagnose all cold injury residuals found. If no cold injury residuals are identified, the examiner should specifically state that fact. (b) Opine whether it is at least as likely as not (50 percent probability or greater) that any identified cold injury residuals had their onset during active service or is related to any incident of service, including the documented in service cold injury and the Veteran's subjective history of cold injury while in the mountains of Afghanistan. 4. Schedule the Veteran for a VA spine examination conducted by a medical doctor to assist in determining the current nature and severity of the service connected lumbar spine disability. The examiner must review the record and should note that review in the report. A rationale for all opinions should be provided. The examiner should: (a) Provide ranges of motion for passive and active motion of the lumbar spine for weight-bearing and nonweight-bearing. The examiner should indicate the degree of lumbar spine motion at which any observed pain begins. The examiner should state whether there is any additional loss of lumbar spine function due to painful motion, weakened motion, excess motion, fatigability, or incoordination. (b) Indicate to what extent the Veteran experiences functional loss of the lumbar spine due to pain or any other symptoms during flare ups or with repeated use. (c) State whether or not there is any ankylosis of the spine or any segment of the spine. (Continued on the next page) (d) Note any incapacitating episodes associated with the lumbar spine disability and the duration. An incapacitating episode is a period of acute signs and symptoms that requires bed rest prescribed by a physician and treatment by a physician. (e) Describe any identified right or left lower extremity neurologic disabilities caused by the service-connected lumbar spine disability J. T. HUTCHESON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Emily A. Kotroco 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.