Citation Nr: 21068711 Decision Date: 11/12/21 Archive Date: 11/12/21 DOCKET NO. 16-19 918 DATE: November 12, 2021 ORDER Entitlement to service connection for a left knee disability is denied. Entitlement to an initial rating higher than 20 percent for a cervical spine disability is denied. REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to an increased initial rating for a left shoulder disability is remanded. FINDINGS OF FACT 1. The Veteran's cervical spine disability has not been shown to be manifested by forward flexion of the cervical spine of 15 degrees or less; or ankylosis of the cervical spine. 2. The preponderance of evidence is against a finding that the Veteran had a left knee disability during or contemporary to the appeal period. CONCLUSIONS OF LAW 1. The criteria for entitlement to an initial rating higher than 20 percent for a cervical spine disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 3.159, 4.1, 4.2, 4.3, 4.7, 4.71a, Diagnostic Codes 5237. 2. The criteria for entitlement to service connection for a left knee disability have not been met. 38 U.S.C. § §§ 1101, 1110; 38 C.F.R. § §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active from February 2004 to March 2015. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Winston Salem, North Carolina. In September 2019, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record. In December 2019, the Board remanded these claims to the Agency of Original Jurisdiction for additional action. Service Connection Service connection may be established for disability caused by disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence, generally medical, of a causal relationship between the claimed in service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247 (1999). Service connection may also be established for any disease initially diagnosed after service, when the evidence establishes that the disease was incurred in-service. 38 U.S.C. § 1113(b); 38 C.F.R. § 3.303(d); Cosman v. Principi, 3 Vet. App. 503 (1992). The disease entity for which service connection is sought must be chronic rather than acute and transitory in nature. For the showing of chronic disease in service, a combination of manifestations must exist sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word chronic. Secondary service connection may be established for a disability that is proximately due to, or aggravated by, a service-connected disability. 38 C.F.R. § 3.310. Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. §§ 3.159(a)(2). Lay testimony is competent when it regards the readily observable features or symptoms of injury or illness and may provide sufficient support for a claim of service connection. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is competent to provide testimony concerning factual matters of which he has firsthand knowledge, such as experiencing a physical symptom such as pain. Barr v. Nicholson, 21 Vet. App. 303 (2007); Washington v. Nicholson, 19 Vet. App. 362 (2005). Therefore, the Board must assess the competence and credibility of lay statements. Barr v. Nicholson, 21 Vet. App. 303 (2007). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while weight and credibility are factual determinations going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67 (1997). A Veteran need only demonstrate that there is an approximate balance of positive and negative evidence to prevail. To deny a claim on its merits, the preponderance of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). While the Board must provide reasons and bases supporting a decision, there is no need to discuss, in detail, the evidence submitted by or on behalf of the Veteran. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record but does not have to discuss each piece of evidence). The analysis will focus on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000). 1. Entitlement to service connection for a left knee disability. The Veteran contends that he is entitled to service connection for a left knee disability. Specifically, the Veteran contends that a left knee disability is the result of the physical nature of service. The Board finds that the evidence of record does not show that the Veteran has had a current diagnosis of a left knee disability during or contemporary to the pendency of the claim. Therefore, as the preponderance of evidence is against a finding that the Veteran has had a current diagnosed left knee disability, or any left knee pain resulting in functional limitation and causing disability, or has had the claimed disability during or contemporary to the claims period, the claim for service connection must be denied. The evidence of record shows no evidence of a current left knee disability diagnosis. The Board notes that there is evidence of record showing the Veteran complaining of left knee pain. However, the record does not indicate that the Veteran has ever been diagnosed with any left knee disability, nor does the evidence suggest pain resulting in functional loss. The Board notes that pain is a symptom and is not considered an actually disabling condition. For purposes of service connection, pain alone, without a diagnosed or identifiable underlying malady or condition, or a showing of functional loss due to the pain, does not in and of itself constitute a disability for which service connection may be granted. There is no evidence showing chronic disability manifested by left knee pain resulting in functional limitation that began in or was caused by service. Importantly, the evidence does not suggest that any left knee pain results in functional loss. An analysis of post-service medical records shows no diagnosed left knee disability or condition. The Veteran has not submitted any competent evidence that demonstrates a current diagnosis of a chronic left knee disability or any other potential chronic left knee conditions during the claim period. No post-service treatment record documents a left knee diagnosis or any findings other than pain. A February 2015 left knee X-Ray was negative. At a March 2020 VA examination, the Veteran was not found to have a current diagnosis associated with any claimed left knee condition. The examiner opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed injury, event, or illness in service. The examiner explained that the Veteran has a normal knee examination and normal radiographs. The Veteran had pain with overuse noted, but medical records were without a clinic diagnosis or pathology to make a diagnosis. The Board notes that, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2); Bruce v. West, 11 Vet. App. 405 (1998) (one not a medical expert is nevertheless competent to offer evidence of his symptoms in support of a claim for an increased rating); Layno v. Brown, 6 Vet. App. 465 (1994). The Board acknowledges that the Veteran has claimed a left knee disability related to service. However, the Board finds that the Veteran, as a lay person, is not competent to provide a diagnosis of a musculoskeletal disability, and thus is not competent to diagnose a chronic left knee disability or provide an opinion as to the etiology of any left knee disability. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran has not submitted competent evidence that supports a finding of a chronic left knee disability, to include pain resulting in functional impairment, during the pendency of the claim. It is to be noted that the Board is not free to substitute its own judgment for a medical expert. Colvin v. Derwinski, 1 Vet. App. 171 (1991). The Board finds the March 2020 VA examiner opinion to be competent, credible, and persuasive. The VA examiner found that the Veteran did not have a diagnosed left knee condition related to service. The Board finds the VA examiner opinion to be more probative than the lay statements of record. The opinion of the VA examiner is highly probative because it is supported by detailed rationale and provided by a trained medical professional, in this case a physician. The VA examiner opinion is found to carry significant weight and to be the most persuasive evidence of record. Among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. Hayes v. Brown, 5 Vet. App. 60 (1993) (it is the responsibility of the Board to assess the credibility and weight to be given the evidence); Wood v. Derwinski, 1 Vet. App. 190 (1992). The probative value of medical evidence is based on the physician's knowledge and skill in analyzing the data, and the medical conclusion he reaches; as is true of any evidence, the credibility and weight to be attached to medical opinions are within the province of the Board. Guerrieri v. Brown, 4 Vet. App. 467 (1993). To the extent that the Veteran's lay statements could be found to be competent and credible, the Board finds that they are outweighed by the March 2020 VA examination opinion because of the examiner's medical training. After a careful review of the evidence of record, the Board finds the preponderance of the evidence is against the claim of entitlement to service connection for a left knee disability. None of the Veteran's medical treatment providers have given any indication that the Veteran had been diagnosed with a chronic left knee disability or had a left knee disability resulting in functional impairment, and the Veteran has not submitted any competent medical evidence which supports the claim of a current left knee disability or shows a relationship between any diagnosed left knee disability and service. In the absence of competent medical evidence providing a current, recurrent chronic left knee diagnosis of left knee disability, of a showing of functional loss constituting a disability, the threshold requirement for substantiating the claims for service connection is not met. Brammer v. Derwinski, 3 Vet. App. 223 (1992). The Board is appreciative of the Veteran's faithful and honorable service to our country. The Board acknowledges that VA is statutorily required to resolve reasonable doubt in favor of the Veteran when there is an approximate balance of positive and negative evidence regarding the merits of an outstanding issue. However, the Board finds that the preponderance of the evidence is against a finding of any diagnosis of a chronic left knee disability, or functional loss resulting in disability, or that any left knee disability is related to active service. Therefore, the claim for service connection for a left knee disability must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to an initial rating higher than 20 percent for a cervical spine disability. Disability ratings are determined by applying the criteria set forth in the VA Schedule for Rating Disabilities. 38 C.F.R. Part 4. The Schedule is primarily a guide in the rating of disability resulting from all types of diseases and injuries encountered as a result of or incident to military service. The ratings are intended to compensate, as far as can practicably be determined, the average impairment of earning capacity resulting from diseases and injuries and their residual conditions in civilian occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In considering the severity of a disability, it is essential to trace the medical history of the Veteran. 38 C.F.R. §§ 4.1, 4.2, 4.41. Consideration of the whole recorded history is necessary so that a rating may accurately reflect the elements of disability present. 38 C.F.R. § 4.2; Peyton v. Derwinski, 1 Vet. App. 282 (1991). Although the regulations do not give past medical reports precedence over current findings, the Board is to consider the Veteran's medical history in determining the applicability of a higher rating for the entire period for which the appeal has been pending. Powell v. West, 13 Vet. App. 31 (1999). Consideration must be given as to whether staged ratings should be assigned to compensate entitlement to a higher rating at any point during the pendency of the claim. When the evidence contains factual findings that demonstrate distinct time periods in which the service-connected disability exhibited diverse symptoms meeting the criteria for different ratings during the course of the appeal, the assignment of staged ratings is necessary. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). While the Board must provide reasons and bases supporting a decision, there is no need to discuss, in detail, all the evidence submitted by or on behalf of the Veteran. Gonzales v. West, 218 F.3d 1378 (Fed. Cir. 2000) (Board must review the entire record but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence of record. The Veteran should not assume that the Board has overlooked pieces of evidence that are not explicitly discussed. Timberlake v. Gober, 14 Vet. App. 122 (2000). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the Veteran. Equal weight is not given to each piece of evidence contained in the record. Every item of evidence does not have the same probative value. When the evidence is assembled, the Board is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Disabilities of the spine that are rated under the General Rating Formula for Diseases and Injuries of the Spine include vertebral fracture or dislocation (Diagnostic Code 5235), sacroiliac injury and weakness (Diagnostic Code 5236), lumbosacral or cervical strain (Diagnostic Code 5237), spinal stenosis (Diagnostic Code 5238), unfavorable or segmental instability (Diagnostic Code 5239), ankylosing spondylitis (Diagnostic Code 5240), spinal fusion (Diagnostic Code 5241), and degenerative arthritis of the spine (Diagnostic Code 5242). Degenerative arthritis of the spine can also be rated using Diagnostic Code 5003. 38 C.F.R. § 4.71a. The Veteran's cervical strain has been rated under Diagnostic Code 5237. Under the General Rating Formula for Rating Diseases and Injuries of the Spine, with or without symptoms such as pain, stiffness or aching in the area of the spine affected by residuals of injury or disease, the following ratings will apply: A 10 percent rating is warranted when forward flexion of the cervical spine greater than 30 degrees but not greater than 40 degrees; or, combined range of motion of the cervical spine greater than 170 degrees but not greater than 335 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted when forward flexion of the cervical spine is greater than 15 degrees but not greater than 30 degrees; or, the combined range of motion of the cervical spine not greater than 170 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 30 percent rating is assigned for forward flexion of the cervical spine of 15 degrees or less; or favorable ankylosis of the entire cervical spine. A 40 percent rating is assigned for unfavorable ankylosis of the entire cervical spine. A 100 percent rating is assigned for unfavorable ankylosis of the entire spine. For VA compensation purposes, normal forward flexion of the cervical spine is to 45 degrees, extension to 45 degrees, left and right lateral flexion are to 45 degrees, and left and right lateral rotation to 80 degrees. The normal combined range of motion of the cervical spine is 340 degrees. The normal ranges of motion for each component of spinal motion provided in this note are the maximum that can be used for calculation of the combined range of motion. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (2), Plate V. Unfavorable ankylosis is a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire spine is fixed in flexion or extension, and the ankylosis results in one or more of the following: difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing limited to diaphragmatic respiration; gastrointestinal symptoms due to pressure of the costal margin on the abdomen; dyspnea or dysphagia; atlantoaxial or cervical subluxation or dislocation; or neurologic symptoms due to nerve root stretching. Fixation of a spinal segment in neutral position (0 degrees) always represents favorable ankylosis. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (5). Disability of the thoracolumbar and cervical spine segments are to be rated separately, except when there is unfavorable ankylosis of both segments, which will be rated as a single disability. The rater is to round each range of motion measurement to the nearest five degrees. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Note (6). Diagnostic Code 5243 provides that intervertebral disc syndrome (IVDS) is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating Intervertebral Disc Syndrome (IVDS) Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than two weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least two weeks but less than four weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least four weeks but less than six weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least six weeks during the past 12 months. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes. An incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (1). If intervertebral disc syndrome is present in more than one spinal segment, provided that the effects in each spinal segment are clearly distinct, each segment is to be rated on the basis of incapacitating episodes or under the General Rating Formula for Diseases and Injuries of the Spine, whichever method results in a higher evaluation for that segment. 38 C.F.R. § 4.71a, Diagnostic Code 5243, Formula for Rating Intervertebral Disc Syndrome Based on Incapacitating Episodes, Note (2). This increased rating claim stems from the initial grant of service connection for cervical strain (claimed as neck condition) with a 20 percent rating assigned, effective March 17, 2015. The Veteran's cervical strain has been rated under Diagnostic Code 5237 as 20 percent disabling, effective March 17, 2015. The Veteran contends that the cervical spine disability is more severe than represented by the assigned ratings. As an initial matter, the Board notes that the Veteran underwent VA neck (cervical spine) examination in February 2015. The Board finds the February 2015, neck examination to be incomplete as the examiner did not provide an opinion as to functional loss of range of motion during flare-ups because the Veteran was not examiner during a flare-up. The Board notes that an opinion is speculative when it is based on the absence of procurable information or an examiner's shortcomings or general aversion to offering an opinion on issues not directly observed. Direct observation of functional impairment during a flare-up is not a prerequisite to offering an opinion. Case law and VA guidelines anticipate that examiners will offer flare up opinions based on estimates derived from information procured from relevant sources, including the lay statements of Veterans. Sharp v. Shulkin, 29 Vet. App. 26 (2017). In any event, that examination does not support the assignment of any higher rating. Accordingly, the Board finds the February 2015 VA neck examination report to be incomplete for rating purposes and they will not be considered in adjudication of this claim A February 2015 cervical spine X-Ray found moderate straightening of the cervical spine. A November 2018 chiropractor examination diagnosed cervicalgia. The Veteran was found to have reduction of range of motion in all directions of the cervical spine. At a September 2019 Board hearing, the Veteran described current symptoms associated with the service-connected disability and how it impacted his life. The Veteran indicated a worsening of the neck disability. A March 2020 VA examination diagnosed cervical strain. The Veteran was found to have range of motion to, at worst, 40 degrees forward flexion, 30 degrees extension, 40 degrees right lateral flexion, 35 degrees left lateral flexion, 60 degrees right lateral rotation, and 60 degrees left lateral rotation. The Veteran did not report experiencing flare-ups of pain. The Veteran did not have guarding or muscle spasm of the cervical spine nor was he found to have ankylosis. The Veteran was also not found to have any episodes of IVDS. Disability ratings are determined by applying the criteria set forth in VA's Schedule for Rating Disabilities. The record currently contains no other examinations or evidence that are valid for rating purposes. Initially, the Board notes that there has been no medical evidence of ankylosis of the cervical spine during the course of the appeal. Thus, a higher rating cannot be assigned on that basis. The Board finds that a higher rating is not warranted. The evidence of record does not show that the Veteran has ever had forward flexion of the cervical spine to 15 degrees or less; or ankylosis of the cervical spine commensurate with an increased rating of 30 percent pursuant to Diagnostic Code 5237. Pursuant to Diagnostic Code 5237, that level of impairment is consistent with the currently assigned 20 percent rating. The Board has considered any additional functional loss due to pain or other factors but finds that the evidence of record does not show additional functional loss that would warrant elevation to any higher ratings. The Board has also considered whether a higher rating could be assigned under the intervertebral disc syndrome formula based on incapacitating episodes. However, the Veteran has not been shown to have incapacitating episodes of intervertebral disc syndrome having a total duration of at least four weeks but less than 6 weeks during the appeal period. Thus, an increased rating of 40 percent cannot be assigned pursuant to Diagnostic Code 5243. Accordingly, the Board finds that the preponderance of the evidence is against the assignment of a rating greater than 20 percent for a cervical spine disability. Therefore, the Board finds that the preponderance of the evidence is against the assignment of any higher ratings and the appeal must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C. § 5107; 38 C.F.R. § 3.102. REASONS FOR REMAND 1. Entitlement to service connection for a back disability. Although the Board regrets the delay, additional development is needed prior to further disposition of the claim of entitlement to service connection a back disability. VA's statutory duty to assist the Veteran includes the duty to conduct a thorough examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski,1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). During VA examination in March 2020, the examiner, a physician, stated that the Veteran did not currently have nor ever have a diagnosed thoracolumbar spine condition. On range of motion testing, the examiner explicitly stated that the Veteran did not have any functional loss or functional impairment of the thoracolumbar spine. However, the examiner also noted decreased ranges of motion and functional limitation in extension, right lateral flexion, and left lateral flexion. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). The Board finds the March 2020 VA medical opinion to be inadequate as it is contradictory. The examiner both opined that the Veteran did not have any functional loss or function impairment of the thoracolumbar spine, yet found functional limitation on range of motion testing. Therefore, the examination is inconclusive and cannot be used to adjudicate the claim. The examiner found the Veteran to have no current disability. However, for Board purposes pain resulting in a functional loss could constitute a current disability. The Board also notes that the March 2020 examiner opined that the claimed back condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed injury, event, or illness in service. The examiner explained that the Veteran could have had episodes of back pain for many years as noted in the lay statements. He was noted to have lumbalgia (low back pain) at chiropractor visits. The examiner noted that a research website showed that in a large survey, more than a quarter of adults reported experiencing low back pain during the past three months. Most low back pain is acute, or short term, and lasts a few days to a few weeks. It tends to resolve on its own with self-care and there is no residual loss of function. Therefore, without Emergency room or clinic visits, imaging or other evidence to suggest a chronic lumbar spine issue, the examiner could not use the lay statements to diagnose a chronic back condition. The March 2020 VA examiner does not appear to have considered the Veteran's contentions regarding the back condition, as that was not addressed in the rationale. While the examiner acknowledged the Veteran's subjective complaints, the VA examiner appears to have based the opinion solely on the objective evidence of record. Because the examiner did not discuss or consider whether there is any subjective evidence or lay evidence to support a theory that a back disability was related to his service, the Board again finds the March 2020 VA examination report to be incomplete. Additionally, an opinion that relies solely only on the absence of symptoms or treatment during service is incomplete. Because the Veteran may have a disability that is related to service, the Board finds that the Veteran should be provided a VA examination to determine the nature and etiology of the Veteran's claimed lumbar spine disability. Therefore, on remand an examination must be scheduled and an opinion as to the etiology of the lumbar spine disability should be requested. McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). 2. Entitlement to an initial rating higher than 10 percent for a left shoulder disability is remanded. Although the Board regrets the delay, additional development is needed prior to further disposition of the claim of entitlement to an initial rating higher than 10 percent for a left shoulder disability. VA's statutory duty to assist the Veteran includes the duty to conduct a thorough examination so that the evaluation of the claimed disability will be a fully informed one. Green v. Derwinski, 1 Vet. App. 121 (1991); Snuffer v. Gober, 10 Vet. App. 400 (1997). Assistance by VA includes providing a medical examination or obtaining a medical opinion when an examination or opinion is necessary to make a decision on a claim. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). The Veteran argues that the most recent VA examination was inadequate because the examiner did not provide an assessment of range of motion during flare-ups of pain. The Board agrees. The Veteran was last provided a VA examination in March 2020. During that examination, the Veteran reported experiencing an increase in pain when using the shoulder. However, the examiner did not provide range of motion testing expressed in degrees during flare-ups. Therefore, the Board finds the March 2020 shoulder examination to be incomplete as the examiner did not provide an opinion as to functional loss of range of motion during flare-ups and did not explain the failure to do so. An opinion is speculative when it is based on the absence of procurable information or an examiner's shortcomings or general aversion to offering an opinion on issues not directly observed. Direct observation of functional impairment during a flare-up is not a prerequisite to offering an opinion. Examiners will offer flare up opinions based on estimates derived from information procured from relevant sources, including the lay statements of Veterans. Sharp v. Shulkin, 29 Vet. App. 26 (2017). The Board finds the March 2020 VA examination report to be incomplete for rating purposes. Therefore, the Board finds that there was not substantial compliance with the March 2020 Board remand requests. The Board finds that additional examination is warranted to determine the current severity and manifestations of the service-connected shoulder disability. After all outstanding medical records are associated with the claims file, the Veteran should be afforded a new examination to rate the claim for an increased rating for left shoulder disability. Allday v. Brown, 7 Vet. App. 517 (1995); Caffrey v. Brown, 6 Vet. App. 377 (1994); Snuffer v. Gober, 10 Vet. App. 400 (1997). The Veteran is notified that it is his responsibility to report for any scheduled examination and to cooperate in the development of this claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. § 3.655. The matters are REMANDED for the following action: 1. Request the Veteran identify the names, addresses, and approximate dates of treatment for all VA and non-VA health care providers who provided treatment for all claimed disabilities. After securing the necessary releases, attempt to obtain all copies of pertinent treatment records identified by the Veteran that are not currently of record. 2. Schedule the Veteran for a VA spine examination, with a medical doctor who has not previously examined the Veteran, to diagnose and determine the nature and etiology of any low back disability. The examiner must review the claims file, including this Remand and the Veteran's lay statements, including hearing testimony, and should indicate review of the file in the report. The examiner should diagnose all low back disabilities found or shown in the record during the pendency of the claim, and should specifically state whether or not there is pain resulting in function loss, and explain the basis of that opinion. For each back disability diagnosed, to include pain resulting in functional loss, the examiner must opine whether it is at least as likely as not (50 percent or greater probability) that each back disability is etiologically related to active service or any event, disease, or injury during service, including whether any back disability (1) began during active service, (2) manifested as back arthritis within one year after separation from service, (3) was noted during service with continuity of the same symptomatology since service, (4) was caused by the service-connected disabilities or treatment for the service-connected disabilities, to specifically include cervical strain, or (5) has been aggravated (increased in severity beyond the natural progress of the disorder) by the service-connected disabilities or treatment for the service-connected disabilities, to specifically include cervical strain. The examiner should cite to any evidence to support a finding of back arthritis within one year following separation from service. The examiner should address the Veteran's lay statements regarding the claimed disabilities and their etiology and symptoms during and since service. The examiner must consider and discuss the lay statements and should reconcile the opinion with any previous opinions of record. A clearly stated rationale for each opinion offered must be provided and cannot be based on the lack of an in-service record of the claimed disability. In writing the report, the examiner should refer to any service medical records indicating in-service treatment for any of the claimed disabilities. 3. Schedule the Veteran for a VA shoulder examination conducted by a medical doctor to assist in determining the current nature and severity of a service-connected left shoulder 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, and for weight-bearing and nonweight-bearing, of both shoulders. The degree at which pain is elicited should be specifically noted. (b) State whether there is any additional loss of left shoulder function due to painful motion, weakened motion, excess motion, fatigability, incoordination, or on flare up. (c) Provide ranges of motion for both shoulders during a flare up. If the Veteran is not experiencing a flare up at the time of the examination, the examiner should provide an estimate of range of motion during flare ups based on the interview. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Mondesir, Eric 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.