Citation Nr: 21070625 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 18-33 053 DATE: November 24, 2021 REMANDED Entitlement to a rating higher than 10 percent for thoracolumbar degenerative joint disease and lumbosacral strain is remanded. Entitlement to service connection for severe headache is remanded. REASONS FOR REMAND The Veteran served on active duty from December 1982 to June 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2017 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2021, the Veteran testified at a Board video conference hearing before the undersigned Veterans Law Judge. A transcript of this hearing is of record. 1. Entitlement to a rating higher than 10 percent for thoracolumbar degenerative joint disease and lumbosacral strain Remand is needed for the Veteran to be afforded a current back examination that complies with Sharp v. Shulkin, 29 Vet. App. 26, 35-36 (2017). Updated treatment records should also be obtained. 2. Entitlement to service connection for severe headache The Veteran contends that he has headaches that are related to his active service and/or to his service-connected back disability. The Veteran testified that his headaches began in service and were self-treated with aspirin. The Board finds that a VA medical opinion should be obtained with respect to the question of whether a current headache disability was caused or aggravated by the Veteran's service-connected back disability. See McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006). The Veteran also testified that it appears there are missing service treatment records (STRs) from 1984 to 1985. He states he was stationed at Davis-Monthan Airforce Base in Tucson, Arizona when his records were lost. Review of his STRs reflect numerous records dated in 1984, but only a few from 1985. On remand, the RO should attempt to obtain any further STRs that might not currently be in the claims file. In remanding this case, the Board makes no credibility determination, expressed or implied, at this juncture. The matters are REMANDED for the following action: 1. Request outstanding STRs through official sources. If additional information is needed from the Veteran to request such records, he should be asked to provide it. 2. Ask the Veteran to provide the names and addresses of any medical care providers who have recently treated his low back disability and headaches. After securing any necessary releases, VA should request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 3. Schedule the Veteran for a VA examination to determine the current nature and severity of his service-connected low back disability. The claims file should be reviewed in conjunction with the examination. All indicated tests should be conducted and the results reported. Range of motion testing should be undertaken and should be tested actively and passively, in weight bearing, and after repetitive use. In reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree during range of motion testing at which pain begins. The examiner should state whether there is likely to be additional range of motion loss due to flare-ups and due to pain, weakness, fatigability, or incoordination. If so, the examiner is asked to describe the additional loss, in degrees, if possible. 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 it is not possible to provide a specific measurement, or an opinion regarding flare-ups, symptoms, or functional impairment without speculation, the examiner must state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), a deficiency in the record (additional facts are required), or the examiner (does not have the knowledge or training). 4. Schedule the Veteran for a VA examination to determine the nature of any headache condition and to obtain an opinion on whether the condition is related to service. After review of the claims file, the examiner should respond to the following and provide a complete rationale for all conclusions: (a.) Whether it is as likely as not (i.e., probability of 50 percent or greater) that any current headache disability had its onset during active service with consideration of that he Veteran's testimony that he self-treated his headaches with asprin. (b.) If not a result of service, whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the Veteran's headaches are caused by his service-connected back disability; (c.) If not caused by the Veteran's back disability, whether it is at least as likely as not (i.e., probability of 50 percent or greater) that the back disability aggravates (i.e., causes an increase in severity of) his headaches. If aggravation is present, the examiner should indicate, to the extent possible, the baseline level of headaches before the onset of the aggravation. 5. If the claim remains denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Asare, Associate 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.