Citation Nr: 21076307 Decision Date: 12/23/21 Archive Date: 12/23/21 DOCKET NO. 19-01 698 DATE: December 23, 2021 REMANDED Entitlement to service connection for a neck disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from September 2007 to September 2012. Entitlement to service connection for a neck disability In April 2019, the Veteran underwent a VA examination for neck (cervical spine) conditions. While the Veteran reported constant neck pain and stiffness since an in-service injury in 2008 and demonstrated limited bilateral lateral rotation range of motion findings, the VA examiner did not render a diagnosis of any current neck disability and concluded in the April 2019 VA medical opinion that there was no evidence of a neck or cervical spine condition thus the requested opinion is moot. In a July 2019 VA addendum/clarification, the same VA examiner explained that decreased range of motion, by itself, is not a medical condition, rather it is a measure of flexibility, and does not denote a medical condition without other parameters needed for a diagnosed condition. Nevertheless, the Board notes that pain alone in the absence of a diagnosed condition is capable of causing functional impairment, and functional impairment is considered a disability. Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Veteran reported neck pain and demonstrated functional impairment at the April 2019 VA examination and reported at the September 2021 Board hearing that his neck has been extremely painful and limiting since an in-service injury in 2009. In light of the Veteran's reported symptoms since separation and description of functional impairment during the appeal period, the Board finds that an addendum opinion is needed to determine the etiology of the Veteran's current cervical spine disability on a direct basis. See 38 U.S.C. § 1110 (2012); 38 C.F.R. § 3.303 (2020); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Additionally, review of the claims file shows the Veteran reported at the September 2021 Board hearing to pursuing an education in chiropractic medicine and getting treated at the clinic where he also attends for school. As of this date, the Veteran has not submitted any private treatment records relevant to his neck disability nor has any attempt been made by VA to obtain any outstanding private treatment records from this identified chiropractic clinic. As such, a remand is also needed to obtain these identified records in order to properly adjudicate this claim on appeal. The matter is REMANDED for the following actions: 1. Contact the Veteran and request that he identify any private treatment facilities or providers relevant to his neck disability and provide him with the appropriate release forms. Then, make appropriate efforts to obtain any outstanding records so authorized for release from any facility identified by the Veteran, to include chiropractic treatment as identified in the September 2021 Board hearing transcript. If these records cannot be located, the agency of original jurisdiction (AOJ) must document the attempts that were made to locate them, and the Veteran must be notified. 2. Then, provide the Veteran's claims file to an appropriate clinician to provide an opinion regarding the Veteran's neck disability. The entire claims file and a copy of this remand must be made available to the examiner for review. A new examination (physical or telehealth) is only required if deemed necessary by the examiner. Although an independent review of the claims file is required, the Board calls the examiner's attention to the following: At the September 2021 Board hearing, the Veteran reported that an in-service injury in 2009 while working on an aircraft carrier when his helmet or cranial got caught on a wing and incidentally jerked his head back. The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's neck disability (pain plus functional impairment, even if since resolved) began during active service or is related to an incident of service, to include consideration of the Veteran's reported in-service neck injury as well as documented complaints and treatment for neck pain and assessments of nonallopathic lesions cervical in August 2009 and September 2009 and neck strain in September 2011. The examiner is advised that pain plus functional impairment is considered a disability for VA purposes, even if no diagnosable condition is present. The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If any of the above requested opinions cannot be made without resort to speculation, the examiner must state this and provide a rationale for such conclusion. 3. Then, review all examination reports and medical opinions provided to ensure that the requested information was provided. If any report or opinion is deficient in any manner, the AOJ must implement corrective procedures. 4. Then, readjudicate the claim. If the decision is adverse to the Veteran, issue a Supplemental Statement of the Case and allow the applicable time for response. Then, return the case to the Board. D. Martz Ames Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Carter, 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.