Citation Nr: 21077047 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 15-15 386 DATE: December 28, 2021 REMANDED Entitlement to a disability rating in excess of 10 percent for lumbosacral strain prior to July 28, 2016, and in excess of 40 percent thereafter is remanded. INTRODUCTION The Veteran served on active duty from May 1979 to July 1992. In April 2017, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of that hearing has been associated with the record. When this case was before the Board in June and December 2018, October 2020, and April and August 2021, the above-noted issue was remanded for additional development. The case has since been returned for further appellate review. REASONS FOR REMAND Though the Board regrets further delay of the Veteran's appeal, addendum medical findings are required prior to final adjudication of this matter. The Veteran recently underwent a VA back examination in October 2021. Although the examiner made a commendable effort to answer all indicated questions the Board finds supplemental examination findings are required. In particular, the Board notes the examiner indicated non weight-bearing and passive range of motion assessments could not be provided as performing these assessments were medically contraindicated because they posed an undue risk of injury to the Veteran. However, the examiner did not comment on whether weight-bearing range of motion assessments were performed, or similarly contraindicated. Further, the examiner noted the Veteran experienced daily aggravations of pain, which she indicated were the result of muscle spasms. Though she did not characterize these exacerbations as flare-ups, prior examiners appear to have characterized these experiences as such. Specifically, the Board notes the Veteran's initial November 2014 VA back examination that was performed following the initiation of his claim in this matter. During that examination the examiner found the Veteran did experience flare-ups, which resulted in decreased mobility. Similarly, the October 2021 VA examiner stated the Veteran's aggravations occur on a daily basis, and result in "significantly limited" and "minimal" range of motion. In this respect, the Board finds additional questions must be answered with respect to the historical nature and functional impairment resulting from these exacerbations. As such, a remand is required in order to obtain supplemental examination findings from the October 2021 VA examiner. Accordingly, this matter is REMANDED for the following actions: Obtain supplemental examination findings from the October 2021 VA back examiner if available, and if unavailable from an examiner with sufficient expertise to address the following questions regarding the historical nature and functional impairments caused by the Veteran's service-connected thoracolumbar spine disability. Following a review of the relevant records and lay statements, the examiner is asked to provide responses to the following: a) Did the Veteran undergo a weight-bearing range of motion assessment in the course of his October 2021 VA examination? i. If so, please provide those findings. ii. If not, please state why this assessment could not be performed. b) Please provide a retrospective opinion as to whether the nature and severity of the Veteran's "aggravations" (exacerbations or flare-ups) of back pain have remained consistent since the Veteran initiated his claim for an increased rating in September 2014. c) Please state whether the Veteran's "aggravations" (exacerbations or flare-ups) of back pain have resulted in his experiencing a functional unfavorable ankylosis of the thoracolumbar spine. In this respect, the examiner is advised that for VA compensation purposes, the requirement of ankylosis can be met with evidence of the functional equivalent of ankylosis (i.e. functional immobility of the joint) during a flare-up. The examiner is also advised that for this inquiry, unfavorable ankylosis is defined as a condition in which the entire thoracolumbar 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. The examiner is asked to discuss and consider the Veteran's competent and credible reports relative to his thoracolumbar spine manifestations. If the examiner is unable to provide answers to any of the above-noted inquiries, they should explain why. If the examiner cannot provide answers to any of the above-noted inquiries without resorting to mere speculation, they must provide a complete explanation as to why this is so. If the inability to provide answers to any of the above-noted inquiries is the result of a need for additional information, the examiner should identify the additional information that is needed. T. REYNOLDS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board G. Fraser, 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.