Citation Nr: 21012459 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 17-13 019 DATE: March 4, 2021 REMANDED Entitlement to an increased evaluation for residuals of a low back injury with degenerative arthritis of the lumbosacral spine, rated as 20 percent disabling is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1971 to February 1997. This matter comes before the Board on appeal from an April 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the claim in November 2018 for further development. 1. Entitlement to an increased evaluation for residuals of a low back injury with degenerative arthritis of the lumbosacral spine, rated as 20 percent disabling is remanded. The Veteran contends that his condition is worse in severity than the 20 percent rating due to how the condition affects him on an everyday basis to include an earlier effective date back to the date he filed the claim for an increase on his lumbar spine. In the November 2018 remand, the Board directed the RO to afford the Veteran an examination where the examiner “in reporting the results of range of motion testing, the examiner should identify any objective evidence of pain, and the degree at which pain begins.” Here, the examiner indicated “pain noted on examination and causes functional loss.” However, the examiner did not note the degree at which pain begins. As the RO did not substantially comply with the mandates of the Board's remand order, the claim must be remanded. Stegall v. West, 11 Vet. App. 268, 271 (1998). The matters are REMANDED for the following action: 1. Obtain updated VA treatment records. 2. Schedule the Veteran a VA examination to determine the current severity of his back disability. The examiner should identify and completely describe all current symptomatology. The examiner should provide a detailed review of the Veteran's current complaints, as well as findings as to the nature, extent, and severity of symptoms caused by the Veteran's disability. All indicated tests and studies should be accomplished, and all clinical findings should be reported in detail, including ranges of motion of the lumbosacral spine AND the degree at which pain begins (e.g., 0 to 130 degrees with pain at 115 degrees) pursuant to DeLuca. Pursuant to Correia v. McDonald, 28 Vet. App. 158 (2016), the examination should record the results of range of motion testing for pain on BOTH active and passive motion and in weight-bearing AND non-weight-bearing. If the back cannot be tested on "weight-bearing," then the examiner must specifically indicate that such testing cannot be done. Pursuant to Sharp v. Shulkin, 29 Vet. App. 26 (2017), regarding flareups, if the Veteran is not currently experiencing a flare-up, based on relevant information elicited from the Veteran, review of the file, and the current examination results regarding the frequency, duration, characteristics, severity, and functional loss regarding his flares, the examiner is requested to provide an estimate of the Veteran's functional loss due to flares expressed in terms of the degree of additional range of motion lost, or explain why the examiner cannot do so. The Board recognizes the difficulty in making such determinations but requests that the examiner provide his or her best estimate based on the examination findings and statements of the Veteran. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Edwin B. Esmenda, 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.