Citation Nr: 21015895 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 17-15 242 DATE: March 18, 2021 REMANDED Entitlement to a rating in excess of 20 percent for spondyloschisis L5-S1 with limitation of motion is remanded. Entitlement to a rating in excess of 10 percent for epiphysitis, thoracic spine, with limitation of motion is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1971 to February 1974. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an October 2014 rating decision of the Department of Veteran’s Affairs (VA) Regional Office (RO). The Veteran was afforded a hearing before the undersigned Veterans Law Judge in January 2021. The transcript has been associated with the file. The Veteran was afforded a VA examination in April 2014 in which the examiner conducted measurements of the Veteran’s limitation of motion in the back. The Veteran reported a burning sensation in his legs and flare ups of his condition. The examiner provided only range of motion information. However, the Veteran testified at his January 2021 hearing that his back conditions have worsened since the April 2014 examination. During that hearing, the Veteran reported that he is unable to walk even short distances without experiencing a burning sensation in his legs. This sensation requires him to lean against something or sit down to relieve the pain. The Veteran also stated that he often loses balance and falls while also experiencing a temporary loss of use of his left arm. He asserts these issues are due to the “bone spur” that “punched into” his spinal cord as a result of his service connected back disabilities. The Veteran’s wife further testified that the Veteran requires assistance to ambulate, this includes holding her shoulders for support as they walk even a short distance. The Veteran also recounts falling in his yard and being unable to lift himself back up. He will have to call to his wife for help or “crawl over to something like the fence or well head…” to pull himself back to his feet. The Veteran’s wife stated “he has no strength [whatsoever]” in his legs. As there is no medical evidence of record pertaining to the current state of the Veteran’s disability picture, and the Veteran has reported worsening since the most recent VA examination, VA is required to afford him a contemporaneous VA examination to assess the current nature, extent and severity of his disabilities. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007); Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected spondyloschisis L5-S1 with limitation of motion and epiphysitis, thoracic spine, with limitation of motion. The examiner should provide a full description of each disability and report all signs and symptoms necessary for evaluating the Veteran’s disabilities under the applicable rating criteria. The examiner should identify all associated abnormalities, including any neurological effects. The examiner must also identify all the functional effects that are due to the service connected spondyloschisis L5-S1 and separately due to the service connected epiphysitis, thoracic spine. The examiner should consider the Veteran’s lay assertions of the functional impacts of his back disabilities. The examiner must test the Veteran’s active motion, passive motion, and pain with weight-bearing and without weight-bearing. If it is not possible to provide a specific measurement 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). (Continued on the next page)   The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups. If it is not possible to provide a specific measurement based on direct observation, the examiner should provide an estimate, if at all possible, of the additional impairment due to flare-ups based on the other evidence of record and the Veteran's statements. If it is not possible to provide a specific measurement 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). LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Associate Counsel, S. Conti 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.