Citation Nr: 21024230
Decision Date: 04/22/21	Archive Date: 04/22/21

DOCKET NO. 17-58 970
DATE: April 22, 2021

REMANDED

A disability rating higher than 10 percent for mechanical lumbar strain is remanded.

REASONS FOR REMAND

The Veteran had active service from August 1998 to May 2004.

The Veteran seeks a higher disability rating for her service-connected lumbar spine disability.  She is currently in receipt of a 10 percent disability rating for mechanical lumbar strain under DC 5237 for lumbar or cervical strain.  38 C.F.R. § 4.71a.  The Board regrets the delay, but remand is necessary to obtain clarification on the nature and severity of the Veteran’s service-connected mechanical lumbar strain. 

VA treatment records and a Veteran-provided Disability Benefits Questionnaire (DBQ) document lumbar spine diagnoses other than strain.  The additional diagnoses include disc disease, sacroiliitis, left hip trochanteric bursitis, and bilateral radiculopathy.  See June 2019 MRI report; December 2019 VA physical therapy consult notes; and August 2020 Back Conditions DBQ.  It is unclear from the record whether these additional diagnoses represent a progression of or are instead separate and distinct from the lumbar strain that characterizes the Veteran’s service-connected musculoskeletal disability at issue.  Therefore, an addendum medical opinion is needed to more precisely identify the degree of disability that is directly attributable to mechanical lumbar strain.  

In evaluating the lumbar strain, the examiner should distinguish between symptoms and functional impairment directly attributable to mechanical lumbar strain versus symptoms and functional impairment attributable to disc disease, sacroiliitis, left hip trochanteric bursitis, and bilateral radiculopathy.   If the examiner is unable to separate the service-connected symptoms from the non-service-connected symptoms, the examiner should explain why.

The matter is REMANDED for the following action:

Schedule the Veteran for a VA examination (or telehealth interview or review of the record during the social distancing restrictions of the COVID-19 pandemic) to determine whether disc disease, sacroiliitis, left hip trochanteric bursitis, and bilateral radiculopathy are related to the service-connected mechanical lumbar strain.  

In providing the requested opinion, the examiner should discuss symptomatology such as pain, reduced muscle strength, reduced reflexes, decreased sensation, positive straight leg raising, paresthesias/dysesthesias, numbness, moderate radiculopathy as reflected in the August 2020 DBQ report in addition to the VA treatment records and MRI report from June 2019 to present.  

(a) The examiner should state whether it is at least as likely as not (50 percent or greater probability) that the now diagnosed disc disease, sacroiliitis, left hip trochanteric bursitis, and bilateral radiculopathy represent (i) a progression of the underlying service-connected mechanic lumbar strain or (ii) are wholly unrelated disorders. 

(b) If it is determined that the Veteran’s disc disease, sacroiliitis, left hip trochanteric bursitis, and bilateral radiculopathy are not a progression of the service-connected lumbar strain, the examiner should identify the symptoms and functional impairment not attributable to the service-connected mechanical lumbar strain.  

(c) If any symptomatology or functional impairment associated with the Veteran’s mechanical lumbar strain cannot be differentiated from that associated with the non-service-connected disc disease, sacroiliitis, left hip trochanteric bursitis, and bilateral radiculopathy, the examiner should provide an explanation as to why. 

 

 

Thomas H. O'Shay

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	Bryant, Jeana R

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.