Citation Nr: 21026047 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-13 389 DATE: April 29, 2021 ORDER Prior to February 11, 2019, a rating in excess of 10 percent for mechanical back pain syndrome with intervertebral disc syndrome (back disability) is denied. From February 11, 2019, a rating in excess of 40 percent for back disability is denied. Service connection for facial trauma disability is denied. REMANDED Service connection for neck condition is remanded. Service connection for right arm condition is remanded. Service connection for right-hand/wrist disability is remanded. Service connection for left-hand/wrist disability is remanded. FINDINGS OF FACT 1. Prior to February 11, 2019, the Veteran’s service-connected back disability was not more nearly manifested by forward flexion of 85 degrees or less, or a combined range of motion of the thoracolumbar spine of 235 degrees of less; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour; ankylosis; or incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks within a 12-month period. 2. From February 11, 2019, the Veteran’s service-connected back disability was not more nearly manifested by forward flexion to 30 degrees or less; or ankylosis; or incapacitating episodes having a total duration of at least 6 weeks within a 12-month period. 3. The preponderance of the evidence is against finding the Veteran had a facial trauma disability at any time during or approximate to the pendency of the claim. CONCLUSIONS OF LAW 1. Prior to February 11, 2019, the criteria for a rating higher than 10 percent for the service-connected back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code (DC) 5243. 2. Since February 11, 2019, the criteria for a rating higher than 40 percent for the service-connected back disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, DC 5243. 3. The criteria for service connection for a facial trauma disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1975 to June 1979. The Veteran died in February 2020. The appellant, his surviving spouse, has been substituted as the claimant in this appeal, which was pending at the time of the Veteran’s death. These matters come before the Board of Veterans’ Appeals (Board) on appeal from an August 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO) that, in pertinent part, granted service connection for the back disability at 10 percent effective January 30, 2014, and denied service connection for a right leg condition, a neck condition, a mental condition, facial trauma, a right arm condition, a right-hand disability, and a left-hand disability. In March 2019, the Veteran was afforded a hearing relating to the claims. A copy of the transcript has been associated with the electronic claims file. In August 2019, the Board remanded the Veteran’s claims for a rating higher than 10 percent for his service-connected back disability as well as service connection for a right-hand disability, left-hand disability, right arm disability, right leg disability, service neck disability, facial trauma, and an acquired psychiatric disability for further development, to include obtaining VA examinations. The Board finds that there has been substantial compliance with the Board’s prior remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998); Dyment v. West, 13 Vet. App. 141 (1999). Given that the Veteran passed away during the pendency of the claims, the agency of original jurisdiction (AOJ) could not afford VA examinations; instead, the AOJ obtained VA medical opinions and associated them to the electronic claims file in September 2020. See 38 C.F.R. § 3.1010(f)(3) (Rights that may have applied to the claimant prior to death but which cannot practically apply to a substitute, such as the right to a medical examination, are not available to the substitute). An October 2020 rating decision granted service connection for an acquired psychiatric disorder (depressive disorder) a right leg disability, radiculopathy of the right lower extremity. These awards reflect in full the benefit sought by the Veteran, there is no remaining allegation of error of fact or law for appellate consideration. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). The October 2010 rating decision also granted a 40 percent rating for the Veteran’s low back disability from February 11, 2019. However, as this does not reflect the maximum benefit potentially available, the issue remains in appeal status. See A.B. v. Brown, 6 Vet. App. 35, 38 (1993) (holding that a decision awarding a higher rating, but less than the maximum available benefit, does not abrogate the pending appeal). 1. Entitlement to a rating in excess of 10 percent prior to February 11, 2019, for back disability. 2. Entitlement to a rating in excess of 40 percent from February 11, 2019, for back disability. An August 2015 rating decision granted service connection for chronic lumbar strain and assigned a 10 percent rating effective January 30, 2014. See Rating Decision (August 2015). This appeal arises from the Veteran’s disagreement with the initial rating. See NOD (August 2015) & VA Form 9 (March 2016). Although a later rating decision assigned a 40 percent rating from February 11, 2019, for back disability, claim for increase remains on appeal as explained above. The Veteran contended that he believed his back symptoms were sufficiently severe to warrant a higher rating for his back disability. See NOD (August 2015) and Hearing Transcript (March 2019). The Board concludes that the preponderance of the evidence is against finding that the criteria for a higher rating were met prior to or after February 11, 2019. In this regard, prior to February 11, 2019, the Veteran’s service-connected back disability was not more nearly manifested by forward flexion of 85 degrees or less, or a combined range of motion of the thoracolumbar spine of 235 degrees of less; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour; ankylosis; or incapacitating episodes having a total duration of at least 2 weeks, but less than 4 weeks within a 12-month period. Also, from February 11, 2019, the Veteran’s service-connected back disability was not more nearly manifested by forward flexion to 30 degrees or less; or ankylosis; or incapacitating episodes having a total duration of at least 6 weeks within a 12-month period. Disability ratings are assigned in accordance with VA’s Schedule for Rating Disabilities and are intended to represent the average impairment of earning capacity resulting from disability. See 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Separate diagnostic codes (DCs) identify the various disabilities. See generally 38 C.F.R. Part 4. If two disability evaluations are potentially applicable, the higher evaluation will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Reasonable doubt regarding the degree of disability will be resolved in favor of the claimant. 38 C.F.R. § 4.3. The Veteran’s back disability is currently rated under 38 C.F.R. § 4.71a, Diagnostic Code 5243. Diagnostic Code 5243 provides that IVDS is to be rated either under the General Rating Formula for Diseases and Injuries of the Spine or under the Formula for Rating IVDS Based on Incapacitating Episodes, whichever method results in the higher rating when all disabilities are combined under 38 C.F.R. § 4.25. The Formula for Rating IVDS Based on Incapacitating Episodes provides that a 10 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least one week but less than 2 weeks during the past 12 months. A 20 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 2 weeks but less than 4 weeks during the past 12 months. A 40 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 4 weeks but less than 6 weeks during the past 12 months. A 60 percent rating is warranted for IVDS with incapacitating episodes having a total duration of at least 6 weeks during the past 12 months. 38 C.F.R. § 4.71a, Formula for Rating IVDS Based on Incapacitating Episodes. Note 1 to Diagnostic Code 5243 provides that, for purposes of ratings under Diagnostic Code 5243, an incapacitating episode is a period of acute signs and symptoms due to intervertebral disc syndrome that requires bed rest prescribed by a physician and treatment by a physician. Id. at Note 1. Under the General Rating Formula for Diseases and Injuries of the Spine, a 10 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 60 degrees but not greater than 85 degrees; or, combined range of motion of the thoracolumbar spine greater than 120 degrees but not greater than 235 degrees; or, muscle spasm, guarding, or localized tenderness not resulting in abnormal gait or abnormal spinal contour; or, vertebral body fracture with loss of 50 percent or more of the height. A 20 percent rating is warranted for forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees; or the combined range of motion of the thoracolumbar spine not greater than 120 degrees; or, muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. A 40 percent rating is warranted for forward flexion of the thoracolumbar spine to 30 degrees or less; or, favorable ankylosis of the entire thoracolumbar spine. A 50 percent rating is warranted for unfavorable ankylosis of the entire thoracolumbar spine. A 100 percent rating is warranted for unfavorable ankylosis of the entire spine. 38 C.F.R. § 4.71a, General Rating Formula for Diseases and Injuries of the Spine. Any associated objective neurological abnormalities, including, but not limited to, bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. Id. at Note 1. Each range of motion measurement is to be rounded to the nearest five degrees. Id. at Note 4. Unfavorable ankylosis is defined as “a condition in which the entire cervical spine, the entire thoracolumbar spine, or the entire 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.” Id. at Note 5. Additionally, fixation of a spinal segment in neutral position (zero degrees) is “always” considered favorable ankylosis. Id. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) (“[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran’s disability, after which a rating is determined based on the § 4.71a criteria.”). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). Turning to the facts of this case, a July 2015 VA examination reflects forward flexion to 80 degrees with painful motion starting at 70 degrees; extension to 30 degrees or greater with no objective painful motion; bilateral flexion to 30 degrees or greater with no objective painful motion; bilateral rotation to 30 degrees or greater with painful motion beginning at 25 degrees; and there was 230 degrees combined range of motion (or 210 degrees combined with pain). Repetitive use testing showed forward flexion limited to 80 degrees, extension to 30 degrees or greater, bilateral flexion to 30 degrees or greater, and bilateral rotation to 30 degrees or greater. There was 230 degrees of combined range of motion. Pain and less movement than normal were noted on examination caused functional loss. See VA Examination (July 2015). All other clinical tests were normal. Radiculopathy was not shown. There was no evidence of localized tenderness or pain to palpation or guarding or muscle spasm. Muscle strength, reflex, sensory, and straight leg testing were normal. There was no evidence of other neurologic abnormalities nor evidence of IVDS. He did not use an assistive device to ambulate nor was there evidence of ankylosis. The examiner noted that no imaging studies were available for review and none was conducted. Id. A January 2016 “Independent Medical Examination” from the Ellis Clinic (John W. Ellis, M.D.) indicates range of motion findings. Single Range of motion testing showed flexion to 45 degrees, extension to 15 degrees, right lateral flexion to 15 degrees, left lateral flexion to 10 degrees, right rotation to 10 degrees and left rotation to 15 degrees of the thoracolumbar spine (110 degrees combined). Yet, there is no indication that a goniometer was used as required by VA regulations. See 38 C.F.R. § 4.46. Therefore, the range of motion findings reported have no probative value. It is noted that this report focused on linking the Veteran’s condition to in-service injury, rather than providing detailed findings for rating the disability under the rating schedule. A February 11, 2019, Disability Benefits Questionnaire (DBQ), completed by a private physiotherapist (M. Jackson, D.P.T.) on behalf of the Veteran, reflects a diagnosis of mechanical back pain syndrome, IVDS and radiculopathy as of 2019. At this time, the Veteran reported he experienced flare-ups; and took ibuprofen and rested when they occurred. The Veteran reported he had difficulty with prolonged sitting, standing, walking, lifting, and squatting. On range of motion testing, forward flexion was limited to 5 degrees, extension to 10 degrees (7 degrees), right lateral flexion to 10 degrees (8 degrees), left lateral flexion to 5 degrees (6 degrees), right lateral rotation to 10 degrees, and left lateral rotation to 15 degrees; 55 degrees combined. On repetitive use testing, there was additional limitation in range of motion with forward flexion to 5 degrees, extension to 5 degrees, left lateral flexion to 5 degrees, right lateral flexion to 10 degrees (7 degrees), left lateral rotation to 10 degrees, and right lateral rotation to 10 degrees; 45 degrees combined. The range of motion measurements have been rounded to the nearest five degrees in accordance with VA regulations for adjudication purposes. See 38 C.F.R. § 4.71a, Note 4. Yet, again, there is no indication that a goniometer was used. See DBQ- Veteran Provided (February 2019). In addition, the clinician noted pain contributed to functional loss on active, passive or repetitive use testing as well as in weight bearing or in non-weight bearing. The clinician noted moderate tenderness to palpation over the lumbar spinous processes, bilateral paraspinals on the right greater than left, and moderate muscle tension along the bilateral erector spinae. The Veteran had an abnormal gait with guarding and abnormal spinal contour with muscle spasm. Contributing factors that contributed to his functional loss was less and weakened movement than normal, excess fatigability, pain on movement, disturbance of locomotion, and interference with sitting and standing. Id. The examiner noted that pain, weakness, fatigability, or incoordination significantly limited functional ability during flare-ups or when used repeatedly over a period of time. He stated he was unable to estimate range of motion for forward flexion or right lateral rotation; he stated the Veteran had pain in all movements even though he had no additional limitation of motion. There were also no signs of ankylosis. Id. While the Veteran had IVDS of the thoracolumbar spine, he did not report any incapacitating episodes over the last twelve months. The examiner noted the Veteran had difficulty with prolonged, sitting, standing, walking, lifting and squatting. Id. February 2019 private treatment records confirm the Veteran had chronic lower back pain with radiation to his right leg. See Medical Treatment Record- Non-Government Facility (December 2019). October 2019 MRI showed neural foraminal narrowing L3-4 through L5-S1. neural foraminal narrowing, severe at L4-5 and L5-S1; and spinal canal stenosis L3-L4. See Medical Treatment Record- Non-Government Facility (February 2020). Collectively, applying the facts in this case to the legal criteria set forth above, the Board finds that the preponderance of the evidence is against the assignment of a higher than 10 percent rating prior to February 11, 2019. Prior to February 11, 2019, the record does not show he experienced incapacitating episodes due to IVDS. The evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. Indeed, the July 2015 VA examination report and the January 2016 independent medical examination make no mention of a prescription for bedrest. The preponderance of the evidence is also against a rating higher than 10 percent prior to February 11, 2019 for the Veteran’s back disability under the General Rating Criteria. The Veteran’s back disability was not more nearly manifested by forward flexion limited to 60 degrees or less; combined range of motion of the thoracolumbar spine limited to 120 degrees or less; or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis, or abnormal kyphosis. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to pain on movement. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in symptoms more nearly approximating forward flexion of the thoracolumbar spine greater than 30 degrees but not greater than 60 degrees or a combined range of motion not greater than 120 degrees or muscle spasm or guarding severe enough to result in an abnormal gait or abnormal spinal contour such as scoliosis, reversed lordosis or abnormal kyphosis. 38 C.F.R. § 4.45. The Board considered the private January 2016 independent medical examination report with favorable findings that he had forward flexion to 45 degrees with combined range of motion of 110 degrees, however the Board finds that this examination is inadequate for VA purposes and is of no probative value because range of motion findings must be obtained using a goniometer and there is no indication that a goniometer was used to obtain those measurements. See 38 C.F.R. § 4.71a, Plate V. The purpose of a goniometer is to assist in more precise measurements of motion. A goniometer is defined as “indispensable” by VA regulations. See 38 C.F.R. § 4.46. Additionally, there is no other medical evidence corroborating flexion more limited. Since February 11, 2019, applying the facts in this case to the legal criteria set forth above, the Board finds that the preponderance of the evidence is against the assignment of a rating higher than 40 percent for the service-connected back disability based on incapacitating episodes. The evidence of record is against a finding that the Veteran was ever prescribed bed rest by a physician for a duration that meets the criteria for a higher rating. Indeed, the February 2019 private DBQ shows the Veteran did not complain of incapacitating episodes. The preponderance of the evidence is also against a rating in excess of 40 percent for the Veteran’s back disability under the General Rating Criteria. The Board acknowledges the Veteran’s lay reports of symptoms and that there was functional loss due to less and weakened movement than normal, excess fatigability, pain on movement, disturbance of locomotion, fatigability, incoordination, and interference with sitting and standing. However, even considering the Veteran’s lay reports of symptoms and noted functional loss, the degree of additional limitation reflected by the statements would not result in symptoms more nearly approximating unfavorable ankylosis of the entire thoracolumbar spine. In the February 2019 private DBQ, while the examiner stated he was unable to render an estimate of functional loss during flare-up, he stated that there would not be any additional loss of motion during painful episodes. There is no indication that the Veteran’s spine was fixed in a neutral position, let alone fixed in flexion or extension, and that the ankylosis resulted in difficulty walking because of a limited line of vision; restricted opening of the mouth and chewing; breathing was limited to diaphragmatic respiration; that the Veteran had gastrointestinal symptoms due to pressure of the costal margin on the abdomen; that the Veteran experienced dyspnea or dysphagia; that there was evidence of atlantoaxial or cervical subluxation or dislocation; or evidence of neurologic symptoms due to nerve root stretching.” 38 C.F.R. § 4.71, General Rating Formula for Diseases and Injures of the Spine, Note 5. Notably, the private February 2019 DBQ does not indicate that a goniometer was used to perform range of motion testing as required by VA regulations. A goniometer is defined as “indispensable” by VA regulations. See 38 C.F.R. § 4.46. There is also no indication that the examiner tested range of motion for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing or solicited the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the Veteran. See Correia v. McDonald, 28 Vet. App. 158 (2016), Sharp v. Shulkin, 29 Vet. App. 26 (2017). However, unfortunately, it is not practical to re-assess the Veteran’s back disability due to his passing. Rights that may have applied to the claimant prior to death but which cannot practically apply to a substitute, such as the right to a medical examination, are not available to the substitute. 38 C.F.R. § 3.1010(f)(3). With no opposing evidence of record, the 40 percent rating predicated on an inadequate examination report will not be undisturbed by the Board. Regarding neurological impairment, the Veteran has been separately rating for radiculopathy of the right and left lower extremities associated with his service-connected back disability, and the lay and medical evidence of record is against a finding that the Veteran had any other neurological abnormality associated with the spine disability. See Rating Decision (October 2020). To the extent the appellant disagrees with the effective date or rating assigned for the radiculopathy, she may appeal the October 2020 Rating Decision. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). It is noted that, to challenge the downstream element of the radiculopathy rating or the effective date, a separate NOD with the initial rating and effective date assigned is required. An October 8, 2020, VA letter notified her of this award and advised her of the options if she disagreed with the decision. Also, given that there was no discussion of the radiculopathy ratings in the October 2020 Supplemental Statement of the Case, it is reasonable to find that the appellant was not misled by the AOJ into thinking such was part of the pending appeal. For the foregoing reasons, the preponderance of the evidence is against the Veteran’s claims for increase for the service-connected back disability. In denying such a rating in excess of 10 percent prior to February 11, 2019, and in excess of 40 percent therefrom, the Board finds the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. Accordingly, the claims are denied. 3. Entitlement to service connection for a facial trauma disability The Veteran contended that he sustained a facial trauma disability in service. Specifically, he reported injury around August or September of 1977 when a dump truck flipped and threw him out onto the asphalt and sand. He stated he landed on his head approximately 60 feet and was taken to dispensary at 29 Palms; that the left side of his face had no skin left; that a Corpsman used a small brush to clean out the abrasions from his face, arms, and wrists; and that he had not required hospitalization or follow-up care. See NOD (August 2015) and Hearing Transcript (March 2019). Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran had a disability during the pendency of the claim that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that the preponderance of the evidence is against finding that the Veteran had a facial trauma disability at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Service treatment records (STRs) show the Veteran sought treatment for cyst in January 1977. He complained of swelling of the lower jaw with a small cut on the lower right corner of his lip. He stated he did not have any pain, only slight numbness. The examiner noted there was a hardened bump. The Veteran was instructed to apply heat to the area. A November 1978 STR reflects that the Veteran presented for left hand problems which he attributed to a motor vehicle accident a year earlier when he “jumping out of a dump truck.” There was no mention of injury to the head, face, or neck, nor was there any report that he was thrown from the truck during the incident. December 1974 enlistment and May 1979 separation examinations showed normal clinical evaluation of the Veteran’s head, face, neck and scalp, and neurologic systems. There is a note of a 2-inch scar on the right rear of the Veteran’s head at enlistment and separation, with no mention of any change. There is no notation relating to the left side of his face or a lack of skin on any portion of his face. Post-service, VA and private treatment records are silent as to any facial injury or trauma, or any indication of a facial disability to include abnormal pathology of the skin or face. Although a January 2016 “Independent Medical Examination” from the Ellis Clinic (John W. Ellis, M.D.) indicates, by history, that the Veteran landed on his face when a dump truck flipped over, throwing the Veteran to the ground; and that the Veteran reported having had immediate pain on the left side of his face, this report does not reflect any abnormal pathology of the Veteran’s face to include skin or cosmetic abnormality. However, the clinician stated that the Veteran had “obviously had traumatic brain injury when he hit the left side of his face.” The Board notes that the issue of traumatic brain injury (TBI) is not before the Board and, to the extent that the Veteran had psychological impairment related to any possibly TBI, service connection has been already established for mental disorder to include symptoms of impaired abstract thinking based on a PTSD DBQ from a private clinician dated in February 2019. Collectively, the preponderance of the evidence is against finding that the Veteran had a facial trauma disability at any point during the pendency of the claim or approximate to its filing. It is noted that pain alone, even without an underlying diagnosis, can still constitute a current disability, for VA compensation purposes, if it reaches the level of a functional impairment of earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). However, here, the Veteran did not assert, and the evidence does not reflect, that he experienced pain any chronic face pain, or facial pain productive of functional impairment. In the absence of proof of a present disability, there can be no valid claim. See Saunders, supra. Accordingly, the claim is denied. There is no doubt to resolve. 38 U.S.C. § 5107(b). REASONS FOR REMAND In remanding these matters, the Board makes no finding, implicit or otherwise, as to the credibility of the Veteran’s assertions. Neither the Veteran’s credibility nor any lack thereof should be presumed in this remand. 1. Entitlement to service connection neck condition The Veteran asserted that he sustained injuries to his neck as a part of the accident with the dump truck. He stated he did not know at the time that he had a neck disability in addition to his low back. See NOD (August 2015) and Hearing Transcript (March 2019). The Board cannot make a fully informed decision on the issue of a neck disability because the September 2020 VA opinion is inadequate for adjudicative purposes. Once the Secretary undertakes the effort to provide an examination when developing a service-connection claim, he must provide an adequate one. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical opinion based solely on the absence of in-service treatment or findings will be deemed inadequate. Jones v. Shinseki, 23 Vet. App. 382, 390 (2010). In this case, the AOJ obtained a VA medical opinion in September 2020. The examiner opined that the neck condition was less likely than not caused by service. The rationale was that there was no indication of a neck injury at the time of the accident. Forty years after the accident, it was noted that he had advanced degenerative changes in the cervical spine with spinal cord compression, likely causing a right-sided cervical radiculopathy. However, there was no evidence to support that the event in 1977 caused the clinical presentation. There was no indication of a neck injury nor a continuum of care for a neck injury. The Board concludes the September 2020 VA medical opinion is inadequate on two bases. First, the medical opinion is inadequate because it does not reflect consideration of the Veteran’s competent report of sustaining an in-service injury and relied on the absence of evidence in the Veteran’s service medical records to support the negative conclusion reached. Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007). Second, the opinion is inadequate because the essential rationale is not discernable. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). The opinion notes the lack of objective evidence, such as continuous medical evaluation, management, or treatment, but makes no attempt to connect the lack of objective evidence to its conclusion. It is noted that a medical opinion or “medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Where VA provides an examination or obtains an opinion, it must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical opinion must also support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record. Stefl v. Nicholson, 21 Vet. App. 102, 124-25. Therefore, remand is necessary for an adequate medical opinion. Barr v. Nicholson, 21 Vet. App. 303 at 311. 2. Entitlement to service connection for right arm condition is remanded. 3. Entitlement to service connection for right-hand/wrist disability 4. Entitlement to service connection for left-hand/wrist disability Issues 2-4: The Veteran contended that he sustained injuries to his hands/wrist/right arm occurred he was when thrown from a dump truck that flipped in 1977 while he was in service. He stated that a Corpsman used a small brush to clean out the abrasions from his face, arms and wrists. He denied getting any follow up care for his neck, hands or facial abrasions. See NOD (August 2015) and Hearing Transcript (March 2019). STRs show the Veteran was diagnosed with left-hand tenosynovitis in November 1978. He reported that he injured his hand while jumping out of a dump truck 1 year prior. The Veteran reported that he had limited range of motion and hand weakness with pain, both of which occurred when in contact with opposing forces. The clinician observed that his range of motion was limited with mild pain when pressure was applied. However, no fracture was noted. There was no treatment for the right-hand. A May 1979 separation examination reflects normal clinical evaluation of the upper extremities and neurologic systems. The first documented indication of any hand/wrist condition was on the Veteran’s February 2015 VA application for disability compensation. See VA Form 21-526EZ (February 2015). A July 2015 VA examination report reflects a diagnosis of Dupuytren’s disease of the hands. A July 2015 VA medical opinion reflects that the Veteran’s Dupuytren’s disease, of the bilateral hands, was less likely than not related to service. No rationale was provided. A January 2017 VA examination report reflects a diagnosis of left wrist arthritis. By history, the Veteran landed on his hands and wrists while jumping out of a truck in service. A January 2017 VAMO reflects that left wrist arthritis is less likely than not caused by the claimed in-service injury because arthritis shown in service, there is no continuity of symptoms, and no nexus. A September 2020 VA medical opinion reflects that it was less likely than not that the Veteran’s right and left-hand conditions were incurred in or caused by the motor vehicle accident described in service. The opinion acknowledged that the Veteran had left-hand symptoms diagnosed as tenosynovitis while on active duty, but it noted that the record then went silent for the next 37 years until he was diagnosed with Dupuytren’s contracture, bilaterally. The VAMO also acknowledged the March 2019 diagnoses of right side DeQuervain’s syndrome and chronic right wrist sprain. The VAMO found that Dupuytren’s contracture is not traumatically induced, referencing information from the Mayo Clinic and how Dupuytren’s contracture is known to develop along with potential causes. As to the March 2019 finding for chronic right wrist sprain by a physiotherapist, the VAMO rejected this diagnosis because it was not “clinically reasonable or reliable in the context of other examinations by physicians in the record,” but no further explanation was provided. The VAMO did not address the 2017 VA examination findings for left wrist arthritis. The Board finds that the VAMO’s addressing the claims for disability of the hands/wrists are inadequate for adjudicative purposes. Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). The 2015 and 2017 VAMO’s lack a complete rational for the conclusion reached. The 2020 VAMO did not fully explain why the diagnosis 2019 physiotherapists findings for chronic right wrist sprain was rejected, or address all diagnoses pertaining to the hands and wrist. The Veteran clearly believed that he had hand and wrist disorders caused by landing on his hands and wrists when he jumped out of a truck in service. The Board acknowledged that the Veteran provided two medical opinions to support his hand/wrist claims. A January 2016 independent medical examination by the Ellis Clinic shows diagnoses for tendonitis and arthritis of the wrists. The finding of arthritis of the wrists is unsupported by x-ray findings. Dr. Ellis opined that the diagnoses presented are more likely than not due to and a consequence of the Veteran’s service. A March 2019 private DBQ completed by a private physiotherapist shows that the Veteran was diagnosed with DeQuervain’s syndrome of the right side and chronic right wrist sprain, diagnosed in March 2019. He opined that the conditions were more likely than not initially caused by the MVA in service, noting the Veteran’s history of injury and report of “a progressive worsening of wrist pain over the years.” The Board has considered the favorable medical opinions provided in support of the appeal. However, the Board finds that they are inadequate to decide the appeal. First, neither medical opinion is supported by a complete rationale. In this regard, while the medical opinions contain not only clear conclusions, Dr. Ellis’ opinion lacks both supporting data and a reasoned medical explanation connecting the two; and the physiotherapist’s opinion lacks a reasoned medical explanation connecting his conclusion to the Veteran’s reported landing on wrists following a dump truck accident and “the Veteran’s reports of progressive worsening over the years.” Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). Further, neither medical opinion reflects any meaningful consideration of the medical records most contemporaneous with the Veteran’s military service and reported injury, that is, his STRs (which include a normal clinical evaluation of the upper extremities at service separation in 1979). Indeed, although Dr. Ellis stated that his opinion was based on his examination of the Veteran and “review of medical and/or service records, among other things, his report does not reference any specific medical or service records, and appears to rely on the Veteran’s reports of in-service injury rather than any actual independent review of the STRs. The recollections of the Veteran paint a picture of a significant and serious accident and accompanying injury that is not borne out by the STRs (e.g. the absence of hospitalization at the time of the incident, or follow-up treatment after the incident, and normal clinical evaluation on service separation roughly 2 years after the incident (dump truck accident)). Therefore, the Board finds that the opinions are insufficient to grant the benefit sought on appeal. Again, a “medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.” Nieves-Rodriguez v. Peake, 22Vet. App.295, 301 (2008). As neither the VA nor the private medicals opinions are adequate to decide the appeal, remand is necessary. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (when VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that it is adequate). The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s neck disability is at least as likely as not related to service, to include as due to the dump truck/motor vehicle accident. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any symptoms. The examiner is advised that the Veteran was competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. The examiner is advised to not rely solely on any gap in treatment when rendering his opinion and to consider the Veteran’s lay statements. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. 2. Obtain an addendum opinion from an appropriate clinician regarding the Veteran’s claimed right arm, right hand/wrist, and left hand/wrist disability. Based on review of the record, detail the Veteran's reported symptoms, including the nature, onset, progression and severity of any hand/wrist symptoms. The opinion should identify and explain the relevance or significance, as appropriate, of any history, clinical findings, medical knowledge or literature, etc., relied upon in reaching the conclusion(s). An adequate medical opinion may not be predicated solely on the absence of an in-service diagnosis or documented complaints. (a.) For each diagnosed disorder (to include right side DeQuervain’s syndrome and chronic right wrist sprain; tendonitis and arthritis of the wrists; Dupuytren’s contracture; and left wrist arthritis), opine on whether it is at least as likely as not due in-service injury or disease, and specifically to landing on his hands and wrists when jumping out of a truck during an accident in service. (b.) Whether any right arm disability is at least as likely as not (i) proximately due to service-connected back (mechanical back pain syndrome with IVDS) disability or (ii) aggravated beyond its natural progression by his service-connected back disability. 3. Ensure that the VA medical opinions obtained include a complete rationale for the conclusions reached. The medical opinions must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. C.A. SKOW Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board N. Pendleton, 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.