Citation Nr: 21026064 Decision Date: 04/29/21 Archive Date: 04/29/21 DOCKET NO. 16-33 228 DATE: April 29, 2021 REMANDED Entitlement to a rating in excess of 20 percent for lumbosacral spine strain, claimed as back condition, is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1991 to July 2011. This matter comes before the Board of Veterans’ Appeals (Board) from a November 2015 rating decision. In a July 2016 VA Form 9, the Veteran requested a hearing in front of a Veterans Law Judge. A hearing was set for July 15, 2019, but on June 25, 2019, the Veteran submitted a request to withdraw his hearing request. As such, no hearing was held, and the Board will consider only the evidence of record. Entitlement to a rating in excess of 20 percent for lumbosacral spine strain, claimed as back condition. The Veteran contends he is entitled to an increased rating in excess of 20 percent for lumbosacral spine strain, claimed as back condition. The Veteran asserts that his disability has worsened since his last VA examination in November 2015. He asserts that he now has a diagnosis from a VA clinician of intervertebral disc syndrome and has reported symptoms of radiculopathy in his left and right lower extremities. See August 2019 Letter. A remand to obtain updated VA treatment records and a more contemporaneous examination is necessary to identify any possible change in the Veteran’s condition. The matters are REMANDED for the following action: 1. Ask the Veteran to identify any outstanding records of treatment for his lumbar disability, to include the locations of treatment at VA facilities. Make reasonable attempts to obtain any identified records. 2. After any outstanding records are received, schedule the Veteran for a VA examination to determine the current severity of his back disability. If the Veteran has a diagnosis other than lumbar strain, the examiner should opine whether it is at least as likely as not a progression of the Veteran’s service-connected back disability. The examiner should identify all back condition pathology found to be present. The examiner should conduct all indicated tests and studies, to include range of motion studies. The joints involved should be tested in both active and passive motion, in weight-bearing and non-weight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner should describe any pain, weakened movement, excess fatigability, instability of station and incoordination present. The examiner should also state whether the examination is taking place during a period of flare-up. If not, the examiner should ask the Veteran to describe the flare-ups he experiences, including frequency, duration, characteristics, precipitating and alleviating factors, severity and/or extent of functional impairment he experiences during a flare-up of symptoms and/or after repeated use over time. The clinician should provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up or after repeated use over time. If the examiner cannot estimate the degrees of additional range of motion loss during flare-ups or after repetitive use without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e. no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e. additional facts are required, or the examiner does not have the needed knowledge or training). Marissa Caylor Acting Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Lee Feldman, 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.