Citation Nr: 21040586 Decision Date: 07/06/21 Archive Date: 07/06/21 DOCKET NO. 16-27 575A DATE: July 6, 2021 REMANDED Entitlement to a rating higher than 10 percent for limitation of left hip extension is remanded. Entitlement to a compensable rating for limitation of flexion of the left hip is remanded. Entitlement to a compensable rating for trochanteric bursitis of the left hip is remanded. Entitlement to a rating higher than 10 percent for left lower extremity radiculopathy is remanded. Entitlement to a rating higher than 20 percent for thoracolumbar sprain with traumatic arthritis is remanded. Entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) is remanded. REASONS FOR REMAND The Veteran had active duty service in the United States Navy from January 1988 to January 1997. He testified before the undersigned Veterans Law Judge (VLJ) at a Travel Board hearing in July 2019. A transcript of the hearing is of record. Entitlement to a rating higher than 10 percent for limitation of left hip extension; entitlement to a compensable rating for limitation of flexion of the left hip; and entitlement to a compensable rating for trochanteric bursitis of the left hip. The Veteran was last afforded a VA examination for his left hip in January 2016. Although he has not reported a worsening of symptoms related to his left hip and has denied experiencing flare-ups, the examination report is not in compliance with Correia v. McDonald. As such, remand is required. 28 Vet. App. 158 (2016); see also Sharp v. Shulkin, 29 Vet. App. 26 (2017). Entitlement to a rating higher than 10 percent for left lower extremity radiculopathy is remanded; entitlement to a rating higher than 20 percent for thoracolumbar sprain with traumatic arthritis is remanded; and entitlement to a TDIU is remanded. The Veteran was most recently afforded a VA examination for his low back in May 2019. The examination report indicates that he denied experiencing flare-ups in his low back. However, at his Board hearing in July 2019, he endorsed flare-ups and indicated his back pain significantly limits his ability to walk more than a few houses down from where he lives. In addition, the examination report indicates that the Veteran's left lower extremity radiculopathy manifested by mild intermittent pain only. However, the Veteran testified to severe pain in his left lower extremity and has submitted private treatment records indicating that he went to the emergency room as a result of such pain. Thus, it is unclear whether the most recent VA examination report is reflective of the Veteran's current disability picture. As such, remand is warranted to afford him additional VA examination. The issue of TDIU is inextricably intertwined with the issues being remanded and as such, is also being remanded. The matters are REMANDED for the following action: 1. Ask the Veteran to submit any relevant outstanding private treatment records. 2. Next, schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected left hip disability. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. 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). 3. Schedule the Veteran for an examination by an appropriate clinician to determine the current severity of his service-connected low back disability with associated left lower extremity radiculopathy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria. In so doing, the examiner must test the Veteran's active motion, passive motion, and pain with weight-bearing and without weight-bearing. 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). The examiner is asked to consider the Veteran's lay reports advanced at his July 2019 Board hearing regarding the severity of his low back and left lower extremity radiculopathy. In addition, the examiner should consider the private treatment records dated in July 2019, which indicate that the Veteran presented to the emergency room as a result of extreme left lower extremity pain. The July 2019 private treatment records indicate that the Veteran also experienced bilateral lower extremity numbness without muscle weakness. Diagnoses of "lower back pain with sciatica and lumbar radiculopathy" were rendered. As a result, the examiner is also asked to opine whether the Veteran has right lower extremity radiculopathy that is at least as likely as not related to his low back disability. The examiner should also comment on how the Veteran's low back disability and radiculopathy impact his ability to sit and stand. The Veteran contends he cannot walk more than a few houses down and he can only sit for 20 to 30 minutes because of his back pain. If possible, the examiner should also comment on the functional impact caused by the Veteran's left hip, left lower extremity radiculopathy, and low back disability, working together. 4. After completing the above, the claims remaining on appeal, including the claim for TDIU, must be readjudicated. If any benefits sought are not granted, issue the Veteran and his attorney an appropriate supplemental statement of the case (SSOC). H.M. WALKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Martha R. Luboch, 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.