Citation Nr: 21041329 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 16-19 148 DATE: July 8, 2021 REMANDED Entitlement to an increased rating for lumbosacral strain is remanded. REASONS FOR REMAND The appellant is a Veteran who served on active duty from January 1970 to November 1971. This matter is before the Board of Veterans' Appeals (Board) on appeal of an April 2014 Department of Veterans Affairs (VA) rating decision. In November 2018, a videoconference hearing was held before the undersigned; a transcript is in the record. In May 2019, this matter was remanded for additional development. The May 2019 Board remand ordered a VA examination by an orthopedist to determine the nature and etiology of his current back disability. The examiner was asked to identify each back disability found (or shown by the record) and to opine whether each diagnosis entity was related to service or was caused or aggravated by his service-connected lumbosacral strain. Specifically, the examiner was to address whether the additional back diagnoses are a manifestation or represents a progression of the service-connected lumbosacral strain or is a separate and distinct disability entity. In December 2019, the Veteran submitted a portion of his private treatment records related to his back from 2012, 2013 and 2016. On January 2020 VA examination, the provider (a family nurse practitioner in general practice) diagnosed intervertebral disc syndrome (IVDS), spinal stenosis, chronic lumbosacral strain, and lumbar decompression surgery were diagnosed. The examiner indicated diagnostic (imaging) studies did not show arthritis. Significantly, on March 2014 VA examination, when diagnostic studies performed included MRI, the diagnoses included degenerative arthritis of the spine. The examiner did not note (or reconcile) the contradictory findings (suggesting a less than complete review of the record). The examiner opined that new diagnoses of IVDS and spinal stenosis are unrelated to back disability diagnosed that is service-connected, noting that due to the duration of the intervening period between service and the current post-service diagnoses, the new diagnoses are unrelated to the service-connected [diagnosed disability entity]. While the examiner appears to indicate that IVDS and spinal stenosis are separate and distinct disabilities from the back disability that is service-connected, she further stated that she cannot identify the etiology for the Veteran's post-service back condition considering the state of the medical evidence in the record (but did not indicate what information needed to enable a non-speculative opinion is lacking). Moreover, the examiner did not address whether or not lumbar radiculopathy is also secondary to (a complication of) the service-connected lumbosacral strain. The January 2020 VA examination is therefore inadequate for rating purposes. Accordingly, another examination to obtain a fully adequate findings and medical opinion in this matter is necessary. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The matter is REMANDED for the following: 1. Ask the Veteran to identify the providers of all evaluations and treatment he has received for his back (records of which remain outstanding), and to submit authorizations for VA to secure for the record all outstanding, updated to the present, records of the private evaluations and treatment identified. Secure for the record complete (all outstanding) clinical records of the evaluations and treatment from all providers identified. If any private records identified are not received pursuant to VA's request, the Veteran should be so notified and advised that ultimately it is his responsibility to ensure that private medical records are received. The critical questions in this matter cannot be properly addressed if relevant private treatment records remain outstanding. 2. Arrange for the Veteran to be examined by an appropriate clinician (e.g., with experience in diagnosing and treating orthopedic disability) to determine the nature and etiology of his current back disability. On examination and review of his record, the examiner should: (a.) Identify (by diagnosis) each back disability found (or shown by the record during the pendency of this claim). Regarding each such diagnosis opine whether it at least as likely as not (a 50% or greater probability) is a manifestation or represents a progression of the service-connected lumbosacral strain (or is a separate and distinct disability entity, with separate and distinct etiology, manifestations, and related functional impairment)? If a diagnosed back disability is determined to be a separate disability entity from the service-connected back disability, cite to factual data that in the record that support such conclusion. (b.) Assess the current severity of the service-connected lumbosacral strain (and any other current back disability entity diagnosed that is determined to be a progression of or secondary to the service-connected lumbosacral strain). All indicated studies should be completed. Findings reported must include complete range of active and passive motion studies, in weight bearing and non-weight bearing, and after extended use (with notation of any additional functional limitations due to factors such as weakness, pain, incoordination, weight-bearing and fatigue, use, etc.). All findings and related functional impairment should be described in detail. The examiner should comment on any restrictions on occupational and daily activity functions due to the disabilities. If any manifestations or functional impairment are found to be due solely to co-existing diagnoses and pathology that are separate and distinct from the service connected disability entity, identify such manifestations and impairment (and the underlying non-service-connected back disability entity/pathology) and cite to the factual data and medical principles that support such conclusion. Any (and all) associated neurological symptoms found should be described in detail. It should also be noted whether there have been incapacitating episodes of disc disease (bedrest prescribed by a physician, and if so the duration and frequency of such episodes should be ascertained/noted). If flare-ups are reported, the examiner should indicate whether the Veteran's descriptions of flare-ups are consistent with the disability picture clinically presented. All opinions must include rationale that cites to supporting factual data and medical principles. If an opinion sought cannot be provided without resort to mere speculation, it must be so stated, with explanation why an opinion would require speculation (e.g., whether further information or testing necessary is needed; or whether the opinion cannot be rendered due to limitations in the current state of knowledge in the medical community at large or of the particular examiner). GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Naumovich, 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.