Citation Nr: 21042130 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 16-08 298 DATE: July 12, 2021 REMANDED Entitlement to an initial rating in excess of 30 percent for posttraumatic stress disorder (PTSD) is remanded. Entitlement to a rating in excess of 20 percent for chronic lumbosacral strain is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1969 to March 1971, including service in the Republic of Vietnam. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan, which, inter alia, granted service connection for PTSD and assigned an initial 30 percent evaluation, effective December 14, 2011, and continued the 20 percent evaluation for chronic lumbosacral strain. In January 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. This matter was previously before the Board in May 2019. At that time, the Board, inter alia, remanded the claims for further evidentiary development, to include VA examinations. 1. Entitlement to an initial rating in excess of 30 percent for PTSD is remanded. The Veteran contends that his PTSD is more severe than currently rated. See January 2019 Transcript of Hearing, pages 18-19. A review of the record indicates that the Veteran has been receiving treatment for his service-connected PTSD from the Dearborn Vet Center since October 2011. However, those treatment records have not been associated with the claims file. While the Board greatly regrets further delay, the Board finds that remand is required to enable the RO to obtain these treatment records. 2. Entitlement to a rating in excess of 20 percent for chronic lumbosacral strain is remanded. The Veteran contends that his low back disability is more severe than currently rated. See January 2019 Transcript of Hearing, pages 11-12. At the January 2019 Board hearing, noted above, the Veteran testified that he experienced numbness and shooting pains in his legs and feet. The Veteran's spouse, K.M., reported that the Veteran suffered from neuropathy and as a result "could lose feeling in his legs from the problem with his back." She testified that the Veteran's primary care physician indicated that "part of [his neuropathy] could be from his back pressing on a nerve." See January 2019 Transcript of Hearing, pages 12-13. While the Veteran filed a separate claim of service connection for lower extremity peripheral neuropathy, which was denied in an August 2014 rating decision, Note (1) for the General Rating Formula for Diseases and Injuries of the Spine indicates that any associated objective neurologic abnormalities, including, but not limited to bowel or bladder impairment, are to be evaluated separately under an appropriate diagnostic code. See 38 C.F.R. § 4.71a. Pursuant to the Board's May 2019 remand instructions, the Veteran was afforded a VA examination in September 2019. The examiner noted the Veteran's reports that he experienced stiffness in his back when he woke in the morning but as the day progressed, the stiffness subsided. The Veteran reported that he used a cane for balance and support. He also reported that he experienced pain and spasm when he over-exerted himself trying to bend forward. The Veteran denied any neurological deficit such as tingling down his legs from pinched nerves due to spinal stenosis. The examiner indicated that there were no neurological manifestations noted on examination of the Veteran. The Board finds that the VA examination is inadequate. In that regard, it appears that the examiner failed to consider the Veteran's VA treatment records noting a diagnosis of peripheral neuropathy. In addition, the examiner failed to address the Veteran's January 2019 hearing testimony indicating that he experienced numbness and pain in his legs and feet, as well as his spouse's reports that the Veteran's primary physician indicated that "part of [his neuropathy] could be from his back pressing on a nerve." While the Board greatly regrets further delay, remand is required for a new VA examination for full compliance with the Board's previous remand instructions. Stegall v. West, 11 Vet. App. 268, 270-71 (1998). Accordingly, the matters are REMANDED for the following action: 1. After obtaining the necessary information and authorization from the Veteran, the RO should undertake efforts to obtain any outstanding medical records pertinent to the Veteran's PTSD claim, including records from the Dearborn Vet Center. 2. Schedule the Veteran for an appropriate examination to determine the current severity of his service-connected lumbar spine disability. The claims file should be made available to and reviewed by the examiner and all necessary tests should be performed. All findings should be reported in detail. The examiner should identify all lumbar spine pathology found to be present, to include any neurological manifestations during the period on appeal and the cause for such. The examiner should specifically address the Veteran's reports that he experiences numbness and pain in his legs and feet, as well as his spouse's reports that the Veteran's primary physician indicated that "part of [his neuropathy] could be from his back pressing on a nerve." The examiner should also note that the Veteran has been diagnosed with peripheral neuropathy. 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. Based on the Veteran's hearing testimony and the other evidence of record, the examiner 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). K. Conner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Ruddy, 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.