Citation Nr: 22017748 Decision Date: 03/26/22 Archive Date: 03/26/22 DOCKET NO. 17-41 755 DATE: March 26, 2022 REMANDED Entitlement to an increased rating in excess of 10 percent disabling for lumbosacral strain is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from October 2001 to October 2005. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in September 2021. Unfortunately, the Board finds that the most recent VA examination is not adequate to decide the claim at this time, and the issue is remanded. The Veteran was afforded an updated VA examination in November 2021 for his lumbar spine disability. The examiner noted that the Veteran's report of progressively worsening since the Veteran's last December 2015 examination. The examiner noted the Veteran stating he has pain to the low back, especially with bending over; bending over causes a loud "clicking," with swelling noted around the abdomen. The Veteran also had weakness and tingling in the left leg that is not related to activity. The examiner conducted range of motion (ROM) testing and found forward flexion limited to 75 degrees, extension limited to 20 degrees, and right and left lateral flexion and right and left lateral rotation each limited to 25 degrees. The examiner found no evidence of ankylosis. Pain was noted on all active ROMs, but without further functional loss. Passive ROM testing was not conducted because it was medically contraindicated. Repetitive use ROM did not result in additional loss of function. The Veteran was not observed immediately after repeated use over time and the examination was not conducted during a flare up. The examiner noted that the procured evidence did not suggest pain, fatigability, weakness, lack of endurance, or incoordination significantly limited functional ability with repeated use over time. The examiner also noted that the Veteran denied flare-ups. The examiner noted objective evidence of localized moderate tenderness, but no guarding or muscle spasms. The examiner noted no radicular pain or any other signs or symptoms due to radiculopathy, and no other neurologic abnormalities. The examiner stated there was no objective evidence to support a diagnosis as related to the reported symptoms to the left leg and therefore found no diagnosis related to radiating symptoms are noted on day of examination. The examiner stated that a February 2013 lumbar spine X-ray revealed minimal degenerative changes of the T11-12 anteriorly which was separate from the lumbar strain and was not related to any activity related to military service. The Board notes that this case was remanded in September 2021 based partly on September 2020 private treatment records indicating that the Veteran had symptoms of low back pain with left sciatica. The Veteran's private records show that he has been found to have muscle spasms, and the Veteran has reported having numbness and tingling to the left leg. These findings appear inconsistent with the November 2021 findings of no radicular symptomatology or muscle spasms. The Board also notes that the examiner recorded the Veteran's description of intermittent increases in symptoms that appear consistent with descriptions of flare-ups, yet the examiner stated that the Veteran did not have any flare ups. It is unclear whether this is a misunderstanding on the part of the Veteran on what a "flare-up" is, on part of the examiner in his documentation, a failure by the examiner to address the Veteran's lay statements, or failure to fully review the evidence of record. As such, clarification between the apparently inconsistent findings in the record. The matters are REMANDED for the following action: 1. Obtain all VA treatment records since March 2021. 2. Schedule the Veteran for an examination to evaluate the nature and severity of his lumbar strain disability and any associated neurological symptoms. If feasible, the examination can be held via telehealth. The examiner must review the claims file, and then address the following: a) Evaluate the current severity of the Veteran's service-connected lumbar strain. If the Veteran is found to have symptoms associated with his thoracolumbar spine that are not related to his service-connected condition, the examiner must fully explain whether it is possible to differentiate these symptoms and how. b) Address the Veteran's description of flare-ups (periods of increased pain and disability), including making determinations of additional range of motion loss with repeated motion or during a flare up. The Board notes that the Veteran has reported having periods of increased symptoms, even if he has not used the phrase "flare up." The Board advises that it is inadequate for the examiner to state that he or she is unable to offer such an opinion because the examination was not performed during a flare up. Rather, the examiner must attempt to estimate the functional loss based on statements provided by the Veteran and available medical records. c) What are the Veteran's current neurological symptoms associated with his lumbar strain? Please specifically discuss evaluate the current severity of the Veteran's reported left leg radiculopathy, including consideration of the September 2020 private treatment records identifying symptoms consistent with left sciatica and left piriformis. If the Veteran's left leg symptoms are found to be due to a cause entirely separate from his service-connected lumbar strain, the examiner must fully explain what that is and how this is known. A complete, well-reasoned rationale must be provided for all conclusions and opinions. If the requested opinions cannot be rendered without resorting to speculation, the examiner must explain why. Mary E. Rude Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Boushehri, Darjush M. 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.