Citation Nr: 22019068
Decision Date: 03/31/22	Archive Date: 03/31/22

DOCKET NO. 18-38 384A
DATE: March 31, 2022

REMANDED

An initial disability rating higher than 10 percent for the service-connected lumbar spine degenerative disc disease, arthritis, and disc herniation is remanded.

An initial disability rating higher than 10 percent for the service-connected right hamstring tendinosis with hip strain is remanded.

REASONS FOR REMAND

In a June 2014 rating decision, the Agency of Original Jurisdiction (AOJ) granted service connection for lumbar spine degenerative disc disease, arthritis, and disc herniation and assigned a 10 percent rating, and for right hamstring tendinosis and assigned a 0 percent rating, both effective September 1, 2013. In a June 2018 rating decision, the AOJ increased the disability rating for the service-connected right hamstring tendinosis with hip strain to 10 percent, effective from the date of service connection. In November 2021, the Veteran testified at a Board of Veterans' Appeals (Board) hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the claims file.

The Veteran was last examined by VA for his lumbar spine and right hamstringdisabilities in February 2017. A review of those examination reports shows that the examiner was unable to describe the Veteran's functional ability in terms of range of motion with repeated use over a period of time or with flare-ups. While the examiner noted that increased low back pain is likely with prolonged walking, sitting, leaning forward, bending, twisting, or heavy lifting, the examiner stated that limitation of range of motion during such times cannot be estimated. Similarly, the examiner stated that increased hip pain would be expected with long strides or climbing activities but that functional loss cannot be described in terms of range of motion. While the Board appreciates the examiner's comments on the inability to provide range of motion estimates, the Board finds that the examiner did not provide a rationale for that inability.

At the November 2021 hearing, the Veteran indicated that both of his disabilities have worsened since the above examinations. Specifically, he testified that he used to hike a lot five or six years ago, but that such activities are too difficult for him now. He also indicated that he has noticed increased pain in his back and right leg over the past three to five years.

Given the deficiencies in the last VA examinations as well as the Veteran's testimony of worsening symptoms since those examinations, the Board finds that the AOJ should provide him with new examination to determine the current severity of his lumbar spine and right hamstring disabilities. 

Lastly, as additional medical records have been added to the claims file since the claims were last adjudicated in the June 2018 statement of the case, the AOJ should consider that evidence in readjudicating the claims.

Accordingly, these matters are REMANDED for the following action:

1. Provide the Veteran with appropriate examinations to determine the severity of his lumbar spine and right hamstring disabilities. The entire claims file must be made available to, and be reviewed by, the examiner(s) in conjunction with the examinations. Any indicated tests and studies must be accomplished, and all clinical findings must be reported in detail and correlated to a specific diagnosis. An explanation for all opinions expressed must be provided. The relevant Disability Benefits Questionnaire must be utilized.

2. Then, readjudicate this appeal with consideration of the entire record, including all the additional evidence added to the record since the June 2018 statement of the case. 

 

 

THERESA M. CATINO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	J. W. Kim, 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.