BVA9503827 DOCKET NO. 93-11 000 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in Boston, Massachusetts THE ISSUE Entitlement to an increased rating for chronic myalgia of Muscle Group XX, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The veteran ATTORNEY FOR THE BOARD J. L. Prichard, Associate Counsel INTRODUCTION The veteran had active service from February 1968 to February 1972. The veteran and his representative have raised two additional issues during the course of this appeal. The veteran has raised the issue of entitlement to service connection for drug addiction secondary to his service-connected back disability in written statements and at the October 1991 personal hearing. In addition, the veteran and his representative have raised the issue of entitlement to a total rating based on unemployability due to service connected disorders. These issues have not been developed for appeal, and are referred to the regional office (RO) for appropriate action. REMAND The veteran contends that his back disability has increased in severity to such a degree as to warrant a higher evaluation. He states that he has increased pain and that pain medication is no longer effective. He notes that he sleeps on plywood and that his back has a greatly reduced range of motion. Movement and bending is productive of pain which makes it difficult to work. The veteran believes that this symptomatology merits an increased rating. A review of the evidence reflects that a 10 percent evaluation has been assigned for the veteran's back disability since February 1972. By rating action of February 1992, the RO confirmed the 10 percent rating assigned. The veteran filed an appeal from this action. In conjunction with his appeal, the veteran testified at a hearing on appeal in October 1991. He also underwent examination by the VA in November 1991. On the basis of the findings on that examination and the veteran's testimony, the evaluation assigned for his back disability was increased to 20 percent, effective from December 26, 1990. The veteran continues to disagree with the rating assigned. The record indicates that the service connection for chronic myalgia of Muscle Group XX was first granted in a May 1973 rating decision. This decision was based on service medical records and post service treatment records which noted that the veteran was seen on several occasions for left scapular pain. X-ray studies obtained at a December 1972 Department of Veterans Affairs (VA) examination were negative for any significant bone or joint change of the dorsal or lumbar spine. The veteran was afforded a VA examination in January 1977. There was some pain and limitation of motion of the lateral flexion of the lumbar spine. An X-ray study conducted at this time was negative for any abnormality. A VA X-ray study conducted in January 1987 was also negative. The veteran was afforded a VA examination in September 1988. There was no spasm or tenderness of the cervical, thoracic, or lumbosacral spine. All motions were full. It was noted that there was excellent muscular development with no atrophy. The diagnosis was myalgia of Muscle Group XX, the thoracic and cervical region. The evidence includes VA treatment records from July 1988 to January 1991. However, while back pain is occasionally noted, these records are primarily concerned with treatment of the veteran's addiction. The veteran was afforded a personal hearing before a hearing officer in October 1991. The veteran indicated that his business had closed, and that he found it hard to work due to his back disorder. He had constant pain, and he was unable to take strong painkillers. Transcript at page 2. (T. at 2). His back hurt in the middle, and the pain extended downwards when he bent over. T. at 2. He was unable to pick up his child. T. at 3. The veteran slept with plywood in his bed, and his back was very painful in the morning. T. at 4. The veteran testified that his disability was worse as a result of increased pain and decreased range of motion. T. at 6. The pain involved the middle of the back down the low back. T. at 7. The veteran was afforded a VA examination in November 1991. At that time, he had recurrent low back pain, which was worse with a cough or sneeze. There was no radiculopathy. The back had tenderness of the mid dorsal area. Flexion was limited to 30 degrees. Extension and lateral bending were both 0 degrees. There was no sensory or motor deficit. The diagnosis was chronic mid dorsal back pain. The evidence in the file raises a question with regard to the etiology and nature of the veteran's low back pain. In order to fairly evaluate the level of disability, the Board is of the opinion that the case should be REMANDED for further evaluation. 1. The RO should contact the veteran to determine where he has been treated for his back disability since 1991. The RO should obtain any records identified, including the veteran's records of treatment for his back disability at the VA Outpatient Clinic, Boston. 2. Thereafter, the veteran should be afforded a VA orthopedic examination to determine the current degree of severity of his mid back disability. The examiner should identify the etiology of the veteran's limitation of motion. Any muscle impairment should be specifically detailed. All indicated tests and studies should be accomplished. The veteran's claims folder, including any records obtained pursuant to the above-requested development, should be made available to the examiner for study in this case. When this development has been completed, the claim should be reviewed by the RO. If any benefit sought on appeal is not granted, the appellant and his representative should be given a supplemental statement of the case with regard to the additional development and should also be afforded an opportunity to respond. The record should be returned to the Board for further appellate consideration, if in order. No action by the appellant or his representative is required until further notice is received. V. L. JORDAN Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).