Citation Nr: 1242613 Decision Date: 12/13/12 Archive Date: 12/20/12 DOCKET NO. 10-35 790 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUE Entitlement to service connection for a muscle disability of the sides and back. ATTORNEY FOR THE BOARD C. Lawson, Counsel INTRODUCTION The Veteran served on active duty from August 2006 to February 2007 and from May 2007 to November 2007. This matter comes to the Board of Veterans' Appeals (Board) on appeal from March 2009 and January 2010 rating decisions by a Regional Office (RO) of the Department of Veterans Affairs (VA). A notice of disagreement was received in February 2010, a statement of the case was issued in August 2010, and a substantive appeal was received in August 2010. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran seeks service connection for a disability which he has characterized as muscle disability of the sides and back, which he claims began in service. A September 2006 service treatment record notes the he complained of back pain when running and with pushups. The assessment was backache: general muscle pain; soldier's indications of pain were not consistent with injury and all reactions were overstated. In June 2007, the Veteran was seen for a headache and chest tightness. A chest X-ray was normal. The impressions were chest pain and viral syndrome. Post-service treatment records from C.R. Dowling, M.D. show that in April 2008, the Veteran complained of aching and pain, stiffness, and soreness in the muscles in the left side and along the chest. Examination revealed tenderness in the chest wall muscles. The assessment was musculoskeletal pain. On evaluation by Dr. Dowling in September 2008, the Veteran complained of pain in his left ribcage area and stated that it had been hurting for some time. The assessment was chest pain. On subsequent evaluation by Dr. Dowling in November 2008, the Veteran reported that Mobic and Robaxin had been helping his side. The assessment was musculoskeletal pain. VA medical records dated in May, August, and October 2009 mention arthritis without directly specifying which joints were involved and without indicating that there was X-ray evidence of arthritis. In May 2009, the Veteran reported diffuse joint aches from working and lifting. He also reported muscle pain. His muscle bulk was normal and his strength was 5/5 then and in August and October 2009. In August 2009, it was reported that he had arthritis and was on Naproxen for back pain. No VA examination has been conducted, and one is required under 38 C.F.R. § 3.159 (2012) under the circumstances of this case, as the evidence contains competent evidence of current disability, establishes that the Veteran had chest tightness and back pain in service, and indicates, through post-service treatment, that the claimed disability or symptoms may be related to service. Moreover, in January 2009, the Veteran authorized VA to obtain records of treatment he received from a Dr. Robert Mitchell at the Haywood Park Hospital in 2008. Also, in November 2009, he reported that he had had treatment in July 2009 from Clarey Dowling, M.D. for side pains. It does not appear that there have been any attempts to obtain such records. Those records and any other available relevant VA or private medical records of treatment the Veteran has received should be obtained and incorporated into the Veteran's claims folder or into Virtual VA as appropriate. Accordingly, the case is REMANDED for the following action: 1. The RO should take appropriate action to request all relevant medical records of treatment the Veteran has received from Dr. Robert Mitchell since 2008, and from Dr. Clarey Dowling. since July 2009, as well as any other available relevant VA or private medical records of treatment the Veteran has received. 2. After completion of the above, the Veteran should be scheduled for a VA examination with regard to the disability which has been characterized as muscle disability of the sides and back. It is imperative that the claims file be made available to the examiner for review. Any current disability of the muscles of the back and/or sides should be clearly reported. After reviewing the claims file and after examining the Veteran, the examiner should offer opinions as to whether it is at least as likely as not (a 50% or higher degree of probability) that the Veteran currently has a muscular, arthritic or other disease or injury of his sides and/or back that is related to service. Reasons should be provided for the opinions furnished. 3. Thereafter, readjudicate the Veteran's pending claim in light of any additional evidence added to the record. If the benefits sought on appeal remain denied, the Veteran should be furnished a supplemental statement of the case and given the opportunity to respond thereto. The case should then be returned to the Board. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2012). _________________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2012).