Citation Nr: 1326238 Decision Date: 08/19/13 Archive Date: 08/26/13 DOCKET NO. 10-18 487 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a back disability. 2. Entitlement to service connection joint condition, to include a leg, knee, ankle or foot condition. REPRESENTATION Appellant represented by: James G. Fausone, Attorney ATTORNEY FOR THE BOARD Marne Marotta, Associate Counsel INTRODUCTION The Veteran served on active duty from November 1983 to October 1987. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina. The RO in Atlanta, Georgia now has jurisdiction over this matter. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the Veteran if further action is required on his part. REMAND The Veteran contends that his current back and joint disabilities resulted from his active duty service, specifically from injuries and the general physical demands of his military occupation specialty. The Veteran's service treatment records (STRs) indicate that the Veteran was diagnosed with mild lumbar strain in June 1986. In August 1984, the Veteran was treated for right foot pain following a road march. The Veteran's STRs also document complaints of a sore knee in May 1984. At discharge, the Veteran indicated that he suffered from swollen or painful joints; cramps in his legs; a bone, joint or other deformity; recurrent back pain; and foot trouble. In a September 2010 letter, the Veteran's private physician (Dr. J.H.) stated that he had treated the Veteran for osteoarthrosis of the lumbar spine, intervertebral disc degeneration, and backache, unspecified. Treatment records from Dr. J. H. also indicate that the Veteran was treated from leg and joint pain on several occasions. Dr. J.H. indicated that he has treated the Veteran since 2000, but that the Veteran's "symptoms predate that by history." Dr. J.H. noted that "degenerative arthritis seen on XRAYS LS spine seen 2005 or before," but these treatment records are not in the record. They should be obtained on remand. 38 C.F.R. § 3.159(c)(3) (2012). An October 2009 VA-contracted examination included an X-ray of the Veteran's lumbar spine that found multilevel anterior osteophytosis and mild bilateral sacroiliac joint degenerative change. The examiner opined that "it is less than likely (less than 50%) that current diagnoses of lumbar strain; mild multi-level degenerative disc disease from QTC evaluation dated 10-12-2009, is related to mild low back strain (Military MER dated 6-30-1986 indicating same)." The examiner did not address the finding of multilevel anterior osteophytosis. The examiner's opinion also indicated that there were no "complaints or treatment for low back problems for 19 years, and medical history indicates low back complaints have been gradual for 6 months." The basis of the examiner's opinion is inadequate because there does not appear to have been any consideration of the Veteran's lay statements regarding his continuous symptoms since service. Thus, another examination is required. Barr v. Nicholson, 21 Vet. App. 303 (2007); 38 C.F.R. § 3.159(c)(4). The Veteran has not been provided a VA examination in connection with his joint condition claim. The Veteran indicated that he suffered multiple injuries to his legs, knees, ankles and feet during service. His STRs indicate that he was treated for foot, knee, and leg pain and a bunion. On his Report of Medical History completed at discharge, the Veteran answered "yes" to whether he ever had or has "now" swollen or painful joints; cramps in his legs; a bone, joint or other deformity; recurrent back pain; and foot trouble. The STRs do not include the reverse of that Report of Medical History and there is no report of a medical examination conducted at separation. Post-service treatment records indicate continued treatment for joint pain. On his April 2008 claim form, the Veteran also indicated that he treated his swollen and painful joint condition with over-the-counter medication. Given his complaints in service and his assertions of continued symptoms since service, the Veteran should be afforded a VA examination to determine the nature and etiology of any condition manifested by swollen and painful joints, specifically in the legs, knees, ankles and feet. 38 C.F.R. § 3.159(c) (4); McLendon v. Nicholson, 20 Vet. App. 7 (2006). Accordingly, the case is REMANDED for the following action: 1. Obtain the names and addresses of all medical care providers who treated the Veteran for back or joint complaints since service. After securing the necessary release, the RO should obtain these records, including any outstanding VA. 2. After completion of the foregoing, schedule the Veteran for an appropriate VA examination to determine the current nature and likely etiology of any back or joint condition. The claims folder should be made available to the examiner for review. Based on the examination and review of the record, the examiner should respond to the following: (a) Can the Veteran's complaints of back pain be attributed to a known clinical diagnosis? If so, please provide the diagnosis. (b) The examiner should then indicate whether it is at least as likely as not (a 50 percent probability or greater) that the diagnosed disorder is related to the Veteran's active military service. The examiner is specifically informed of the Veteran's ongoing complaints of back pain since service and the unavailability of private treatment records from the 1990s that have been destroyed. The examiner should also address the October 2009 X-ray finding of multilevel anterior osteophytosis. (c) Can the Veteran's complaints of joint pain and swelling in the feet, ankles, knees, and legs be attributed to a known clinical diagnosis? If so, please provide the diagnosis. (d) The examiner should then indicate whether it is at least as likely as not (a 50 percent probability or greater) that any currently diagnosed joint disorder is related to the Veteran's active military service. The medical basis for all conclusions reached should be provided. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. 3. Then, readjudicate the claim on appeal. If the benefit sought on appeal is not fully granted, issue a supplemental statement of the case before returning to the Board, if otherwise in order. The appellant has the right to submit additional evidence and argument on the 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). ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs