Citation Nr: 18139843 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 16-06 947 DATE: October 1, 2018 REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a left foot disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1981 to April 1985. The Board remands the issue of entitlement to service connection for a back disorder in order to secure an addendum opinion which accurately addresses the nature and etiology of any currently diagnosed back disability. In this regard, while the appellant attended a VA examination in October 2012, the examining nurse practitioner did not address evidence of a low back disorder that are clearly indicated in service personnel and treatment records, as well as at the claimant’s April 1985 separation examination. The Veteran’s service treatment records specifically note frequent complaints and treatment relating to low back pain. In an April 1982 medical history report the claimant reported a history of recurrent back pain. The appellant’s service personnel records include a June 1983 personnel rating noting numerous problems with his back. In November 1983, the Veteran referenced a persistent back ailment. In a March 1985 service medical record a treating physician indicated that the Veteran had persistent lower back pain that was unresponsive to conservative care. Finally, at his April 1985 separation examination it was noted that the Veteran had had recurrent back pains since 1982 due to a partial pinched nerve of S-1 and that he had been treated with back braces, Dorval, and physical therapy. The previous examiner mentioned an April 1985 low back injury, but failed to fully consider and discuss the other instances of back pain and extensive medical reports related to it. The examiner also did not consider the Veterans statements, which he is competent to make, that his back has consistently bothered him since service. This issue is therefore remanded in order to obtain an addendum opinion addressing the relationship of the Veteran’s low back disability and multiple complaints of back pain in service. With respect to his claim of entitlement to service connection for a left foot disorder the Veteran has contended that additional medical records may be available. Upon review of the record, it appears that some of the Veteran’s service treatment records may indeed be missing. Although the Veteran reported having been seen for a foot injury, service treatment records do not contain any records showing treatment for a foot injury in 1982. On remand, additional efforts should be made to obtain any outstanding service treatment records. Pending the results of the search for these additional records, the Veteran’s claim of entitlement to service connection for a left foot injury should be remanded. The matters are REMANDED for the following action: 1. The AOJ should undertake appropriate development to obtain any outstanding service treatment records, to include any records regarding an inservice foot injury. All records requests and responses received should be documented in the evidentiary record, and efforts to obtain these records must continue until a negative response is received or it is determined that additional development efforts would be futile. If additional service treatment records regarding the Veteran’s foot injury cannot be located, document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. Then: (a) notify the Veteran and his representative of the specific records that are unable to be obtained; (b) explain the efforts made to obtain such records; and (c) describe any further action that will be taken with respect to the claim. The Veteran must then be given an opportunity to respond. 2. Provide the Veteran with another opportunity to submit a completed release form (VA Form 21-4142) authorizing VA to request any additional, relevant private treatment records. The Veteran should be advised that he can also submit those records himself. If the Veteran provides a completed release form, then request the identified treatment records. All attempts to secure those records must be documented in the Veteran’s claims file, and the Veteran and his representative should be notified of any unsuccessful efforts. 3. Request all relevant VA treatment records. All records obtained should be associated with the claims file. If the AOJ cannot locate any Federal records requested herein, it must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AOJ must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. The claimant must then be given an opportunity to respond. 4. Thereafter request an addendum opinion from an orthopedist. If a new examination is necessary to answer the Board’s questions, one should be scheduled. The orthopedist must be provided access to all files in Virtual VA and VBMS, and the examiner must specify in the examination report that all files have been reviewed. The orthopedist is asked to address the multiple instances of back pain treatment reported in the service records, along with the Veteran’s statements regarding continuity of back troubles since service. The orthopedist should then address the following question: Is it at least as likely as not that any current lumbar disorder had its onset during, or was otherwise related to any event or injury in the Veteran’s service? The orthopedist must discuss the Veteran’s recurring treatment from 1982 to 1985 for back pain. This specifically includes the notations on his April 1985 separation examination, the numerous complaints during the prior three years, and the Veteran’s reports of consistent back pain since service. A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge, i.e., no one could respond given medical science and the known facts, or by a deficiency in the record or the examiner, i.e., additional facts are required,   or the examiner does not have the needed knowledge or training. DEREK R. BROWN Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Joseph Montanye, Associate Counsel