Citation Nr: 18139871 Decision Date: 10/01/18 Archive Date: 10/01/18 DOCKET NO. 16-18 782 DATE: October 1, 2018 REMANDED Entitlement to service connection for lower back disability is remanded. REASONS FOR REMAND The Appellant served on active duty for training in the United States Army from May 1970 to September 1970. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, OH, which denied service connection for a lower back disability because the records do not show evidence of complaints, treatment, or diagnosis of a back disability or injury while in-service. The Appellant testified at a Travel Hearing Board before the undersigned Veterans Law Judge (VJL) in April 2017. A transcript of the file is associated with the claims files. 1. Entitlement to service connection for lower back injury is remanded. The Veteran alleges that his lower back disability is a result of an in-service injury to his left hip in September 1970. The Appellant has not received a VA examination and opinion pertinent to his claimed lower back injury since the June 2012 claim was made. The Appellant has received periodic treatment from a private practitioner near his home but has not received an examination and opinion to ascertain the etiology of his claimed lower back disability. The service treatment records (STRs) contain evidence of an emergency orthopedic clinic visit in September 1970 following an in-service incident, a direct blow to the Appellant’s left hip. The record shows that the Veteran filed for Social Security Administration (SSA) benefits for his lower back disability. To date, VA has not made any inquiries with SSA to obtain the Veteran’s social security records. Post-service, the Appellant claims to have sought care from various chiropractors but was unable to provide records because the alleged providers are no longer in practice. The Appellant alleges that he has had back problems since the in-service injury to his hip. Testimony was also presented by the Appellant’s wife, who testified that the Appellant’s back pain has always existed, she recalled the Appellant experiencing back pain as far back as 1973. In light of the evidence and testimony on record, the Board finds that an examination regarding the claimed condition is warranted. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). The Board is obligated to request and obtain the Veteran’s social security records. 38 C.F.R. § 3.159(c)(2) (2017); see also Baker v. West, 11 Vet. App. 163, 139 (1998) (holding that VA’s duty to assist includes obtaining SSA records); Golz v. Shinseki, 590 F.3d 1317, 1323 (Fed. Cir. 2010) (clarifying that VA’s duty to obtain social security records applies only to records relevant to a Veteran’s present claim). In addition, attempts to obtain additional service records, including the Veteran’s service separation physical examination records, should be made. The matter is REMANDED for the following action: 1. Attempt to obtain any in service treatment records, to include any available treatment records of treatment at the Orthopedic Clinic where the Appellant was seen for his left hip injury in September 1970. 2. Obtain the Appellant’s Social Security records. If such records are not available, such unavailability should be documented in the record. The Appellant and his representative should be notified of unsuccessful efforts in order to allow them the opportunity to obtain and submit those records for VA review. 3. Schedule the Appellant for the appropriate VA examination to evaluate the nature and etiology of the Appellant’s lower back disability. The examiner should be provided a copy of the Appellant’s claims file and is requested to review it conjunction with this remand. Any appropriate evaluations, studies, and testing deemed necessary by the examiner should be conducted, and the results included in the examination report. Based on the examination results and review of the record, the examiner should provide an opinion as to the following: Whether it is at least likely as not (50 percent or greater likelihood) that the current lower back disability had its onset in-service or is otherwise related to service, to include the in-service incident that involved the Appellant’s direct blow to his left hip in September 1970. In formulating the opinions, the term “at least likely as not” does not mean “within the realm of possibility.” Rather, it means that the weight of the medical evidence both for and against the claim is so evenly divided that it is as medically sound to find in favor of the claim as it is to find against. Any opinions offered should be accompanied by the underlying reasons for the conclusions. If the examiner is unable to offer any of the requested opinions, a rationale should be provided for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. Attention is invited to the Appellant’s own lay statements and the statements from his spouse that discuss his lower back disability. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD E. Steele, Associate Counsel