Citation Nr: 18139882
Decision Date: 10/01/18	Archive Date: 10/01/18

DOCKET NO. 12-27 194A
DATE:	October 1, 2018
REMANDED
Entitlement to service connection for a lower back disability, to include as secondary to service-connected bilateral pes planus, is remanded.
REASONS FOR REMAND
The Veteran served on active duty from June 1984 to March 1988.    
This matter comes before the Board of Veterans’ Appeals (Board) from a May 2010 rating decision made by a Department of Veterans Affairs (VA) Regional Office.  This matter was previously remanded by the Board in June 2017 for a hearing.  The Veteran testified at a hearing with the undersigned in March 2018.  A transcript of that hearing has been added to the Veteran’s file.   
This issue was previously finally denied after the Veteran failed to perfect an appeal of a December 2004 rating decision.  However, since that time relevant service department records which existed at the time of the December 2004 rating decision but were not in his VA file have been associated with the file.  As such, the claim will be reconsidered without the need for new and material evidence.  38 C.F.R. § 3.156(c).  
In this case an additional medical opinion is necessary to address whether the claimed lower back disability is secondary to the Veteran’s service-connected bilateral pes planus and to ensure that the lay evidence of record is fully considered.  
Updated treatment records should be obtained as necessary on remand.  
The matter is REMANDED for the following action:
1. Ask the Veteran to identify all outstanding treatment records relevant to his lower back disability claim.  All identified VA records should be added to the claims file.  All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran.  If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records.
2. After records development is completed, the claims file should be sent to an appropriate examiner to offer an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the current lower back disability:
(a)	is related to an in-service injury, event, or disease, to include the May 1996 assessment of rule out muscle strain after complaints of mid back pain and the in-service assessment of lumbosacral strain; or
(b)	is (i) caused or (ii) aggravated (worsened beyond natural progression) by the service-connected bilateral pes planus.  
The examiner should consider the Veteran’s testimony that he has had back pain since his time on active duty.  
The need for an examination is left to the discretion of the examiner.  A rationale for all opinions offered is requested as the Board is precluded from making any medical findings.

 
Nathan Kroes
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	Megan Shuster, Law Clerk