Citation Nr: 18140854 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 16-08 249 DATE: REMANDED Entitlement to service connection for a lower back condition is remanded. REASONS FOR REMAND The Veteran served on active duty from August 2000 to August 2004, and was a reservist from August 2004 to August 2008. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision issues by a Department of Veterans Affairs (VA) Regional Office (RO). The file shows there are relevant private treatment records that have not been obtained. The Veteran should fill out the authorization forms for VA to get his records from Dr. Martin and Dr. Kaur. Since it is necessary to remand for private records, the Board also notes the RO referenced VA outpatient records in the statement of the case that are not in the claims file (“West LA, from 03/27/2015 to 04/01/2015”). This should also be rectified on remand. The Veteran contends his low back disability is etiologically related to his active duty service. In the notice of disagreement filed in April 2015, the Veteran claims that his duties as an aviation ordinanceman while on active duty with the U.S. Navy are what caused his back strain, and he discussed his service duties involving heavy lifting. The Veteran further contends in a letter sent July 2015 that his jobs after service did not consist of repetitive or heavy lifting or required physical labor, as they consisted of being a gas station cashier, retail sales manager, car wash assistant manager, yard man, and Costco meat manager. Although service treatment records do not specifically show complaints of low back pain, the Veteran did report shoulder pain/ interscapula pain from physical activity (May 15, 2002 ) and musculoskelatal pain – trapezius pain (August 15, 2002) after moving heavy equipment. The Veteran has stated his current VA doctor in San Luis Obispo believes his work in the U.S. Navy caused the herniated discs and sciatica. There is currently no such opinion in the record. The Veteran is advised he should ask his doctor to write a statement on his behalf. The Veteran also stated that he was told by Dr. Kaur that his sciatica is caused by repetitive lifting of heavy things over time. Although the Board is requesting that his records be obtained from Dr. Kaur, he should also ask this doctor to write a statement on his behalf. At the VA examination in March 2015, the examiner opined that while there is a current diagnosis of lumbosacral strain, it is not likely related to or aggravated by a service event. However, the examiner’s entire rationale rests on no complaints of back pain during service. There is no legal requirement that a claimed condition be demonstrated during service. The Veteran’s statements as to his military duties involving heavy lifting are consistent with the circumstances of his service, and he can be service-connected for a disease that is diagnosed AFTER service if it is likely related to those duties. An addendum opinion is needed that considers the Veteran’s lay statements. The matter is REMANDED for the following actions: 1. Ask the Veteran to complete releases authorizing VA to obtain his records from any private provider who has treated him for his back condition, to include Dr. Martin and Dr. Kaur. If any requested records are not obtained, inform the Veteran. 2. Obtain the Veteran’s COMPLETE VA treatment records from West LA, including the clinic at San Luis Obispo. 3. DO NOT PROCEED WITH THE FOLLOWING INSTRUCTION UNTIL THE ABOVE RECORDS ARE OBTAINED TO THE EXTENT POSSIBLE. 4. Then, obtain an addendum opinion. The examiner should opine whether it is as likely as not the Veteran’s current back condition is related to service. The examiner should take into consideration the Veteran’s complaints of musculoskeletal pain during service, his work during service as an aviation ordinanceman, and his jobs since service. If and only if an examiner determines that a physical examination of the Veteran is required, then please schedule a VA examination. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD G. Hoy, Law Clerk