Citation Nr: 18140976 Decision Date: 10/09/18 Archive Date: 10/09/18 DOCKET NO. 11-14 252 DATE: October 9, 2018 REMANDED The issue of entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the Army National Guard from May to September 2002, and in the Army from January 2003 to July 2008. This case is before the Board of Veterans’ Appeals (Board) on appeal from a March 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The Veteran is seeking service connection for a low back disability, initially claimed as “severe back pain,” to include as secondary to her service connected left knee, left shoulder, and bilateral foot disabilities. In a July 2017 decision, the Board denied service connection for the Veteran’s low back disability (characterized as bilateral lumbar paraspinal muscle strain). The Veteran appealed the decision to the United States Court of Appeals for Veterans’ Claims (the Court), which in June 2018 issued an order granting a joint motion for remand (JMR) filed by both parties. The JMR stated that the Board failed to fulfill its duty to assist since its July 2017 decision denying service connection relied on two inadequate VA medical examinations and opinions, afforded the Veteran in January 2010 and July 2014. Specifically, the JMR stated that the examinations and opinions were inadequate inasmuch as neither included an opinion as to whether the Veteran’s service-connected left knee or bilateral foot disabilities aggravated her low back disability. VA examinations for claims of secondary service connection must discuss not only whether the claimed condition was caused by the directly service-connected condition, but also whether the claimed condition was aggravated by the directly service-connected condition. El-Amin v. Shinseki, 23 Vet. App. 136, 140 (2013). The JMR concluded that because neither VA medical opinion of record discussed whether the Veteran’s claimed low back disability was aggravated by her service-connected disabilities, the claim must be remanded for a new VA examination and opinion. During the pendency of the Veteran’s appeal to the Court, a new VA examination and opinion was requested, to include opinions as to whether the Veteran’s low back disability was secondary to her service-connected left knee, left shoulder, or bilateral foot disabilities. An examination and opinion were afforded the Veteran in July 2018, shortly after the Court’s decision had been promulgated. However, the opinion does not include a discussion of whether the Veteran’s claimed low back disability was aggravated by her service-connected disabilities, and thus a remand is necessary to afford the Veteran a new VA examination and opinion to include such a discussion, in accord with the Court’s order. The matter is REMANDED for the following action: 1. Obtain any outstanding VA treatment records and associate them with the claims file. 2. Schedule the Veteran for a VA examination regarding her claim for service connection for a low back disability, to include as secondary to her service-connected left knee, left shoulder, and bilateral foot disabilities. Upon complete review of the claims file and physical examination of the Veteran, the examiner should respond to the following: (a.) Is it at least as likely as not (50 percent probability or more) that the Veteran’s low back disability (to include any presently diagnosed disability as well as any diagnosed before and during the pendency of the Veteran’s claim) was either: 1) caused by, or 2) aggravated by her service-connected left knee, left shoulder, or bilateral foot disabilities. Aggravation here means permanent worsening beyond the normal progression of the low back disability. (b.) If you find that a low back disability has been permanently worsened beyond its normal progression by one or more of the Veteran’s service-connected disabilities, please attempt to quantify the degree of aggravation beyond the baseline level of the back disability that is attributable to the service connected disability or disabilities. (c.) Is it at least as likely as not that the Veteran’s low back disability had its onset in or is otherwise related to her active duty service? The examiner must provide a fully articulated medical rational for each opinion, citing to peer-reviewed medical literature referenced in formulating it, if any. If the examiner finds that an opinion cannot be provided, this conclusion should also be clearly explained (e.g. lack of sufficient information/evidence in this case, or a lack of knowledge among the medical community at large, and not the insufficient knowledge of the individual examiner). S. C. KREMBS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. Timmerman, Associate Counsel