Citation Nr: 18143199 Decision Date: 10/18/18 Archive Date: 10/18/18 DOCKET NO. 17-42 919 DATE: October 18, 2018 ORDER Service connection for low back disability (variously diagnosed, to include as discogenic disease and myositis) is granted as secondary to pes cavus and left ankle achilles tendonitis. REMANDED Entitlement to service connection for an acquired psychiatric disorder, claimed as major depressive disorder, is remanded. FINDINGS OF FACT 1. The Veteran is service connected for bilateral pes cavus and left ankle achilles tendinitis. 2. The Veteran has a current low back disability; it is at least as likely as not that the disability is secondary to his service-connected pes cavus and left ankle achilles tendonitis. CONCLUSION OF LAW The criteria for secondary service connection for low back disability have been met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran served on active duty in the U.S. Army from February to April 1974. This matter comes to the Board of Veterans Appeals (Board) on appeal from a March 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for low back disability. The Veteran seeks to establish service connection for low back disability. His evidentiary submissions raise the issue of secondary service connection. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). In this case, the record contains opinions on this matter from a private physician, the most recent of which is dated in September 2017. After examining the Veteran and reviewing his medical history, the physician opined, in effect, that service-connected left ankle/foot insults led to disability of the Veteran’s low back (identified as discogenic disease and myositis). The examiner explained that the low back disability was a result of limping and a weight bearing shift to the contralateral side following left knee sprain that developed due to the left ankle/foot insults. The physician’s opinion is probative and uncontradicted by other medical opinion evidence of record. As such, the Board finds that the criteria for an award of service connection for low back disability have been met. The evidence, at a minimum, gives rise to a reasonable doubt on the matter. 38 C.F.R. § 3.102. REASONS FOR REMAND Service connection for an acquired psychiatric disorder, claimed as major depressive disorder, is remanded. The Veteran has been diagnosed with major depressive disorder. During a September 2016 examination, he reported that he got depressed due to functional limitations associated with his decline in health. Thus far, no medical opinion has been obtained as to whether his depression is secondary to his service-connected disabilities. Additional development is required. This matter is REMANDED for the following action: 1. Ask the Veteran to provide releases for updated records of treatment from any private care providers who may possess new or additional evidence pertinent to the issue remaining on appeal. If he provides the necessary release(s), assist him in obtaining the records identified, following the procedures set forth in 38 C.F.R. § 3.159. Any new or additional (i.e., non-duplicative) evidence received should be associated with the record. If any of the records sought are not available, the record should be annotated to reflect that fact, and the Veteran and his representative should be notified. 2. Obtain copies of records pertaining to any relevant VA treatment the Veteran has received since the time that such records were last procured, following the procedures set forth in 38 C.F.R. § 3.159. The evidence obtained should be associated with the record. 3. After the foregoing development has been completed to the extent possible, arrange to have the Veteran scheduled for a VA mental disorders examination. The examiner should review the record. All indicated tests should be conducted and the results reported. After examining the Veteran and reviewing the record, together with the results of any testing deemed necessary, the examiner should identify any mental disorders that are present. Then, with respect to each such disorder, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., whether it is 50 percent or more probable) that the disability had its onset in, or is otherwise attributable to, the Veteran’s period of active service. If it is the examiner’s opinion that it is unlikely that an identified mental disorder had its onset in, or is otherwise attributable to, service, the examiner should offer a further opinion as to whether it is at least as likely as not that such disability has been (a) caused or (b) aggravated by the Veteran’s service-connected disabilities. In so doing, the examiner should specifically address the Veteran’s assertion that he has developed depression as a result of functional limitations associated with his decline in health. A complete medical rationale for all opinions expressed must be provided. 4. After completing the above, and any other development as may be indicated by any response received as a result of the actions taken in the preceding paragraphs, the claim remaining on appeal should be readjudicated based on the entirety of the evidence. If the benefit sought remains denied, the Veteran and his representative should be issued a supplemental statement of the case. An appropriate period of time should be allowed for response. DAVID A. BRENNINGMEYER Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K. Boyea, Law Clerk