Citation Nr: 18145791 Decision Date: 10/30/18 Archive Date: 10/30/18 DOCKET NO. 16-05 640 DATE: October 30, 2018 REMANDED Entitlement for service connection for a low back condition is remanded. Entitlement for service connection for right leg numbness associated with lower back condition is remanded. REASON FOR REMAND The Veteran served on active duty less than 90 days, from May 10, 2011 to July 21, 2011. He was discharged with an Entry Level Separation. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a June 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge at an August 2016 videoconference hearing. A transcript of the hearing has been associated with the file. Entitlement for service connection for a low back condition and right leg numbness as secondary to a low back condition are remanded. The Veteran asserts that he is entitled to service connection for a low back condition and right leg numbness as secondary to his low back condition. The Veteran claims he injured his back when he started basic training while carrying his equipment above his head while running. A May 2011 service treatment record (STR) shows he was diagnosed with back sprain and lumbar radiculopathy. During the separation examination on July 6, 2011, the clinician commented the back sprain and low back pain were non-significant findings and there was no functional limitations or effect on function. After discharge, records show the Veteran was not seen for his back pain until 2015 at a private medical clinic. The Veteran testified that he went to two doctors working in one group practice and was seen a year after discharge, however, the earliest record on file is dated January 2015. On the most recent private medical treatment records, dated August 2016, a family nurse practitioner noted no vertebral tenderness and that the Veteran has no difficulty walking, but did note a decrease L4-5 to pinprick in the right leg. The Veteran was diagnosed with low back pain and lumbar radiculopathy, which the nurse appeared to relate to a 2011 injury, although she did not state whether the Veteran’s pertinent STRs were reviewed. VA’s duty to assist veterans, includes the duty to obtain a medical examination and/or opinion when necessary to make a decision on a claim, and is triggered when there is medical evidence of a current disability; there is evidence the veteran suffered an event, injury or disease in service, and there is evidence that indicates the claimed disability may be associated with the established event, injury or disease in service. 38 C.F.R. 3.159; McLendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the Veteran has documented in-service back complaints, a current diagnosis and a suggestion the current disability may be related to service. Moreover, the Veteran has not been afforded an examination with x-rays and MRI despite recommendations from health care providers, and which would likely help clarify the diagnosis and perhaps assist in determining the etiology of any current disability. The matters are REMANDED for the following action: 1. Ask the veteran to identify any location from which he has received treatment for back complaints post service. The records of the identified treatment not already associated with the claims file should be sought. 2. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any low back disorder and right leg numbness. Any indicated tests or studies should be accomplished. The examiner is asked to identify any current low back disability, including any radiculopathy, and to provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any such disorder had its onset in-service, or is otherwise related to service, including the back complaints noted in the Veteran’s service treatment records. All opinions are to be accompanied by a complete rationale consistent with the evidence of record. 3. After completing the requested actions, and any additional development deemed warranted, readjudicate the claim in light of all pertinent evidence and legal authority. If the benefit sought remains denied, furnish to the Veteran and his representative a Supplemental Statement of the Case and afford them the appropriate time period for response before the claims file is returned to the Board for further appellate consideration. MICHAEL E. KILCOYNE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD B. Jaigirdar, Associate Counsel