Citation Nr: 18147658 Decision Date: 11/05/18 Archive Date: 11/05/18 DOCKET NO. 16-30 672 DATE: November 5, 2018 REMANDED 1. Service connection for a sinus disorder claimed as sinusitis is remanded. 2. Service connection for headaches claimed as secondary to a sinus disorder is remanded. 3. Service connection for a low back disorder is remanded.   REASONS FOR REMAND The Veteran served on active duty from February 1975 to February 1978 with additional service in the Army Reserves. The case is on appeal from a June 2014 rating decision. 1. Service connection for a sinus disorder claimed as sinusitis. 2. Service connection for headaches claimed as secondary to a sinus disorder. The Veteran claims that he has sinusitis due to service and headaches secondary to his sinusitis. The Veteran’s service treatment records (STRs) show that he noted a history of hay fever on a February 1975 report of medical history. However, no conditions were noted during his February 1975 enlistment examination. The Veteran was afforded an examination in regard to these claims in June 2014. The examiner reported that the Veteran was diagnosed with chronic sinusitis and allergic rhinitis in 1976. She noted that the Veteran was treated for sinusitis and a hay fever allergy during service. The examiner found that the Veteran’s sinus and headache condition existed prior to service based on the February 1975 report of medical history and was not aggravated beyond its natural progression by an in-service injury, event, or illness. Thereafter, in June 2016, the Veteran was afforded VA examinations in regard to these claims. The headache examiner found that the Veteran has recurrent headaches that are more likely than not due to allergic rhinitis. The sinus examiner reported that the Veteran has allergic rhinitis with nasal and sinus congestion, but not sinusitis. He also reported that the Veteran experiences headaches due to allergic rhinitis. However, the examiner stated that the Veteran’s allergic rhinitis pre-existed service and was not worsened beyond its normal progression during service. The Board notes that a veteran is presumed to be in sound condition when examined, accepted, and enrolled for service, except for the disorders noted at time of the examination. See 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). While the Veteran noted a history of hay fever on a February 1975 report of medical history, his entrance examination did not note such condition. Therefore, the presumption of soundness applies. Furthermore, while hay fever is analogous to allergic rhinitis, sinusitis appears to be a distinct condition. See https://www.mayoclinic.org/diseases-conditions/hay-fever/symptoms-causes/syc-20373039. On remand, the Veteran should be afforded another examination in regard to his sinus claim. Furthermore, while the Veteran’s Army Reserve records from July 1980 to October 1988 have been associated with the file, the RO has indicated he served in the Army Reserves until September 1992. Thus, on remand the RO should locate and associate with the record all outstanding STRs or service personnel records (SPRs). 3. Service connection for a low back disorder is remanded. The Veteran claims that he has a low back disorder that onset during service. In this regard, in a June 2016 VA Form 9, he reported that he has experienced a low back disorder since his discharge from service that he treated on his own for many years. The Veteran’s STRs show that he was treated for low back pain during service in June 1975 and April 1976. The Veteran was afforded VA examination in regard to this claim in June 2014. The examiner noted a diagnosis of chronic low back strain in 1976. The Veteran reported being treated for low back injuries during service twice in 1976. The examiner found that the Veteran’s persistent low back pain is less likely than not to have been incurred in or caused by a progression of back complaints based on a lack of medical records showing a progression of complaints since the Veteran’s discharge from service. Notably, the Veteran indicated any gap in time can be explained by the fact that he could not afford treatment. On remand, the Board finds that the Veteran should be afforded another examination and opinion should be obtained in regard to this claim. In addition, updated VA treatment records should be associated with the file. These matters are REMANDED for the following actions: 1. Contact the appropriate service department and/or records custodian(s), to include the National Personnel Records Center, with a request for copies of the Veteran’s complete Army Reserve STRs and SPRs. All reasonable attempts should be made to obtain such records. If any records cannot be obtained after reasonable efforts have been made, issue a formal determination that such records do not exist or that further efforts to obtain such records would be futile, which should be documented in the claims file. The Veteran must be notified of the attempts made and why further attempts would be futile, and allowed the opportunity to provide such records, as provided in 38 U.S.C. § 5103A(b)(2) and 38 C.F.R. § 3.159(e). 2. Obtain complete VA treatment records from May 2016. 3. After completing the records development indicated above, schedule the Veteran for an appropriate VA examination to address the nature and etiology of his sinus disorders. The entire claims file should be reviewed by the examiner. The examiner is to identify all sinus disorders experienced by the Veteran during the period on appeal (since November 2012). In doing so, the examiner should explain from a medical perspective any difference between any identified hay fever/allergic rhinitis and any distinct sinus disorder. (a.) For each identified disorder, the examiner should state whether it is undebatable from a medical standpoint that the disorder pre-existed the Veteran’s military service. (b.) If yes, state whether it is undebatable from a medical standpoint that the disorder was not aggravated during service beyond its natural progression. Aggravation is an increase in disability beyond the natural progress of the disease or temporary flare-up. (c.) In any case, state whether it is at least as likely as not that any current disorder had its onset in, or is otherwise related to, his service. A detailed rationale for all opinions should be provided. 4. Schedule the Veteran for an appropriate VA examination to address the nature and etiology of all low back disorders. The entire claims file should be reviewed by the examiner. The examiner is to identify all low back disorders experienced by the Veteran during the period on appeal (since November 2012). For each identified disorder, the examiner should state whether it is at least as likely as not that it had onset during service, within one year of service, or is otherwise related to service, to include his incidents of low back pain during service in June 1975 and April 1976. Consideration should be given to the Veteran’s statement that a lack of medical documentation after service was due to not being able to afford treatment. A detailed rationale for all opinions should be provided. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Jimerfield, Associate Counsel