Citation Nr: 18154060 Decision Date: 11/29/18 Archive Date: 11/28/18 DOCKET NO. 16-50 045 DATE: November 29, 2018 REMANDED Entitlement to service connection for back injury residuals is remanded. REASONS FOR REMAND The Veteran had active duty service from February 1968 to February 1971. Entitlement to service connection for back injury residuals. The Veteran seeks entitlement to service connection for back injury residuals. Essentially, he claims that he first injured his back in 1970 while serving in Vietnam. He claims that he was lifting 55-gallon trash cans and strained his back. The Veteran stated that he went to sick bay, where X-rays were taken and he was given a hot pad along with 3 days’ rest. He contends that since the initial in-service injury, he has had continuous back trouble. Initially, the Board observes that the Veteran’s service records are silent for any treatment for or complaints of back pain. The Board further observes that the Veteran has received some private treatment for back pain. An October 1989 X-ray report includes an impression of “Focal disk protrusion at L5-S1 on the right. Smaller disk bulge at L4-5 on the right and centrally at L3-L4. A July 2014 report includes a diagnosis of “chronic back pain secondary to chronic DDD between L4-L5, L5-S1 with lumbar radiculopathy on the right.” However, no nexus to service has been indicated. It does not appear that the Veteran has ever received a VA back examination. Considering the above, the Board finds that a VA examination would be particularly helpful in this instance. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). As noted above, the Veteran has received some private treatment for complaints of back pain. It is unclear whether he has received any VA or additional private treatment. Therefore, it would be prudent for VA to obtain all outstanding medical treatment records. The matter is REMANDED for the following action: 1. With the assistance of the Veteran as necessary, identify and obtain any outstanding, relevant treatment records, and associate them with the Veteran’s electronic claims file. This includes all private treatment as well as any pertinent VA treatment records. If the Agency of Original Jurisdiction (AOJ) cannot locate or obtain such records, it must specifically document the attempts that were made to locate or obtain them, and explain in writing why further attempts to locate or obtain any government records would be futile. The AOJ must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claim. All attempts to obtain records should be documented in the Veteran’s electronic claims file. 2. After pertinent records are obtained, but whether or not records are obtained, schedule the Veteran for a VA orthopedic-type examination with an examiner of appropriate expertise in order to determine the nature and etiology of the Veteran’s claimed back injury residuals. The examiner is to be provided access to the Veteran’s electronic claims file. The examiner is requested to review all pertinent records associated with the claims file, the Veteran’s service treatment records, post-service medical records, and lay statements of record. Any indicated diagnostic tests and studies should also be accomplished. It should be noted that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The VA examiner must opine whether it is at least as likely as not (50 percent or higher degree of probability), that the Veteran’s claimed back injury residuals manifested in-service or is otherwise causally or etiologically related to his military service. All examination findings/testing results, along with complete, clearly-stated rationale for the conclusions reached, must be provided. Any prior reports should be reconciled, as necessary. 3. After the development requested has been completed, the AOJ should review any report to ensure that it is in   complete compliance with the directives of this remand. If the report is deficient in any manner, the AOJ must implement corrective procedures at once. MICHAEL D. LYON Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Miller, Associate Counsel