Citation Nr: 18155448 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 15-34 825 DATE: December 4, 2018 REMANDED Entitlement to service connection for lumbar spine degenerative disc disease is remanded. Entitlement to service connection for a left hip disability is remanded. Entitlement to service connection for a right hip disability is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1967 to April 1987. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2013 rating decision by the Nashville Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran presented testimony at a Board hearing in February 2016. A transcript of the hearing is associated with the Veteran’s claims folder. In August 2018 the Veteran submitted private medical records. Unfortunately, the image quality of the documents is poor, rendering the documents unreadable. To ensure that the evidence is fully considered, the Veteran should consider resubmitting higher-quality versions of the evidence. 1. Entitlement to service connection for lumbar spine degenerative disc disease is remanded. The Board concludes that a remand is necessary to ensure that the Veteran receives an adequate VA examination and opinion. The Veteran asserts that he injured his back during active service. In December 2012 the Veteran was afforded a VA examination in which the examiner diagnosed degenerative disc disease of the lumbar spine. (01/30/2013, Medical Treatment Record - Government Facility, p. 12). The examiner opined that the lumbar spine disability was less likely than not related to service, as the examiner found “no documentation of onset, diagnosis, or treatment of a low back condition in [service treatment records].” (01/30/2013, Medical Treatment Record - Government Facility, p. 22). Contrary to the examiner’s findings, the Veteran’s service treatment records demonstrate that the Veteran complained of and sought treatment for a back disability while in service. In his May 1987 separation examination, he reported recurrent back pain, which, as the examiner noted, the Veteran received periodic treatment for while at Fort Devens. (9/13/2012, STR - Medical, p. 9, 10). In June 1985 the Veteran reported “constant” lower back pain over the previous two weeks. The examiner noted that his range of motion was decreased by 50 percent and diagnosed a lumbosacral sprain. (9/13/2012, STR - Medical, p. 25). When the VA decides to provide a Veteran with an examination, it must ensure that the examination is adequate. See Barr v. Nicholson, 21. Vet. App. 303, 311 (2007). The examiner’s failure to acknowledge or discuss relevant evidence from the Veteran’s service treatment records indicates the examiner conducted an incomplete review of the Veteran’s medical records and based her subsequent opinion on an inaccurate factual premise. See Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). As a result, the Board concludes that a new medical opinion is necessary. Additionally, it is not clear whether the Veteran’s service treatment records are complete. The Board notes several “witness statements” included in the Veteran’s personnel records, which indicate that the Veteran was stabbed by a fellow service member, resulting in the Veteran being transported to a military hospital. (8/27/2018, Military Personnel Record, p. 155-63). However, the hospital records are not associated with the claims file. For the foregoing reasons, the Board concludes that a remand is warranted. 2. Entitlement to service connection for a left hip disability is remanded. 3. Entitlement to service connection for a right hip disability is remanded. The Board cannot make a fully-informed decision on the issue of a bilateral hip disabilities because no VA examiner has opined on whether the disabilities are related to the Veteran’s lumbar spine disability. Generally, a VA examination is necessary when there is competent evidence of a current disability, evidence establishing that an event, injury, or disease occurred in service, and an indication that the disability may be associated with another service connected disability, but insufficient competent medical evidence to decide the claim. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). The Veteran’s private medical records from Crestwood Medical Center, dated in August 2011, indicate the Veteran has been diagnosed with bilateral joint space narrowing of the hip joints. (07/02/2013, Medical Treatment Record - Non-Government Facility, p. 21). The Veteran has suggested that his bilateral hip disabilites were caused by his lumbar spine disability the service treatment records reflect lumbar complaints during active service. Based on the foregoing, the Board finds that a VA examination is needed. The matters are REMANDED for the following action: 1. The AOJ should obtain copies of VA treatment records for the Veteran’s disabilities from May 2018 to the present. 2. Obtain records of any inpatient treatment at United States Army Hospital Berlin in 1974. Document all requests for information as well as all responses in the claims file. 3. Obtain records of any inpatient treatment at Cutler Army Hospital from 1979 to 1987. Document all requests for information, as well as all responses in the claims file. 4. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s lumbar spine degenerative disc disease is at least as likely as not related to active service. In rendering an opinion, the examiner should: (a.) Consider the Veteran’s June 1985 complaint of “constant” back pain. (b.) Consider the Veteran’s May 1987 separation examination report of recurrent back pain. (c.) Consider the lay statement from the Veteran’s wife in which she indicates that the Veteran had back problems throughout his career. (d.) Consider the lay statement from B.W. in which he describes his observations of the Veteran suffering from back pain. (e.) The examiner must provide a complete rationale for all opinions expressed. 5. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any bilateral hip disabilities. (a.) The examiner must opine on whether it is at least as likely as not (1) proximately due to lumbar spine degenerative disc disease, or (2) has been aggravated beyond its natural progression by lumbar spine degenerative disc disease. If aggravation is found, the examiner should identify baseline level of disability prior to such aggravation. (b.) The examiner must provide a complete rationale for all opinions expressed. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD R. Glenn, Law Clerk