Citation Nr: 18155603 Decision Date: 12/04/18 Archive Date: 12/04/18 DOCKET NO. 16-12 090 DATE: December 4, 2018 REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for an acid reflux disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from July 1992 to July 1996, with additional service in the Navy Reserve. 1. Entitlement to service connection for a back disorder is remanded. In October 2013, the Veteran underwent a VA examination to assess the etiology of his back disorder. The Veteran reported that his low back pain began while he was in the military and has continued to this day. He also reported that, after the military, he saw a chiropractor on a monthly basis for adjustments. The examiner diagnosed the Veteran with spondylolisthesis and chronic lumbosacral strain/sprain and opined that the Veteran’s back disorder was less likely as not caused by or a result of the back strain in service. The examiner explained that the back injury that occurred during service was a mild strain of the latissimus dorsi muscle, which was documented as a minor injury and would have recovered completely in a few weeks. The examiner also explained that the service treatment records, to include the Veteran’s last examination in October 2012, were silent regarding a back condition. The Board, nevertheless, finds the October 2012 VA examination insufficient for rating purposes. In pertinent part, the Veteran has indicated on several occasions that his back pain began during service (after a 1993 accident) and has continued since. See October 2012 VA Examination and December 2016 VA Treatment records. However, the VA examiner did not reconcile his finding that the Veteran’s back injury would have recovered completely in a few weeks, with the Veteran’s reports of experiencing back pain since the 1993 accident. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). The Board emphasizes that symptoms, not treatment, are the essence of any evidence of continuity of symptomatology. Savage v. Gober, 10 Vet. App. 488, 496 (1997). Of note, the Veteran provided that he did not seek treatment after the 1993 accident because the military physician performed a rectal examination, which made him uncomfortable and he decided to deal with the issue without further treatment from the military. See March 2016 VA Form 9. Accordingly, on remand, a new VA examination and opinion must be provided consistent with the directives herein. 2. Entitlement to service connection for acid reflux disorder is remanded. The Veteran’s VA treatment records document a current diagnosis for gastroesophageal reflux disease (GERD). See March 2016 VA Treatment record. The Veteran has also indicated that his acid reflux disorder began during and has continued since active duty service. See January 2014 Notice of Disagreement and March 2016 VA Form 9. Accordingly, as the Veteran has not been provided a VA examination with regard to his acid reflux disorder, the Board finds that such information is sufficient to meet the requirements for affording the Veteran a VA examination. See McLendon v. Nicholson, 20 Vet. App. 79, 81-84 (2006). The matters are REMANDED for the following actions: 1. Make reasonable efforts to obtain any outstanding VA or private treatment records. With the Veteran’s assistance, if necessary, obtain copies of any pertinent records and add them to the claims file. If VA attempts to obtain any outstanding records which are unavailable, the Veteran and his representative should be notified in accordance with 38 C.F.R. § 3.159(e). 2. After the above records request has been completed, schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of the Veteran’s back disorder. The examiner must review pertinent documents in the Veteran’s claims file in conjunction with the examination. All indicated studies should be completed. All findings must be fully reported. a) The examiner should provide a diagnosis for any current back disorder. b) The examiner must provide an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that any diagnosed back disorder had its onset in, or is otherwise related to, the Veteran’s active duty service. The examiner must specifically consider and discuss the Veteran’s reports of continued back pain since his 1993 in-service back injury. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. After the above records request has been completed, schedule the Veteran for a VA examination with an appropriate examiner to determine the nature and etiology of the Veteran’s acid reflux disorder. The examiner must review pertinent documents in the Veteran’s claims file in conjunction with the examination. All indicated studies should be completed. All findings must be fully reported. a) The examiner should provide a diagnosis for any current acid reflux disorder. b) The examiner must provide an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that any diagnosed acid reflux disorder had its onset in, or is otherwise related to, the Veteran’s active duty service. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. A rationale for all requested opinions shall be provided. If the examiner cannot provide an opinion without resorting to mere speculation, he or she shall provide a complete explanation stating why this is so. In so doing, the examiner shall explain whether the inability to provide a more definitive opinion is the result of a need for additional information or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD P. E. Metzner, Associate Counsel