Citation Nr: 19103843 Decision Date: 01/16/19 Archive Date: 01/16/19 DOCKET NO. 13-28 267A DATE: January 16, 2019 ORDER Service connection for sacroiliac joint pain is granted. REMANDED Service connection for a back disorder (other than sacroiliac joint pain) is remanded. Service connection for a bilateral ankle disorder, to include as secondary to a back condition, is remanded Service connection for a bilateral knee disorder, to include as secondary to a back condition, is remanded. Service connection for a bilateral hip disorder, to include as secondary to a back condition, is remanded. Service connection for a bilateral disorder condition, to include as secondary to a back condition, is remanded. Service connection for a neck condition, to include as secondary to a back condition, is remanded. Service connection for a psychiatric disorder, to include anxiety and posttraumatic stress disorder (PTSD), is remanded. FINDING OF FACT The Veteran’s sacroiliac joint pain had its onset during service. CONCLUSION OF LAW The criteria for service connection for sacroiliac joint pain have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1984 to April 1992. This matter is before the Board from an October 2009 rating decision. The Veteran appeared at a hearing before the undersigned Veterans Law Judge in September 2014. In July 2015, the Board remanded the case for additional development. Service Connection Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Analysis The Veteran seeks service connection for a back disorder. He maintains that his back disability was incurred during service. More specifically, he reports that he worked as a wire systems installer for 7½ years during service, which required him to climb 12 to 18-foot poles, and to lift over 150 pounds of cable. See August 2013 statement from Veteran; see also Board Hearing Transcript, pp. 4-6. Military records (including DD-214) confirm a military occupational specialty of Wire Systems Installer. In a May 2017 submission, he noted having had back pain ever since falling through a ceiling while installing cable during service in 1985. The service treatment records (STRs) reflect complaints of right knee pain after falling through a ceiling in October 1985, and although there was no reference to back symptoms at that time, STRs dated in June1990 show he complained of and was treated for low back-low/lumbar pain after a fall. X-ray examination of the lumbar spine at that time was negative, but the examination report reflects swelling and tenderness in the sacroiliac areas. The diagnosis was moderate sprain and “L-5/S-1 strain.” Additionally, STRs dated in August 1991 describe treatment, including heat and ASA for low back pain after moving heavy objects up stairs. In November 2010, the Veteran was granted Social Security Administration (SSA) disability benefits based on a degenerative back disorder. Although SSA records reflect a diagnosis of “L5-S1 herniated nucleus pulposus by MRI related to an industrial injury sustained on November 10, 2008, these records also note the Veteran’s history of a back injury during service. See SSA disability medical records. In addition, the March 2017 VA examination report reflects a diagnosis of lumbar degenerative joint and disc disease. Although the examiner opined that it was less than likely that the Veteran’s back disability was related to service, available evidence was noted to be limited to a single acute and transitory lower back injury during service in June 1990. As above, however, STRs reflect subsequent complaints of back pain during service, to include in August 1991. Further, the Board requested an expert medical opinion from the Veterans Health Administration (VHA), which was obtained in May 2018. The VHA opinion notes sacroiliac joint pain during service and it was concluded that sacroiliac joint pain had its onset during service and is therefore at least as likely as not related to the Veteran’s service. In reaching a decision, the Board has afforded the VHA opinion the greatest probative value. The opinion rendered by the VHA expert, a chief of neurosurgery, is unequivocally stated, consistent with the contemporaneous records, and supported by cited evidence of record. The evidence is at least evenly balanced as to whether the Veteran’s sacroiliac joint pain is related to service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, service connection for the specific back disorder of sacroiliac joint pain is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The issue of service connection for a back disorder, other than sacroiliac joint pain, is discussed in the remand below. REASONS FOR REMAND 1. Service connection for a back disorder (other than sacroiliac joint pain). The May 2018 VHA opinion states that is less than likely that either lumbar spondylosis or a herniated nucleus pulposus is related to the Veteran’s service. In March 2018, however, the Veteran submitted a private back DBQ prepared by Dr. Bash reflecting other back diagnoses, to include mechanical back pain syndrome, degenerative scoliosis, and foraminal/lateral recess/central stenosis. The Board notes that in addition to some legibility issues, as well as the section requesting dates of diagnoses having been left blank, treatment notes in February 2018 referenced do not appear to be associated with the claims file. In view of the evidence and the Veteran’s assertions, a new VA examination is warranted with respect to the nature and etiology of a back disorder, other than sacroiliac pain, after an attempt is made to obtain the referenced February 2018 records/notes, as well as complete VA treatment records since May 2017. 2. Service connection for a bilateral ankle disorder. 3. Service connection for a bilateral knee disorder. 4. Service connection for a bilateral hip disorder. 5. Service connection for a bilateral shoulder disorder 6. Service connection for a neck disorder. The issues of entitlement to service connection for a neck disorder and bilateral ankle, knee, hip, and shoulder disorders on a secondary basis are inextricably intertwined with the issue of entitlement to service connection for a back condition. See Harris v. Derwinski, 1 Vet. App. 180 (1991). In addition, in view of the decision above granting service connection for sacroiliac joint pain, VA examination is warranted with respect to the nature and etiology of a neck disorder, and bilateral ankle, knee, hip, and shoulder disorders. 7. Service connection for a psychiatric disorder. A May 2018 VHA opinion by a VA psychiatrist notes that the Veteran’s anxiety and depressive symptoms are more likely due to a 2008 work-related back injury and chronic pain as well as overlapping symptoms of depression and anxiety that can occur with elevated alcohol and opioid pain use. It was noted that the Veteran’s misuse of opioid medications with alcohol can result in increased negative mental health outcomes, including exacerbation of anxiety and depression. Thus, the issue is raised as to whether any service-connected back disorder and required opioid pain medication aided in the development of and permanently aggravated his psychiatric symptoms. Thus, the outcome with respect to the service connection for a back disorder may have an impact on the issue of service connection for a psychiatric disorder. As such, the service connection claim for a psychiatric disorder will also be remanded as intertwined. See Harris, 1 Vet. App. at 180. The matters are REMANDED for the following action: 1. Attempt to obtain the February 2018 treatment notes referenced in the March 2018 DBQ. 2. Obtain complete VA treatment records since May 2017. 3. Schedule the Veteran for a VA examination by an appropriate medical professional in connection with the musculoskeletal claims. The entire claims file must be reviewed by the examiner. The examiner is to conduct all indicated tests. The examiner should first identify all current back disorders. The examiner is to provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that a back disorder (other than sacroiliac joint pain) had its onset during, or is otherwise related, to service. The examiner should then provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) that a neck disorder, or a bilateral ankle, knee, or shoulder disorder is caused by or aggravated by service-connected sacroiliac joint pain or any other back disorder determined to be related to service. The term “aggravation” means an increase in the claimed disability; that is, a worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. In rendering the opinion, the examiner should address the March 2018 DBQ. A rationale for all opinions expressed should be provided 4. Schedule the Veteran for a VA psychiatric examination. The examiner should first identify the Veteran’s psychiatric disorders. Then, the examiner should provide an opinion as to whether any psychiatric disorder is caused by or aggravated by service-connected disability, including sacroiliac joint pain. Consideration should be given to medication, such as opioids, to treat service-connected disability. (Continued on the next page)   The term “aggravation” means an increase in the claimed disability; that is, a worsening of the condition beyond the natural clinical course and character of the condition due to the service-connected disability as contrasted to a temporary worsening of symptoms. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD M. Taylor