Citation Nr: 20006328 Decision Date: 01/28/20 Archive Date: 01/24/20 DOCKET NO. 17-39 126 DATE: January 28, 2020 REMANDED Entitlement to service connection for a back disability, to include as secondary to service-connected bilateral knee disability, is remanded. REASONS FOR REMAND The Veteran served in active duty service with the Army to include the Army Reserves from March 1995 to September 1995, November 2004 to November 2005, June 2006 to September 2007, and from October 2009 to July 2011. This matter is on appeal from an August 2016 rating decision. The Veteran did not request a hearing. The Board notes that a claim for a disability includes any disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. See Clemons v. Shinseki, 23 Vet. App. 1, 5-6 (2009). The Veteran filed a claim in October 2015 for service connection for a lower back and mid-back disability as secondary to service-connected bilateral knee disabilities. In August 2016 the Veteran filed a claim for a low back condition, and in July 2017 filed a claim for lumbar degenerative disc disease (DDD) and spondylosis of the lumbosacral spine. Review of the Veteran’s medical treatment record show diagnoses and treatment for low back pain, degenerative joint disease (DJD) of the lumbar spine, lumbar DDD and spondylosis of the lumbar spine. As such, the Board will recharacterize the claim as to consider whether the Veteran is entitled to service connection for a back disability to include as secondary to service-connected bilateral knee disabilities. The Board finds that additional development is warranted before adjudication of the Veteran’s appeal. The Veteran contends that her back disability is due to her active duty service to include as due to her service-connected bilateral knee disabilities. The Board notes that review of the Veteran’s service treatment records show the Veteran was treated for back pain in June 1995 and in October 2009. The Veteran has submitted statements that she was injured in October 2009 while training to go overseas, experienced pain throughout her tour and was unable to receive treatment until she returned home. The Veteran has also submitted statements that she has suffered from symptoms from her claimed back disability for several years. In a June 2012 VA GYN examination, the Veteran reported that in June 2010 she developed an acute onset of lower abdominal and back pain which resulted in a hysterectomy in October 2010; in December 2012 the Veteran then complained of constant and chronic severe pain in her knees, feet, bladder, migraines and lower back. The Veteran was afforded a November 2015 VA examination for her claimed back disability. The examiner found that it was less likely than not that the Veteran’s back condition was proximately due to or the result of the Veteran’s service-connected knee condition. The examiner opined that the Veteran had long standing knee chondromalacia, but there was no clear evidence on examination or in the medical records that the knee condition was connected to the Veteran’s back condition. However, the Board notes that the November 2015 VA examiner did not provide an opinion on whether the Veteran’s service-connected bilateral knee disability aggravated the Veteran’s back disability or whether the Veteran’s back disability was directly incurred in or caused by her active duty service. Furthermore, the examiner did not refer to or address the Veteran’s STR complaints and treatment for back pain in 1995 or in 2009 or statements made by the Veteran that her symptoms have been present for several years. As such, the Board finds that remand is warranted to obtain an addendum opinion for aggravation and direct causation, and to consider the STRs and statements submitted by the Veteran. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file all updated and outstanding treatment records. 2. After all outstanding records have been associated with the claims file, return the claims file to the VA examiner who provided the November 2015 medical opinion on the Veteran’s back disability. The record and a copy of this remand must be made available to the examiner. If the examiner determines that an examination of the Veteran is necessary to provide the requested opinion with rationale, then such examination should be scheduled. If the November 2015 VA examiner is not available, the requested opinion with rationale should be rendered by another appropriate medical professional. The VA examiner should opine as to the following: (a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s back disability is due to her service-connected bilateral knee disabilities. (b.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s back disability is aggravated by her service-connected bilateral knee disabilities. “Aggravation” is defined as any worsening beyond the natural progression of the disability. (c.) If the Veteran’s back disability condition is NOT aggravated by her service-connected bilateral knee disabilities, is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran’s back disability had its onset during, or is otherwise related to, his active duty service. (d.) In addressing any of the above, the VA examiner should discuss the Veteran’s treatment in her service treatment records in June 1995 and October 2009, her statements relating to back pain at her June 2012 VA gynecological examination, as well as the Veteran’s submitted statements regarding symptoms relating to her back disability over the appeal period. (e.) The examiner should provide a complete rationale for any opinion provided, and if the examiner is unable to provide any opinion request, then the examiner should state so and why. (f.) If the VA examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner’s medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. A clearly stated rationale for any opinion offered should be provided. 3. After completion of the above and any additional development deemed necessary, the issues on appeal should be reviewed with consideration of all applicable laws and regulations. If any benefit sought remains denied, the Veteran should be furnished a supplemental statement of the case and be afforded the opportunity to respond. Thereafter, the case should be returned to the Board for appellate review. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Yang, Attorney-Advisor The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.