Citation Nr: 20042452 Decision Date: 06/23/20 Archive Date: 06/23/20 DOCKET NO. 17-43 194 DATE: June 23, 2020 ORDER Entitlement to service connection for a chronic low back condition (claimed as back pain with bulging disc) is remanded. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service from December 1989 to July 1997. This matter comes before the Board of Veterans’ Appeals (Board) from a September 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). A hearing was held in February 2020 before the undersigned Veterans Law Judge. A transcript of that hearing is of record. REASONS FOR REMAND Entitlement to service connection for a chronic low back condition (claimed as back pain with bulging disc) The question before the Board is whether the Veteran’s claimed low back condition at least as likely as not incurred in service, or is related to an in-service injury, event, or disease. As to the first element of Shedden, for service connection the Veteran must show a current disability. Per the VA examinations of record, the Veteran has diagnoses of thoracolumbar strain as well as arthritis. See August 2014 and September 2017 VA examination(s). As to the second element of Shedden, for service connection the Veteran must show an in-service incurrence or aggravation of a disease or injury. Documented in the Veteran’s Service Treatment Records (STRs) are a number of instances in which he experienced lower back muscle strains with accompanying back pain during service. See Aug. 12, 1992; Apr. 15, 1992; Aug. 7, 1991; July 10, 1991; Apr. 3, 1991; Mar. 21, 1991 STRs. As such the Board finds that the Veteran’s claim meets the second Shedden element for service connection. As to the last element of Shedden, for service connection the Veteran must show a causal relationship between the current disability and the in-service disease or injury. Upon review, there are no probative medical opinions weighing in favor of the Veteran’s claim. Weighing against the Veteran’s claims are August 2014 and September 2017 VA medical opinions. The August 2014 VA medical examiner did not find that the Veteran’s currently diagnosed back disorder incurred in, or is related to service, opining that the muscle strains noted in the his STRs are short self-limiting soft tissue conditions that most often resolve without resulting sequelae. Rather, the August 2014 VA examiner provided an alternative etiology for any disc condition or stenosis, namely aging. Id. Likewise, the September 2017 VA examiner did not find that the Veteran’s currently diagnosed thoracolumbar strain incurred in, or is related to, service, echoing the August 2014 VA medical examiner’s finding that the Veteran’s muscle strains are acute, self-limiting, and portend to no chronic sequelae. Here, the Board finds the VA medical opinions of record to be incomplete for purposes of deciding the Veteran’s claim to the extent that neither specifically addressed the Veteran’s documented arthritis of the thoracolumbar spine, and whether that condition incurred in, or is related to, service. See Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). As such, the Board finds that a remand is needed to acquire an addendum medical opinion to address the nature and etiology of the same. The matters are REMANDED for the following action: 1. Associate with the Veteran’s claims file any outstanding VA treatments records since September 2017. 2. Contact the Veteran and request that he identify any pertinent private treatment records regarding the claimed back condition, not previously identified, to include those of a family physician he saw after service as indicated in his testimony in February 2020. Attempt to obtain any appropriately identified records. 2. Obtain an addendum medical opinion for the Veteran’s claimed for low back condition. Upon review of the pertinent medical evidence of record, to include this remand, the VA medical examiner is requested to opine as to the following: (Continued on the next page)   Is it at least as likely as not (50 percent probability or greater) that the Veteran’s documented arthritis of the thoracolumbar spine was incurred in, or is related to, service? See August 2014 and September 2017 VA medical examinations (both noting a diagnosis of arthritis of the thoracolumbar spine). Here, the VA examiner’s attention is alerted to: (i) the Veteran’s lay reports that he has experienced low back pain continuously since separating from service; and (ii) the Veteran’s STRs noting complaints of lower back pain. See February 2020 Board hearing transcript; Aug. 12, 1992; Apr. 15, 1992; Aug. 7, 1991; July 10, 1991; Apr. 3, 1991; Mar. 21, 1991 STRs. K. J. ALIBRANDO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S.R. Fey, Associate Counsel 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.