Citation Nr: 21001908 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 16-26 435 DATE: January 12, 2021 REMANDED Entitlement to service connection for a back disorder is remanded. Entitlement to service connection for a bilateral foot disorder is remanded. Entitlement to service connection for a bilateral knee disorder is remanded. Entitlement to service connection for an acquired psychiatric disorder is remanded. REASONS FOR REMAND The Veteran had active service in the Army from November 1976 to December 1979 and March to May 1985. The appeal originates from an October 2013 decision of a Department of Veterans Affairs (VA) Regional Office. The Veteran appeared for a hearing before the undersigned in January 2020. The appeal was remanded in April 2020 to obtain VA opinions for the musculoskeletal disorders, an examination with opinion for the psychiatric disorder, and private treatment records identified by the Veteran at the January 2020 hearing. Following the Remand, the record does not show that any correspondence was sent to the Veteran requesting authorization to obtain the private treatment records. With respect to the back and bilateral knee disorders, examinations with opinions were obtained in August 2020. The examiner found that the disorders are less likely as not related to service partly based on the absence of complaints or treatment in the service treatment records. However, the record shows that treatment records from the Veteran’s first period of active service are unavailable, which is the period when he claims he was treated for back and knee problems. See September 2013 VA Memo; January 2020 Hearing Transcript. The examiner did not address any of the lay reporting of in-service injury and treatment for the back and knees. Regarding a bilateral foot disorder, an examination and opinions were obtained in August 2020. The examiner opined that a bilateral foot disorder is less likely as not related to service. Though the examiner indicated that bilateral pes planus was noted on entry in November 1976, the examiner did not provide an opinion on aggravation of a preexisting disability per the Remand directives. As in the opinions for the back and knees, the examiner relied on the absence of evidence in the service treatment records and did not address the lay reporting of in-service treatment for the feet. As to an acquired psychiatric disorder, an examination with opinions was obtained in August 2020. The examiner determined that the Veteran met the DSM-5 criteria for depressive disorder but not PTSD. However, the examiner did not discuss the VA treatment records showing diagnosis of PTSD, including a DSM-5 diagnosis in May 2014, and whether there was a valid diagnosis that resolved during the appeal. The examiner indicated it was less likely as not that the Veteran experienced military sexual trauma but did not address the behavioral problems from 1978 to 1979 reflected in the military personnel records. For the preceding reasons, VA should request authorization to obtain private treatment records and obtain new opinions concerning the musculoskeletal and psychiatric disorders.   The matters are REMANDED for the following action: 1. Request authorization to obtain private treatment records identified in the January 2020 Board hearing. 2. Provide the Veteran’s file to an examiner with the appropriate knowledge and expertise to opine on back, knee, and foot disorders. The examiner is asked to address the following: a. Is it at least as likely as not that a back disorder had its onset in service or within a year of service discharge or is otherwise etiologically related to active service or a service-connected disability? b. Is it at least as likely as not that a bilateral knee disorder had its onset in service or within a year of service discharge or is otherwise etiologically related to active service or a service-connected disability? c. As for the bilateral pes planus that was noted at service entrance, is it at least as likely as not that the pes planus underwent an increase in disability during service? d. If an increase in severity of bilateral pes planus is shown to have occurred in service, is there clear and unmistakable evidence that the disorder was not aggravated beyond its natural progress by service? e. As for any foot disorder other than pes planus, is it at least as likely as not that the disorder had its onset in service or within a year of service discharge or is otherwise etiologically related to active service?   The examiner is advised that treatment records for the Veteran’s first period of active service are unavailable. The examiner must address the claimed history of back, knee, and foot problems during that period. 3. Request an addendum opinion from the August 2020 PTSD examiner. The examiner is asked to address the following: a. Specify whether the Veteran has had a DSM-5 diagnosis of PTSD at any time during the appeal. The examiner must reconcile any finding with the VA treatment records reflecting diagnosis of PTSD, including a DSM-5 diagnosis in May 2014. b. Describe any supporting evidence of military sexual trauma and opine whether it is at least as likely as not that the evidence supports that the Veteran experienced a physical or sexual assault/trauma during his active service. The examiner must address the military personnel records showing behavioral problems in 1978 to 1979. c. For any diagnosed mental disorder, is it at least as likely as not that the disorder had its onset in or is otherwise etiologically related to active service?   The examiner is advised that treatment records for the Veteran’s first period of active service are unavailable. The examiner must address the claimed history of psychiatric problems during that period. MICHAEL A. HERMAN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Alhinnawi 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.