Citation Nr: 21002146
Decision Date: 01/12/21	Archive Date: 01/12/21

DOCKET NO. 17-54 046
DATE: January 12, 2021

REMANDED

Entitlement to service connection for a low back disability is remanded.

Entitlement to service connection for a disability manifested by hyperreflexia is remanded.

REASONS FOR REMAND

In February 2020, the Board of Veterans’ Appeals (Board), in pertinent part, remanded the two issues on appeal for examination and opinion; however, medical addendums are needed.  

In its remand, with regard to service connection for a low back disability, the Board indicated that the Veteran should be afforded a VA examination to determine all current back diagnoses and to ascertain if they are etiologically related to service to include the report of lumbosacral strain and recurrent back pain on the August 1966 separation Report of Medical History.  On remand, a VA medical opinion was obtained in April 2020.  The examiner opined that it is less likely than not that any current back disability had its clinical onset during service, indicating that the service treatment records are silent on treatment, clinic visit or diagnosis.  However, that is inaccurate as lumbosacral strain and back pain are noted on the separation Report of Medical History as indicated above.  

With regard to service connection for a disability manifested by hyperreflexia, the examiner opined that it is less likely than not that any current hyperreflexia disability had its clinical onset during service, noting that the Veteran did not have hyperreflexia on examination.  However, the clinical records show that hyperreflexia is shown as active within the appeal period at the Detroit VA medical facility.  McClain v. Nicholson, 21 Vet. App. 319, 323 (2007); see also VA medical records dated between 2013 and 2020.

The matters are REMANDED for the following action:

1. Obtain a medical addendum to determine the etiology of the Veteran’s claimed back disability and disability manifested by hyperreflexia.  The examiner should provide an opinion as to whether it is more likely than not, less likely than not, or at least as likely as not, that current the Veteran’s back disability and/or disability manifest by hyperreflexia (as diagnosed and noted in VA treatment records dated between 2013 and 2020) had its clinical onset during service, that arthritis was manifest within a year of service, or that the disorder(s) is otherwise etiologically related to any in-service disease, event, or injury to include the June 1965 report of a back injury with diagnostic impression of low back strain; and report of lumbosacral strain and back pain on the August 1966 separation Report of Medical History.  

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2. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 

 

 

S. L. Kennedy

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board	J. Connolly, 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.