Citation Nr: 21002545 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 17-63 668 DATE: January 14, 2021 REMANDED Entitlement to service connection for a thoracolumbar spine disability (claimed as a back injury) is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from June 1961 to June 1965. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an April 2015 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In April 2019, the Veteran and his wife testified at a hearing before the undersigned; a transcript of that hearing is of record. In September 2019, the Board remanded the Veteran’s appeal to the RO for further evidentiary development.   Entitlement to service connection for a thoracolumbar spine disability (claimed as a back injury) is remanded. The Veteran has contended that he injured his back during active duty service while in California in 1962 and reinjured it while at Guantanamo Bay in 1964. See Hearing Transcript, April 2019. The Board remanded this claim in September 2019 and directed the RO to obtain a VA examination and medical opinion for his thoracolumbar spine disability. An examination report and medical opinion were prepared in January 2020. The examiner opined that it was less likely than not that the back disability was incurred in or caused by an in-service injury, event, or illness. The examiner’s rationale was that the Veteran reported injuring his back in 1976 during service working on repairs for a plane. The examiner indicated that this event would have occurred after the Veteran’s service. However, at the examination the Veteran reported injuring his back in 1962 while working under an airplane and that after he was transferred to Guantanamo Bay, he did a lot of physical work. Although a February 1977 letter regarding a worker’s compensation claim indicates the Veteran may have experienced a post-service back injury, the Veteran has competently and credibly testified to experiencing back injuries in service. Notably, the February 1977 letter also indicates that the Veteran reported at that time that he had injured his back in 1962 and reflects that there were letters regarding the Veteran’s back condition dating back to as early as 1968. Additionally, a May 2015 statement from the Veteran’s friend S.K. indicates that he met the Veteran in 1973 and remembered him having back pain and discussing that his back pain began in service. Such statements place the Veteran’s back pain as beginning at least before any 1976 injury and more contemporaneous in time to the Veteran’s service. Therefore, the medical opinion is inadequate as it does not appear to have clearly considered the evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); see also Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that a VA examination is inadequate where the examiner did not comment on the report of in-service injury and relied on lack of evidence in service treatment records to provide a negative opinion).   As the January 2020 medical opinion is inadequate for VA purposes, the Board must remand for an addendum medical opinion. The matter is REMANDED for the following actions: 1. Obtain updated VA treatment records from July 2020 to the present. 2. Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran’s thoracolumbar spine disability. The clinician must opine whether it is at least as likely as not that the Veteran’s thoracolumbar spine disability is related to an in-service injury, event, or disease, including injuries alleged to have occurred during service in 1962 and 1964. In providing this opinion, the clinician should consider and address the Veteran’s competent and credible April 2019 testimony that he first injured his back in 1962, reinjured it later in service, was treated with a hot tub/ whirlpool, and got treatment from a private doctor shortly after separation from service; the February 1977 letter indicating that the Veteran had a back condition dating back to June 1968 and that he reported an injury in 1962; and the May 2015 witness statement that as early as 1973 the Veteran reported having chronic back pain. A complete rationale for all opinions must be provided. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why an opinion would require speculation. The clinician must indicate whether there was any further need for information or testing necessary to make a determination. Additionally, the clinician must indicate whether any opinion could not be rendered due to limitations of knowledge in the medical community at large and not those of the particular examiner. M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Dean 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.