Citation Nr: 21003070 Decision Date: 01/19/21 Archive Date: 01/19/21 DOCKET NO. 10-32 420 DATE: January 19, 2021 REMANDED Entitlement to service connection for a back disability, to include as due to service connected disease or injury is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1970 to May 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). This matter was before the Board in September 2019, at which time the Board denied the claim. The Veteran appealed the Board’s denial to the United States Court of Appeals for Veterans Claims (Court). In June 2020, pursuant to a Joint Motion for Remand (JMR) by the parties, the Court vacated the decision that denied the back disability claim, and returned it to the Board for further consideration consistent with the JMR. 1. Entitlement to service connection for a back disability, to include as due to service connected disease or injury is remanded. In the JMR, the parties determined the 2017 VA examination and 2018 addendum opinions were inadequate because they were based on the inaccurate factual premise that the first notation of a back complaint was in 2000, nearly three decades after discharge. The parties indicated, however, the Veteran was noted to have “discomfort in the back” by a VA examiner in 1976, only three years after her discharge. Further, in August 1983, the Veteran submitted correspondence contending that she had a lower back condition that was related to service and in May 1989, asserting that a mid to low back condition was entitled to service connection. Additionally, the parties agreed that the examiner did not address whether the Veteran’s back condition was aggravated by her service connected knee conditions. In light of the JMR, the Board finds that an additional examination and opinion are needed. Updated treatment records should also be requested. The matters are REMANDED for the following action: 1. Ask the Veteran to provide the names and addresses of all medical care providers who have recently treated her for her claimed disability. After securing any necessary releases, request any relevant records identified. In addition, obtain updated VA treatment records. If any requested records are unavailable, the Veteran should be notified of such. 2. After records development is completed, schedule the Veteran for a VA back examination. The claims file should be reviewed by the examiner. All necessary tests should be performed and the results reported. All symptomatology associated with the back should be reported. Following review of the claims file, the examiner should address the following: (a.) Whether it is at least as likely as not (50 percent probability or greater) that the Veteran’s back disability arose during service or is otherwise related to his military service. The examiner should explain why or why not, to include addressing the Veteran’s report of back discomfort on VA examination in 1976, and statements in August 1983 and May 1989 that her back pain is related to service. (b.) If not caused by service, is it at least as likely as not (50 percent probability or better) that the Veteran’s back disability has been caused by the service-connected knee conditions? Please explain why or why not. (c.) If not caused by the service-connected knee conditions, is it at least as likely as not that the Veteran’s back disability has been worsened beyond the normal progression (aggravated) by the service-connected knee conditions? Please explain why or why not. (d.) If the examiner finds the back disability has been aggravated by the service-connected knee conditions, the examiner should attempt to quantify the degree of aggravation beyond the baseline level of back disability. A clear rationale must be provided for all opinions expressed.   3. If the claim remains denied, issue a supplemental statement of the case. K. A. BANFIELD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Asare, 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.