Citation Nr: 21061834 Decision Date: 10/05/21 Archive Date: 10/05/21 DOCKET NO. 14-37 081 DATE: October 5, 2021 REMANDED The claim for service connection for a low back condition is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1993 to December 1995. In October 2017, the Veteran testified at a travel Board hearing before the undersigned Veterans Law Judge (VLJ). A complete transcript is of record. This appeal was previously before the Board in October 2019. The October 2019 Board decision denied the Veteran's service connection claims for a low back condition and for a bilateral knee condition. The Veteran appealed the adverse decisions to the United States Court of Appeals for Veterans Claims (Court). The Veteran specifically did not appeal the issue of service connection for a bilateral knee condition, and she requested that the Court dismiss the appeal as to that claim. As such, the service connection claim for a bilateral knee condition is no longer before the Board and the only issue on appeal is the service connection claim for a low back condition. Service connection for a low back condition is remanded. Per the JMPR, the parties found that the Board failed to obtain an adequate medical opinion regarding the Veteran's rotoscoliosis. The parties additionally agreed that the Board erred when it did not provide an adequate statement of reasons or bases regarding whether the low back condition was secondary to iliotibial band syndrome (ITBS). Regarding whether the Veteran's rotoscoliosis was related to her active duty service, the JMPR pointed out that the August 2014 VA examiner appeared to indicate that the mild rotoscoliosis was related to the Veteran's muscle spasms, but was unclear whether this meant that her rotoscoliosis was caused by her muscle spasms, or if the muscle spasms were caused by the rotoscoliosis. Further, the examiner did not provide an opinion as to whether those manifestations were themselves related to her active duty service. The JMPR also pointed out that the Board failed to discuss an October 2018 treatment record indicating that the ITBS persists and the Veteran appeared to have some SI joint dysfunction; the October 2017 Board hearing testimony that her physical therapist felt like she had a bulging disc; and a March 2013 Statement in Support of Claim indicating a diagnosis of kyphosis. The parties agreed that remand was warranted so that the Board could provide a statement of reasons or bases that addressed the foregoing favorable lay and medical evidence and that if the Board determined that a medical opinion was necessary to address the Veteran's lay statement indicating a diagnosis for kyphosis, it must obtain one. The Board agrees with the JMPR, that the August 2014 VA examiner's opinion was inadequate and acknowledges that the October 2019 Board decision did not discuss the aforementioned favorable evidence. As such, based on the JMPR, the Board finds that remand is necessary to afford the Veteran a VA examination. Accordingly, service connection for a low back condition is remanded. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination to determine the nature and etiology of her low back condition. The examiner should indicate whether there is a current diagnosis for kyphosis of the low back, and/or a diagnosis for a bulging disc. The examiner should also provide an opinion regarding whether there was a diagnosis for kyphosis, and/or a bulging disc at any time. The examiner's attention is directed towards the Joint Motion for Partial Remand ("Court of Appeals for Veterans Claims (Court) Decision received 5/18/21) to understand why the Veteran was entitled to a new VA examination. The JMPR pointed out that the August 2014 VA examiner appeared to indicate that the mild rotoscoliosis was related to the Veteran's muscle spasms, but was unclear whether this meant that her rotoscoliosis was caused by her muscle spasms, or if the muscle spasms were caused by the rotoscoliosis. The examiner should provide the following opinions: (a) Is it at least as likely as not (50 percent or greater probability) that the Veteran's low back condition had its onset during her active duty service, or is proximately due to or caused by the Veteran's active duty service? Why or why not? The examiner should also provide an opinion as to whether any back spasms began in or were otherwise caused by the Veteran's active military service to service. (b) Is it at least as likely as not (50 percent or greater probability) that the Veteran's low back condition was caused by her service-connected ITBS? Why or why not? (c) Is it at least as likely as not (50 percent or greater probability) that the Veteran's low back condition was aggravated (made worse) by her service-connected ITBS? Why or why not? If aggravation is found, the examiner should identify a baseline level of severity of the low back condition by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity. If such cannot be done, it should be explained why. The examiner should clearly explain whether Veteran's muscle spasms, that are related to her service-connected ITBS, have caused or aggravated her low back condition, to include rotoscoliosis. In providing the requested opinions, the examiner should also discuss the importance of the October 2018 treatment note that showed the ITBS persisted and the Veteran appeared to have some SI joint dysfunction. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Fu, 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.