Citation Nr: 21062719 Decision Date: 10/12/21 Archive Date: 10/12/21 DOCKET NO. 18-27 150 DATE: October 12, 2021 REMANDED Entitlement to service connection for an acquired psychiatric disorder, including posttraumatic stress disorder (PTSD), is remanded. Entitlement to service connection for a lumbar spine disability is remanded. Entitlement to service connection for a right shoulder disability is remanded. REASONS FOR REMAND The Veteran had active military service from July 1989 to July 1992. This matter comes before the Board of Veterans' Appeals (Board or BVA) on appeal from a July 2014 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In May 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing. A transcript of that hearing is of record. 1. Entitlement to service connection for an acquired psychiatric disorder, including PTSD The Veteran contends that he has PTSD due to his active military service. The service treatment records are absent complaints, findings, or diagnoses of any psychiatric problems during service. In a December 2014 statement, the Veteran indicated that he had four different stints in mental health hospitals, the first in 1995/1996, approximately three years after his separation from service, in Wichita, Kansas. The second was in 2000 in Aurora, Colorado. The Veteran stated that he was not able to obtain his records from these first two medical providers given the amount of time that had passed. The Veteran underwent VA examination in May 2014 at which time he reported that his stressors included firefights and that his unit lost eight people. The examiner noted that the Veteran's stressor was related to the Veteran's fear of hostile military or terrorist activity. After obtaining a complete history and providing a mental status examination, the examiner noted, Based on the results of this Compensation and Pension Psychological Evaluation, the Veteran was NOT found to be experiencing Post-Traumatic Stress Disorder related to his fear of hostile military and/or terrorist activity, according to the diagnostic criteria established for PTSD in the DSM-V. The examiner indicated that the Veteran had no mental disorder diagnosis. In May 2021, the Veteran submitted mental health records from a private counseling center. The records indicate that the Veteran had been admitted in January 2009 after he made statements of self-harm. The Veteran noted that he was having marital problems, that he injured his back when he fell out of a helicopter in Desert Storm, and that he was treated for PTSD in 1991. He was diagnosed with partner relational problem and rule out adjustment disorder with mixed disturbance of emotions and conduct. In February 2009, the Veteran was noted to have been having more issues regarding PTSD. In April 2009, the Veteran reported occasional issues with sleep and PTSD flashbacks. In April 2010 and November 2010, the Veteran was diagnosed as having major depressive disorder, partner relational problem, and PTSD. As the May 2014 VA examiner was not able to review the medical records submitted by the Veteran in May 2021, the Board finds that a remand is required to schedule the Veteran for an additional VA examination to determine whether he has a current psychiatric disorder related to his military service. 2. Entitlement to service connection for a lumbar spine disability 3. Entitlement to service connection for a right shoulder disability The Veteran's service treatment records indicate that in March 1992, he complained of lower back injury two weeks prior; assessment was low back pain and sacroiliitis. On the clinical examination for separation from service in March 1992, the Veteran's upper extremities and spine were evaluated as normal; however, on the Report of Medical History completed by the Veteran in conjunction with his separation physical, he reported pain or "trick" shoulder and recurrent back pain. Physician's summary and elaboration of all pertinent date indicated that the Veteran had acute low back pain which resolved in March 1992 and right shoulder pain secondary to bursitis, asymptomatic at present. The Veteran underwent VA examinations in May 2014 at which time he was diagnosed as having bulging disc, status post laminectomy, and facet disease L5-S1. The Veteran reported that while lifting shelves in the military, he "popped" his back in 1993. He reported that he went to see a doctor, that he was off duty for four to five weeks, that he underwent physical therapy, and that his back did not improve. The Veteran reported that once he was discharged from active duty, he entered the Reserves; he went to his primary care physician and was told he needed back surgery which he had in 1995. The Veteran reported that the records from his 1995 surgery were unavailable as the hospital was closed. At the May 2014 VA examination, the Veteran was also diagnosed as having synovial osteochondromatosis of the right shoulder. The Veteran denied any acute injury but reported that the pain began three years prior as a sharp pain. In July 2014, the VA examiner who conducted the May 2014 VA examination opined that the claimed conditions were less likely than not incurred in or caused by the claimed in-service injuries and noted that there was no documentation of continuous treatment from service until the present time. In July 2021, the Veteran submitted medical opinions regarding his low back pain and shoulder pain rendered by a physician from primary care and sports medicine. The physician stated that the Veteran had had problems with chronic low back pain and chronic bilateral shoulder pain since his service in the military in the early-mid 1990s. The physician noted that the Veteran described a specific injury in 1991 when loading a cannon as an artillery soldier, doing PT, and having a discectomy in 1995. The physician noted that the Veteran reported having bilateral shoulder pain since his military service. The physician opined, "For both of these issues, given when they began and in relation to the timing of his military service, I do not feel they are due to typical wear and tear patterns." Neither of the opinions are adequate. The May 2014 VA examiner does not address the lay statements of the Veteran; and the private physician did not have access to the Veteran's records which an acute low back pain which resolved in March 1992 and right shoulder pain secondary to bursitis, asymptomatic at present or the Veteran's statement to the VA examiner that his shoulder pain began only three years before. The Board notes that the Veteran's service personnel records indicate that he was discharged from the Kansas Army National Guard in January 1997. There are no service treatment records dated past the Veteran's period of active duty ending in July 1992. In light of the foregoing, the Board finds that on remand, the AOJ should obtain any outstanding service treatment records during his Army National Guard service. The matters are REMANDED for the following action: 1. Request all service medical records from the Kansas Army National Guard from the years 1992 to 1997. 2. After any additional medical records have been obtained and associated with the file, schedule the Veteran for a VA orthopedic examination. The examiner must review the claims file. The examiner is asked to provide a response to the following: (a) Are the Veteran's current lumbar spine disorders at least as likely as not related to service, including low back pain and sacroiliitis noted in March 1992? (b) Is the Veteran's current right shoulder disorder at least as likely as not related to service, including bursitis noted on discharge in March 1992? Provide a rationale to support the opinion. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? 3. Schedule the Veteran for a VA psychiatric examination. The examiner must review the claims file. (a) The examiner should identify all psychiatric disorders found to be present. In so doing, the examiner should consider the Veteran's history of psychiatric treatment, beginning in 1995/1996, as well as his post-service treatment records dated in 2009 and 2010 showing diagnoses of rule out adjustment disorder with mixed disturbance of emotions and conduct, major depressive disorder, and PTSD. (b) If the Veteran is diagnosed with PTSD, the examiner must explain how the diagnostic criteria are met and opine whether such is at least as likely as not related to the Veteran's claimed in-service stressor(s), i.e., fear of hostile military or terrorist activity during service. (c) As to any other diagnosed psychiatric disorder, the examiner must opine whether each diagnosed disorder is at least as likely as not related to any incident of service, to include fear of hostile military or terrorist activity during service. The examiner must provide a rationale to support the opinion. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Olson, Patricia 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.