Citation Nr: 21063847 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 16-10 144 DATE: October 18, 2021 REMANDED Entitlement to service connection for a low back disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Entitlement to service connection for a left shoulder disorder is remanded. Entitlement to service connection for a right hand disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1977 to September 1981. In a July 2020 decision, the Board denied the Veteran's claims for service connection for a low back disorder, a left knee disorder, a left shoulder, and a right hand disorder. The Veteran then appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In a July 2021 Joint Motion for Remand (JMR), which was adopted by the Court, the parties agreed to vacate the July 2020 decision and remand the case to the Board for additional development. The Veteran claims entitlement to service connection for a low back disorder, a left knee disorder, a left shoulder disorder, and a right hand disorder. With regard to his lower back, he reports that he fell and hurt his back during service and that he has suffered low back problems since that time. He also indicates that he injured his left knee during service and that his gait problems may have caused his low back disability. He further asserts that he has a left shoulder disability as a result of his period of service. The Veteran also reports that he has pain and numbness in the medial area of the right hand, as well as in the medial forearm and ring and little fingers as a result of his military service. A July 1980 service treatment record notes that the Veteran complained of lower back pain for one day. The examiner reported that the Veteran had full range of motion with pain. The impression was low back pain due to muscle strain. An October 1980 service treatment record noted that the Veteran slammed his right thumb into an elevator door, and that he experienced discoloration, slight bleeding, and numbness. He was diagnosed with blunt trauma to the right thumb. In the July 2021 JMR, the parties agreed that a remand was necessary because the December 2019 VA examination reports and opinions upon which the Board relied failed to provide sufficient rationale in support of the conclusions reached, and the opinions failed to reflect consideration of the Veteran's lay statements concerning the onset and continuity of the symptoms. As to the Veteran's claimed right hand disorder, the parties also agreed that the December 2019 VA examination report was also inadequate as it was based on the inaccurate factual premise that he did not have a documented right hand injury during service. Indeed, as noted above, he was diagnosed with blunt trauma to the right hand in October 1980 after slamming his right thumb into an elevator door. Thus, to ensure an adequate record upon which to decide the Veteran's claims, and to ensure compliance with the terms of the July 2021 JMR, he should be scheduled for new examinations to assess address whether any current disabilities of the low back, left knee, left shoulder, and/or right hand are related to his military service. On remand, the AOJ should also associate with the record any outstanding VA treatment records that are not currently associated with the claims file. Additionally, he should be given the opportunity to identify any outstanding pertinent records. The matters are REMANDED for the following action: 1. Associate with the claims file any VA treatment records dated from October 6, 2020, to the present. 2. Give the Veteran an additional opportunity to identify any outstanding pertinent evidence that has not already been associated with the claims file. The AOJ should then attempt to obtain those records if the Veteran provides the appropriate authorization. 3. The Veteran should be afforded a VA examination to determine whether his current disabilities of the low back, left knee, left shoulder, and/or right hand had its onset during, or is otherwise related to, his military service; or whether such is secondary to his service-connected right knee disability. The record must be made available to the examiner. Any indicated evaluations, studies, and tests should be conducted. The examiner should take a history from the Veteran as to the progression of his claimed disabilities. Following a review of the entire record, the examiner should address the following: For each identified disability of the low back, left knee, left shoulder, and/or right hand, is it at least as likely as not (50 percent or greater probability) that such had its onset during, or is otherwise related to, his military service? In this regard, the Board notes that Veteran has argued that he injured his low back, left knee, left shoulder, and right hand during his military service and that they have continued to bother him since that time. Also, the examiner's attention is drawn to the July 1980 treatment entry noting the Veteran's report of lower back pain, as well as the October 1980 service treatment record noting blunt trauma to the right thumb after he slammed his right thumb into an elevator door. In offering any opinion, the examiner must consider the full record, to include the Veteran's lay statements regarding the onset and continuity of his symptomatology, and the opinion and rationale provided should reflect such consideration. A clearly-stated rationale for any opinions offered must be provided and should be based on consideration of all pertinent evidence. Further, the provided rationale must not be based solely upon the absence of documented treatment in the Veteran's service treatment records without explanation as to why such is clinically significant. 4. Thereafter, and after any further development deemed necessary, the issues on appeal should be readjudicated. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James R. Springer, 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.