Citation Nr: 21064910 Decision Date: 10/22/21 Archive Date: 10/22/21 DOCKET NO. 16-02 730 DATE: October 22, 2021 REMANDED Entitlement to service connection for a lower back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from November 1969 to March 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In May 2019, the Veteran testified at a hearing before the undersigned. This matter was previously remanded by the Board in September 2019 and November 2020. The case has been returned to the Board at this time for further appellate review. Entitlement to service connection for a lower back disability is remanded. Pursuant to the Board's November 2020 remand, the Veteran was afforded a VA back examination in May 2021 which the Board finds to be inadequate because it does not provide sufficient or consistent information such that the Board can make an informed decision. Specifically, as with the prior examination, the May 2021 VA examiner did not address all of the Veteran's back diagnoses during the appeal period. For example, the Veteran's medical treatment records establish that he was diagnosed with lumbago in October 2012, but this diagnosis is not discussed in the May 2021 VA back examination. In addition, the May 2021 VA examiner improperly dismissed the Veteran's lay statements that he has experienced back pain since his time in service solely on the basis that such symptoms were not recorded in the Veteran's contemporaneous medical records. The Veteran's contentions are supported by a June 2018 private treatment record reflecting that the Veteran has reported experiencing back pain since his time in service. Finally, the VA examiner stated that back muscle strains typically heal with time, many within a few days and most within 3 to 4 weeks, and that most patients with mild or moderate lumbar strains make a full recovery and are free of symptoms within days, weeks, or possibly months. This appears to be a completely speculative assertion with respect to addressing the etiology of the Veteran's back disability. For these reasons the Board finds that the May 2021 VA back examination is inadequate, and a new VA examination is warranted. This matter is REMANDED for the following action: Obtain an opinion, preferably with a qualified clinician who has not previously examined the Veteran, to determine whether any back disability found during the period on appeal is related to the Veteran's military service. If the selected clinician determines that an examination or telehealth interview is necessary to respond to this request, such should be scheduled. The Board notes that the May 2021 VA examination reflects that range of motion measurements cannot be safely obtained because of the Veteran's fall risk. After review of the claims file, and examination or telehealth interview of the Veteran if deemed necessary, the examiner should identify all back disabilities found during the period on appeal, even if now asymptomatic or resolved. For each back disability identified, even if now asymptomatic or resolved, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the disability began in or is otherwise caused by the Veteran's active service. In doing so, the examiner must address the Veteran's in-service injuries, as well as his contentions that he has experienced back pain since his in-service injuries. The examiner may not dismiss the Veteran's account of back pain solely because it is not documented in contemporaneous medical records (Continued on the next page) The examiner is advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide a reason for doing so. Again, the Veteran's report of symptoms capable of lay observation may not be disregarded solely on the basis that they are not recorded in contemporaneous medical treatment records. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. M. HYLAND Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Elias, 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.