Citation Nr: 21067430 Decision Date: 11/04/21 Archive Date: 11/04/21 DOCKET NO. 17-14 087 DATE: November 4, 2021 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 1977 to October 2001. This case comes to the Board of Veteran' Appeals (Board) from a March 2014 rating decision from a Department of Veterans Affairs (VA) Regional Office (RO). In January 2019, the Board remanded the case for additional development and it now returns for appellate review. Entitlement to service connection for a back disability. The Veteran contends that his current back disability is related to his back pain that was treated in service. He further states that his back problems occurred in service and have progressively gotten worse. In accordance with the January 2019 Board remand, the Veteran was afforded a VA examination in December 2019. At such time, the examiner diagnosed the Veteran with spondylosis without myelopathy, status post laminectomy with residual paresthesias. The examiner concluded that the Veteran's condition was not caused by service or service-connected conditions. The examiner further stated that the Veteran's condition was not caused by anecdotal muscle strains nor by the reported accident in October 1979 while in service, and such a causative nexus could not be sustained by current peer review medical literature. As rationale, the examiner explained that a 2001 lumbar spine series was deemed as normal, and his condition was not diagnosed within 2 years after service. The examiner also stated that the Veteran's condition was not documented until 2011. The examiner further concluded that the Veteran's condition was not caused by his report of pain while in service. As rationale, the examiner explained that pain may represent unusually benign or extremely pathological conditions and the causes could be multiple or even multifactorial. It may represent a local condition or be the result of referred symptoms. The same local pain, subjectively, may represent many different and/or unrelated etiologies. The examiner stated that pain is simply not reliable as a diagnostic or prognostic indicator. As per medical literature, the examiner explained that degeneration of the spine is an inevitable consequence of aging. However, it does not appear that the VA examiner considered the Veteran's reports of symptomatology since service. Dalton v. Nicholson, 21 Vet. App. 23 (2007) (holding that an examination was inadequate where the examiner did not comment on the veteran's report of in-service injury but relied on the service medical records to provide a negative opinion). In this regard, the Veteran reported his back problems occurred in service and have progressively gotten worse since such time. Moreover, while in service, an October 1979 accident resulted in emergency treatment, physical therapy, and prescribed crutches. Consequently, the Board finds that an addendum opinion is necessary to decide this claim. Additionally, the theory of a back disability as secondary to his service-connected condition has been reasonably raised by the December 2019 VA examiner's opinion. In this regard, the examiner concluded examiner that the Veteran's back disability was not caused by service or service-connected conditions. In this regard, the Veteran is service connected for residual arthritis, status post right knee arthroscopy and partial medial meniscectomy. However, the examiner did not provide rationale to support the conclusion. Thus, an addendum opinion is necessary to determine Veteran's back disability was proximately due to or aggravated by his service-connected residual arthritis, status post right knee arthroscopy and partial medial meniscectomy. The matters are REMANDED for the following action: 1. Return the record to an appropriate VA examiner in order to provide opinions for the Veteran's back disability. The claims file and this Remand should be reviewed by the examiner. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. (A) Identify all back disorders that have that existed during the appeal period, even if resolved. (B) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's back disability had its onset in, or is otherwise related to, his military service, to include his in-service duties? In rendering an opinion, the examiner should consider: (i) the Veteran's reports of pain back pain since service; and (ii) the Veteran's STRs which document numerous complaints and treatment for back pain, strain, and muscle spasms, to include the October 1979 in-service accident treatment that resulted in physical therapy and crutches. The Veteran was in service from October 1977 to October 2001. (C) Is it at least as likely as not (i.e., a 50 percent or greater probability) that the Veteran's back disability was proximately due to or aggravated by service-connected residual arthritis, status post right knee arthroscopy and partial medial meniscectomy? The term "aggravation" in the above context refers to any incremental increase in disability - any additional impairment of earning capacity -in non-service-connected disabilities resulting from service-connected conditions regardless of its permanence. In formulating the above opinions, the examiner must consider and discuss all lay statements and assertions provided by the Veteran. A complete rationale must be provided for any and all opinions offered. If any requested opinion cannot be provided without resorting to mere speculation, the examiner must fully explain why this is the case and identify what, if any, additional evidence or information might allow for a more definitive opinion. C. CRAWFORD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Brennae L. Brooks, 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.