Citation Nr: 21068510 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 17-63 535 DATE: November 10, 2021 REMANDED Entitlement to service connection for a back disability, to include as secondary to service-connected status-post left tibia-fibula fracture, is remanded. Entitlement to service connection for a left hip disability, to include as secondary to service-connected status-post left tibia-fibula fracture, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1988 to September 1989. These matters come to the Board of Veterans' Appeals (Board) from an April 2015 rating decision which denied entitlement to service connection for a back disability and a left hip disability. In December 2019, the Veteran and his wife testified at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. In April 2021, the Board remanded these matters for further development. The Board notes that VA treatment records were added to the Veteran's claims file after the May 2021 Supplemental Statement of the Case. While these records have not been reviewed by the agency of original jurisdiction (AOJ) in the first instance, the Board finds no prejudice to the Veteran because the AOJ can consider these records on remand. Entitlement to service connection for a back disability is remanded. Entitlement to service connection for a left hip disability is remanded. The Board cannot make a fully informed decision at this time. Following the April 2021 remand, the May 2021 VA examiner opined that the Veteran's back and left hip disabilities were not proximately due to or aggravated by service-connected status-post left tibia-fibula fracture. While the Veteran has primarily asserted that his back and left hip disabilities are secondary to this service-connected disability, the Veteran also appears to assert that he injured his back and left hip at the same time that he fractured his left tibia and fibula during service at Fort Benning. He also appears to assert that his left hip disability is due to a fall during service in Germany. No VA examiner has opined whether the Veteran's back or left hip disabilities are related to these incidents during service. On remand, the AOJ should schedule the Veteran for a new VA examination. On remand, the AOJ should also develop the Veteran's service treatment records because there are no records for either incident, although the Veteran appears to assert that he sought no treatment following the fall in Germany. The AOJ should ask the Veteran to provide details about the approximate dates and locations of any treatment for both incidents, to include any military or non-military facilities. The AOJ should also request the Veteran's service treatment records from the appropriate records repositories. The matters are REMANDED for the following actions: 1. Provide the Veteran with a VA Form 21-4138 to provide details about the approximate dates and locations of any treatment for his left tibia-fibula fracture or fall in Germany, to include any military or non-military facilities. Undertake appropriate efforts to obtain records from the identified providers. Document all requests for information as well as all responses in the claims file. 2. Request the Veteran's complete service treatment records from the appropriate records repositories. 3. Obtain the Veteran's VA treatment records for the period from September 2021 to the present. 4. Schedule the Veteran for a VA examination for his back disability. The examiner must opine whether this disability is at least as likely as not related to service, to include at the same time that the Veteran fractured his left tibia and fibula. The examiner must review the claims file and provide a rationale for the opinion. (Continued on the next page.) 5. Schedule the Veteran for a VA examination for his left hip disability. The examiner must opine whether this disability is at least as likely as not related to service, to include at the same time that the Veteran fractured his left tibia and fibula, or as due to a fall in Germany. The examiner must review the claims file and provide a rationale for the opinion. K. Parakkal Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. Ormson, 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.