Citation Nr: 21070269 Decision Date: 11/23/21 Archive Date: 11/23/21 DOCKET NO. 17-29 035 DATE: November 23, 2021 ORDER Entitlement to a rating in excess of 10 percent for a right knee condition is denied. Entitlement to a rating in excess of 10 percent for a left knee condition is denied. Entitlement to a 10 percent rating, but no more, for a left wrist condition is granted. REMANDED Entitlement to service connection for a low back condition is remanded. FINDINGS OF FACT 1. For the entirety of the appeal period, the Veteran's right knee patellofemoral syndrome is manifested by flexion limited to no less than 120 degrees, full extension, and no ankylosis, impairment of the tibia or fibula, instability, or dislocated semilunar cartilage; however, the left knee has been actually painful for the entire appeal period. 2. For the entirety of the appeal period, the Veteran's left knee patellofemoral syndrome is manifested by flexion limited to no less than 120 degrees, full extension, and no ankylosis, impairment of the tibia or fibula, instability, or dislocated semilunar cartilage; however, the left knee has been actually painful for the entire appeal period. 3. For the entirety of the appeal the left wrist condition has been manifested by pain and limited motion without evidence of ankylosis or involvement of multiple joints as indicated by radiographic examination. CONCLUSIONS OF LAW 1. The criteria for entitlement to a rating in excess of 10 percent for a right knee condition are not met for the entirety of the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5260. 2. The criteria for entitlement to a rating in excess of 10 percent for a left knee condition are not met for the entirety of the appeal period. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.40, 4.45, 4.59, 4.71a, Diagnostic Cods 5260. 3. The criteria for an initial disability rating of 10 percent, but no more, for a left wrist condition have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.2, 4.6, 4.7, 4.21, 4.31, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5215. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 2006 to February 2014. The Board notes that it has considered whether a claim for a total rating based on individual unemployability (TDIU) has been raised by the Veteran during the pendency of this appeal. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that VA must address the issue of entitlement to a TDIU in increased rating claims when the issue of unemployability either is raised expressly or by the record. Upon review of the totality of the evidence, the Board does not find that entitlement to TDIU has been raised by the record. Although not dispositive, the Board highlights that the Veteran has been fully employed for the majority of the appeal period. Furthermore, while it is acknowledged that the Veteran experiences some impairment of functioning as due to his bilateral knee disabilities and left wrist disability, and this is corroborated by the VA examinations of record, no medical professional who has evaluated the Veteran has found that the service-connected disabilities on appeal together preclude the Veteran from securing and following substantially gainful employment. Accordingly, a claim for TDIU is not raised by the record, and the Board will not address it. Increased Rating Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Schedule), 38 C.F.R. Part 4. The percentage ratings contained in the Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. § 4.1. In determining the disability evaluation, VA has a duty to acknowledge and consider all regulations that are potentially applicable through the assertions and issues raised in the record, and to explain the reasons and bases for its conclusions. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). In determining the appropriate rating for musculoskeletal disabilities, particular attention is focused on functional loss of use of the affected part. Factors of joint disability include increased or limited motion, weakened movement, excess fatigability, incoordination, and painful movement, including during flare-ups and after repeated use. DeLuca v. Brown, 8 Vet. App. 202, 206-08 (1995); 38 C.F.R. § 4.45. A finding of functional loss due to pain must be supported by adequate pathology and evidenced by the visible behavior of the claimant. 38 C.F.R. § 4.40. Additionally, "pain itself does not rise to the level of functional loss as contemplated by the VA regulations applicable to the musculoskeletal system." Mitchell v. Shinseki, 25 Vet. App. 32, 38 (2011). Pain in a particular joint may result in functional loss, but only if it limits the ability to perform the normal working movements of the body with normal excursion, strength, speed, coordination, or endurance. Id.; 38 C.F.R. § 4.40. Under 38 C.F.R. § 4.59, painful joints are entitled to at least the minimum compensable rating for the joint. The Board notes that during the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. As will be discussed, none of the diagnostic codes applicable to the evaluation of the Veteran's various musculoskeletal conditions on appeal were altered by these amendments; any ancillary impacts to each of the various evaluations detailed below are discussed in due course. When electing whether to apply the amended criteria or the criteria previously in place, the Board will apply those criteria that are most beneficial to the Veteran. 1. Right and Left Knee Conditions The Veteran is service connected for left and right knee conditions, characterized as patellofemoral pain syndrome. The conditions are rated as 10 percent disabling for the entirety of the appeal period, which extends back to February 8, 2014, the date of the original claim seeking entitlement to service connection for right and left knee conditions. The Veteran seeks an evaluation in excess of these ratings for the entirety of the appeal period. As the evidence in support of both claims is largely identical, the Board will consider both disabilities together. The rating for both knee conditions was assigned pursuant to 38 C.F.R. § 4.71a, 5260. The Board will consider additional diagnostic codes pertinent to the evaluation of knee disabilities in order to determine the highest possible evaluation for the bilateral knee conditions during the entire period of the appeal. In considering the applicability of the remaining available diagnostic codes, the Board finds that Diagnostic Codes 5256 (ankylosis), 5258 (dislocated semilunar cartilage), 5259 (symptomatic removal of semilunar cartilage), 5262 (disability of the tibia and fibula), and 5263 (genu recurvatum) are not applicable in this instance as the medical evidence does not show that the Veteran experiences these conditions in the right knee. 38 C.F.R. § 4.71a, Diagnostic Codes 5256, 5257 (both prior to and since February 7, 2021), 5258, 5259, 5263. Under Diagnostic Code 5260, limitation of flexion of the leg, a 10 percent rating is assigned when flexion is limited to 45 degrees; a 20 percent rating is assigned when flexion is limited to 30 degrees; and a 30 percent rating is assigned when flexion is limited to 15 degrees. Under Diagnostic Code 5261, limitation of extension of the leg, a noncompensable rating is assigned when extension is limited to 5 degrees; a 10 percent rating is assigned when extension is limited to 10 degrees; a 20 percent rating is assigned when extension is limited to 15 degrees; a 30 percent rating is assigned when extension is limited to 20 degrees; a 40 percent rating is warranted for extension limited to 30 degrees; and a 50 percent rating is assigned when extension is limited to 45 degrees. The standardized description of joint measurements is provided in Plate II under 38 C.F.R. § 4.71a. For VA purposes, "normal" extension and flexion of the knee is from zero to 140 degrees, and references to normal motion below indicate that the Veteran, in fact, had motion from zero to 140 degrees. 38 C.F.R. § 4.71a, Plate II. The VA General Counsel has held that a knee disability may receive separate ratings under diagnostic codes evaluating instability (Code 5257) and those evaluating range of motion (Codes 5003, 5010, 5256, 5260, and 5261). See VAOPGCPREC 23-97. The Board additionally notes that separate ratings under Diagnostic Codes 5260 and 5261 may be assigned for disability of the same knee joint. See VAOPGCPREC 9-2004. Under Diagnostic Code 5257, slight recurrent subluxation or lateral instability will be rated as 10 percent disabling, moderate recurrent subluxation or lateral instability will be rated as 20 percent disabling, and severe recurrent subluxation or lateral instability warrants a 30 percent rating. That being said, Diagnostic Code 5257 was amended effective February 7, 2021 to provide ratings for recurrent subluxation or lateral instability. A 30 percent rating is warranted for unrepaired or failed repair of complete ligament tear causing persistent instability and a medical provider prescribing both an assistive device (e.g., cane(s), crutch(es), walker) and bracing for ambulation. A 20 percent rating is warranted for either (a) sprain, incomplete ligament tear, or repaired complete ligament tear causing persistent instability, and a medical provider prescribing a brace and/or assistive device (e.g., cane(s), crutch(es), walker) for ambulation; or (b) unrepaired or failed repair of complete ligament tear causing persistent instability, and a medical provider prescribing either an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. A 10 percent rating is warranted for sprain, incomplete ligament tear, or complete ligament tear (repaired, unrepaired, or failed repair) causing persistent instability, without a prescription from a medical provider for an assistive device (e.g., cane(s), crutch(es), walker) or bracing for ambulation. Diagnostic Code 5257 also provides for ratings based on patellar instability. A 30 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for a brace and either a cane or a walker. A 20 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability after surgical repair that requires a prescription by a medical provider for one of the following: a brace, cane, or walker. A 10 percent rating is warranted for a diagnosed condition involving the patellofemoral complex with recurrent instability (with or without history of surgical repair) that does not require a prescription from a medical provider for a brace, cane, or walker. Note [1] to Diagnostic Code 5257 states that for patellar instability, the patellofemoral complex consists of the quadriceps tendon, the patella, and the patellar tendon. Note [2] to Diagnostic Code 5257 states that a surgical procedure that does not involve repair of one or more patellofemoral components that contribute to the underlying instability shall not qualify as surgical repair for patellar instability (including, but not limited to, arthroscopy to remove loose bodies and joint aspiration.) The Veteran was first afforded a VA examination to evaluate the nature and severity of his bilateral knee conditions in November 2014, during which he reported experiencing daily bilateral knee pain. He also endorsed experiencing flare-ups of additional symptomatology that resulted in difficulty with ambulation; in addition, he noted that his knees would swell and turn red during a flare-up. Furthermore, he related that he could not run, which prevented him from being a police officer. Range of motion testing did not reveal any loss of flexion, extension, instability, or ankylosis bilaterally, although the examiner did note that the Veteran exhibited some tenderness under the right kneecap. The examiner also noted that during a flare-up of pain the Veteran appeared to be additionally limited to the point that ambulation was difficult for him. However, the examiner did not make any estimate as to the additional loss of function in the form of an estimated loss of range of motion. In summation, the only impairment to occupational functioning endorsed by the examiner was that the Veteran was precluded from running as due to his bilateral knee conditions. More recently, the Veteran was afforded a VA knee examination in March 2017,during which he reported experiencing chronic pain in his knees bilaterally that was relieved by the use of pain medication. According to the Veteran, most mornings his knees would swell and get red and hot. This also reportedly occurred following prolonged standing or walking. The Veteran did not endorse experiencing flare-ups of additional symptomatology but did detail that his standing and walking were limited to 30 minutes at a time. Range of motion testing revealed knee flexion bilaterally reduced to 120 degrees, with no loss of extension, instability, effusion, crepitus, or ankylosis. The examiner did note evidence of localized tenderness of the upper and lateral soft tissues bilaterally, as well as pain with weightbearing. There was no additional limitation after three repetitions of range of motion. The examiner did remark that the Veteran exhibited the following additional factors contributing to disability: less movement than normal, disturbance of locomotion, and interference with standing. In summation, the examiner found that the bilateral knee conditions contributed to impairment of occupational functioning in the form of a limitation of the amount of standing or walking that the Veteran could do at a given time. A November 2019 X-ray examination report reflects that there were no abnormalities in either knee. A review of post-service VA medical records does not reflect any specific treatment for knee pain other than the continued prescription of pain medication as well as the Veteran's sporadic attendance of physical therapy. Bilateral knee pain has been listed as an active problem for the entirety of the appeal period. Upon consideration of the evidence, the Board finds that a rating in excess of 10 percent is not warranted for either the right or left knee patellofemoral syndrome at any point during the appeal period. The available evidence, to specifically include the November 2014 and March 2017 VA examinations, does not reflect that the Veteran experienced any of the symptomatology that would warrant a compensable or separate rating for either the right or left knee under any of the possible applicable diagnostic criteria. The Veteran has not exhibited a loss of flexion or extension that would warrant a compensable rating. 38 C.F.R. § 4.71a, Diagnostic Codes 5260, 5261. There is no indication that he experienced any dislocated semilunar cartilage. 38 C.F.R. § 4.71a, Diagnostic Code 5258. Moreover, although the Veteran reported that he experienced difficulty with ambulation, there was no evidence of instability on either VA knee examination, and the Veteran has not reported nor does the record reflect that he requires the use of any prescribed assistive device for ambulation. 38 C.F.R. § 4.71a, Diagnostic Code 5257. The Board also notes that there is no evidence of ankylosis (Diagnostic Code 5256) or impairment of the tibia or fibula (Diagnostic Code 5262). However, the Board does find that the Veteran credibly reported experiencing pain upon ambulation in both knees, and as such he is entitled to at least a minimal 10 percent initial rating for both the right and left knee conditions for the entire period of the appeal. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. § 4.71a, Diagnostic Codes 5003, 5010. The Board has reviewed the Veteran's lay testimony and the VA treatment records in the claims file, but this evidence does not tend to show that the symptoms of the right or left knee condition warranted a rating in excess of 10 percent at any point during the appeal period. As stated, for any additional functional loss to warrant a higher rating, that loss must rise to the level of the more severe symptomatology represented by the ratings in excess of those assigned and/or must reflect additional symptomatology not encompassed within the current assigned ratings which is sufficient to be rated separately, none of which has been shown. Furthermore, the Board acknowledges that the Veteran reported experiencing flare-ups of bilateral knee symptomatology on the November 2014 VA examination, and the examiner did not opine as to whether the Veteran would experience any additional impairment of function during such flare-ups of symptoms. That being said, there is no indication from the record that the Veteran would exhibit such a dramatic increase in bilateral knee impairment to warrant a rating in excess of 10 percent at any point during the appeal period. Indeed, the Veteran did not even endorse experiencing flare-ups on the subsequent March 2017 VA examination. Accordingly, the Board does not find that the Veteran's symptoms during a flare-up in either knee would be so significant as to equate to flexion reduced to 30 degrees, as would be necessary for an evaluation in excess of the currently assigned ratings or which would warrant a separate rating. Sharp, supra; Correia, supra. The Board acknowledges the Veteran's statements regarding the pain and stiffness he experienced in his knees. However, painful motion is contemplated and compensated by the 10 percent ratings that are currently assigned. DeLuca, supra. Therefore, the Board finds that the assigned 10 percent rating for right and left knee conditions from February 8, 2014 contemplates the impaired motion exhibited by the Veteran during the appeal period. A rating in excess of that 10 percent is not warranted for either knee at any point during the appeal period. 2. Left Wrist Condition The Veteran is currently in receipt of a noncompensable rating for his left wrist condition, characterized as deQuervain's syndrome. He seeks a compensable rating for the entirety of the appeal. The Veteran's residuals of a left wrist fracture with degenerative changes are currently assigned a noncompensable rating under 38 C.F.R. § 4.71a, Diagnostic Code 5215. Diagnostic Codes 5214 and 5215 assign disability ratings based on limitation of motion of the wrist. Under Diagnostic Code 5215, a 10 percent rating is warranted for limitation of motion of the wrist manifested by dorsiflexion limited to less than 15 degrees or by palmar flexion limited in line with the forearm. This is the maximum possible schedular rating under Diagnostic Code 5215. 38 C.F.R. § 4.71a, Diagnostic Code 5215. However, higher ratings are assignable under Diagnostic Code 5214 for ankylosis of the wrist. Under Diagnostic Code 5214, with respect to the minor extremity, a 20 percent rating is warranted where there is favorable ankylosis of the wrist in 20 to 30 degrees of dorsiflexion. A 30 percent rating is warranted where there is ankylosis of the wrist in any other position, except favorable. A maximum 40 percent rating is warranted where there is unfavorable ankylosis in any degree of palmar flexion, or with ulnar or radial deviation. A note following Diagnostic Code 5214 states that extremely unfavorable ankylosis will be rated as loss of use of the hands under Diagnostic Code 5125. 38 C.F.R. § 4.71a, Diagnostic Code 5214. Normal range of motion of the wrist includes dorsiflexion (extension) from zero to 70 degrees, palmar flexion from zero to 80 degrees, ulnar deviation from zero to 45 degrees, and radial deviation from zero to 20 degrees. 38 C.F.R. § 4.71a, Plate I (2016). As a reminder, the evaluation of a service-connected disability involving a joint rated on limitation of motion requires adequate consideration of functional loss due to pain under 38 C.F.R. § 4.40 and functional loss due to weakness, fatigability, incoordination or pain on movement of a joint under 38 C.F.R. § 4.45. See DeLuca v. Brown, 8 Vet. App. 202 (1995). Handedness for the purpose of a dominant rating will be determined by the evidence of record, or by testing on VA examination. Only one hand shall be considered dominant. As demonstrated by the medical evidence of record, including the November 2014 and March 2017 VA examinations, the Veteran is right-handed, and, as such, a disability rating for his non-dominant left hand is applicable here. See 38 C.F.R. § 4.69. The intent of the schedule is to recognize painful motion with joint or periarticular pathology as productive of disability. Joints that are actually painful, unstable, or malaligned, due to healed injury, should be entitled to at least the minimum compensable rating for the joint. Special note should be taken of objective indications of pain on pressure or manipulation, muscle spasm, crepitation, and active and passive range of motion of both the damaged joint and the opposite undamaged joint. 38 C.F.R. § 4.59. Moreover, the United States Court of Appeals for Veterans Claims (Court) has held that the application of 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. When § 4.59 is raised by the claimant or reasonably raised by the record, even in non-arthritis contexts, VA should address its applicability. Burton v. Shinseki, 25 Vet. App. 1, 3-5 (2011). Further, 38 C.F.R. § 4.59 requires that "[t]he joints involved should be tested for pain on both active and passive motion, in weight-bearing and nonweight-bearing and, if possible, with the range of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158, 169-170 (2016). In addition, the assignment of a disability rating should take into account limitation of functional ability or additional range of motion lost during flare-ups or after repetitive motion. See 38 C.F.R. §§ 4.40, 4.45, 4.59; Sharp v. Shulkin, 29 Vet. App. 26, 33 (2017); DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). During the appeal period, the nature and severity of the left wrist condition was first evaluated in a November 2014 VA examination, during which the Veteran stated that he experienced daily left medial wrist pain with nodule. According to the Veteran, he is unable to lift heavy objects and wears a brace on his left wrist daily. He did not endorse experiencing any flare-ups of additional symptomatology. Range of motion testing did not reveal any loss of palmar flexion, dorsiflexion, ulnar deviation or radial deviation, and the Veteran did not exhibit any pain during the examination. However, the examiner did note that the Veteran exhibited tenderness at the base of the thumb as well as pain with extension of the thumb. In summation, the examiner did not find that the left wrist condition contributed to any impairment of occupational functioning. More recently, the severity of the left wrist condition was evaluated in a March 2017 VA wrist examination, during which the Veteran detailed that he experienced left wrist pain at the base of the thumb and at the medial wrist once or twice per week. He again related that he wore a thumb spica splint, and that he avoided using his left hand in order to prevent a flare-up of wrist pain. To that end, while he endorsed experiencing flare-ups of left wrist pain occasionally, he did not report experiencing any functional loss or impairment as due to the left wrist condition. Range of motion testing did not reveal any loss of palmar flexion, dorsiflexion, ulnar deviation, or radial deviation, and the Veteran did not exhibit any pain or tenderness during the examination. In summation, the examiner did not find that the left wrist condition contributed to any impairment of occupational functioning. A November 2019 X-ray examination report reflects that there were no abnormalities in the left wrist. A review of post-service VA medical records does not reflect any specific treatment for a left wrist disorder other than the prescription of pain medication as well as a left wrist brace. Left wrist pain has been listed as an active problem for the entirety of the appeal period. Upon consideration of the evidence, the Board finds that a minimum 10 percent rating is warranted for the left wrist condition for the entirety of the appeal period. The available evidence, to specifically include the November 2014 and March 2017 examinations, does not reflect that the Veteran experiences any of the symptomatology that would warrant a compensable rating for the left wrist disability under the applicable diagnostic criteria. He has not demonstrated any limitation of motion or ankylosis. 38 C.F.R. § 4.71a, Diagnostic Codes 5214, 5215. However, the Board does find that the Veteran credibly reported experiencing chronic pain in his left wrist, and as such he is entitled to at least a minimal 10 percent rating for the entire period of the appeal. See 38 C.F.R. §§ 4.10, 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 202. That being said, a rating in excess of 10 percent is not warranted at any point during the appeal period. The minimum compensable rating for the Veteran's left wrist condition under Diagnostic Code 5215 is also the maximum compensable rating under the relevant diagnostic code. That rating, the newly assigned rating here, is 10 percent. Based on a review of the relevant evidence and the applicable law and regulations, it is the Board's conclusion that the evidence most nearly approximates the current assignment of a 10 percent rating, and no higher, for the Veteran's left wrist condition on a schedular basis for the entire relevant period. The Board considered whether a higher rating is warranted under the regulations relating to additional functional loss due to pain, weakness, fatigability, incoordination, and other factors under DeLuca, 8 Vet. App. at 204-07; 38 C.F.R. §§ 4.40, 4.45. The evidence of record does not indicate that the Veteran's functional impairment due to DeLuca factors is equivalent to the criteria for a rating greater than 10 percent for his left wrist disability at any point during the period on appeal. Inasmuch as the Veteran has reported experiencing left wrist pain throughout the appeal period, a higher rating is still not warranted, as this pain is already contemplated in the assignment of the 10 percent rating for limitation of motion under Diagnostic Code 5215. See Johnston v. Brown, 10 Vet. App. 80, 84-85 (1997). The Board acknowledges that the Veteran reported experiencing flare-ups of left wrist pain following use of the left wrist on the November 2014 examination. However, there is no indication from those examinations or the available treatment records that any increase in pain during such flare-ups would equate to an increase in limitation of motion or involvement of multiple joints, as would be necessary for an evaluation in excess of 10 percent. Sharp v. Shinseki, 29 Vet. App. 26 (2017); Correia v. McDonald, 28 Vet. App. 158 (2016). Thus, although the November 2014 examiner did not provide an estimate as to the additional limitation in range of motion during a flare-up, such an estimate is not necessary, as it would not result in a higher rating even if additional range of motion limitation was indicated by the evidence. In summation, the Board finds that the criteria for a rating in excess of 10 percent have not been met under any of the applicable diagnostic codes as the Veteran has not exhibited ankylosis or involvement of two or more joints at any point during the pendency of the appeal. Accordingly, an initial rating of 10 percent for a left wrist condition, but not more, is warranted for the entirety of the appeal period. REASONS FOR REMAND Entitlement to service connection for a low back condition is remanded. The likely etiology of the claimed low back condition was most recently evaluated in a March 2017 VA examination and opinion, wherein the Veteran was diagnosed with lumbosacral strain after an in-person evaluation. The examiner then opined that it was less likely than not that the Veteran had a low back condition that was incurred in or is otherwise attributable to his service. In support thereof, the examiner stated that the Veteran was evaluated with a normal back on his November 2014 separation examination, with no history of a back diagnosis and no medical documentation showing a chronic back condition. The Board cannot rely on this opinion, as the examiner apparently ignored clear evidence that the Veteran complained of experiencing back pain while in service. Specifically, the Board highlights that the Veteran reported a history of experiencing back pain on a September 2013 Report of Medical Assessment. He also sought treatment in service in November 2013 for right upper back pain that was evaluated as a strain. Additional treatment records dating from December 2013 show that he was still experiencing pain over a month after he initially sought treatment. These records appear to contradict the March 2017 VA examiner's findings that there was no medical documentation of a chronic back condition and no history of a back diagnosis in service. As such, the opinion cannot be relied upon, based as it is on an inaccurate factual premise. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Under these circumstances, the Board finds that remand is necessary in order for the AOJ to secure an opinion which takes into consideration this potentially positive evidence suggesting that the Veteran did indeed have a diagnosable back condition while in service. The matters are REMANDED for the following action: Provide the claims file to a qualified VA medical professional for the purpose of eliciting an addendum opinion as to the likely etiology of the low back condition. The entire claims file, to include a complete copy of this Remand, must be made available to the chosen examiner, and that individual must indicate that they reviewed the entire file prior to setting forth any opinion as to the likely etiology of the low back condition. After a thorough review of the claims file, the examiner is asked to opine as to whether it is at least as likely as not (an approximate balance of positive and negative evidence) that the Veteran's low back condition had its onset during service or is otherwise related to active service. In setting forth this opinion, the examiner should consider, and comment upon as necessary, documentation of the Veteran having reported experiencing back pain in service in 2013 prior to his discharge. It is essential the examiner discuss the underlying rationale of all opinions expressed, preferably citing to relevant evidence in the file supporting conclusions and/or medical literature or authority. A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Christopher M. Collins, 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.