Citation Nr: 21070520 Decision Date: 11/24/21 Archive Date: 11/24/21 DOCKET NO. 17-28 592A DATE: November 24, 2021 ORDER New and material evidence having been received, the claim of entitlement to service connection for a low back disability is reopened. REMANDED The appeal regarding entitlement to service connection for a low back disability is remanded. FINDINGS OF FACT 1. In a September 1990 rating decision, the Agency of Original Jurisdiction (AOJ) denied service connection for a low back disability; the Veteran did not appeal. 2. In a July 1995 rating decision, the AOJ declined to reopen the Veteran's claim; he did not appeal. 3. The evidence received since the July 1995 rating decision is not cumulative or redundant of evidence previously of record, relates to an unestablished fact necessary to substantiate the claim of entitlement to service connection for a low back disability, and raises a reasonable possibility of substantiating the claim. CONCLUSIONS OF LAW 1. The September 1990 and July 1995 rating decisions are final. 38 U.S.C. §§ 5108, 7105; 38 C.F.R. § 3.156. 2. New and material evidence has been received and the claim of entitlement to service connection for a low back disability is reopened. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. § 3.156. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty for training (ACDUTRA) from December 1984 to May 1985, and active duty from June 1986 to July 1989. This matter comes before the Board of Veterans' Appeals (Board) from an April 2015 rating decision by the AOJ that reopened the Veteran's claim of entitlement to service connection for a low back disability and denied the claim on its merits. REASONS FOR REMAND The Veteran asserts that his low back disability is related to service. Service treatment records indicate that on enlistment examination in May 1986, the Veteran endorsed recurrent back pain. However, clinical examination of his spine was normal and the Veteran was deemed fit for service. In October 1986, he reported that he was struck by a heavy machine in 1984 and experienced low back pain with radiation down his right leg following that incident. Examination was positive for decreased sensation at the L5 dermatome. The assessment was mechanical low back pain. The Veteran was treated with pelvic traction in November 1986. On separation examination in November 1988, he endorsed recurrent back pain. On VA examination in May 1990, the Veteran reported that he had been hit by a track vehicle while driving a 2.5 ton truck at Ft. Irwin. He also indicated that he experienced numbness below the waist and underwent treatment including traction in 1986. He indicated that he had experienced symptoms since service. Alternatively, the Veteran has argued that his low back disability is related to his service-connected bilateral knee disability. See March 2014 VA Form 21-526EZ. In this regard, the Board notes that VA examinations have identified disturbance of locomotion related to the Veteran's bilateral knee disability. See May 2016 VA examination report. The record contains medical evidence of central disc protrusion at L4-5. See October 1992 private MRI report. There is also evidence showing central canal stenosis and central foraminal narrowing at L4-5 and L5-S1. See June 2017 private CT scan report. A VA examination was conducted in February 2015. The examiner did not provide an opinion regarding whether the current back disability is related to service. Regarding secondary service connection, the examiner indicated that she could not determine a baseline level of severity of the claimed condition. She stated that she could not link worsening chondromalacia and retropatellar syndrome to worsening back symptoms without resorting to speculation. She concluded that the Veteran's low back disability had not been aggravated by his knee disability, reasoning that there were no medical records to support this for the Veteran. To the extent that the February 2015 examiner failed to provide opinions regarding whether the Veteran's back disability is related to service or was caused by his service-connected knee disability, the examination is inadequate. Moreover, the rationale provided regarding aggravation by the service-connected knee disability does not adequately explain the medical principles underlying the examiner's conclusion. An additional examination and opinion is necessary. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination to determine the nature and etiology of his claimed low back disability. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The examination report must include a notation that this record review took place. After the record review and examination of the Veteran, the examiner should provide an opinion regarding whether it is at least as likely as not that the Veteran's low back disability was incurred in, or is otherwise related to, his period of active service from June 1986 to July 1989. In rendering this opinion, the examiner is directed to service treatment records showing a normal spine on enlistment in May 1986 and subsequent complaints and treatment for his low back. The examiner should also provide an opinion regarding whether it is at least as likely as not that the Veteran's low back disability was the result of an injury or disease incurred during the Veteran's period of ACDUTRA from December 1984 to May 1985. The examiner should also provide an opinion regarding whether it is at least as likely as not that the Veteran's low back disability was caused or aggravated by his service-connected right and left knee disabilities. The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, he or she must provide an explanation for such rejection. The examiner is not to improperly discount the Veteran's lay statements or mistakenly rely on an absence of medical evidence in the record to support his or her conclusions. The complete rationale for all opinions should be set forth, and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the requested opinions cannot be provided without resorting to mere speculation, the examiner must provide a complete explanation for why an opinion cannot be rendered. In so doing, the examiner must explain whether the inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 2. Then, readjudicate the Veteran's claim. If the decision remains adverse to the Veteran, he and his representative should be furnished a supplemental statement of the case (SSOC) and afforded an appropriate period within which to respond thereto. DONNIE R. HACHEY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Barone, 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.