Citation Nr: 21070886 Decision Date: 11/26/21 Archive Date: 11/26/21 DOCKET NO. 16-27 109 DATE: November 26, 2021 REMANDED Entitlement to service connection for a low back disorder is remanded. REASONS FOR REMAND The Veteran had active service from July 1973 to July 1975, along with service in the U.S. Army Reserve including from January 1991 to April 1991. This case comes before the Board of Veterans' Appeals on appeal from rating decisions from a Department of Veterans Affairs (VA) Agency of Agency of Original Jurisdiction (AOJ). The Veteran and his spouse testified before the undersigned in an October 2020 Board hearing. A transcript of the hearing is of record. The Board previously remanded this matter in November 2020 and August 2021. 1. Entitlement to a low back disorder The Veteran contends that his low back disorder resulted from a fall he sustained during his service in the 1970s. Specifically, the Veteran contends that he fell in December 1974. In August 2021, the Board remanded this matter in order to obtain an addendum medical opinion to address whether the Veteran's diagnosed back conditions to include intervertebral disc syndrome (IVDS) and lumbsacral strain are related to Veteran's claimed in-service incident. As noted in the August 2021 Board remand, the Veteran's service treatment records document a knee injury in December 1974 related to a fall, the treatment record does not note any back complaint. The Veteran's service treatment records also include a Report of Medical History dated September 1983, which includes a report of recurrent back pain. Upon remand, the RO was to obtain an addendum medical opinion that address the service treatment records, the Veteran's statement and a December 2012 private physician's opinion that the Veteran's low back is "possibly" associated with a fall sustained in 1974. In August 2021, the RO obtained an addendum medical opinion. The VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner reasoned that the available service treatment records are silent for the claim. The examiner then provided a list of reviewed evidence. The Board finds that August 2021 VA examiner failed to address the Veteran's statement that he fell in service, the service treatment record of a fall (albeit related to a knee injury) in December 1974, or the report of recurrent back pain in September 1983 Report of Medical History. The Board notes that simply listing the evidence reviewed, which included some evidence of a fall, is not properly addressing the evidence and whether it is related the Veteran's current back disorder. Therefore, a remand is required to obtain an adequate addendum medical opinion. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion from an appropriate clinician regarding the Veteran's diagnosed back conditions, including IVDS and lumbosacral strain. The examiner must provide the following opinions: (a.) Whether it is at least as likely as not the Veteran's back conditions is etiologically related to an in-service injury, event, or disease. The examiner must address: i. The Veteran's statement that he fell on his back in November or December 1974. ii. The service treatment record that notes that the Veteran sustained a fall in December 1973. iii. The September 1983 Report of Medical History notation of a recurrent back pain. iv. A December 2012 private physician opinion that the Veteran's low back pain is "possibly" associated with a fall sustained in 1974. (b.) The examiner must provide a complete medical rationale for all opinions and reconcile it with all pertinent evidence in the record. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Robert Batten 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.