Citation Nr: 21071880 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 17-09 296 DATE: December 1, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from July 1975 to July 1995. The case comes before the Board of Veterans' Appeals (Board) on appeal from an August 2016 rating decision. In August 2021, the Veteran testified before the undersigned Veterans Law Judge during a videoconference hearing. A transcript of the hearing is of record. Although the Board regrets the additional delay, a remand is necessary to ensure that there is a complete record upon which to decide the Veteran's claims so that he is afforded every possible consideration. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159. Entitlement to service connection for a low back disability is remanded. The veteran asserts that his low back disability began in service. He contends that he has chronic problems with his back, he has leg cramps that are due to his back problems, and he had back problems while in the service, and he still does until this day. See January 2017 Notice of Disagreement. As an initial matter, there is no dispute that the Veteran has a current low back disability. However, an August 2016 VA examiner opined against a relationship to service. The examiner noted that the Veteran's entrance examination was negative for any back condition with a normal back examination, but also that the Veteran was seen in April 1976, June 1976, and February 1981 for acute episodes of back pain with a diagnosis of muscle strain of the back. The examiner noted normal lumbar spine x-rays in February 1981. The examiner also noted positive complaints of back pain, and a diagnosis of recurrent, occasional back pain, but no diagnosis of chronic back pain during the Veteran's March 1995 exit examination. The examiner noted that the Veteran reported a history of hurting his back many times during service and that he would go to medical, receive a hot pack, and be sent on his way. The examiner also noted that the Veteran reported he was diagnosed with degenerative disc disease in 2011 and that his back hurts most of the time; the pain varies through the day; he has been seen by a chiropractor and receives injections; and he takes pain medications. As a result of the VA examination, the examiner opined that the Veteran's degenerative disc disease (DDD) was less likely than not (less than 50 percent probability) related to his treatment in service for back pain/strain. By way of rationale, the examiner explained that the Veteran was treated for recurrent strains during his military service, but there was no evidence of DDD noted during service, and no evidence of trauma which would most likely result in early degenerative changes. The examiner also noted that there was no evidence of continuity of care for a back condition since his release from military service until around 2012, which was 17 years after service, and that age has been shown by a preponderance of the most recent peer reviewed medical literature as the most likely cause for degenerative arthritis. See August 2016 VA examination report. After this examination, the Veteran provided additional information about his in-service back problems. During his August 2021 hearing, the Veteran testified that most of his back issues started close to when he first joined the Navy. He testified that his duties while in service included maintaining and repairing boilers and associated equipment, rebricking furnaces, and carrying packages weighing 80 to 100 pounds up and down 10 flights of stairs. He testified that he experienced a lot of wear and tear, and that he hurt his back a few times and went to medical to seek treatment for the pain, but that he was just given a heating pad or aspirin. He testified that it was just something he had to work through during his 20 years in the service. He testified that, since service, he has had chiropractic care and private treatment for his back. See August 2021 Hearing Transcript. In support of his claim, the Veteran has submitted a medical opinion authored by T.K., PA-C, indicating that the Veteran's back pain and degenerative disc disease is more likely than not due to his military service. See September 2021 T.K. opinion. However, no rationale was offered in support of his opinion; therefore, it is not sufficient for an award of benefits at this time. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2004) (concluding that a medical opinion is not entitled to any weight "if it contains only data and conclusions"). The record also includes a Back Conditions Disability Benefits Questionnaire (DBQ) completed in March 2016 by T.K. The DBQ, which appears to have been authored by the provider of the September 2021 opinion, was completed based upon review of civilian medical records, but not the Veteran's VA claims file. The provider noted diagnoses of degenerative disc disease, intervertebral disc syndrome, radiculopathy, back pain, and sciatica. In the DBQ, the provider noted that the Veteran reported pain began several years ago with normal activity and also referenced a 2012 EMG. See March 2016 DBQ (received in June 2016). The record includes a buddy statement from the Veteran's friend who noted he had been stationed with the Veteran in the Navy, and that they became friends and enjoyed outdoor activities together over the years, but over time, the Veteran began to participate less and less on the outings due to back pain and discomfort when doing physical activities. See September 2021 R.P. statement. The record also includes a statement offered by a family friend in which she stated that in the fifteen years they were stationed together, the Veteran's pain seemed to increase, that he often complained of serious pain when doing any physical activity, and that the Veteran had told her his pain has gotten worse over the years and simple tasks seem difficulty to perform. See September 2021 J.G. statement. Given the assertions of the Veteran and his additional description of symptoms during and since service, as well as the buddy statements offered in support of the Veteran's contentions of back pain after service, the Board believes an updated opinion should be ordered to assess the etiology of the Veteran's claimed low back disability. The Veteran also testified that he has received private treatment, and the 2016 private DBQ referenced review of civilian medical records and a 2012 EMG. Therefore, on remand, the Veteran should be asked to submit, or authorize VA to obtain on his behalf, all records of private care that are not already associated with the record. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file outstanding VA treatment records. 2. Give the Veteran an additional opportunity to submit, or authorize VA to obtain on his behalf, any records of private treatment for his back that are not already associated with the claims file. All efforts to obtain these records should be fully documented. 3. After any outstanding records have been associated with the claims file, furnish the Veteran's claims file to an appropriate clinician to address the etiology of his low back disability. The record must be made available for the clinician's review. The need for an additional examination is left to the discretion of the medical professional selected to write the addendum opinion. Following a review of the entire record, the examiner is asked to address the following: a) Identify all current back disabilities. b) For each of the identified disability, is it at least as likely as not (approximately 50 percent probability) that such had onset in, or is otherwise related to active-duty service, to specifically include wear and tear from the physical rigors of his service? The examiner should specifically discuss whether the nature of the Veteran's current back disability, from a medical perspective, is consistent with the Veteran's in-service duties and his lay reports of ongoing symptoms after service. The mere fact that he did not receive treatment immediately following service cannot be the exclusive basis upon which a negative determination is made without further discussion as to why, medically, such observation is dispositive. All opinions should be supported by a medical explanation or rationale. 4. Thereafter, readjudicate the issue on appeal. If the claim remains denied, send the Veteran a supplemental statement of the case. V. Chiappetta Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Fulmer, 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.