Citation Nr: 21073374 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 18-21 178 DATE: December 8, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to a nerve disability of the right lower extremity to include sciatica is remanded. Entitlement to service connection for a right leg disability is remanded. Entitlement to service connection for a right hip disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1992 to January 2000. In addition, the Veteran served active duty for training for the United States Army Reserves from May 1991 to August 1991. This matter is before the Board of Veterans' Appeals (Board) on appeal of a November 2015 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). In August 2021, the Veteran appeared at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is in the record. 1. Entitlement to service connection for a low back disability is remanded. The Veteran asserts he has a low back disability resulting from active-duty service. Service treatment records show that in September 1992, he sought treatment for what he thought was a pinched nerve after running. He was diagnosed with a paraspinal muscle strain and placed on profile for four days. The Veteran contends that he was either misdiagnosed or mistreated because four days of light duty is an insufficient time to recover. In addition, the Veteran testified that his back problem began while driving a truck in a convoy in 1995. He developed pain after driving for a long time. A doctor told him to walk normally to avoid aggravating the problem. The Veteran, however, testified his back problems have continued. Finally, the Veteran states that his problems are frequently experienced by truck drivers. His service involved driving a HEMTT (heavy expanded mobility tactical truck) refueling tanker. Therefore, the Veteran argues performance of his service duties generally resulted in a low back disability that should be service connected. The Board has determined that a remand is necessary for a complete record. The Veteran has submitted a May 2016 treatment note by a chiropractor, Dr. W. G., who expressed an opinion that the Veteran's back disability is related to service. Dr. G., however, planned further treatment and workup on the back including X-rays. The Veteran testified he has sought additional treatment from Dr. G. as well. The additional treatment records are not of record. The Board has determined that the records are relevant and there is a reasonable possibility that the records could help substantiate the claim. See Golz v. Shinseki, 590 F.3d 1317, 1322 (Fed. Cir. 2010) (discussing records from the Social Security Administration). Ongoing medical records should also be obtained. Further, the November 2017 VA examination is incomplete. The VA examiner only discussed whether the September 1992 treatment is related to the Veteran's current back symptoms. He did not discuss the Veteran's lay evidence that the problems continued and he had not sought further treatment. Instead of treatment, the Veteran's supervisor exercised his authority and allowed the Veteran to return to quarters whenever he had a symptom flare-up. The examiner also did not discuss the effect of the 1995 convoy or service overall as the cause or onset of any current back symptoms. A new VA examination is required to provide the necessary missing information. See D'Aries v. Peake, 22 Vet. App. 97, 104 (2008) (VA examinations must contain opinions and rationale that will allow the Board's decision to be a fully informed one). 2. Entitlement to a nerve disability of the right lower extremity to include sciatica is remanded. 3. Entitlement to service connection for a right leg disability is remanded. 4. Entitlement to service connection for a right hip disability is remanded. As to the other three issues, the Veteran asserts that they are connected to and flow from his back problems. These claims are inextricably intertwined with the Veteran's other claims and must also be remanded. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). Further, once the records development is completed, a VA medical examination and accompanying medical opinion is needed to ascertain whether the disabilities are present and to ascertain the relationship to service. 38 C.F.R. § 3.159; see also McLendon v. Nicholson, 20 Vet. App. 79, 86 (2006). The Board recognizes that the Veteran currently does not appear to have diagnosed right leg, right hip, and sciatica disabilities. Pain, by itself, may become a service-connected disability. See Saunders v. Wilkie, 886 F.3d 1356, 1367-68 (Fed. Cir. 2018) (finding pain resulting in functional impairment, even if there is no identified underlying diagnosis, can constitute a disability). Therefore, the Board has determined that VA examinations are warranted. The matters are REMANDED for the following action: 1. Ask the Veteran to identify all outstanding treatment records relevant to his claims including records from Dr. W. G. All identified VA records should be added to the claims file. All other properly identified records should be obtained if the necessary authorization to obtain the records is provided by the Veteran. If any records are not available, or the Veteran identifies sources of treatment but does not provide authorization to obtain records, appropriate action should be taken (see 38 C.F.R. § 3.159(c)-(e)), to include notifying the Veteran of the unavailability of the records. 2. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current back disability to include a compressed disc, scoliosis, or sciatica, had its onset during service or is otherwise related to an in-service injury, event, or disease, to include a September 1992 incident where the Veteran sought medical treatment and a 1995 convoy that the Veteran reports as the onset of continuing back symptoms. In offering the opinion, the examiner is asked to consider each of the following: a). Whether the Veteran has a back disability resulting from a September 1992 injury of back pain after running. b). whether the Veteran has a back disability resulting from a long 1995 convoy. c). Whether the Veteran's service duties generally driving trucks played a role in a current back disability. d). The examiner is asked to consider and discuss the Veteran's evidence that his supervisor had the authority and discretion to allow the Veteran to return to quarters in lieu of seeking treatment when the Veteran experienced pain. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 3. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current disability of the right leg had its onset during service or is otherwise related to an in-service injury, event, or disease The examiner should also address whether any current disability of the right leg is at least as likely as not (a) caused by, or (b) aggravated by (worsened beyond natural progression) a back disability. The examiner is also instructed that even if there is no diagnosed condition, a symptom such as pain, by itself, may become a service-connected disability if it results in functional impairment. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 4. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current disability of the right hip had its onset during service or is otherwise related to an in-service injury, event, or disease. The examiner should also address whether any current disability of the right leg is at least as likely as not (a) caused by, or (b) aggravated by (worsened beyond natural progression) a back disability. The examiner is also instructed that even if there is no diagnosed condition, a symptom such as pain, by itself, may become a service-connected disability if it results in functional impairment. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. 5. After records development is completed, schedule the Veteran for a VA examination to determine whether it is at least as likely as not (50 percent probability or greater) that any current neurological disability of the right lower extremity had its onset during service or is otherwise related to an in-service injury, event, or disease. The examiner should also address whether any current disability of the right leg is at least as likely as not (a) caused by, or (b) aggravated by (worsened beyond natural progression) a back disability. The examiner is also instructed that even if there is no diagnosed condition, a symptom such as pain, by itself, may become a service-connected disability if it results in functional impairment. The examiner should elicit a full history from the Veteran and consider the lay statements of record. The Veteran is competent to attest to factual matters of which he has first-hand knowledge, and if there is a medical basis to support or doubt the history provided by the Veteran the examiner should provide a fully reasoned explanation. A rationale for all opinions expressed is requested as adjudicators are precluded from making any medical findings. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Russell P. Veldenz, 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.