Citation Nr: 21074096 Decision Date: 12/14/21 Archive Date: 12/14/21 DOCKET NO. 20-21 425 DATE: December 14, 2021 REMANDED The issue of entitlement to service connection claim for a back disability, to include back pain and herniated disks, is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from September 1972 to September 1974. He had additional unverified periods of service in the United States Army Reserve. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2018 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Honolulu, Hawaii, in which the RO, inter alia, denied service connection for a back disability. The Veteran disagreed with that determination and subsequently perfected an appeal to the Board. Unfortunately, the Board finds that further action on the claim on appeal is warranted, even though such will, regrettably, further delay an appellate decision on this matter. In the instant case, the Veteran has stated his belief that he has a back disability that is related to service. Specifically, in a December 2017 statement, he reported that during basic training, he was required to run with a 60 pound rucksack on his back, which tore into his shoulders, for several miles, up hills, down trains, in mud and dirt, and on rough roads, with all this weight on his back, in addition to his M16 ammunition and a "WWII steel pot." He reported experiencing burning pain in his shoulders and upper and lower back. In his April 2020 VA Form 9 (Appeal to the Board of Veterans' Appeals), the Veteran stated that he sought treatment for a back condition during service in December 1973 and that he has back pain, to include a burning sensation that spreads to his neck and across his shoulders, since his military service. The Board notes that the Veteran has not been provided with a VA examination in connection with his claim for service connection for a back disability. Here, the evidence shows that the Veteran has consistently complained of upper and low back pain. There is also complaints of upper back pain noted in the Veteran's service treatment records in December 1973 and post-service evidence of herniated discs. The Board also points out that the Veteran contends that he has experienced back symptomatology since service. In this regard, the Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has firsthand knowledge, such as symptoms or events experienced during and/or since service. See Washington v. Nicholson, 21 Vet. App. 191, 195 (2007) (holding that, "[a]s a layperson, the appellant is competent to provide information regarding visible, or otherwise observable, symptoms of disability"). Based on this evidence, the Board has determined that the "low threshold" necessary to establish entitlement to a VA medical examination has been satisfied. McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006); see 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4). Accordingly, the Board finds that the matter must be remanded for the agency of original jurisdiction (AOJ) to provide the Veteran with a VA examination to fully assess the nature of any back disability and to obtain an opinion regarding the likelihood that any such disability is due to service. The Board also finds it necessary to remand the back claim as it appears that there may be potentially relevant records outstanding. Specifically, the evidence suggests that the Veteran had additional service after 1974 and that records related to this additional service may be outstanding. Notably, although the RO requested and obtained the Veteran's service treatment and service personnel records, the records obtained were limited to the Veteran's period of service from September 1972 to September 1974. However, the Veteran clarified that he had an additional period of service, in which he served in the 442 Infantry Army Reserve unit from October 1974 to October 1975, during which time he was stationed at Fort DeRussy, Honolulu, Hawaii. See August 2020 Correspondence. Further, available military personnel records show that the Veteran was transferred to the United States Army Reserve Control Group in October 1975 and that he was discharged from the Standby Reserve in September 1978. Here, there is no indication that the AOJ has attempted to verify the Veteran's Reserve service dates or obtain any treatment records related to his Reserve service. As these outstanding records may contain evidence relevant to the Veteran's claim of service connection for a back disability, as they may contain information to substantiate the Veteran's reported continuity of symptomatology, a remand is also required for the AOJ to attempt to verify the Veteran's Reserve service dates and to obtain the Veteran's complete military treatment records. The matter is REMANDED for the following action: 1. First, undertake all reasonable efforts to verify all periods of the Veteran's service in the military, especially including periods of service in the Army Reserve after September 1974. 2. Then, provide a clearly enumerated list of the Veteran's periods of service in the Army Reserve, which should indicate for each period, whether the service was active duty, ACTDUTRA, INACTDUTRA or unverified. If necessary, a request should be submitted to the Defense Finance and Accounting Service (DFAS). If any information is unavailable or cannot be verified, please provide the Veteran with a Memorandum of Unavailability, and associate a copy of this memorandum with the claims file. 3. After verifying the Veteran's periods and characterizations of service, ensure that all service treatment and personnel records, especially including service records from the Army Reserve, are associated with the claims file. If any records are unavailable, provide the Veteran with a Memorandum of Unavailability, and associate a copy of this memorandum with the claims file. 4. After undertaking all of the above-mentioned developments, schedule the Veteran for a VA examination for his claimed back condition. The VA examiner must review a complete claims file and must note that review in the report. A copy of this REMAND must also be provided to the VA examiner. The VA examiner must undertake the following: a. For each diagnosed back condition, including upper and lower back pain, as well as upper back herniated discs, independently opine whether it is at least as likely as not (more than 50 percent probability) the pertinent back condition was incurred in service; is the result of an illness, injury, or event in service; or is otherwise related to the Veteran's active service. b. In rendering an opinion, please consider the Veteran's lay statements about onset and continuity of symptoms, including, among others, lay statements about the weight and impact of heavy items on his back during basic training, as well as his assertion that he has had pain, with a burning sensation, since his he was in military service. c. A detailed explanation is requested for all opinions. If it is not possible to render an opinion without resorting to speculation, please provide an explanation as to why this is this case, and what additional evidence, if any, would make it feasible to render such an opinion. KRISTIN E. NEILSON Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board V-N. Pratt, 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.