Citation Nr: 21075189 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 15-02 115 DATE: December 17, 2021 REMANDED Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran had active naval service from June 1962 to August 1966. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In July 2018, the Veteran and his spouse testified before a Veterans Law Judge. A transcript of that hearing has been associated with the record. This case was previously before the Board, most recently in June 2020, at which time the Board denied entitlement to service-connection for a back disability. The Veteran appealed to the United States Court of Appeals for Veterans Claims (Court). In July 2021, the Court granted a Joint Motion of the parties, vacated the Board's decision, and remanded the case to the Board for action consistent with the Joint Motion. Pursuant to an October 2018 Board remand, the Veteran was afforded a VA examination in November 2019. The examiner opined that the Veteran's back disability was less likely as not caused by or a result of the Veteran's reported slip and fall during service. In support of this opinion, the examiner noted that the Veteran's service treatment records were silent for any slip and fall. While the Veteran had documented treatment for low back pain in April 1966, the examiner found that the Veteran's separation examination was within normal limits in July 1966. The examiner concluded that the Veteran's reported in-service slip and fall was not severe enough to develop lumbar degenerative joint diseases, stenosis, and disc herniations shown by a September 2011 private MRI, 48 years post-service. Referencing medical literature, the examiner stated that the leading cause of spinal stenosis was wear and tear on the spine due to aging. The most common direct cause of spinal stenosis was osteoarthritis, where the cartilage that cushions joints starts to degenerate due to age. Some patients were genetically more prone to stenosis. Further, lumbar spine disc herniation was most often the result of a gradual, age-related wear and tear called disc degeneration. The Board finds that the November 2019 examiner did not address the mechanism of injury to the Veteran's back, including his six-foot drop fall. Furthermore, the examiner did not consider the Veteran's lay assertions regarding the continuity of his symptoms since service. As such, the opinion is incomplete and additional medical evidence to supplement the existing record would be beneficial in the adjudication of this appeal. The Veteran testified that he received chiropractic treatment for approximately the past 20 years. Upon remand, those records should be obtained and associated with the record. The matter is REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records, to specifically include private chiropractic records, and associate them with the record. 2. Then, schedule the Veteran for an examination to determine the nature and etiology of his back disability. The claims file must be made available to and reviewed by the examiner. Any indicated studies should be performed. Based on the examination results and the review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or better probability) that the Veteran's back disability had its onset during his active service, or is otherwise etiologically related to such service. The examiner must comment on the Veteran's reported injury to his back after falling approximately six feet, and the continuity of his symptomatology since service. The rationale for all opinions expressed must be provided. 3. Confirm that the VA examination report and all medical opinions provided comport with this remand, and undertake any other development determined to be warranted. 4. Then, readjudicate the appeal. If the decision is adverse to the Veteran, issue a supplemental statement of the case and allow the appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Ware, 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.