Citation Nr: 21076651 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 17-34 053 DATE: December 27, 2021 REMANDED The issue of entitlement to service connection for a back condition is remanded. The issue of entitlement to service connection for headaches is remanded. Entitlement to a disability rating greater than 10 percent for left knee strain is remanded. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from August to November 1979 and again from November 1990 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In furtherance of the claim, the Veteran testified in a hearing before the undersigned Veterans Law Judge, and the transcript is of record. REASONS FOR REMAND When the VA orders a medical examination, it must conduct a "thorough and contemporaneous [one]." Proscelle v. Derwinski, 2 Vet. App. 629, 632 (1992). All medical examinations ordered by the VA must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) ("[O]nce the Secretary undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, he must provide an adequate one or, at a minimum, notify the claimant why one will not or cannot be provided."). A medical opinion is adequate "where it is based on consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.'" Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (quoting Ardison v. Brown, 6 Vet. App. 405, 407 (1994)). Additionally, a thorough and adequate examination must consider all other relevant evidence of record, including lay statements. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). An adequate medical opinion does not contain only data and conclusions, "but also a reasoned medical explanation connecting the two." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008). Ultimately, if an examination report does not contain sufficient detail, "it is incumbent upon the rating board to return the report as inadequate for evaluation purposes." 38 C.F.R. § 4.2; see Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return inadequate examination reports); Hicks v. Brown, 8 Vet. App. 417, 421 (1995) (inadequate medical evaluation frustrates judicial review). 1. The issue of entitlement to service connection for a back condition is remanded. In the instant case, the Veteran was afforded two VA examinations with three related opinions in furtherance of his claim for entitlement to service connection for a back condition. Unfortunately, the two VA opinions regarding the relationship of the Veteran's back condition to service were inadequate. The August 2015 opinion merely stated that no back condition was found upon examination. That opinion is conclusory and does not consider the Veteran's statements regarding continuous back pain since service. Furthermore, despite the fact that pain which results in functional impairment constitutes a disability for VA purposes, the opinion gave little consideration to objective manifestations of pain. On the other hand, the June 2017 VA examination opinion regarding the negative relationship between the Veteran's service-connected left knee condition and his claimed back condition is adequate. There the examiner noted that there were no compensatory changes in gait or stance to account for the degenerative joint disease of the lumbar spine and attributed the Veteran's current lumbar condition to both age and his civilian work as a carpenter. Nonetheless, the opinion regarding the Veteran's back condition and its direct relationship to service was inadequate. There, the examiner, while noting complaints of muscle spasm as remote as 1988, relied on the absence of chronic reports of back problems in the Veteran's service treatment records to provide a negative opinion. Therefore, remand to obtain an adequate opinion addressing the Veteran's claim of back pain which began in service and continued ever since is warranted. 2. The issue of entitlement to service connection for headaches is remanded. With respect to the Veteran's headache claim, one VA examination was conducted. The resultant opinion is, however, inadequate for VA purposes. While the opinion noted complaint of headache in 1991, it indicated that there was no injury in service to account for recurrent headaches to date. 8/26/2015 C&P Examination. The opinion is conclusory; does not consider other, non-traumatic causes of headache; and does not consider lay statements which attribute the Veteran's headaches to noise exposure. Thus, remand for an addendum opinion is needed. 3. Entitlement to a disability rating greater than 10 percent for left knee strain is remanded. Although "the mere passage of time" does not itself trigger the duty to provide a new medical examination, "additional evidence showing a change in [the relevant] condition" may do so. Palczewski v. Nicholson, 21 Vet. App. 174, 182 (2007). A "bald, unsubstantiated claim for an increase in disability rating," is also insufficient to compel VA to provide a veteran with a new, contemporaneous medical examination. Glover v. West, 185 F.3d 1328, 1333 (Fed. Cir. 1999). However, reexamination is required when "evidence indicates there has been a material change in a disability or that the current rating may be incorrect." 38 C.F.R. § 3.327(a) (2020). To trigger the need for a new examination, there must at least be an allegation that the claimant's condition has worsened. Palczewski, 21 Vet. App. at 182. Here, the Veteran was diagnosed with left knee instability in October 2017, and, during the Board hearing, he reported that his knee gives way and has caused him to fall. 1/22/2020 CAPRI; 9/20/2021 Hearing. Accordingly, remand for a new knee examination is warranted. The matters are REMANDED for the following action: 1. Forward the Veteran's claims file to an appropriate VA medical examiner to issue a medical opinion regarding the Veteran's claim of service connection for a lower back disability. The entire claims file, including a copy of this Remand, must be made available to, and must be reviewed by, the examiner providing the opinion. If, and only if, the examiner determines that an examination should be conducted, one should be scheduled. Thereafter, the examiner should address the following: a) Please identify any current disability of the lower back. "Current" is defined as any condition identified since the filing of the claim in November 2014 to the present. "Disability" includes any diagnosable conditions as well as pain or symptoms that are not diagnosable but, nonetheless, cause functional impairment. b) For each disability identified in part (a.), please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's current lower back disabilities were incurred in, caused by, or related to service. The examiner should consider medical and lay evidence dated both prior to and since the filing of the claim in November 2014, including Veteran statements that his lower back pain began in service and has continued since. The examiner must provide a complete rationale for any opinion rendered. If the examiner cannot provide an opinion without resort to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information or evidence, the limits of medical knowledge, etc.). 2. Forward the Veteran's claims file to an appropriate VA medical examiner to issue a medical opinion regarding the Veteran's claim of service connection for headache disability. The entire claims file, including a copy of this Remand, must be made available to, and must be reviewed by, the examiner providing the opinion. If, and only if, the examiner determines that an examination should be conducted, one should be scheduled. Thereafter, the examiner should address the following: a) Please identify any current headache disability, to include migraine, tension headache, and cluster headache. "Current" is defined as any condition identified since the filing of the claim in November 2014 to the present. "Disability" includes any diagnosable conditions as well as pain or symptoms that are not diagnosable but, nonetheless, cause functional impairment. (a.) For each disability identified in part (a.), please state whether it is at least as likely as not (50 percent probability or more) that the Veteran's current headache disabilities were incurred in, caused by, or related to service. Please comment on the multiple occasions of recurrent headache noted in February 1991 and discuss whether recurrent headaches are indicative of early onset undiagnosed hypertension. The examiner should consider medical and lay evidence dated both prior to and since the filing of the claim in November 2014, including Veteran statements that his headaches began in service and has continued since. The examiner must provide a complete rationale for any opinion rendered. If the examiner cannot provide an opinion without resort to speculation, he or she should explain why an opinion cannot be provided (e.g., lack of sufficient information or evidence, the limits of medical knowledge, etc.). S.C. Krembs Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Z. Sloley, 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.