Citation Nr: 21077586 Decision Date: 12/30/21 Archive Date: 12/30/21 DOCKET NO. 17-37 844 DATE: December 30, 2021 REMANDED Entitlement to service connection for a lumbar spine disorder is remanded. Entitlement to service connection for a right knee disorder is remanded. Entitlement to service connection for a left knee disorder is remanded. Preliminary Matters The Veteran served on active duty from May 1978 to September 1978, from April 1979 to June 1983, from December 1990 to March 1991, and from November 1991 to May 1992. This appeal comes before the Board of Veterans' Appeals (Board) from a June 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In November 2021, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of this hearing has been associated with the claims file. REASONS FOR REMAND Upon review of the current evidence of record, the Board finds that a remand is required for several reasons, as discussed below. First, during a May 2016 VA spine examination, the Veteran reported that he initially started receiving treatment at VA for his back in "2011." During the May 2016 VA knee examination, the Veteran similarly indicated that he had been treated by VA for his knees for "some time." However, current VA treatment records are dated from 2015 to 2016. As such, VA treatment records prior to 2015 and after 2016 should be obtained on remand as these may prove relevant to any continuity of symptomatology related to the Veteran's back and knee disorders. Next, the Board finds that a remand is required to obtain any outstanding service treatment records. In this regard, there are no separation physical examinations of record for any period of active duty service. There are also only minimal treatment records for the Veteran's periods of active duty service from December 1990 to March 1991 and from November 1991 to May 1992. Another attempt to obtain these records should be made on remand. Moreover, as discussed below, the Veteran was seen in 1988 for a back injury. It is unclear as to whether the Veteran was on ACDUTRA or INACDUTRA at the time of the injury. A remand is warranted so that the Agency of Original Jurisdiction (AOJ) may attempt to confirm the Veteran's actual periods of ACDUTRA and INACDURTA. A remand is also required to obtain new VA examinations and medical opinions for the Veteran's lumbar spine and bilateral knee disorders. Regarding the lumbar spine disorder, available service treatment records show that, in February 1980, the Veteran stated that he had back pain for over 1 year. Pain was noted to be worse while driving and with exertion. In March 1980, the Veteran underwent x-rays of the spine due to low back pain for one month. X-rays showed no significant abnormality. Also in March 1980, the Veteran was diagnosed with mechanical low back pain and was treated with ice, massages, and antiinflammatory medication. In a separate March 1980 treatment notes, the Veteran was noted to have "chronic" low back pain with sciatica for the last 30 days; a possible muscle stain was noted. In a separate March 1980 note, the Veteran complained of sharp pain radiating to his lower middle back. He reported having a history of back problems and was unable to lay for extended periods of time. The Veteran reported that his prior treatment (heat and asprin) was not working. In July 1982, the Veteran was again seen for complaints of low back pain after lifting a heavy back and twisted his back. He was diagnosed with a mild muscle strain. In April 1983, the Veteran complained of sharp pains when bending his back; a diagnosis of mild muscle spasm was noted. In May 1988, the Veteran was treated for mechanical low back pain after twisting his back during PT. At that time, the Veteran stated that the pain "comes and goes." He was diagnosed with a muscular strain. The Veteran was afforded a VA spine examination in May 2016 and the examiner diagnosed the Veteran with an acute muscle spasm/strain with a date of diagnosis as "1982." In providing a negative nexus opinion, the examiner stated that the Veteran had some episodes of non-traumatic mechanical low back pain and muscle spasms in service that were treated conservatively. According to the examiner, these appeared to be acute and limited and there was no objective date to support a chronic, ongoing condition. The Board finds the VA medical opinion pertaining to the Veteran's lumbar spine to be inadequate. Specifically, the examiner did not address the February 1980 service treatment note where the Veteran stated that he had back pain for over 1 year. Further, the March 1980 service treatment notes indicated that the Veteran's prior treatment (heat and asprin) was not effective. This evidence appears to contradict the examiner's findings of an acute and limited injury. On remand, a new medical opinion should be obtained that properly addresses the Veteran's service treatment records. Regarding the Veteran's bilateral knee disorder, in a July 1979 treatment note, the Veteran was noted to have sustained a fall off a ladder resulting in swelling to the right knee; x-rays showed no fracture or other joint abnormality. The Veteran was place on physical prole for 2 days. In a following July 1979 note, the right knee pain was noted as "unresolved" and the Veteran was diagnosed with a contusion to the right knee. In June 1982, the Veteran was seen for complains of bilateral knee pain for 2 weeks, with no history of trauma. There was mild tenderness around the patella on both knees. In a separate June 1982 note, the Veteran was found to have crepitus in both knees with laxity. The impression notes were "R/O retropatellar syndrome." In September 1982, the Veteran was seen twice for bilateral knee pain for one month. He was found to have mild tenderness below both kneecaps. A VA examination was obtained in May 2016. Despite the Veteran's complains of "bilateral" knee pain in VA treatment records, the examiner only provided a diagnosis of osteoarthritis in the right knee. No diagnosis for the left knee was rendered. In providing a negative nexus opinion, the examiner acknowledged the Veteran's episodes of non-traumatic retro patella knee pain; however, the examiner stated that there was no objective evidence to support a chronic, ongoing condition that was related to service. The examiner did not address the Veteran's continued complaints of bilateral knee pain following service. See e. g., April 2016 VA treatment note. Moreover, it is unclear based on the examiner's opinion as to what objective evidence would be needed to show a chronic, ongoing condition. Notably, the Veteran's complaints of knee pain spanned from 1979 to 1982 (almost the entirety of the Veteran's first period of active duty service). For these reasons, a new examination and medical opinion is required. The matters are REMANDED for the following actions: 1. Obtain any outstanding VA treatment records for the period prior to May 2015 and after May 2016 and associate them with the claims file. 2. Obtain any outstanding service treatment records, including the Veteran's separation examinations from each of his periods of active duty service (May 1978 to September 1978, April 1979 to June 1983, December 1990 to March 1991, and from November 1991 to May 1992). Make as many requests as are necessary to obtain relevant records and only end efforts to do so if the records sought do not exist or further efforts to obtain those records would be futile. All negative responses must be documented. If no records are available, the claims folder must indicate this fact and the Veteran should be notified; this notice should advise the Veteran to submit any copies of these records he might have in his possession. 3. The AOJ should request that the National Personnel Records Center (NPRC), the Defense Finance and Accounting Service (DFAS), or any other appropriate source verify all periods of ACDUTRA or INACDUTRA. Specifically, the AOJ should establish whether the Veteran was serving on ACDUTRA or INACDUTRA at the time of the May 1988 low back injury. 4. Then, schedule the Veteran for a VA examination to determine the nature and etiology of his lumbar spine disorder. The claims file must be made available to and reviewed by the examiner. The examiner is asked to address the following: (a.) List all diagnoses pertaining to the Veteran's lumbar spine. (b.) For each current diagnosis concerning the lumbar spine, provide an opinion as to whether it at least as likely as not (i.e., 50 percent or greater probability) was incurred in or is otherwise related to service. The examiner is asked to consider the following evidence: **Service treatment records show that, in February 1980, the Veteran stated that he had back pain for over 1 year. Pain was noted to be worse while driving and with exertion. **In March 1980, the Veteran underwent x-rays of the spine due to low back pain for one month. X-rays showed no significant abnormality. Also, in March 1980, the Veteran diagnosed with mechanical low back pain and was treated with ice, massage and antiinflammatory medication. In a separate March 1980 treatment notes, the Veteran was noted to have "chronic" low back pain with sciatica for the last 30 days; a possible muscle stain was noted. In a separate March 1980 note, the Veteran complained of sharp pain radiating to his lower middle back. He reported having a history of back problems and was unable to lay for extended periods of time. The Veteran reported that his prior treatment (heat and asprin) was not working. **In July 1982, the Veteran was again seen for complaints of low back pain after lifting a heavy back and twisted his back. He was diagnosed with a mild muscle strain. **In April 1983, the Veteran complained of sharp pains when bending his back; a diagnosis of mild muscle spasm was noted. **In May 1988, the Veteran was treated three for mechanical low back pain after twisting his back during PT. At that time, the Veteran stated that the pain "comes and goes." He was diagnosed with a muscular strain. (c.) A complete rationale for all opinions must be provided. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of his right and left knee disorders. The claims file must be made available to and reviewed by the examiner. The examiner is asked to address the following: (a.) List all current diagnoses related to the Veteran's right and left knee. **Please note that VA treatment records show complaints of bilateral knee pain. (b.) For each current diagnosis concerning the right and/or left knee, provide an opinion as to whether it at least as likely as not (i.e., 50 percent or greater probability) was incurred in or is otherwise related to service. The examiner is asked to consider the following evidence: **In a July 1979 treatment note, the Veteran was noted to have sustained a fall off a ladder resulting in swelling to the right knee; x-rays showed no fracture or other joint abnormality. The Veteran was place on physical prole for 2 days. In a following July 1979 note, the right knee pain was noted as "unresolved" and the Veteran was diagnosed with a contusion to the right knee. **In June 1982, the Veteran was seen for complains of bilateral knee pain for 2 weeks, with no history of trauma. There was mild tenderness around the patella on both knees. In a separate June 1982 note, the Veteran was found to have crepitus in both knees with laxity. The impression noted was "R/O retropatellar syndrome." **In September 1982, the Veteran was seen twice for bilateral knee pain for one month. He was found to have mild tenderness below both kneecaps. (c.) A complete rationale for all opinions must be provided. 6. Then, readjudicate the claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Casadei, 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.