Citation Nr: 21005747 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 10-38 606 DATE: February 2, 2021 REMANDED Entitlement to service connection for a low back disability, to include as secondary to service-connected bilateral medial tibial stress syndrome, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 2002 to November 2006, to include service in Southwest Asia. In June 2018, the Board remanded the claim to obtain an addendum medical opinion. Specifically, the Board asked the examiner to address the Veteran’s competent lay statements that she had lower back pain in service after performing heavy lifting, physical training, and sit-ups during active duty service, and was treated in sick call with anti-inflammatory medications, rest, and an exercise profile. In January 2019, the Veteran underwent a VA compensation examination, at which time the examiner confirmed a diagnosis of lumbar strain and degenerative lumbar disc disease and opined that the Veteran’s lumbar spine disability is less likely as not related to service or to service-connected bilateral medial tibial stress syndrome. While the examiner acknowledged the Veteran’s competent lay reports regarding the onset of her back symptoms, those were dismissed in the opinion simply because there was no documented evidence of treatment for a back disability in service. See Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (the lack of contemporaneous medical records does not, in and of itself, render lay evidence not credible or serve as an “absolute bar” to service connection). Accordingly, this rationale is inadequate. Moreover, the January 2019 VA examiner did not provide any rationale as to why the Veteran’s back disability is less likely as not aggravated by the service-connected bilateral medial tibial stress syndrome. For these reasons, another medical opinion is needed prior to adjudicating the merits of the claim. The matter is REMANDED for the following action: 1. Obtain another medical opinion from an appropriate VA examiner to help determine the likely etiology of the Veteran’s lumbar spine disability. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. After review of the record, the examiner is asked to respond, with complete rationale, to the following: (a) Did the Veteran’s current lumbar spine disability at least as likely as not (a 50 percent or higher probability) have its onset during service or is it otherwise related to it? (b) In doing so, the examiner should consider and address the Veteran’s competent lay statements that she had lower back pain in service after performing heavy lifting, physical training, and sit-ups during active duty service, and was treated in sick call with anti-inflammatory medications, rest, and an exercise profile; 2008 problem list showing backache; September 2008 suspected muscular spasm/disc disease with radiation to right leg; January 2009 private treatment records showing a disc protrusion only three years after discharge; January 2009 MRI showing evidence of multilevel disc disease with some disc bulges; and, the August 2009 nexus letter from Dr. N.O. Please note: lack of contemporaneous medical records does not serve as an “absolute bar” to the service connection claim and cannot be used as a rationale in explaining why the current disability is not related to service. If the examiner cannot offer an opinion without resort to speculation, he or she should explain why and state what additional evidence, if any, would be required to offer an opinion. (Continued on the next page)   (c) Address the question of aggravation of a service-connected disability. Specifically, explain why it was determined that the Veteran’s back disability is less likely aggravated by the service-connected bilateral medial tibial stress syndrome. 2. Thereafter, readjudicate the remanded claim. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Yaffe, 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.