Citation Nr: 21006495 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 16-47 280 DATE: February 4, 2021 ORDER Entitlement to service connection for lumbar strain is denied. REMANDED Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) and an anxiety disorder, is remanded. FINDING OF FACT The Veteran has low back strain that was not incurred during active duty and did not result from an in-service injury, illness, or event. CONCLUSION OF LAW The criteria for service connection for lumbar strain are not met. 38 U.S.C. §§ 1110, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty from August through November of 1978 and from February 1980 through December 1985. The appeal arises out of the Veteran’s June 2012 claim and a rating decision issued by the agency of original jurisdiction (AOJ) in February 2013. The Veteran testified during a July 2019 Board hearing; however, audio difficulties during the proceedings prevent VA from creating a transcript. The Veteran was notified of this difficulty in a December 2020 letter and was given the opportunity to request within 30 days a new hearing. He did not reply. The Board will therefore proceed with adjudication. 1. Entitlement to service connection for lumbar strain. The Veteran claims entitlement to service connection for lumbar strain. The Veteran does not contend expressly that he has had chronic back problems that date all the way back to his period of service. Although he reported during a January 2013 spine examination that he has had longstanding back pain, he elaborated that his back problems seemed to date back approximately 20 years (i.e., began years after he was separated from service) and that they began after lifting activity. Also of note, he reported that he sustained a re-injury to his back following a motor vehicle accident that occurred four years before the examination (i.e., sometime in 2009 decades after the Veteran’s separation from service). The service treatment records show that the Veteran was treated during service in November 1980 and in November 1981 for low back pain caused by apparent muscle strain. There is no indication in the service treatment records that the Veteran subsequently reported ongoing back problems over the remainder of his active duty service, and indeed, the records reflect no continuing objective findings, diagnoses, or treatment for any ongoing chronic back problems. The post-service treatment records show no further back-related complaints by the Veteran prior to VA treatment in February 2011. Records for subsequent VA treatment received by the Veteran note ongoing low back tenderness. Nonetheless, those records express no opinion as to the cause or origin of the Veteran’s back problems, nor do they provide any information or findings that suggest that the Veteran has had chronic back problems since service. The January 2013 spine examination revealed essentially normal objective findings in the Veteran’s low back other than the Veteran’s complaints of back pain. Demonstrated thoracolumbar spine motion was normal. No evidence of pain or spasms was observed during palpation over the spine. Neurological tests revealed normal muscle strength, reflexes, and sensation in the Veteran’s lower extremities. Spine x-rays showed no signs of arthritis. The examiner diagnosed muscle strain but opined that it is less likely than not that the Veteran’s back condition was incurred during service or caused by an in-service injury, illness, or event. The examiner explained that although service treatment records document lumbar muscle strain injuries during service, there is no indication in the service treatment records or post-service treatment records of chronicity until 2011. Moreover, and critically, the examiner noted that the record reflects self-reported incidences of post-service back injuries in 2005 and 2009. Hence, the examiner essentially concluded that the Veteran’s in-service muscle strain injuries appear to have resolved during service and his present lumbar strain likely resulted from post-service injuries. The January 2013 examiner’s negative opinion and rationale are not rebutted by any evidence in the record. Indeed, the examiner’s opinion is supported by the other evidence, to include the Veteran’s own reported medical history that his back complaints seemed to originate from acute injuries incurred post-service. Based on the same, the Board concludes that the Veteran’s current lumbar strain is not related etiologically to his active duty service. The Veteran is not entitled to service connection for lumbar strain. To that extent, this appeal is denied.   REASONS FOR REMAND 1. PTSD stressor corroboration. The Veteran contends in an August 2012 PTSD stressor statement that he was stationed at Fort Bliss, Texas in 1984 or 1985 when he witnessed an accident in the motor pool where a weapon exploded and struck another serviceman named “Bryan” in the face. The Veteran believes that the serviceman died from his injuries. The Veteran also described during a February 2015 telephone conversation with VA personnel an accident that occurred during his deployment to Bamberg, Germany from December 1982 through February 1985. It is unclear from the record as to whether VA has undertaken any effort to corroborate the Veteran’s stressors with appropriate agencies. To that end, there is no documentation of any requests for information or records based on the Veteran 2012 statement and/or the February 2015 telephone conversation. VA has also yet to make a formal determination as to whether there is sufficient evidence to corroborate the PTSD stressors reported by the Veteran. Where remand of the issue remaining on appeal is required for the examination described below, VA should also contact the Veteran again and ask that he provide additional information and detail concerning the claimed stressor events that occurred at Fort Bliss, Texas and at Bamberg, Germany. VA should also undertake efforts to corroborate the Veteran’s reported stressors. 38 C.F.R. §§ 3.159 (c)(2) and 3.304 (f). 2. Mental health examination. The Veteran contends in an August 2012 PTSD stressor statement that he has had chronic and ongoing mental health symptoms since active duty service. Despite the same, there is no evidence in the record that the Veteran has sought any mental health treatment, and indeed, the Veteran has not identified any such treatment or evidence. The Veteran is competent to report and describe his perceived symptoms. Given the Veteran’s assertions describing his chronic symptoms dating back to service, the evidence raises the question of whether the Veteran has a mental health disorder that has yet to be diagnosed, and if so, whether that disorder was incurred during service or resulted from an in-service injury, illness, or event, to include stressor events described in the Veteran’s August 2012 PTSD stressor statement and his February 2015 conversation with VA personnel. In the absence of any apparent mental health treatment received by the Veteran, there is insufficient evidence in the record to determine those questions. Under the circumstances, the Veteran should be scheduled to undergo a mental health examination to determine the nature and etiology of any diagnosed mental health disorders. 38 C.F.R. § 3.159 (c)(4). The matters are REMANDED for the following action: 1. The Veteran should be asked whether he has additional evidence pertaining to his claimed mental health disorder. Records for VA treatment received by the Veteran since June 2016 and any private treatment identified by the Veteran and not already of record should be obtained. If the records are not available, such unavailability should be documented in the record. The Veteran and his representative should be notified of unsuccessful efforts in order to allow them the opportunity to obtain and submit those records for VA review. 2. Ask the Veteran to provide additional information and detail concerning the claimed stressor events that took place during the Veteran’s deployment to Bamberg, Germany and Fort Bliss, Texas, to include specific dates, locations, and names of other servicemen who were involved in each event. 3. Attempt to corroborate the following reported PTSD stressors, if possible: 1) the alleged accident witnessed by the Veteran during service in Bamberg, Germany, and 2) the alleged accidental explosion that occurred in the motor pool at Fort Bliss, Texas and was witnessed by the Veteran within the time period from 1984 through 1985. 4. After the development ordered in Paragraphs 1 through 3 are complete, schedule the Veteran to undergo a mental health examination to determine the nature and etiology of any diagnosed disorders. The examiner should review the claims file in conjunction with the examination. The examiner should provide mental health diagnoses, and for each diagnosis, opine as to whether it is at least as likely as not (at least a 50 percent probability) that the diagnosed disorder was: 1) incurred during service; and/or 2) resulted from an in-service injury, illness, or event, to include the stressor events described by the Veteran in his August 2012 PTSD stressor statement and February 2015 telephone conversation with VA personnel. The examiner should provide a detailed rationale that explains fully all of the reasons for the given opinions. (Continued on the next page)   5. After completion of the above development, the issue on appeal should be readjudicated. If the determination remains averse to the Veteran, he and his representative should be furnished with a SSOC and be given an opportunity to respond. DONNIE R. HACHEY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.S. Lee 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.