Citation Nr: 21006623 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 17-25 105 DATE: February 4, 2021 REMANDED Service connection for back pain is remanded. REASONS FOR REMAND The Veteran had active service from February 1980 to June 1989. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2012 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Decatur, Georgia. In his May 2017 VA Form 9, the Veteran requested a videoconference hearing. In light of the closure of VA’s regional offices due to COVID-19, the Veteran was offered the option to attend a virtual tele-hearing. In September 2020, he testified before the undersigned at a virtual tele-hearing; a transcript of which is of record. The Veteran states that while stationed in North Dakota in January 1985, he slipped on stairs in his barracks and woke up the next day with a sore back. See Hearing Transcript at p. 3. He said that he did not seek treatment, but a year or two later, started to notice that he had leg pains that he also believed were related to that fall, and for which he filed a claim for benefits in 1989. He said that he subsequently noticed during his time as a Reservist that he had problems with his back being sore, but said he did not get any medical treatment between 1989 and 2011, until he got to a point in 2011 when he could not walk. Id. at 4. He underwent magnetic resonance imaging (MRI) and was told he had arthritis. The Veteran’s spouse has submitted a recent November 2020 statement indicating she has observed the Veteran experiencing problems with his back for over 20 years. To date, no examiner has opined as to whether any of the Veteran’s back disabilities may be related to a fall in service. The matter is REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his claimed back pain. If an examination cannot be scheduled at a location to which the Veteran can safely travel, or if health considerations make the scheduling of an in-person examination not possible, the RO should consider whether other virtual options, to include telehealth interviews or examinations are possible. The examiner should take a complete history from the Veteran as to the onset and progression of his back pain. Then, after a complete review of the file, the examiner should address the following: (a.) Identify any back disabilities present during the appeal period, i.e., since July 2011. If a diagnosis cannot be provided but the Veteran’s condition manifests in symptoms that cause functional impairment, then the examiner should consider them a “disability” for the purpose of providing the requested opinion(s) below. (b.) Is it at least as likely as not that any identified back disabilities, including back pain manifesting in functional impairment, are related to the Veteran’s active period of military service, to include his claimed fall on stairs in January 1985? In providing the requested opinion, consider the Veteran’s description of his in-service injury and symptoms, as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran’s reported injury and symptoms during and since service represented the onset of his current disability, this should be noted. Stated another way, do the Veteran’s reports about his injury and symptoms align with how the current disability is known to develop? The examiner should consider the submitted lay statements from the Veteran and others. A thorough medical rationale should accompany any opinion offered. 2. Then, readjudicate the issue on appeal. V. Chiappetta Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Polly Johnson, 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.