Citation Nr: 21007558 Decision Date: 02/10/21 Archive Date: 02/10/21 DOCKET NO. 17-55 127 DATE: February 10, 2021 REMANDED Entitlement to service connection for a low back disability, to include as secondary to service-connected left foot injury, is remanded. REASONS FOR REMAND The Veteran served active duty in the United States Army from July 1961 to July 1963. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2016 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In October 2018, the Veteran presented testimony at a hearing before the undersigned Veterans Law Judge. A transcript of the hearing is of record. The Board remanded the case for further development in February 2019 and August 2020. The case has been returned to the Board for further review. Unfortunately, the Board finds that remand is necessary once again. It is briefly noted that the claim was remanded for another VA medical opinion to address direct service connection, and aggravation of the Veteran’s low back disability due to his service-connected left foot injury. However, a review of the medical opinions obtained shows they are inadequate as they are based on inaccurate facts. Additionally, it is unclear if the examiner has considered all of the relevant evidence. Post-service treatment records indicate the Veteran was treated for low back pain as early as 1990. See March 2016 treatment record. Additionally, 2014 and 2015 treatment records indicate the Veteran experienced low back pain. However, the November 2020 examiner indicated there was no documentation that the Veteran had low back pain prior to 2016. Additionally, the examiner opined that it is less likely than not the Veteran’s low back disability is proximately due to or aggravated beyond natural progression by the Veteran’s service-connected left foot injury. The examiner noted the Veteran’s abnormal gait but indicated that there was no indication that it was due to his left foot injury. He referenced a treatment record in which the Veteran was initially diagnosed with a left foot fracture but later it was noted that perhaps the finding was congenital as later imaging showed evidence of an older injury, supported by records that the Veteran injured his foot before active service. Ultimately, he found that it was highly unlikely that the Veteran’s left foot disability, including mild degenerative joint disease and a moderate calcaneal spur was related to his in-service left foot injury. Thus, the left foot disability was not related to the low back disability. Moreover, he indicated that lower back pain radiates down to the left buttock to the left leg to the foot, not from the foot up to the back. He indicated the description of the pain was clinically impossible. Thus, the residual of the service-connected left foot injury has nothing to do with his current lumbar spine disabilities. Rather, imaging shows gradual degeneration of the lumbar spine which is common for people in their later decades of life. Notably, he mentioned the Veteran walked four to five miles per day prior to his lower back flare up. Nevertheless, several treatment records show the Veteran was treated for low back pain along with left foot, left knee, and left leg pain. Specifically, a March 2016 record shows the Veteran complained of low back pain and intermittent pain in his left leg and foot. A June 2016 record indicates the Veteran’s left foot pain radiates up his left side to his back. Additionally, April 2017 treatment records stated the Veteran had low back pain associated with his left foot and that he had a slight limp favoring his left leg. The examiner did not mention any of these treatment records, including those that note the Veteran’s pain radiated up to his back from his left foot. Notably, the Board points out that the Veteran reported that he hurt his mid-back in several car accidents, and he indicated that the most recent car accident was in 2003. See August 2015 record. It is also noted that a May 2014 record indicated the Veteran had back pain associated with a right foot injury that had occurred months ago. Lastly, treatment records reference the Veteran was evaluated for low back pain since 1990. However, the records have not been obtained and associated with the claims file. For the reasons stated above, remand is necessary. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his claimed low back or lumbar spine disability. A specific request should be made for treatment records from physicians that treated the Veteran beginning in 1990. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. 2. The AOJ should schedule the Veteran for a VA examination with a qualified examiner, who has not previously examined the Veteran, and a copy of this remand should be provided to him/her. The Veteran should be afforded a VA examination to determine the nature and etiology of any low back disability that may be present. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran’s low back disability is causally or etiologically related to his military service, to include any injury or symptomatology therein. The examiner should address the Veteran’s assertions that his disability was caused by physical labor while he performed his duties as a cannoneer in service. The examiner should also provide an opinion as to whether it is at least as likely as not that the low back disability was either caused by or aggravated by the Veteran’s service-connected left foot injury. The examiner should consider and address the several medical records that note the Veteran was treated for left foot pain simultaneously with low back pain. See e.g., June 2016 treatment record. The examiner should also address the Veteran abnormal gait and whether that was caused by the left foot injury, and if so, if it is related to the development of the Veteran’s low back disability. See March 2016 treatment record. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of a certain conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M. Walker 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.