Citation Nr: 21008929 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 17-15 275 DATE: February 18, 2021 REMANDED Service connection for residuals of a left arm injury is remanded. Service connection for low back condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the Marine Corps from August 1980 to August 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2017 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference in August 2020; a transcript is of record. 1. Service connection for residuals of left arm injury is remanded. 2. Service connection for low back condition is remanded. The Board sincerely regrets delaying the Veteran's appeal of these issues, but further evidentiary development is necessary before the Veteran’s claims for entitlement to service connection can be adjudicated on the merits. The Veteran asserts that he has a left arm disorder as a result of an injury incurred in an in-service motor vehicle accident in 1982. He testified that he currently has pain in his arm, “like a bad case of tennis elbow,” impaired dexterity and coordination of his hand and fingers, as well as some scars. The Veteran denied suffering any specific injury to his back during service, but asserts that he has a current low back disorder from the cumulative “wear and tear” of his in-service physical training, such as running and carrying heavy gear. He testified that he experienced low back pain during service, but did not seek treatment. He described his current back symptoms as including pain and difficulty bending. Efforts to obtain the Veteran's complete service treatment records (STRs) have been unsuccessful. However, in November 2017 the Veteran submitted some of his service treatment records to the RO. These records show that on June 19, 1982 he suffered a crush injury to his left forearm and hand in a motor vehicle accident and was seen in the emergency room. A physical therapy (PT) consultation was conducted on June 21, 1982; however, only a partial copy of that record was provided. It appears that the Veteran was referred to PT by orthopedics. Also of record is a portion of the Veteran’s separation examination which shows that he reported experiencing back pain. VA is obligated to provide an examination or obtain a medical opinion in a claim of service connection when: 1) the record contains competent evidence that the claimant has a current disability, or persistent or recurrent symptoms of a disability; 2) the record indicates that the disability or symptoms may be associated with active service or an already service-connected disability; and 3) the record does not contain sufficient information to make a decision on the claim. See 38 U.S.C. § 5103A(d); McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); 38 C.F.R. § 3.159 (c)(4). The evidentiary requirement that the record indicates that the claimed disability may be associated with active service is a "low threshold." McLendon, 20 Vet. App. at 83. In order to properly adjudicate the Veteran’s claims, a factually accurate, fully articulated, and soundly reasoned medical opinion is needed. Further, as the case must be remanded an additional request should be made for the Veteran’s complete service treatment records as his updated VA treatment records. Therefore, the matters are REMANDED for the following action: 1. Contact the Veteran and ask him to submit copies of all service treatment records in his possession. 2. Obtain the Veteran's complete service treatment records from the NPRC and/or any other appropriate entity, specifically to include all records related to his left arm injury from a June 1982 motor vehicle accident, i.e., emergency department records, orthopedic consultations, physical therapy records, etc. 3. Obtain the Veteran's updated VA treatment records. 4. After any additional records are associated with the claims file, schedule the Veteran for a VA examination to determine the nature and etiology of his left arm condition. The entire claims file, including a copy of this remand, must be made available to the examiner, who must note its review. (a) The examiner should identify all current left arm disorders found to be present, to include of the elbow, forearm and hand, as well as any scars. (b) For each identified left arm disorder, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the condition had its onset during service or is the result of any incident of service, the include the Veteran’s left arm injury in June 1982. • In providing this opinion, the examiner should consider the June 19, 1982 emergency department record showing that the Veteran suffered a crush injury to his left forearm and hand in a motor vehicle accident; as well as the June 21, 1982 physical therapy consultation showing that he had limited motion of the left elbow and wrist, was able to make a “loose fist,” and a had a “partial thickness appearing burn” on the volar surface of his forearm. A complete rationale must be provided for all opinions and conclusions reached. 5. Schedule the Veteran for a VA examination to determine the nature and etiology of his low back condition. The entire claims file, including a copy of this remand, must be made available to the examiner, who must note its review. (a) The examiner should identify all current low back disorders found to be present. (b) For each identified low back disorder, the examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that the condition had its onset during service or is the result of any incident of service, to include cumulative “wear and tear” from extensive physical training on a regular basis such as running on hard-surface roads and steel decks; and carrying weighted packs, 782 gear, machine guns, mortar rounds, base plates and mortar tubes. • In providing this opinion, the examiner should consider the Veteran’s lay statements that he began experiencing back pain and stiffness during service, as well as his separation examination showing that he complained of back pain. A complete rationale must be provided for all opinions and conclusions reached. P.M. DILORENZO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Gonzalez, Damian 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.