Citation Nr: 21008975 Decision Date: 02/18/21 Archive Date: 02/18/21 DOCKET NO. 19-19 621 DATE: February 18, 2021 REMANDED Entitlement to service connection for lumbar spine disability is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1972 through August 1973. In September 2019, the Board issued a decision denying the issue at hand. The Veteran filed an appeal to the U.S. Court of Appeals for Veterans Claims (CAVC) contesting the Board’s September 2019 decision. In an August 2020 joint motion for remand, the CAVC remanded the Board’s denial of service connection for lumbar spine disability for further development and re-adjudication. In its decision, the CAVC found the Board failed to provide an adequate statement of reasons or bases for its finding that service connection was not warranted. Accordingly, the appeal has been remanded to the Board for action consistent with the CAVC decision. Entitlement to service connection for lumbar spine disability The Veteran contends that he has a lumbar spine disability due to his period of service. Specifically, the Veteran contends that he suffered an injury to his lower back during physical training while on active duty. At his entrance examination in April 1972, the examiner noted no identifying body marks or scars. However, a July 1973 separation examination noted a four-inch scar on the Veteran’s back. An April 2008 examination indicated pain radiating from the neck to the lumbar spine. In a July 2018 private medical examination, the examiner diagnosed the Veteran with degenerative joint disease with emphasis of the lumbosacral region. The examiner opined that the etiology of the degenerative joint disease was due to an injury the Veteran sustained in his low back during physical training while in service. The examiner also noted that the details for the aforesaid injury are included within the Veteran’s military service treatment records. Upon review of the medical evidence of record, the Board does not observe any complaints of low back pain while in service. Additionally, the July 1973 notation coupled with the absence of the notation at entry raises the possibility of an in-service incurrence of a low back disability. Further, the Veteran has not been afforded a VA examination regarding his low back pain. Thus, a remand is necessary. By this remand, the Board makes no determination, express or implied, concerning the credibility of any statements on file. The matters are REMANDED for the following action: 1. With any necessary identification of sources and authorization by the Veteran, request all VA and private treatment records for the Veteran not already associated with the file. Copies of any outstanding VA and private treatment records should be added to the Veteran’s claims file. 2. Obtain all outstanding service treatment records for the Veteran’s active service. All efforts to obtain these records should be documented, and if the records cannot be located, a formal finding of unavailability should be associated with the Veteran’s claims file. Thereafter, schedule the Veteran for a VA examination to determine the nature and current severity of his lumbar spine disability. The Veteran’s electronic claims file must be made available to the designated professional for review in conjunction with the examination. A complete history from the Veteran should be obtained and recorded. All testing deemed necessary by the examiner should be performed and the results reported in detail. In particular, the examiner must test the range of motion in active motion, passive motion, weight-bearing, and non-weight-bearing. If the examiner is unable to conduct any aspect of the required testing or concludes that it is not necessary, e.g., non-weight-bearing, the examiner should clearly explain why that is the case. Following the review of the claims file and examination of the Veteran, the examiner is then requested to respond to the following: (a.) Describe any functional limitation due to pain, weakened movement, excess fatigability, pain with use, or incoordination. (b.) Indicate whether the examination is taking place during a period of flare-up, and if it is not, the examiner should ask the Veteran to describe the flare-ups, including frequency, duration, severity, and functional impairment. (c.) Provide an opinion estimating any additional degrees of limited motion caused by functional loss during a flare-up. If the examiner cannot estimate the degrees of additional range of motion during flare-ups without resorting to speculation, the examiner should state whether the need to speculate is caused by a deficiency in the state of general medical knowledge or by a deficiency in the record or the examiner. (d.) Is it at least as likely as not (a 50 percent probably or greater) that the Veteran’s bilateral ankle disability had its onset in, or is otherwise related to, active service? (Continued on the next page)   A complete rationale for any opinion expressed should be provided. If an opinion cannot be provided without resort to speculation, the examiner should state why an opinion cannot be provided, and whether the inability to provide a definitive opinion is due to a need for further information or because the limits of medical knowledge have been exhausted regarding the etiology of the disability at issue or because of some other reason. 3. After completing all indicated development, the AOJ should readjudicate the Veteran’s claim. If the benefit sought on appeal remains denied, the Veteran should be furnished with a supplemental statement of the case, given the opportunity to respond, and the case should thereafter be returned to the Board for further appellate review, if warranted. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Hamilton, 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.