Citation Nr: 21011922 Decision Date: 03/03/21 Archive Date: 03/03/21 DOCKET NO. 13-07 074 DATE: March 3, 2021 REMAND The issue of service connection for a lumbar spine disability is remanded. The Veteran had active duty service from January 1986 to February 1996. The Veteran’s appeal was remanded in June 2019 for additional development. Having reviewed the most recent medical examination, the Board finds it must again remand the claim for clarification. REASONS FOR REMAND The matter is therefore REMANDED for the following action: 1. BACKGROUND FOR THE RO ADJUDICATOR: As a result of the most recently-obtained medical examination, the record is unclear as to whether the Veteran has, or does not have a present disability: In September 2011, a VA examiner found that the Veteran had a back disorder (“low back strain”); In January 2018, a VA examiner found that the Veteran did not have, nor ever had, a back disorder, and; In October 2019, a VA examiner found that the Veteran had a diagnosis of thoracolumbar spinal strain. The presence of a disability is the fundamental component of service connection. In order to complete appellate review, this matter must be clarified in accordance with the remand directives below. 2. RETURN THIS MATTER TO THE VA EXAMINER WHO CONDUCTED THE OCTOBER 2019 EXAMINATION, and ask the examiner to issue an addendum and clarify the findings of the January 2018 examination as to whether the Veteran has had a back disorder at any time since the submission of the claim in August 2011. If necessary, a further medical examination may be conducted. At all events, it is critical that the examiner fully explain the basis of the addendum opinion. If the Veteran here has exhibited objective indications of a qualifying chronic disability that became manifest during active military service in the Southwest Asia theater of operations during the Persian Gulf War, or that became manifest to a degree of 10 percent or more not later than December 31, 2016, he may obtain service connection for that disability. 38 C.F.R. § 3.317 (a)(1) (2020). The include (1) an undiagnosed illness; or (2) a medically unexplained chronic multi-symptom illness. The examiner is advised that disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. 38 C.F.R. § 3.317(a)(4). Although the examiner must review the entirety of relevant information in the electronic file, his/her attention is called to the following: -The Veteran’s service treatment records (STRs) show no complaints, treatments, or diagnosis for a lumbar spine condition. In a July 1993 in-service physical evaluation, the Veteran indicated that he was in good health and his “spine, other musculoskeletal” were noted to be normal. The Veteran was assigned a “1” rating assessing his upper extremities under the PULHES profile system, indicating a high level of fitness. See Odiorne v. Principi, 3 Vet. App. 456 (1992); ((observing that the “PULHES” profile reflects the overall physical and psychiatric condition of the veteran’s capacity and stamina (“P”); upper extremities (“U”); lower extremities (“L”); hearing (“H “); eyes (“E”) and psychiatric condition (“S”); assessed on a scale of 1 (high level of fitness) to 4 (a medical condition or physical defect which is below the level of medical fitness for retention in the military service)). The Veteran was discharged from active service in February 1996. -In a September 2011 Gulf War examination, the VETERAN HAD A DIAGNOSIS of a low back strain. The examiner also noted the Veteran’s accounts of intermittent joint pain throughout the preceding ten years. The examiner did not opine as to the etiology of the Veteran’s low back strain. A separate medical progress note indicates that with the exception of loss of five degrees of lateral flexion, the Veteran’s back range of motion studies were normal but with “slight discomfort.” -In January 2018, the Veteran was afforded a VA examination. The examiner stated that the VETERAN DID NOT HAVE A DIAGNOSIS for a low back condition and HAD NEVER HAD A DIAGNOSIS FOR A LOW BACK DISORDER. The Veteran told the examiner that he first injured his back when lifting ammunition while in service and subsequently hurt his back during “ruck” marches. The Veteran acknowledged that he did not report back problems or pain or seek medical help while in-service. However, the examiner stated that the Veteran’s physical examination was completely normal with no reduction in range of motion and no tenderness or pain. The examiner stated that no opinion was warranted regarding the Veteran’s back pain because he did not have a diagnosis for which an opinion could be provided. -In October 2019, the Veteran was afforded a VA examination. The examiner noted the VETERAN HAD A DIAGNOSIS of thoracolumbar spinal strain. The examiner stated that the Veteran’s lumbar spine condition had an onset of 1998. However, the examiner’s medical opinion indicated that the Veteran’s symptoms do not represent an objective indication of a chronic disability resulting from an undiagnosed illness or a medically unexplained chronic multi-symptom illness related to his Persian Gulf War Service. The examiner noted that the Veteran did not report back pain in-service. The examiner also noted that the Veteran worked a job unloading windows immediately after service but did not report back pain at that time. The examiner is requested to clarify: a. Does the Veteran presently have a back disability? b. If the Veteran does not have a back disability, did he have such a disability at any time since August 2011 when he submitted his claim? c. If the Veteran has a back disability, is it the result of his military activities as he has alleged? (Continued on the next page)   d. If the Veteran has a back disability,, it is it a “diagnosed” disorder or is it otherwise an undiagnosed illness or part of a medically unexplained chronic multi-symptom illness? 3. After receipt of the examiner’s addendum opinion, readjudicate the claim. Vito A. Clementi Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Wozniak, Associate 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.