Citation Nr: 21012436 Decision Date: 03/04/21 Archive Date: 03/04/21 DOCKET NO. 16-45 743 DATE: March 4, 2021 REMANDED Entitlement to service connection for neck condition (also claimed as upper back) is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1969 to December 1971. This matter comes before the Board of Veterans’ Appeals (Board) from a May 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned Veterans Law Judge in January 2021, and the transcript of that hearing is of record. During the Board hearing, the Veteran clarified that his current upper back/neck condition was due to an in-service parachute accident that resulted in his injuring the lower back (for which he is service-connected) and upper back/neck, after which he was hospitalized at the Martin Army Community Hospital in Fort Benning for approximately four to six weeks. He testified that he first noticed neck/upper back problems immediately after the accident. When asked whether he was provided with any diagnosis for these conditions, he answered he just recalls being rubbed and massaged on the neck and back and was prescribed with medications. With regards to the inpatient records from the Martin Army Community Hospital, there is only one emergency room note from July 1969 (documenting the Veteran’s parachute accident and his complaint of pain in the right leg and the back), as well as x-rays of the back and the right ankle (showing that he was admitted from July 7, 1969 to July 18, 1969, and the diagnosis provided in the discharge note was only the right ankle sprain, with no indication of back/neck). Thus, the Board finds it necessary to obtain all outstanding inpatient records from this facility. When asked whether he had received any physical therapy prior to 2005, the Veteran affirmed yes during the Board hearing. As the Veteran’s claims file currently does not include any treatment records preceding 2005, it is necessary to obtain those records. Furthermore, the Veteran testified he was treated by a private doctor, Dr. R. Attanasio, post-service for over 30 years, until the Veteran recently moved in 2019. It appears there are treatment records from Dr. Attanasio from only 2005. The Veteran also indicated that he now sees Dr. V. Lewis, but it does not appear any treatment records have been obtained from this private medical provider. Thus, the Board finds it necessary to obtain all outstanding private treatment records. As the Veteran’s July 1969 service treatment records clearly document the Veteran “fell 25 ft free fall in jump,” a medical opinion is needed as to the etiology of the claimed condition. Even without in-service complaints of neck or upper back pain, such an injury could conceivably involve trauma to other parts of the spine, satisfying the service connection element of an in-service injury. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file all outstanding inpatient treatment records from Martin Army Community Hospital for July 7, 1969 to July 18, 1969. 2. Ask the Veteran to complete a release authorizing VA to obtain his records for any private treatment records from the following: (a.) Any private treatment received prior to 2005 (b.) Treatment records from Dr. R. Attanasio (c.) Treatment records from Dr. V. Lewis If any records are requested but not received, advise the Veteran of that fact. 3. DO NOT SCHEDULE THE FOLLOWING until all efforts have been made to obtain the above records. 4. Then, schedule and obtain a VA medical opinion from an orthopedic specialist. The examiner must review the complete claims file, including this remand. Then, the examiner must address the following, with full supporting rationales: Determine if it is at least as likely as not the Veteran’s current upper back/neck condition is related to any in-service disease or injury, to include his in-service 1969 parachute accident? In doing so, the examiner should consider and address the followings: July 1969 service treatment records (complaint of “back pain” but documenting an x-ray of only lumbar spine, showing “within normal limits”); see also October 1971 separation examination (showing normal upper extremities and spine/other musculoskeletal); Board hearing testimony (noting that he injured his upper back/neck from the in-service parachute accident); any pertinent information relating to upper back/neck in the additionally obtained inpatient records. If an opinion cannot be made without resort to speculation, the examiner must explain why this is so and note what, if any, additional evidence would permit an opinion to be made. However, the examiner is advised that regardless of whether the Veteran complained during service of neck or upper back pain, he could still be service-connected if the current condition is related to the in-service injury. MICHELLE L. KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Lee 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.