Citation Nr: 21013476 Decision Date: 03/09/21 Archive Date: 03/09/21 DOCKET NO. 20-14 711 DATE: March 9, 2021 REMANDED Entitlement to service connection for a low back disability, to include as secondary to a service-connected right foot disability is remanded. REASONS FOR REMAND The Veteran served on active duty from February 1956 to February 1960. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Entitlement to service connection for a low back disability, to include as secondary to a service-connected right foot disability is remanded. The Veteran contends that his diagnosed degenerative arthritis of the lumbar spine (low back disability) is related to active service, or alternatively is caused or aggravated by his service-connected degenerative arthritis of the right foot (right foot disability). When this matter was last before the Board in April 2020, it was remanded to obtain a new VA medical opinion, based on a finding that the record did not contain a competent medical opinion as to whether the Veteran’s back disability is proximately due to or aggravated by his service-connected right foot disability. The Veteran was then afforded such an examination and opinion in December 2020. The Board finds that additional remand is warranted for two reasons. First, in finding that the low back disability was not aggravated, the examiner stated as rationale only that the two conditions were entirely separate. A conclusory statement without further rationale is insufficient to allow the Board to make an informed decision as to the weight to assign to the medical opinion. See Stefl v. Nicholson, 21 Vet. App. 120, 125 (2007). Accordingly, a remand is necessary to obtain an addendum medical opinion for the Veteran's secondary service connection claim. Second, with regards to direct service connection, the April 2020 remand directives instructed the examiner to consider the Veteran’s reported physical activities during service in determining whether his low back disability was related to active service. The Board recognizes that the examiner took note of the Veteran’s reports of back pain during service due to heavy labor and a reported back injury resulting from a fall. In finding that the Veteran’s condition was not related to active service, the examiner relied only on the absence of service treatment records showing a back disability during service. The Board notes that the rationale for an examiner's opinion must not be based solely on the absence of treatment records during service. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination must consider lay evidence of in-service incurrence or continuity of symptomatology since service). For this reason, remand is also necessary to obtain an addendum medical opinion for the Veteran's direct service connection claim. Additionally, the Board points out that the Veteran has reported on several occasions that his current low back disability is related to repairing and operating large trucks and buses during service which had no suspension or “air-ride”. He has also reported that his back complaints and treatment during service were not properly documented as there were medical stations but no doctors. See Correspondences, submitted March 2020 and December 2020; and February 2019 Notice of Disagreement. To that extent, the Board notes that the Veteran’s military personnel records indicate that he served as a Vehicle Operator for 11 months during active service. In this case, for the purpose of providing an opinion, the examiner should accept as true for purposes of the examination the Veteran's lay statements regarding symptoms and treatment for back pain during service. The matters are REMANDED for the following action: 1. Provide access to the electronic claims file to the December 2020 examiner, or appropriate substitute if this individual is not available, to provide addendum opinions. The electronic claims file must be made available to and reviewed by the examiner. An examination should be performed if deemed necessary by the examiner providing the requested opinion. The examiner should address the following: a.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s degenerative arthritis of the lumbar spine had its onset in service or is otherwise related to active service. The examiner must address the Veteran’s contentions regarding heavy physical labor and repairing and operating large trucks and buses during service which had no suspension or “air-ride”. See Correspondences, submitted March 2020 and December 2020; and February 2019 Notice of Disagreement. For the purpose of providing the requested opinion, the examiner should accept as true the Veteran's lay statements regarding symptoms and treatment for back pain during service. The examiner is reminded that the rationale for the opinion rendered must not be based solely on the absence of treatment records during service. b.) Whether it is at least as likely as not (50 percent or greater probability) that the Veteran’s degenerative arthritis of the lumbar spine is (1) caused or (2) aggravated by his service-connected right foot disability. A complete rationale for all opinions must be provided. 2. Upon completion of the addendum opinion ordered above, review the opinions to ensure that they address the questions presented. Any inadequacies should be addressed prior to recertification to the Board. 3. After completing the requested actions, and any additional notification and/or development deemed warranted, the RO should readjudicate the claim on appeal. If any benefit sought on appeal remains denied, the RO must furnish the Veteran with an appropriate supplemental statement of the case and afford a reasonable opportunity for response. R. M. KELLY Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Marsh II, 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.