Citation Nr: 21021999 Decision Date: 04/14/21 Archive Date: 04/14/21 DOCKET NO. 17-24 664 DATE: April 14, 2021 REMANDED Entitlement to service connection for a back disability is remanded. Entitlement to service connection for bilateral lower extremity neurological impairment is remanded. REASONS FOR REMAND The Veteran had active military service from June 1978 to June 1981. This case comes before the Board of Veterans’ Appeals (Board) on appeal of an April 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In September 2020, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that hearing is of record. Service Connection – Back Disability The Veteran asserts that her back disability is etiologically related to an injury she sustained during active service. The Veteran’s service treatment records (STRs) reveal that in April 1981, she reported hurting her back while bending over, lifting heavy objects, and moving a coffee table. At that time, she was assessed as having lower back pain. From September 1992 to October 1992, private chiropractor notes reveal that the Veteran made several complaints of lower mid-back discomfort. In those notes, Dr. W.N. collectively assessed that the Veteran had moderate muscle soreness, stiffness, and acute trigger points in the lower paradorsal muscles; right sacroiliac joint tenderness; and positive marked instrumentation findings at the second lumbar vertebrae. During the Veteran’s September 2020 Board hearing she testified that she sought medical treatment for back pain within one year of her separation, and that her pain had continued since that time. The Veteran also testified that she worked as a graphic designer upon her separation from service and did not become a massage therapist until later in life. The Veteran was afforded a VA examination in February 2014. However, the Board finds that the VA medical opinion provided at that time is inadequate for adjudication purposes. In that regard, the VA examiner failed to consider the Veteran’s lay statements pertaining to the onset and continuity of her symptoms, based her opinions on the absence of evidence in the Veteran’s STRs, and failed to provide support for her opinion that the Veteran’s back disability was due to her age and occupation. Accordingly, the Board finds that remand is warranted for a new VA examination to determine the nature and etiology of the Veteran’s back disability. Service Connection – Bilateral Lower Extremity Neurological Impairment The Veteran asserts that her peripheral neuropathy is due to her service-connected plantar fasciitis, or alternatively her service-connected PTSD. The Board notes that the Veteran’s STRs reveal numerous complaints of issues with her feet. The complaints include intense heel pain when pressure is applied and cramping in her forefoot. Additionally, the Veteran’s in-service diagnoses include tendonitis, heel pain in the left foot, plantar fasciitis, and a bone spur in the left heel. In March 2011, the Veteran was assessed as having peripheral neuropathy. During the Veteran’s September 2020 Board hearing, she testified that her foot pain had continued since service. At that time, the Veteran stated that the peripheral neuropathy was secondary to her service-connected foot disability (i.e. plantar fasciitis). Additionally, the Veteran’s representative asserted that the Veteran’s peripheral neuropathy may be related to her service-connected PTSD, due to the medications causing different issues such as numbness. In February 2014, the Veteran was afforded a VA examination. The Board finds that the VA medical opinion provided at that time is inadequate for adjudication purposes. In that regard, the VA examiner supported his conclusions with an absence of medical evidence in-service. The VA examiner also failed to provide support for the conclusions that there were no conditions that would lead to her peripheral neuropathy and consider the Veteran’s contentions pertaining to the onset and continuity of her symptoms. Accordingly, the Board finds that a remand is necessary for a new VA examination to determine the nature and etiology of any currently present neurological impairment of the bilateral lower extremities. The matters are REMANDED for the following action: 1. Identify and obtain any pertinent, outstanding VA and private treatment records and associate with the claim file. 2. Then, schedule the Veteran for an examination to determine the nature and etiology of any currently present back disability. The claims file must be made available to and reviewed by the examiner. Any indicated test or studies should be performed. Based on the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently present back disability had its onset during the Veteran’s active service, or is otherwise etiologically related to such service. In forming the opinion, the examiner must consider the Veteran’s lay statements regarding the onset and continuity of her symptoms. The examiner must also provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently present back disability was caused or aggravated by a service-connected disability, to include any altered gait and/or body mechanics caused by such. The examiner must provide a complete rationale for all opinions provided. 3. Then, schedule the Veteran for an examination to determine the nature and etiology of any currently present neurological impairment of the lower extremities. The claims file must be made available to and reviewed by the examiner. Any indicated test or studies should be performed. Based on the examination results and a review of the record, the examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently present neurological impairment of the lower extremities had its onset during the Veteran’s active service, or is otherwise etiologically related to such service. is related to the Veterans active service. In forming the opinion, the examiner must consider the Veteran lay statements regarding the onset and continuity of her symptoms. The examiner must also provide an opinion as to whether it is at least as likely as not (50 percent probability or better) that any currently present neurological impairment of the lower extremities was caused or aggravated by a service-connected disability, to include any altered gait and/or body mechanics caused by such. The examiner must provide a complete rationale for all opinions provided. 4. Confirm that all VA examination reports and medical opinions provided comport with this remand, and undertake any other development determined to be warranted. 5. Then, readjudicate the appeal. If a decision is adverse to the Veteran, issue a supplemental statement of the case and allow appropriate time for response. Then, return the case to the Board. Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Byrd, 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.