Citation Nr: 21023670 Decision Date: 04/21/21 Archive Date: 04/21/21 DOCKET NO. 15-14 244 DATE: April 21, 2021 REMANDED Entitlement to service connection for degenerative disc disease and degenerative arthritis of the lumbar spine is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from October 1974 to June 1981 and also served in the Reserves. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2018, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of that hearing is associated with the claims file. In July 2019, the Board last remanded this matter to the RO for further development. Entitlement to service connection for degenerative disc disease and degenerative arthritis of the lumbar spine Although the Board sincerely regrets the additional delay and recognizes the importance of the Veteran’s claim, a remand for an addendum VA opinion is again necessary in order to make a fully informed decision on the Veteran’s claim and to afford him every possible consideration. In this regard, the July 2019 Board decision found that a remand was warranted to obtain an addendum VA opinion because the April 2019 negative nexus opinion concerning the Veteran’s lumbar spine disability was inadequate. As such, in January 2020, VA obtained an addendum opinion from the same VA examiner that provided the April 2019 opinion. Although, the January 2020 VA examiner again found that the Veteran’s disability was not caused by his claimed in-service injury, event, or illness, the examiner’s rationale appears to overwhelmingly center on why his April 2019 opinion was not inadequate, despite the July 2019 Board finding that it was, and why he believed the Veteran’s in-service back pain derived from a separate incident than from the Veteran’s documented in-service fall in Hawaii where the Veteran hurt his knee. Regardless of how the Veteran experienced back pain in service, the examiner did not further explain why he concluded that the Veteran’s diagnosed disability was not related to the documented and reported in-service back pain. Additionally, the July 2019 Board remand instructions asked that the examiner discuss the Veteran’s post-active service back injuries in the 1980s in relation to the Veteran’s claim. The examiner noted that “[s]tatements from the Veteran’s post-discharge era show trauma to the lower back in a man who had previously been fit enough to be active in martial arts while working as a laborer and mechanic” and that “the Veteran’s Workman’s comp[ensation] claim stated this injury made him unemployable.” Based on these notations, it is unclear if the examiner found that the Veteran’s current disability is a result of a post-active service work related back injury. In light of these deficiencies, the Board finds that a remand is warranted for an addendum VA opinion that contains adequate rationale and from a VA examiner who has not previously provided an opinion in this case. The matters are REMANDED for the following action: 1. Obtain and associate with the claims file any outstanding VA treatment records. The last VA treatment of record is dated January 2020. 2. Then, obtain an addendum opinion from an appropriate medical professional, who has not previously provided an opinion in this case, to determine the nature and origin of the of the Veteran’s claim for service connection for degenerative disc disease and degenerative arthritis of the lumbar spine. The claims file, to include a copy of this Remand, should be made available to and be thoroughly reviewed by the VA examiner. The examiner is asked to respond to the following: Is it at least as likely as not (50 percent probability or greater) that the Veteran’s diagnosed lumbar spine disability (1) had an onset in active duty service; (2) manifested within a year of discharge from active duty service; or (3) is otherwise related to active service, to include the Veteran’s reports of back pain and treatment for back pain during active service? In providing the above opinion, the examiner MUST ADDRESS the following: (1) the STRs reflecting reports of back pain. See what appears to be either a December 1976 or 1978 STR (noting that his back and joints ache); April 1979 STR (noting back problems and an assessment of a muscle spasm); and March 1980 STR (assessing the Veteran with low back pain). (2) The Veteran’s reports that he hurt his low back in service (as opposed to his mid-back), to include experiencing back pain after falling during a training while carrying a heavy rucksack, and that he continued to experience back pain since. For the limited purpose of this examination only, the examiner should assume the Veteran fell while carrying a rucksack during active service and experienced back pain. (3) The Veteran’s post-active service back injuries. See June 1997 Physical Medicine and Rehabilitation letter (reflecting the Veteran has a low back pain secondary to a work related incident in 1984 and that he developed pain in the low back that radiated to the legs secondary to this incident); August 1996 private treatment record (reflecting the Veteran was in a motorcycle accident in 1992 resulting in a crushed spinal disk, level indeterminate); May 2001 VA new patient treatment note (reflecting the Veteran has a history of multiple back injuries in the 1980s while working for the Department of labor); November 2013 private treatment record (reflecting the Veteran reported lumbar problems for quite some time ever since he had a severe fall injury while in the military carrying heavy pack and munitions and was assessed with a muscle spasms as well as thoracic radiculopathy secondary to an old industrial injury). A complete rationale must be provided for all opinions. In this regard, a detailed discussion of the relevant facts and medical principles involved would be of considerable assistance to the Board. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Amanda Purcell, 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.