Citation Nr: 21024748 Decision Date: 04/26/21 Archive Date: 04/26/21 DOCKET NO. 15-12 180A DATE: April 26, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1989 to November 1996. Entitlement to service connection for a low back disability is remanded. The Veteran asserts that a back disability is the result of heavy lifting and prolonged standing while in service. The record shows that in July 2008, the Veteran reported that a wrist injury impaired his ability to do janitorial work and ride a 4-wheeler. In August 2009, he reported that wrist pain was exacerbated by work, fishing, and riding a motorcycle. During a July 2008 VA examination, the Veteran reported a post-service on-the-job back during. During a February 2012 VA examination, the Veteran reported that he injured his back in an all-terrain vehicle (ATV) accident six years prior. During the January 2018 Board hearing, the Veteran testified that he was unable to work and received disability through the State of Illinois. In March 2019, the Board requested a medical opinion which addressed whether it was at least as likely as not that any low back disability was related to service, or low back pain in service. A June 2019 VA examiner opined that lumbosacral strain was not the result of service because there was no pertinent evidence showing complaints, evaluation, or treatment for lower back strain since separation from service. The examiner explained that was consistent with the fact that an lower back strain in service had resolved. The examiner stated that the current symptoms of lower back pain were caused by degenerative arthritis which, according to medical literature, was a “normal aging process.” The Board finds the VA examination incomplete. The examiner noted the in-service diagnosis of lower back strain. However, the examiner did not discuss the significance, if any, of other in-service lower back diagnoses. For example, the record shows a diagnosis of myofascial lower back pain in December 1989, mild scoliosis in January 1990, and mechanical back pain secondary to increased lordosis in June 1995. The examiner opined that arthritis was the result of natural age progression. However, the examiner did not discuss (1) whether there was evidence of arthritis in service, or within one year of separation from service; (2) whether any of the noted in-service diagnoses had likely caused or progressed to degenerative arthritis; and (3) the significance, if any, of reported post-service back injuries, post-service job duties, and post-service recreational activities. While in service, the Veteran reported low back pain with prolonged standing. In September 2009, the Veteran reported chronic low back pain with bending, movements, and driving which worsened after an ATV accident and thoracic spine fracture. The examiner did not discuss the significance, if any, of the in-service versus post-service low back pain symptoms. When VA provides an examination or obtains an opinion, the examination or opinion must be adequate. Barr v. Nicholson, 21 Vet. App. 303 (2007). Therefore, additional VA examination is necessary to determine the etiology of a low back disability. The Board notes the Veteran’s 2008 report of a work-related back injury and the Veteran’s testimony regarding state disability benefits. The Board additionally notes that VA medical records associated with the claims file in March 2019 show that as recently as 2018, the Veteran received treatment from providers at Springfield Clinic and Advanced Rehab and Sports Medicine. Notably, there are medical records from Springfield Clinic and Advanced Rehab and Sports Medicine in the claims file. However, there are no records since 2014. March 2019, correspondence asked the Veteran to provide authorization for VA to obtain all relevant medical records, particularly “the names and addresses of all medical care providers who ha[d] treated [the Veteran] for [the] claimed back and wrist disability.” The Veteran was asked to provide or give authorization for VA “to retrieve records related to any workers compensation claim for a low back disability.” In an April 2, 2019 statement, the Veteran’s representative stated that “the Veteran ha[d] been seeing Omaha VAMC (Iowa City).” The representative then submitted several lay statements from the Veteran and his family. To date, neither the Veteran nor the representative have provided the information sought. The Board finds that the requested workers' compensation records and private medical records Springfield Clinic and Advanced Rehab and Sports Medicine are pertinent to the claim and must be obtained. Sullivan v. McDonald, 815 F.3d 786 (Fed. Cir. 2016). The Board finds that the State of Illinois disability benefits records may provide additional information such any evaluation of the spine or other relevant medical records used to adjudicate the claim. Therefore, on remand, those records should be obtained and associated with the claims file. The matter is REMANDED for the following action: 1. Ask the Veteran to identify and submit, or authorize VA to obtain: (a.) All relevant VA and non-VA medical records, to include treatment records from Springfield Clinic and Advanced Rehab and Sports Medicine from 2014 to present. (b.) A copy of the determination associated with the reported claim for workers' compensation for a back injury and all documents and medical records associated with the determination. (c.) All records pertaining to claims for disability benefits from the Social Security Administration and any disability benefits claim with the State of Illinois. 2. Then, schedule the Veteran for a VA examination to determine the nature and etiology of a back disability. The examiner must review the claims file, to include a copy of this Remand, and should note that review in the report. A clearly stated rationale with references to the record, diagnostic tests, and any medical literature or research should be provided. The examiner should: (a.) Opine whether it is at least as likely as not (50 percent or greater probability) that a back disability was incurred in service. Discuss all in-service back diagnoses to include muscle spasms, back strain, myofascial pain, scoliosis, and mechanical back pain secondary to increased lordosis. (b.) Opine whether it is at least as likely as not (50 percent or greater probability) that evidence of arthritis was shown in service, or within one year of separation from service. Discuss (1) in-service and post-service symptomatology; (2) lay statements regarding continuous symptoms in and after service; (3) the significance of a diagnosis of degenerative changes approximately 14 years after separation from service; and (4) whether any noted in-service diagnoses was at least as likely as not to progress to the current back disability. (c.) If a low back disability is attributed to another etiology, the examiner should explain why the other etiology is more likely. Discuss post-service reports of (1) a workers’ compensation back injury; (2) an ATV back injury; (3) job duties; and (4) recreational activities (riding a motorcycle and a 4-wheeler). Harvey P. Roberts Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E.O., 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.