Citation Nr: 21025417 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 18-00 105A DATE: April 28, 2021 REMANDED Entitlement to service connection for a right shoulder condition is remanded. Entitlement to service connection for a low back disability, characterized as narrowing of the disc space L4-L5 with degenerative changes at L5-S1, is remanded. Entitlement to service connection for a right knee condition is remanded. Entitlement to service connection for high blood pressure is remanded. REASONS FOR REMAND The Veteran served in the United States Army from August 1989 to August 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ) rating decisions dated in October 2015 and September 2016. As an initial matter, the Board notes that a claim for service connection for a low back injury was denied in an unappealed August 1995 rating decision. However, since the August 1995 rating decision, service department records in existence but unavailable for consideration in August 1995 have been added to the record and are relevant to the claim for service connection for a low back injury. As such, new and material evidence is not required to reopen the Veteran’s claim and the claim will be reconsidered and addressed on the merits. See September 2016 AOJ rating decision; see also 38 C.F.R. § 3.156(c). 1. Entitlement to service connection for a right shoulder condition is remanded. 2. Entitlement to service connection for a low back disability is remanded. 3. Entitlement to service connection for a right knee condition is remanded. 4. Entitlement to service connection for high blood pressure is remanded. The Veteran seeks service connection for a right shoulder condition, a low back disability, a right knee condition and high blood pressure, which he asserts are related to service. At the August 2020 Board hearing, regarding the Veteran’s low back injury, he testified that he injured his low back during service while moving a wall-walker; he was seen in a hospital and was later placed on light duty for a few days. He testified that his back has always bothered him. With regard to his right knee condition, he testified that prior to service, when he was 17, he strained the ligaments of his right knee and underwent a surgical procedure. The Veteran reported that he had no pain when he entered service. He testified that during service his military occupation specialty was in communications, which required him to carry heavy equipment/gear, set up communication equipment and jump on top of vans. He testified that he began feeling pain from his right knee in service which has worsened as he has gotten older. With regard to his high blood pressure, he testified that it had its onset during service and that he was diagnosed with borderline high blood pressure in 1992 during service; further, he purportedly was also diagnosed with high blood pressure by a private treatment provider approximately a year or two after service. The Veteran also testified that his high blood pressure may have caused or aggravated his right shoulder condition, low back disability and right knee condition. The Veteran also testified that he sought treatment following service; however, it took a year and a half before he was seen by VA. See also March 1995 Correspondence. The Veteran has a current diagnosis of a lumbar back spasm with early degenerative changes noted in the facet joints of L5-S1 and early narrowing of disc space at L4-5 from at least May 1995; osteoarthritis of the knees from at least January 2016 and hypertension from at least September 2016. Considering the Veteran’s contentions and the record on appeal, a VA examination should be obtained to determine the probable etiology of the Veteran’s right shoulder condition, low back disability, right knee condition, and high blood pressure. 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4)(i); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). During the August 2020 Board hearing the Veteran identified relevant outstanding private treatment records; on remand, VA should attempt to obtain authorization and request those records. Finally, the Board notes that although some of the Veteran’s service department records have been added to the file, it is unclear whether all the Veteran’s treatment records have been obtained. Although the Veteran’s medical history and examination reports for enlistment have been obtained, the Veteran’s medical history and examination reports for separation if available have not been added to his file. On remand, VA should ensure that the Veteran’s complete service records have been obtained. The matters are REMANDED for the following action: 1. The AOJ should obtain the Veteran’s complete VA treatment records. 2. The AOJ should obtain authorization from the Veteran and request the Veteran’s private treatment records. 3. The AOJ should obtain the Veteran’s complete service records from his active duty service, including his separation medical history and examination reports. 4. Then, schedule the Veteran for a VA examination to ascertain the nature and etiology of the Veteran’s high blood pressure. Following a review of the Veteran’s record, the examiner should state whether it is at least as likely as not (50 percent or greater likelihood) that hypertension manifested during service, that hypertension was manifest to a compensable degree within one year of service, or that it is otherwise causally or etiologically related to a period of active duty service. The examiner should also indicate whether the Veteran’s high blood pressure proximately caused or aggravated the Veteran’s right knee, right shoulder, and/or low back disabilities. In rendering the opinions, the examiner should consider the statements of the Veteran regarding the symptoms of his hypertension to be competent. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 5. Schedule the Veteran for a VA examination to ascertain the nature and etiology of the Veteran’s right knee condition. Following a review of the Veteran’s record, the examiner should address the following: (a.) whether a right knee disability clearly and unmistakably (obvious, manifest, undebatable) existed prior to the Veteran’s period of active service, and if so, is there also clear and unmistakable evidence that the preexisting right knee disability was NOT aggravated in service beyond the natural progression of such disorder. (a.) If there is no clear and unmistakable evidence that the Veteran had a right knee disability that preexisted active duty service and was not aggravated in active duty service, then is it at least as likely as not (50 percent or greater likelihood) that a right knee condition had its onset in service, that arthritis was manifest to a compensable degree within one year of active duty service, or is otherwise causally or etiologically related to a period of active duty service. In rendering the opinions, the examiner should consider the statements of the Veteran regarding the symptoms of his right knee disability to be competent. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 6. Schedule the Veteran for a VA examination to ascertain the nature and etiology of the Veteran’s low back disability. Following a review of the Veteran’s record, the examiner should state whether it is at least as likely as not (50 percent or greater likelihood) that a low back disability manifested during service, that arthritis was manifest to a compensable degree within one year of service, or that it is otherwise causally or etiologically related to a period of active duty service. In rendering the opinions, the examiner should consider the statements of the Veteran regarding the symptoms of his low back disability to be competent. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. 7. Schedule the Veteran for a VA examination to ascertain the nature and etiology of the Veteran’s right shoulder condition. Following a review of the Veteran’s record, the examiner should indicate whether it is at least as likely as not (50 percent or greater likelihood) that a right shoulder condition manifested during service, that arthritis was manifest to a compensable degree within one year of service, or that it is otherwise causally or etiologically related to a period of active duty service. In rendering the opinions, the examiner should consider the statements of the Veteran regarding the symptoms of his right shoulder condition to be competent. The examiner should provide a complete rationale for all opinions expressed and conclusions reached. S. L. Kennedy Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board G. Johnson 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.