Citation Nr: 21025629 Decision Date: 04/28/21 Archive Date: 04/28/21 DOCKET NO. 17-44 435 DATE: April 28, 2021 REMAND Entitlement to service connection for a back disability is remanded. REASONS FOR REMAND The Veteran had active service in United States Marine Corps (USMC) from June 1979 to March 1982. This case comes before the Board of Veterans’ Appeals (Board) on appeal of a September 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a hearing before the undersigned Veterans Law Judge in February 2021. A transcript of that hearing is associated with the claims file. Service Connection – Back Disability The Veteran asserts that his low back disability is related to an injury he sustained during his active service. In a February 2021 statement, the Veteran’s wife, C.S., stated that the Veteran complained of back pain when they met in 1982. C.S. also stated that the Veteran’s back pain increased once they had children and became more severe from 1989 to 1995. Additionally, C.S. stated that she urged the Veteran to seek medical attention, and that when he finally saw the doctor, he was prescribed medication and physical therapy. During the Veteran’s February 2021 hearing, he testified that his back pain had continued since service and that while in-service he only went to sick call for his back pain when the pain became constant. The Veteran’s service treatment records (STRs) reveal that in September 1981 he was seen for complaints of lower back pain and assessed as having a lower back strain. At that time, the Veteran was objectively assessed as having limited range of motion in bending, stiff lower back muscles and spasms. In a May 2015 treatment note, the Veteran was documented as reporting an in-service injury that resulted in back pain which had increased since approximately December 2013. In March 2016 and September 2016 statements, the Veteran’s physician, Dr. J.C., opined that the Veteran’s diagnosis of low back pain could be related to his military service. In June 2017, the Veteran was afforded a VA examination. At that time, the Veteran reported that the date of the onset of his symptoms was 2012. X-rays revealed degenerative bony spurring of the lumbar spine. The VA examiner diagnosed lumbosacral strain with degenerative changes and left lower extremity radiculopathy. However, the VA examiner opined that the Veteran’s back disability was less likely than not incurred in or caused by his active service. The VA examiner reasoned that the Veteran’s in-service diagnosis would have been self-limiting and resolved without any future issues. Further, the examiner noted that there were no additional complaints regarding the Veteran’s back while he was in service. The VA examiner noted that the Veteran stated that his current symptoms of back pain did not start until 2012, which was 30 years after his low back strain from over-lifting. The Board initially finds that the March 2016 and September 2016 private medical opinions from Dr. J.C. are of no probative value. In that regard, Dr. J.C. failed to address relevant medical records and provide any rationale for his conclusions. See Sklar v. Brown, 5 Vet. App. 140 (1993). Additionally, the Board finds that the June 2017 VA medical opinion is inadequate for adjudication purposes. In that regard, the VA examiner based the conclusion on a lack of medical evidence documenting complaints of low back pain and failed to incorporate prior treatment notes where the Veteran stated that his back pain had continued since his in-service injury. Therefore, the Board finds that an addendum opinion is warranted to address the etiology of the Veteran’s current low back disability. This matter is 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 by an examiner with sufficient expertise 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 tests and studies must be performed. Based on the examination of the Veteran and review of the record, the examiner must provide an opinion as to whether it is at least as likely as not (50 percent or better probability) 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 lay statements of record regarding the onset and continuity of the Veteran’s symptoms. A complete and detailed rationale for all opinions expressed must be provided. 3. Confirm that the VA examination report and all medical opinions provided comport with this remand, and undertake any other development found to be warranted. 4. 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.