Citation Nr: 21026889 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 12-30 733 DATE: May 4, 2021 REMANDED Entitlement to service connection for a low back condition is remanded. REASONS FOR REMAND The Veteran served on active duty from January 1983 to January 1991; September 1999 to March 2000; March 2002 to April 2002; April 2008 to July 2008; and October 2009 to December 2009. This matter is in the Department of Veterans Affairs (VA) legacy appeals system and comes before the Board of Veterans' Appeals (Board) on appeal from a July 2011 rating decision of the VA Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge (VLJ) in August 2017. A transcript of the hearing is of record. Entitlement to service connection for a low back condition is remanded. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The record contains VA examinations and opinions of July 2011, April 2016, and October 2019. Unfortunately, there are still significant questions about the completeness of the record and the adequacy of the opinions provided. First, in its July 2011 rating decision, the RO seems to reference an October 2010 thoracolumbar spine examination that does not appear to be in the record. A July 2011 VA foot examination included range of motion results for the thoracolumbar spine but these were different than those cited in the July 2011 rating decision and other specific information cited was not included in the foot exam. A remand is required to determine whether this examination actually occurred and if so, to add it to the record. Second, the opinions offered by the July 2011, April 2016, and October 2019 VA examiners, whether taken alone or together, are inadequate to support a Board decision on the issue of entititlement to service connection for a low back condition. The July 2011 examiner diagnosed low back strain, resolved in service without residuals, and lumbar degenerative disc disease consistent with aging and not related to service-connected plantar fasciitis. It did not include a complete sentence, much less a supporting rationale. The April 2016 examiner opined that there was no evidence to support the Veteran's claim that his condition started during service or that it was related to his left hip disability. The April 2016 examiner did not discuss the Veteran's lay statements regarding continuity of symtoms since service or the possibility of causation or aggravation by service-connected plantar fasciitis. Finally, the October 2019 examiner did address secondary service-connection related to both plantar fasciitis and left hip disabilities. However, they stated the Veteran's condition was not diagnosed until 33 years after his 1986 in-service complaints, but did not address his diagnoses as early as July 2011 or the Veteran's statement's regarding continuity of symptoms. A new opinionbased on full review of the record and supported by stated rationaleis needed to fairly resolve the appellant's claims. See 38 U.S.C. § 5103A (2012); 38 C.F.R. § 3.159 (2017); McLendon v. Nicholson, 20 Vet. App. 79, 83 (2006). The matters are REMANDED for the following action: 1. Obtain the Veteran's VA October 2010 VA examination for a low back condition. Document all attempts to do so in the claims file. 2. Obtain an opinion from an appropriate clinician as to the etiology of the Veteran's low back condition. The examiner must review the claims file. If, at any point during the period on appeal, a diagnosis cannot be provided but the Veteran's condition manifests in symptoms that cause functional impairment, then the examiner should consider them a "disability" for the purpose of providing the requested opinions below. For each low back condition diagnosed during the period on appeal, the examiner is asked to provide a response to the following: Is this condition at least as likely as not related to service, including a. in-service complaints of low back pain, diagnosed as mechanical back pain with muscle spasms, or b. March 2007 survival school injury with left leg stuck under buried tree? Provide a rationale to support the opinions. In providing the requested opinion, consider the Veteran's description of his in-service injury and symptoms as well as his post-service symptoms. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? Is this condition at least as likely as not proximately due to service-connected plantar fasciitis and/or left hip disabilities? Is this condition at least as likely as not aggravated, i.e., worsened beyond its natural progression, by service-connected plantar fasciitis and/or left hip disabilities? If arthritis is diagnosed, is it at least as likely as not that the lumbar spine arthritis (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service? Only if the examiner cannot provide the required opinions based on the record alone, schedule the Veteran for an appropriate in-person examination. (Continued on the next page) 3. After the above development, and any additionally indicated development, has been completed, readjudicate the issue on appeal. If any benefit sought is not granted to the Veteran's satisfaction, send the Veteran and his representative a Supplemental Statement of the Case and provide an opportunity to respond. If necessary, return the case to the Board for further appellate review. L. M. BARNARD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zimmerman, Micah 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.