Citation Nr: 21028366 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 14-06 063 DATE: May 11, 2021 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2007 to July 2011. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2012 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In February 2017, the Veteran testified at a Travel Board hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. By way of background, this matter was initially before the Board in December 2017, when it was remanded for additional development. See December 2017 Remand BVA or CAVC. Thereafter, in a December 2019 decision, the Board, in pertinent part, denied the Veteran's claim of entitlement to service connection for a low back disability, and the Veteran appealed that decision to the U.S. Court of Appeals for Veterans Claims (Court). See December 2019 BVA Decision. In January 2021, the Court granted the parties' Joint Motion for Partial Remand (JMPR), which vacated the portion of the December 2019 Board decision that denied entitlement to service connection for a low back disability and remanded the matter for readjudication. See January 2021 CAVC Decision. Entitlement to service connection for a low back disability is remanded. In the January 2021 JMPR, the Court found that the Board erred in relying on a June 2018 VA medical opinion that failed to substantially comply with a December 2017 Board remand. Specifically, in the December 2017 decision, the Board found that a VA medical opinion was needed to address a 2017 diagnosis of lumbar facet syndrome. As such, the Board, in pertinent part, asked the VA examiner to specifically consider the January 2017 diagnosis of lumbar facet syndrome and the Veteran's assertion that wear and tear during service caused or contributed to his low back disability. See January 2017 Remand BVA or CAVC. As stated above, the Veteran was afforded a VA examination in June 2018. The examiner noted that the Veteran had been diagnosed with lumbosacral strain. During the examination, the Veteran reported that his symptoms manifested in 2011, shortly after he was discharged from active duty service, and indicated that they were caused by strenuous activity and overhead during service. After performing an examination and reviewing the evidence of record, the June 2018 VA examiner opined that it was less likely than not that the Veteran's back pain was incurred in or caused by the claimed in-service injury, event, or illness. In support of his opinion, the examiner noted that there was no documentation of back problems during service. The examiner further opined that it was more likely that the Veteran's back pain was related to his post-service work as a firefighter and weightlifter. To this end, the examiner noted that the Veteran appeared incredibly muscular and fit and that, to maintain such a physique, would require a lot of gym use working on weight bearing weights. The examiner also stated that the Veteran was working in construction, which could also have contributed to his back problems. See August 2018 C&P examination. Based on the foregoing, the Board finds that a remand is necessary to obtain an addendum medical opinion to evaluate the nature and etiology of the Veteran's claimed low back disability. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. 2. After completion of the above development, obtain an addendum opinion by an appropriate examiner to determine the nature and etiology of any diagnosed low back disability, to include lumbar facet syndrome and lumbosacral strain. It is up to the discretion of the examiner as to whether an in-person examination is necessary. The examiner should provide the following opinions: (a.) The examiner should identify, with specificity, all current diagnoses pertinent to the Veteran's claimed low back disability. By "current disability" the Board means: (1) any disability diagnosed by the examiner; (2) any relevant diagnosis during the appeal period (beginning on July 18, 2011, the day after the Veteran was discharged from active duty service); and/or (3) symptoms resulting in functional impairment but not otherwise warranting a specific diagnosis. The examiner should specifically consider the diagnoses of lumbar facet syndrome and lumbosacral strain, respectively diagnosed during a January 2017 physical therapy consultation and during the June 2018 VA examination. See May 2017 CAPRI; August 2018 C&P examination. If the examiner determines that any prior diagnoses are incorrect, he or she should provide an explanation for why the diagnosis was in error. (b.) For each diagnosed low back disorder, the examiner should offer an opinion as to whether it is it at least as likely as not (50 percent or greater probability) that such disability is etiologically related to the Veteran's active duty service, to include as due to wear and tear sustained while he was serving on active duty. Please explain why or why not. Reasons should be provided for any opinion rendered. If the examiner is unable to provide an opinion without resort to speculation, an explanation as to why this is so should be provided and any additional evidence that would be necessary before an opinion could be rendered should be identified. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.