Citation Nr: 21030767 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-32 554 DATE: May 19, 2021 REMANDED Entitlement to service connection for a back disorder is remanded. REASONS FOR REMAND The Veteran served on active duty from May 1968 to May 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified before the undersigned at a hearing in February 2020. The Board remanded this matter in August 2020 for additional development. The matter is now returned to the Board for further appellate review. Service connection for a back disorder is remanded. The Veteran contends running while carrying a heavy backpack and equipment during active duty caused his low back disorder. In August 2020, the Board remanded this matter to determine the nature and etiology of the Veteran's back disorder. VA provided the Veteran an examination in February 2021. Unfortunately, this medical opinion is inadequate to adjudicate the Veteran's claim. The February 2021 examiner diagnosed the Veteran with lumbosacral strain with bilateral lower extremity radiculopathy. The examiner opined that the Veteran's back disorder was less likely than not caused by active duty service, in part, because there was no evidence of complaints or treatment for a back condition in the Veteran's medical records. However, the Veteran testified at the February 2020 Board hearing that he injured his back while running and carrying a heavy backpack and equipment during active duty. Moreover, during the examination the Veteran specifically reported injuring his back during training while crawling in the rain wearing "full gear." In other words, the examiner appears to have impermissibly dismissed the Veteran's reports of an in-service back injury and continuous back problems solely because these complaints were not documented in medical treatment records. See Dalton v. Nicholson, 21 Vet. App. 23, 39-40 (2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (that reports of symptomatology are not supported by contemporaneous clinical evidence does not render them inherently not credible). In September 2020, the Agency of Original Jurisdiction (AOJ) sent the Veteran a VA Form 21-4142, Authorization and Consent to Release Information to the Department of Veterans Affairs, so VA could obtain treatment records on the Veteran's behalf. Although the Veteran has not returned a VA Form 21-4142 since the August 2020 Board remand, to afford the Veteran every opportunity to substantiate his claim, the Board will again request the AOJ provide the Veteran another opportunity to complete the form. The Veteran is advised he must cooperate with the AOJ's efforts to obtain relevant evidence or VA will decide the issue on appeal based on the evidence of record. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) (indicating the duty to assist is not always a one-way street). The matter is REMANDED for the following action: 1. Ask the Veteran to complete a VA Form 21-4142 for any outstanding private treatment (medical) records concerning a back disorder. Make two requests for the authorized records from any identified physician unless it is clear after the first request that a second request would be futile. If identified records are not ultimately obtained, the Veteran should be notified pursuant to 38 C.F.R. § 3.159(e). 2. Associate with the record all VA treatment records pertaining to the treatment of the Veteran's back, not already of record, for the period from August 2020. 3. Obtain an addendum opinion from an appropriate clinician to determine whether the Veteran's lumbosacral strain is related to the Veteran's military service. If the examiner determines that an additional in-person examination is required, one should be scheduled. Please note, if the examiner deems it reasonable, an alternate format such as a telehealth interview is acceptable. Following review of the claims file and, if indicated, examination of the Veteran, the examiner should opine whether it is at least as likely as not (50 percent or greater probability) that the Veteran's lumbosacral strain began in or is otherwise caused by the Veteran's active service. The clinician should address the Veteran's lay statements regarding running while carrying a heavy backpack and equipment. The clinician may not dismiss the Veteran's contentions solely because they are not documented in the Veteran's service treatment records. The examiner should address any other pertinent evidence of record. All findings must be reported in detail and all opinions must be accompanied by a clear rationale. If any of the above issues cannot be resolved without resorting to speculation, then a detailed medical explanation as to why this is so must be provided. 4. Then, readjudicate the remanded issue. E. BLOWERS Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Zachery S.C. Luce, 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.