Citation Nr: 21031116 Decision Date: 05/20/21 Archive Date: 05/20/21 DOCKET NO. 17-18 398 DATE: May 20, 2021 REMANDED Entitlement to service connection for a back injury is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Air Force from August 1965 to January 1969 with additional Reserve service. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). By way of background, in an August 2019 decision, the Board denied the Veteran's claim. The Veteran subsequently appealed that decision to the United States Court of Appeals for Veterans Claims (Court). In July 2020, the Court granted a Joint Motion for Remand (JMR), which vacated and remanded the Board's August 2019 decision. In December 2020, the Board last remanded the matter to the RO for further development. Entitlement to service connection for a back injury Although the Board sincerely regrets the additional delay, a remand is warranted to ensure that there is a complete and accurate record upon which to decide the Veteran's claim so that he is afforded every possible consideration. After careful review of the evidence of record, the Board finds that it cannot make a fully informed decision on the Veteran's service connection claim based upon the evidence of record. In this regard, the Veteran was last afforded a VA examination in May 2014 where the VA examiner opined that the Veteran's diagnosed back disabilities were not related to his service, in part, because the Veteran denied recurrent back pain upon his separation from service and because his x-ray results were likely related to his post-service active lifestyle and work history. The Board notes that the VA examiner did not explain why the Veteran's x-ray results were likely related to his post-service lifestyle/work history rather than his in-service muscle strain. Following this opinion, the Veteran submitted additional medical and lay evidence relevant to his claim. Specifically, the Veteran submitted a statement from his former private treating physician, Dr. L.G., stating that he treated the Veteran in the late 1980s and early 1990s for his chronic low back and neck pain, that the Veteran's symptoms started after he sustained in-service injuries that never completely abated, and that the Veteran presented to him with a history of Grade 1/4 retrolisthesis and scoliosis, which are significant enough diagnoses to cause the Veteran's chronic symptoms. See July 2014 private medical statement. The Board notes that it is unclear whether Dr. L.G., in reaching these conclusions, reviewed the Veteran's service treatment records, which detail the Veteran's in-service back complaints and contain his separation Report of Medical History where he denied experiencing recurrent back pain. This is significant as the Veteran is claiming that his in-service back injury/pain never resolved. The Veteran also submitted a statement from his former chiropractor who indicated that he treated the Veteran between October 2006 and December 2009 for his complaints of chronic neck and low back pain. See August 2014 private medical statement. Given the foregoing, and in light of the fact that no VA opinion of record has considered the medical evidence showing treatment and diagnoses at least as early as the late 1980s for low back pain, a remand is warranted for an addendum medical opinion that considers all the evidence of record, to include the lay and private medical statements of record. The Board notes that it cannot properly evaluate the Veteran's service connection claim until it can clarify the nature and origin of the Veteran's disability, to include whether the Veteran experienced continuous symptomatology related to his current diagnoses from service. Finally, although the evidence of record reflets that the Veteran served in the Air Force Reserves after his discharge from active service until August 1971, the service treatment records do not reflect any medical records from his Reserve service. As such, on remand, any outstanding Reserve medical records should be obtained. The matters are REMANDED for the following action: 1. The RO should undertake appropriate development to obtain the Veteran's Air Force Reserve service treatment records. All efforts to obtain such records should be documented in the claims file. 2. Obtain and associate with the claims file any outstanding VA treatment records. The last VA treatment of record is dated February 2021. 3. Provide the Veteran with another opportunity to identify and/or submit any further outstanding private treatment records relevant to his claim. After securing the necessary releases, attempt to obtain and associate any identified treatment records with the claims file. 4. Then, obtain an addendum opinion from an appropriate medical professional to determine the nature and origin of the Veteran's back disability. The entire claims file, to include a copy of this Remand, must be made available to and be reviewed by the examiner. The examiner is asked to respond to the following: (a) Is it at least as likely as not (50 percent probability or greater) that the Veteran's diagnosed back disability (1) had its onset in service; (2) manifested within one year of his discharge from service; OR (3) is otherwise related to service, to include as due to the Veteran's in-service February 1967 muscle spasm and April 1968 muscle strain? (b) If the examiner determines that the Veteran's back disability is not related to his service, how does that reconcile with the opinion provided by the Veteran's private treatment provider, Dr. L.G., who noted that the Veteran's symptoms started after the Veteran sustained in-service injuries that never completely abated and that the Veteran presented to him with a history of Grade 1/4 retrolisthesis and scoliosis, which are significant enough diagnoses to cause the Veteran's chronic symptoms? See July 2014 private medical statement. In providing the above opinions, the VA examiner MUST ADDRESS the lay assertions of record that the Veteran experienced back pain in and since his service. In this regard, the Veteran, his spouse, and a friend he has known for over 50 years have provided statements that the Veteran complained of back pain over the years related to service. The examiner must provide a complete rationale for all opinions provided. A detailed discussion of the relevant facts and medical principles involved would be of considerable assistance to the Board. MARJORIE A. AUER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Amanda Purcell, 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.