Citation Nr: 21041396 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 14-12 458 DATE: July 9, 2021 REMANDED Entitlement to service connection for a back condition is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Army from July 1978 to September 1978, with additional National Guard service. The claim was brought before the Board in September 2018 and was denied. The Veteran appealed the decision to the Court of Appeal for Veterans for Veterans Claims (Court) and pursuant to an August 2019 Joint Motion for Remand (JMR), the Court remanded the claim to the Board for further development. The claim was again brought before the Board in July 2020 and was remanded for further development in accordance with the Court's August 2019 remand. Entitlement to Service Connection: Back Condition The Veteran's service treatment records show that the Veteran was noted as having an abnormal spine with limited forward flexion in his May 1978 enlistment examination. Although a October 2020 VA opinion was provided and opined that the Veteran's condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, due to the Veteran being noted as having an abnormal spine in the form of limited forward flexion on his enlistment examination, the Board finds that an opinion on whether the Veteran entered active duty with a pre-existing condition, and whether such condition was aggravated by his active duty service is needed. Moreover, the examiner found that the Veteran's medical records show a disability determination noted shoulder and back pain reported since October 1998. However, the Board notes that the evidence of record shows the Veteran consistently reported during treatments and/or psychiatric visits from 2001-2003 that his 1998 injury was only to his left shoulder. Further, in a March 2003 medical visit, the Veteran reported that he has suffered from low back pain since the 1970s. Therefore, the Board finds that a remand is required to obtain an addendum addressing the above. The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran's electronic claims file any outstanding VA and private treatment records relevant to the Veteran's back disability. 2. After all outstanding records have been associated with the claims file, return the file to the examiner who provided the October 2020 VA opinion. If the October 2020 examiner is not available, then the file should be sent to appropriate examiner for the requested opinion. The record and a copy of this Remand must be made available to the examiner. Following a review of the entire record, to include the Veteran's competent lay statements, as well as the Veteran's report regarding the onset and progression of his current symptomatology, the examiner should opine as to the following: (a) Is it clear and unmistakable that the Veteran entered his active military service from July 1978 to September 1978 with a pre-existing back condition? (b) If YES, is it clear and unmistakable that the Veteran's pre-existing back condition WAS NOT aggravated beyond the natural progress of the disorder by his active military service from July 1978 to September 1978? In other words, please determine whether it is clear and unmistakable that there was no increase in disability during service or that it is clear and unmistakable that any increase in disability was due to the natural progress of the pre-existing condition. (c) If NO, is it at least as likely as not that the Veteran's back disability is related to his periods of active service? In offering any opinion, the examiner must consider the full record, to include the lay statements regarding in-service incurrence, and the opinion should reflect such consideration. (Continued on the next page) A clearly stated rationale for any opinion offered should be provided and must not be based solely on the lack of any in-service records. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain whether the inability is due to the limits of the examiner's medical knowledge, medical knowledge in general or there is evidence that, if obtained, would permit the opinion to be provided. ROBERT C. SCHARNBERGER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Negron, 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.