Citation Nr: 22011501 Decision Date: 03/01/22 Archive Date: 03/01/22 DOCKET NO. 17-13 654 DATE: March 1, 2022 REMANDED Entitlement to service connection for a low back disability, to include degenerative arthritis of the lumbar spine, is remanded. REASONS FOR REMAND The Veteran served on active duty from June 2007 to April 2008. He had additional periods of inactive service in the United States Navy Reserve between 2005 and 2013. This case comes to the Board of Veterans' Appeals (Board) from a January 2016 rating decision of the Department of Veterans Affairs (VA) Regional Office. The case was remanded for further development in April 2019. The Board previously remanded this issue to obtain the Veteran's complete service personnel records in order to determine whether he underwent any back injury during a period of active duty for training or inactive duty for training. The Board also requested that a VA examination be held, and the examiner was asked to elicit a full history from the Veteran and to consider his lay statements of record. It specifically noted that the Veteran was competent to attest to factual matters of which he has first-hand knowledge, and if there was a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. A medical opinion was then obtained in June 2021. The examiner performed an in-person examination of the Veteran and discussed his service treatment records, but the examiner did not discuss, at all, the Veteran's lay assertions. The examiner concluded that the Veteran's lumbar spine disorder was less likely than not incurred in or caused by service, and as rationale, wrote that there were no medical facts in the evidence from 2007-2008 showing that the Veteran had any diagnosis, signs, symptoms, or relevant physical examination findings to support that a low back disability. He wrote that the Veteran did not have documentation of lumbar spine pathology until 2010, which was almost 2 years after leaving service. While the examiner relied on the absence of any diagnoses or clinical findings of lumbar spine degenerative arthritis in the Veteran's service treatment records for his conclusion, he appears to have completely disregarded the Veteran's reports of having back pain in service, and did not provide a full history as elicited from the Veteran, which was specifically requested in the Board's prior remand. See Stegall v. West, 11 Vet. App. 268 (1998) (holding that a remand confers on the claimant, as a matter of law, the right to compliance with the remand instructions). At the January 2016 VA examination, the Veteran reported that his lower back pain began shortly after his return from deployment to Iraq and Afghanistan, and he denied any specific trauma to his back after service. The Veteran is competent to report on his own observations regarding his symptoms as he experiences them. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). These types of assertions do need to be considered and addressed by the examiner, and, in the absence of any contradictory evidence or information, the Board currently finds the Veteran's assertions to be highly credible, especially in light of the short period of time that passed between his active duty service in 2008 and his diagnosis of lumbar degenerative changes in May 2010. The Board therefore remands this issue so that another VA medical opinion can be obtained that fully addresses and considers the Veteran's lay assertions. The Veteran's VA treatment records have only been obtained up to October 2019, with the exception of some records from August and September 2020. The Board therefore requests that all treatment records from October 2019 also be obtained. The matters are REMANDED for the following action: 1. Obtain all VA treatment records since October 2019. 2. Obtain an addendum medical to address the nature and etiology of the Veteran's back disorder. If the examiner finds that a new VA examination must be held prior to providing an opinion, schedule the Veteran for an examination. If feasible, the examination may be held via telehealth during social distancing restrictions and an opinion can be provided based on other medical evidence of record. The examiner must be provided access to the Veteran's entire claims file and must specify in the report that the claims file has been reviewed. The examiner should then address: For all current lumbar spine disorders, is it as likely as not that the disorder had its onset during active duty service or is otherwise related to any event or injury in service? Please discuss the Veteran's lay assertions that he began experiencing back pain in 2008 after his return from the Middle East and that this pain continued since that time, and whether this could have been a manifestation of what was later diagnosed as lumbar degenerative changes in May 2010. The Board notes that there is not currently any evidence of record contradicting the Veteran's assertions, which it currently finds to be credible, so if these assertions are not found to be credible, the examiner must explain why. (Continued on the next page) A complete and fully explanatory rationale must be provided for any opinion offered. If any opinion cannot be rendered without resorting to speculation, the examiner must explain why. DELYVONNE M. WHITEHEAD Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Rude, Mary 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.