Citation Nr: 22011677 Decision Date: 03/01/22 Archive Date: 03/01/22 DOCKET NO. 18-02 204 DATE: March 1, 2022 REMANDED Entitlement to service connection for a low back disability is remanded. REASONS FOR REMAND The Veteran had honorable active duty service in the United States Air Force from April 1965 to June 1968. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a November 2017 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in April 2019. The Board remanded the Veteran's claims for entitlement to service-connection for a psychiatric disability and a low back disability. In a December 2020 rating decision, the RO granted the Veteran's claim for service-connection of a psychiatric disability. Therefore, the only matter remaining before the Board is entitlement to service-connection for a low back disability. The RO issued a supplemental statement of the case (SSOC) in December 2020. This matter is now properly before the Board. 1. Low Back Disability. The Veteran contends that he should be service connected for his low back disability. The Veteran noted in his notice of disagreement that he suffered from a fall while in-service that injured him and caused him pain. The October 2017 VA examiner stated that the Veteran does have lower back pain and spasms with limited range of motion. The October 2017 examiner determined that there was a lack of factual evidence to support a finding of an in-service injury. However, a June 1966 service treatment record noted that the Veteran was treated for a back injury following a significant fall. Therefore, the October 2017 examiner failed to discuss or consider this service treatment record when determining that there was no evidence of an in-service injury. Thus, this opinion was based on an inaccurate factual premise and the Board determined it had no probative weight. The Veteran was afforded a new VA examination in October 2019. The examiner found that the Veteran does have a current diagnosis of a low back disability. The examiner stated that the Veteran said the onset date of the condition was in 1966 when he fell from a 30-foot-tall building and landed on his back. The Veteran was taken to the emergency department and given an x-ray which revealed that he had a fracture of his coccyx spine. The Veteran's records indicate he was placed on a soft brace for two weeks and placed on bedrest. After two weeks recovery, the Veteran was placed on light duty and took motrin for pain. The October 2019 examiner noted that the Veteran was not seen by any medical providers for a back problem after release from service. The Veteran stated that he did not seek out medical care due to financial issues. The Veteran reported that he self-medicated his back pain with over-the-counter Tylenol. The examiner noted that the Veteran stated that his back pain has worsened over the last several years. The examiner noted that the Veteran had a neurology consult in 2017 and a CT (computed tomography) scan of the lower back was completed. The Veteran was referred to pain management for facet joint injection; however, the Veteran said he did not receive his injection because of his medical coverage limits. The examiner noted that the Veteran's symptoms included constant back pain with radiation down the posterior legs and calves with intermittent spasms. The examiner opined that the physical exam is positive for pertinent findings for lower back pain and spasm with limited range of motion and radiculopathy symptoms. The examiner stated that there was no evidence of continual medical care or follow up treatment of record for the Veteran's lower back pain since leaving service and therefore that the claimed condition is less likely than not incurred in or caused during service. The examiner made his determination based on a lack of chronicity of care and opined that a nexus could not be established. The Board finds that the examiner failed to provide an opinion as to the etiology of the Veteran's current low back condition. The Board finds that the Veteran does have a current diagnosis of a low back disability. The Veteran did have a back injury in service as noted by his June 1966 service treatment record. The Veteran also reported that he self-medicated after service with Tylenol because due to financial issues he did not seek out formal medical treatment. The examiner did not provide an opinion as to the etiology of the Veteran's current diagnosis of a low back condition and whether the current low back disability is etiologically related ot the Veteran's in-service back injury. The mere absence of medical treatment does not render obsolete the Veteran's competent assertions of chronic symptomatology as he has fully explained why there is no such evidence. Although further delay is regrettable, the Board finds that a new opinion is needed to determine if the Veteran's current low back condition is etiologically related to the Veteran's injury incurred in service. The matters are REMANDED for the following action: 1. Obtain any outstanding or updated VA and private treatment records not already of record and associate them with the claims file. 2. Obtain an addendum opinion from a qualified clinician to determine the nature and etiology of the Veteran's lower back disability. The examiner is asked to answer the following: a) Is it as least as likely as not that the Veteran's current low back disability was caused by or is related to his in-service fall and subsequent injury that was incurred in-service? b) Is it as least as likely as not that the Veteran's recurrent back pain which the Veteran self-medicated for since discharge from service, was caused by or is related to his in-service fall and subsequent injury? The medical professional is asked to provide a complete rationale with a reasoned medical explanation in support of any and all opinions provided. The medical professional must discuss whether the Veteran's current low back disability and pain are related to the fall noted in the Veteran's June 1966 service treatment record. The Board stresses that the mere absence of medical documentation does not in and of itself demonstrate a lack of symptomatology, as the Veteran has clearly expressed he has suffered from chronic pain since service with self-medication and that he did not seek professional medical treatment due to his limited finances. If the medical professional is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. 3. Then, the RO should readjudicate the issues on appeal. If the decision remains adverse to the Veteran, the Veteran and his representative should be furnished with an appropriate supplemental statement of the case and be afforded the requisite opportunity to respond. Thereafter, the case should be returned to the Board for further appellate action. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board H. Hailu, 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.