Citation Nr: 22012189 Decision Date: 03/02/22 Archive Date: 03/02/22 DOCKET NO. 17-31 442 DATE: March 2, 2022 REMANDED Entitlement to service connection for a low back disability is remanded. Entitlement to service connection for a right knee disability is remanded. Entitlement to service connection for a left knee disability is remanded. Entitlement to service connection for a right ankle disability is remanded. Entitlement to service connection for a left ankle disability is remanded. Entitlement to service connection for a right arm disability is remanded. Entitlement to service connection for tinnitus is remanded. REASONS FOR REMAND 1. Entitlement to service connection for a low back disability is remanded. 2. Entitlement to service connection for a right knee disability is remanded. 3. Entitlement to service connection for a left knee disability is remanded. 4. Entitlement to service connection for a right ankle disability is remanded. 5. Entitlement to service connection for a left ankle disability is remanded. 6. Entitlement to service connection for a right arm disability is remanded. The Board cannot make fully-informed decisions on the issues of service connection for low back, right knee, left knee, right ankle, left ankle, and right arm disabilities, because no VA examiner has opined whether the disabilities are related to the Veteran's activities in service, to include playing football and lifting generators. Remand is necessary to schedule an orthopedic examination. 7. Entitlement to service connection for tinnitus is remanded. The Board cannot make a fully-informed decision on the issue of service connection tinnitus, because no VA examiner has opined whether the disaiblity is related to the Veteran's service, to include the Veteran's exposure to noise-related to weapons fire during service. Remand is necessary to schedule an examination. Regarding all issues, evidence indicates that there may be outstanding relevant VA treatment records. During a January 2021 Board hearing, the Veteran reported that he had been receiving treatment at VA medical facilities. The most recent VA treatment records included in the claims file were acquired in May 2017. Any VA treatment records are within VA's constructive possession, and are considered potentially relevant to the issues on appeal. Remand is required to allow VA to obtain them. During the January 2021 Board hearing, the Veteran indicated that he was treated for a low back disability at the 306 Field Hospital in Memphis, Tennessee, while serving in the Reserves. Although some Reserves records are included in the claims file, a review of the records does not include any notation regarding hospital treatment during Reserves duty. Additionally, the personnel records in the current claims file do not contain the dates of the Veteran's active duty for training (ACDUTRA) or inactive duty for training (INACDUTRA). Remand is necessary to obtain any outstanding treatment and personnel records for reserve service. During the January 2021 Board hearing, the Veteran identified relevant outstanding private treatment records. Specifically, the Veteran reported receiving treatment in the emergency room at the Jackson County General Hospital for a low back disability in approximately 2007. Remand is required to allow VA to obtain authorization and request any identified outstanding private treatment records. At the January 2021 Board hearing, the Veteran reported receiving disability payments from the Social Security Administration (SSA). As the record indicates that there may be outstanding and relevant SSA records, remand is required to allow VA to request these records. The matters are REMANDED for the following action: 1. Request treatment records and personnel records for the Veteran's Reserves service from any appropriate source, to include the 306 Field Hospital in Memphis, Tennessee, where the Veteran reports having received treatment for a low back disability. Any records obtained should be associated with the claims file. Attempt to obtain all records regarding the Veteran's ACDUTRA and INACDUTRA, including the dates of ACDUTRA and INACDUTRA to include, if necessary, pay or retirement point records. 2. Obtain the Veteran's VA treatment records from May 2017 to the Present. 3. Ask the Veteran to complete a VA Form 21-4142 for any private treatment providers, to include the Jackson County General Hospital. Make two requests for the authorized records from any identified facility, unless it is clear after the first request that a second request would be futile. 4. Obtain the Veteran's federal records from SSA. Document all requests for information and all responses in the claims file. 5. Schedule the Veteran for a VA examination by a VA orthopedist who has not previously examined the Veteran in conjunction with these claims to determine the etiology of any low back, right knee, left knee, right ankle, left ankle, and right arm disabilities. The examiner must review the claims file, including the service medical records, the post-service treatment records, and the lay statements of record. In writing the opinions, the examiner should address the Veteran's lay statements regarding each claimed disability, and the reported symptoms during and since service. The examiner is advised that the Veteran is competent to report symptoms and history, and that those reports must be acknowledged and considered in formulating any opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. A clearly stated rationale for each opinion offered should be provided. In performing the required examination, all tests deemed reasonably necessary should be performed. After a review of the evidence, an interview with the Veteran, and an examination, the examiner should offer the following: (a.) State all low back, knee, ankle, and right arm disabilities diagnosed at the examination or during the pendency of the appeal, dating to February 2014. If the examiner finds that any previously diagnosed disabilities are no longer present or disagrees with any prior diagnoses, the examiner should note those diagnoses and offer clinical reasons for that finding. (b.) For each diagnosed low back disability found to have existed during the pendency of the appeal, opine whether it is at least as likely as not (50 percent or greater probability) that each low back disability is related to the Veteran's active service, a period of ACDUTRA, or a period of INACDUTRA, to include the Veteran's service duties requiring the lifting of generators and participation in football games during service. The examiner should consider and discuss the Veteran's lay testimony and assertions regarding any pertinent complaints and symptoms. A detailed explanation is requested, including citing to supporting clinical data or medical literature, as appropriate. (c.) If an arthritic low back disability is diagnosed, opine whether it is at least as likely as not (50 percent or greater probability) that the disability (1) began during service, (2) manifested within one year after the Veteran's February 1988 separation from service, or (3) was noted during service with continuity of the same symptomatology since service. (d.) For each diagnosed disability of either knee found to have existed during the pendency of the appeal, opine whether it is at least as likely as not (50 percent or greater probability) that each knee disability is related to the Veteran's active service, a period of ACDUTRA, or a period of INACDUTRA, to include the Veteran's service duties requiring lifting of generators and his participation in football games during service. The examiner should consider and discuss the Veteran's lay testimony and assertions regarding any pertinent complaints and symptoms. A detailed explanation is requested, including citing to supporting clinical data or medical literature, as appropriate. (e.) If an arthritic disability of either knee is diagnosed, opine whether it is at least as likely as not (50 percent or greater probability) that the disability (1) began during service, (2) manifested within one year after the Veteran's February 1988 separation from service, or (3) was noted during service with continuity of the same symptomatology since service. (f.) For each diagnosed disability of either ankle found to have existed during the pendency of the appeal, opine whether it is at least as likely as not (50 percent or greater probability) that each ankle disability is related to the Veteran's active service, a period of ACDUTRA, or a period of INACDUTRA, to include the Veteran's service duties requiring the lifting of generators and his participation in football games during service. The examiner should consider and discuss the Veteran's lay testimony and assertions regarding any pertinent complaints and symptoms. A detailed explanation is requested, including citing to supporting clinical data or medical literature, as appropriate. (g.) If an arthritic disability of either ankle is diagnosed, opine whether it is at least as likely as not (50 percent or greater probability) that the disability (1) began during service, (2) manifested within one year after the Veteran's February 1988 separation from service, or (3) was noted during service with continuity of the same symptomatology since service. (h.) For each diagnosed disability of the right arm found to have existed during the pendency of the appeal, opine whether it is at least as likely as not (50 percent or greater probability) that each right arm disability is related to the Veteran's active service, a period of ACDUTRA, or a period of INACDUTRA, to include the Veteran's service duties requiring the lifting of generators and his participation in football games during service. The examiner should consider and discuss the Veteran's lay testimony and assertions regarding any pertinent complaints and symptoms. A detailed explanation is requested, including citing to supporting clinical data or medical literature, as appropriate. (i.) If an arthritic disability of the right arm is diagnosed, opine whether it is at least as likely as not (50 percent or greater probability) that the disability (1) began during service, (2) manifested within one year after the Veteran's February 1988 separation from service, or (3) was noted during service with continuity of the same symptomatology since service. 6. Schedule the Veteran for a VA examination by a VA medical doctor examiner who has not previously examined the Veteran in conjunction with this claim to determine the etiology of tinnitus. The examiner must review the claims file, including the service medical records, the post-service treatment records, and the lay statements of record. In writing the opinion, the examiner should address the Veteran's lay statements regarding the claimed disability, and symptoms during and since service. The examiner is advised that the Veteran is competent to report symptoms and history, and that those reports must be acknowledged and considered in formulating any opinion. If the Veteran's reports are discounted, the examiner should provide a reason for doing so. A clearly stated rationale for each opinion offered should be provided. In performing the required examination, all tests deemed reasonably necessary should be performed. After a review of the evidence, an interview with the Veteran, and an examination, the examiner should offer the following: (a.) Opine whether it is at least as likely as not (50 percent or greater probability) that the tinnitus is related to the Veteran's active service, a period of ACDUTRA, or a period of INACDUTRA, to include the Veteran's reported exposure to weapons fire. The examiner should consider and discuss the Veteran's lay testimony and assertions regarding any pertinent complaints and symptoms. A detailed explanation is requested, including citing to supporting clinical data or medical literature, as appropriate. (b.) Opine whether it is at least as likely as not (50 percent or greater probability) that tinnitus (1) began during service, (2) manifested within one year after the Veteran's February 1988 separation from service, or (3) was noted during service with continuity of the same symptomatology since service. Harvey P. Roberts Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T.M. Gillett 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.