Citation Nr: 22014007 Decision Date: 03/11/22 Archive Date: 03/11/22 DOCKET NO. 18-02 528 DATE: March 11, 2022 REMANDED Service connection for a low back disability is remanded. Service connection for sciatic pain is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1977 to September 1983. This matter comes before the Board of Veterans' Appeals (Board) from a May 2015 rating decision from a Department of Veterans Affairs (VA) regional office (RO). The Veteran had a hearing before the undersigned Veterans' Law Judge in August 2021. A transcript of the hearing is part of the record. 1. Service connection for a low back disability is remanded. 2. Service connection for sciatic pain is remanded. The matters are REMANDED for the following action: 1. BACKGROUND FOR THE ADJUDICATOR: A remand is necessary to assist the Veteran in developing relevant records identified at his hearing and to obtain additional medical opinions for secondary service connection. At the August 2021 hearing, the Veteran identified that he received treatment at St. Mary's Hospital in Houston, Texas for the back injury that occurred in service. A statement by the Veteran in his personnel file indicated he sought private treatment at an emergency room in March 1983 for the back injury. Due efforts are necessary to assist the Veteran in obtaining these records. Additionally, the Veteran stated at the hearing that he received chiropractic treatment for his low back disorder two months following his separation from service. These records were not previously identified. Due efforts are necessary to assist the Veteran in obtaining these records. Finally, a November 2019 treatment record indicates the Veteran's service-connected bilateral ankle disabilities may cause or aggravate the Veteran's back pain and hip pain. The opinion does not note a baseline or if the pain causes any additional functional loss. An addendum opinion is necessary to clarify whether the back pain and hip pain constitute a worsening of the low back disability and/or sciatic pain. THE REMAND DIRECTIVES FOLLOW. 2. Ask the Veteran to complete a VA Form 21-4142 for St. Mary's Hospital in Houston, Texas and for the chiropractor that treated his back post-service. Make two requests for the authorized records from the providers unless it is clear after the first request that a second request would be futile. 3. After the above actions, return this matter to the examiner who conducted the September 2017 VA examination for a file review. If the examiner is not available, have the record reviewed by an equally qualified PHYSICIAN. The examiner must review the evidence and express a fully explained opinion as to: (a.) Whether the Veteran's low back disability was caused by his active service, to include a fall in March 1983 where he injured his back. (b.) Whether the Veteran's low back disability was either (1) caused by or (2) worsened by a service-connected disability to include an altered gait from service-connected bilateral ankle disabilities. (c.) If aggravation is found, the examiner must also state, to the extent possible, the baseline level of the back disability prior to aggravation. This may be ascertained by the medical evidence of record and by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. (d.) Whether the Veteran's sciatic pain was caused by his active service, to include a fall in March 1983 where he injured his back. (e.) Whether the Veteran's sciatic pain was either (1) caused by or (2) worsened by a service-connected disability to include an altered gait from service-connected bilateral ankle disabilities. (f.) If aggravation is found, the examiner must also state, to the extent possible, the baseline level of the sciatic pain prior to aggravation. This may be ascertained by the medical evidence of record and by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. If necessary, the examiner or the RO may schedule the Veteran for another VA medical examination or appropriate clinical testing. The examiner must consider all evidence, including statements made by the Veteran about the onset and severity of the back disorder and sciatic pain. If there is any medical reason to accept or reject the proposition that the Veteran's reported injury and symptoms in service and thereafter represented the onset of his current disability, this should be noted. Stated another way, do the Veteran's reports about his symptoms align with how the currently diagnosed disability is known to develop or are the Veteran's reports generally inconsistent with medical knowledge or implausible? The examiner must review the record as found in VA treatment reports and the electronic file. However, the record in substance indicates the following: In July 1983, the Veteran reported a history of back pain related to a strain occurring 4 months prior. In August 1983, the Veteran failed a fitness test. The Veteran wrote a letter in August 1983 stating he failed the fitness test due to back problems that stemmed from an injury in March 1983. He stated the doctor diagnosed a back strain and ordered 45 days of bed rest for the injury. In December 2014, the Veteran reported chronic low back pain that radiated with standing and walking. In January 2015, the Veteran reported his back pain runs down both of his legs. In February 2015, the Veteran reported a tingling sensation in his back and that the pain from his back and legs wakes him up at night. An April 2015 examination showed low back strain with moderate radiculopathy. A May 2016 treatment note indicated chronic low back pain with polyneuropathy in all 4 extremities. In July 2017, neurogenic claudication and sensory polyneuropathy were noted. In September 2017, an examination showed lumbosacral strain with degenerative arthritis of the spine and moderate radiculopathy. It was noted that the Veteran's guarding resulted in an antalgic gait, and he had a right foot drop. An October 2017 opinion stated the Veteran's back pain was more severe than imaging would suggest. It also noted that the sciatic pain was not explained by the x-ray and MRI of the lumbar spine. In June 2019, the Veteran reported a remote shrapnel injury to the lower back. In November 2019, a provider indicated that the Veteran's bilateral ankle disabilities resulted in the Veteran altering his gait causing pain in the back and hips. In April 2020, a treatment note states the Veteran had changed his gait over the years due to the bilateral ankle disabilities. At his August 2021 hearing the Veteran testified that he hurt his back twice in the Marines. The first time he did not report it because he thought it would not affect his performance. The second time he stated that he fell on concrete while moving an engine. He stated he went to an emergency room where there was an x-ray and they proscribed him muscle relaxers and hydrocodone. The Veteran also testified that he sought treatment from a chiropractor starting two months after he left service. (CONTINUED ON THE NEXT PAGE) 4. Readjudicate the Veteran's claims for service connection for a low back disability and sciatic pain. Vito A. Clementi Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Reed, Counsel The Board's decision is only binding on this case. This action is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.