Citation Nr: 22015659 Decision Date: 03/18/22 Archive Date: 03/18/22 DOCKET NO. 18-12 882 DATE: March 18, 2022 REMANDED Entitlement to service connection for a low back condition is remanded. Entitlement to service connection for a bilateral knee condition is remanded. Entitlement to service connection for an acquired psychiatric disorder, to include posttraumatic stress disorder (PTSD) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 1983 to June 1986. These matters are before the Board of Veterans' Appeals (Board) on appeal of September 2016 and June 2017 rating decisions of the Department of Veterans Affairs (VA) Regional Office. The Veteran was afforded a hearing before the undersigned Veterans Law Judge in October 2021. A transcript of the hearing has been associated with the Veteran's electronic claims file. 1. Entitlement to service connection for a low back condition 2. Entitlement to service connection for a bilateral knee condition The Veteran asserts that his low back condition, bilateral knee condition, and acquired psychiatric disorder are related to his active duty military service. At the October 2021 Board hearing, the Veteran testified that he began experiencing pain in his knees and back and swelling in his knees during active duty service as a result of his military occupational specialty (MOS). Specifically, the Veteran testified that basic training included marches of over 40 miles. The Veteran also testified that he worked in petroleum, oil, lubrication which required jumping up and down off the trucks, pumping with his knees, and grabbing hoses to set them up and put them away. The Veteran testified that his duties caused wear and tear on his back and knees. Since active duty service, the Veteran testified that his back pain began in 1986, that he started seeing a private doctor in approximately 1989 for symptoms related to his back and knees, and that he began treatment at VA in 2004. The Veteran also testified that he has been receiving Social Security disability benefits since 2016, in part due to his back and knee conditions. The Veteran was afforded a VA examination for his back in June 2017. The examiner opined that degenerative back disease is not related to his military service. However, in the body of the examination report the examiner stated, "no exam done". The examiner provided no response to all sections of the examination report. When VA undertakes to provide a Veteran with an examination, that examination must be adequate for VA purposes. Barr v. Nicholson, 21 Vet. App. 303 (2007). In this case, the VA examiner provided a medical opinion but did not perform an examination of the Veteran. Further, the examiner noted that there are no complaints of back pain in the Veteran's record until 2014. The Veteran has subsequently reported experiencing back pain shortly after discharge and seeking treatment from a private provider in approximately 1989. As such, a remand is warranted to obtain an adequate VA examination, and for the examiner to consider the Veteran's reports of symptoms since service and any additional medical records obtained pursuant to the remand directives below. The Veteran has not undergone a VA examination for his bilateral knee condition. Yet, the Veteran has a current diagnosis of degenerative joint disease of the bilateral knees and has reported experiencing knee swelling and pain in service and symptoms and treatment since service. See September 2014 VA treatment record. As the record suggests a diagnosis and the Veteran suggests an association to a current diagnosis, the low bar to secure a VA exam has been met. McClendon v. Nicholson, 20 Vet. App. 79 (2006); 38 C.F.R. § 3.159(c)(4). As such, VA's duty to assist has been triggered. Thus, the Veteran should be afforded an exam pertaining to his bilateral knees. The examiner is asked to confirm a diagnosis of degenerative joint disease and address the etiology of the disability. 3. Entitlement to service connection for an acquired psychiatric disorder, to include PTSD Regarding his acquired psychiatric disorder, at the October 2021 Board hearing the Veteran testified to two previously unreported in-service stressors. First, he testified to witnessing a fellow soldier, S.Y. get shot in the eye and subsequently being discharged as a result of his eye injury. Second, the Veteran testified that a soldier he slept next to had an M16 rifle "explode" while he was handling it. The Veteran testified that the soldier was taken out on a stretcher and that he never saw him again. The Veteran stated that both of these incidents happened in the summer of 1985 while he was stationed at Ft. Campbell, Kentucky. The Veteran also testified that while he was in service, he received notice that his brother, E., was shot five times. The Veteran testified that while he spoke to the chaplain about this incident, he did not go home to see his family. The Veteran testified that afterwards, he cried and had nightmares, and that he began drinking heavily and became an alcoholic. The Veteran testified that he ultimately decided to leave the military although he was given the option to reenlist. The Board notes that in the September 2016 rating decision, the RO indicated that it is unable to verify the reported stressor of his brother, E., being shot because he was deceased at the time the Veteran enlisted. At the October 2021 Board hearing, the Veteran testified that the RO confused E. with a different brother, I., and that E. is still living. The Veteran also provided information about two additional stressors at the October 2021 hearing. VA treatment notes show that the Veteran sought treatment for substance abuse in 2005. VA treatment records also show a positive PTSD screen and a diagnosis of depression nos. See November 2015 VA treatment record. Accordingly, remand is warranted to develop the Veteran's alleged in-service stressors and provide him a VA examination for his psychiatric condition(s). The Board notes that the most recent VA treatment records associated with the Veteran's file are from February 2018. The Veteran has also reported receiving private treatment and being in receipt of Social Security disability benefits. Any additional VA treatment records, private treatment records, and records from the Social Security Administration should be obtained on remand. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include records of treatment received from a private doctor in 1989 and any VA medical records that were created since the Veteran's records were last obtained by VA in February 2018. Any records obtained should be associated with the claims file. 2. Obtain the Veteran's federal records from the Social Security Administration. Document all requests for information as well as all responses in the claims file. 3. Once the development above has been completed, schedule the Veteran for a VA examination to determine the nature and etiology of the claimed back and bilateral knee disabilities. The claims file must be provided to and reviewed by the examiner. Any indicated tests and studies must be performed. The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any back and bilateral knee disability (or if no such disability is identified, any back and knee pain that causes any functional impairment) is etiologically related to the Veteran's military service, to include his MOS as a petroleum supply specialist during which time he participated in marches of over 40 miles, and worked in petroleum, oil, lubrication which required jumping up and down off the trucks, pumping with his knees, and grabbing hoses to set them up and put them away. The Veteran contends that the cumulative effect of his activities caused his back and bilateral knee disability. The examiner should indicate whether any pathology/disease process associated with the Veteran's back and knees are consistent with the mechanism of injury claimed by the Veteran. A complete rationale for all opinions expressed must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. 4. Develop the Veteran's claimed in-service stressors with regard to his psychiatric condition(s) as provided in the October 2021 Board hearing transcript, to include witnessing a fellow soldier S.Y. shoot himself in the eye and witnessing a M16 explode while a soldier was handling it at Ft. Campbell in the summer of 1985, and to include learning during his active duty service that his brother, E., was shot five times. If any stressors cannot be verified, the agency of original jurisdiction should specifically make such a finding. 5. After the Veteran's claimed in-service stressors have been developed, schedule the Veteran for a VA examination to determine the nature and etiology of his psychiatric condition(s). The electronic claims file must be reviewed by the examiner, and a note that it was reviewed should be included in the report. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that the Veteran's psychiatric condition(s) are related to his active service. A detailed rationale for the opinion must be provided. If the examiner is unable to offer the requested opinion, it is essential that the examiner offer a rationale for the conclusion that an opinion could not be provided without resort to speculation, together with a statement as to whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Bynum, 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.