Citation Nr: 22016556 Decision Date: 03/22/22 Archive Date: 03/22/22 DOCKET NO. 19-30 474 DATE: March 22, 2022 REMANDED Entitlement to service connection for a neck disorder is remanded. REASONS FOR REMAND The Veteran served on active duty in the Navy from September 1967 to June 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal of a March 2018 rating decision issued by a regional office (hereinafter agency of original jurisdiction or AOJ) of the Department of Veterans Affairs (VA). The Veteran testified before the undersigned Veterans Law Judge at an August 2020 hearing, a transcript of which has been attached to the record. 1. Entitlement to service connection for a neck disorder is remanded. The Veteran asserts that his current neck disorder, described as chronic neck pain as well as stiffness during flareups, is due to his active service. His entry and separation examinations are silent for complaints of a neck disorder. However, March 1969 service treatment records indicate that he fell from a seven-foot fence, noting a possible broken nose and "spasm of the left SCM." The Board notes the SCM is a large cervical muscle. Two days later the Veteran reported soreness in his neck since the fall, and an examination revealed muscle tenderness with pain on all movement, but no evidence of trauma to the area with normal sensory and reflex testing. He was diagnosed with a muscle strain. March 1971 service treatment records note the Veteran was in an accident while walking across a busy street in Saigon. A motorcycle knocked him down, and he was then run over a VW bus, resulting in a fractured left clavicle and left AC joint separation. Records note no other injuries besides an abrasion behind the Veteran's left ear, and neurological testing was normal. He was taken to a nearby hospital and eventually medevac'd to Tacoma, Washington. After four weeks of treatment with a splint and physical therapy, the Veteran was returned to active duty. The Veteran corroborated these events during the August 2020 Board hearing. The Veteran was afforded a VA cervical spine examination in February 2018, during which the examiner noted a 1971 diagnosis of cervical strain as well as a 2016 diagnosis of cervical spinal stenosis, confirmed by a June 2017 MRI. The Veteran corroborated the service treatment record account of his Saigon accident, stating that the VW bus struck his head and left shoulder. He described chronic intermittent cervical pain since the accident, as well as flareups in which he is unable to turn his neck to the sides. The examiner opined that the Veteran's neck disorder was less likely than not due to his active service, stating there was no documentation that his current symptoms were related to either inservice injury. The Board finds this opinion inadequate as it does not include a supporting rationale for the opinion reached. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Additionally, the examiner did not address the Veteran's consistent lay statements reporting neck pain since service. Unless the Board finds the lay statements not competent or not credible, an examiner's opinion must address the Veteran's relevant lay statements in order to include enough detail to inform the Board's decision. Failure to do so renders that opinion inadequate. Miller v. Wilkie, 32 Vet. App. 249, 258-60 (2020). As such, remand for an addendum opinion is required. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The matters are REMANDED for the following action: 1. Attach to the claims file all updated and any relevant private treatment records. 2. Forward the Veteran's claims file to a qualified VA examiner in order to obtain an addendum opinion regarding the nature and etiology of his neck disorder. The need for an additional examination is left to the discretion of the examiner. After reviewing the evidence of record, the examiner is asked to opine whether there is a nearly equal or greater chance that the Veteran's current neck disorder first manifested in or is otherwise due to his active service, to include his inservice accidents. When providing the requested opinion, the examiner is asked to address the Veteran's lay descriptions regarding the onset of his symptoms and provide an explanation as to whether the Veteran's assertions are generally consistent with medical knowledge or implausible and whether the Veteran's consistent reports of chronic neck pain since his inservice injury align with how his current disorder, identified by a 2019 MRI as facet hypertrophy and disc space narrowing throughout the cervical spine, worst at C5-6, is known to develop. A full rationale is required for any opinion offered. T. MAINELLI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. C. Schumacher, 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.