Citation Nr: 22017161 Decision Date: 03/24/22 Archive Date: 03/24/22 DOCKET NO. 17-58 272 DATE: March 24, 2022 REMANDED Entitlement to service connection for a lower back disability, to include as due to exposure to environmental hazards in the Persian Gulf and an undiagnosed illness and as secondary to a service-connected right ankle disability, is remanded. REASONS FOR REMAND The Veteran served on active duty from April 1990 to June 1992. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2021, the Veteran testified at a hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. The undersigned agreed to keep the record open for 60 days to allow the Veteran additional time to submit outstanding medical treatment records and nexus evidence to support his claim. See November 2021 Hearing Transcript, pages 16-17. Additional evidence, to include a private medical opinion and nexus statement, was received in December 2021. See December 2021 Medical Treatment Record Non-Government Facility; December 2021 Medical Treatment Record Government Facility. Entitlement to service connection for a lower back disability, to include as due to exposure to environmental hazards in the Persian Gulf and an undiagnosed illness and as secondary to a service-connected right ankle disability, is remanded. During his November 2021 Board hearing, the Veteran testified that his current lower back disability manifested while he was serving on active duty. Specifically, he reported that his lower back was damaged by wear and tear from lifting and offloading heavy items during service and indicated that he began experiencing lower back pain in or around 1991. To this end, the Veteran testified that he failed his Army Physical Fitness Test twice and received an early discharge from service because his lower back disability caused his body to lock-up during the run portion of the examination. He further noted that he has continued to experience lower back pain since service. In addition, the Veteran testified that his lower back disorder may have been caused or aggravated beyond its normal progression by his service-connected right ankle disability. Alternatively, he indicated that his current symptoms, to include lower back pain, joint pain, and muscle cramping, may have been caused by exposure to environmental hazards while he was stationed in the Persian Gulf. See November 2021 Hearing Transcript, pages 3-12; August 2015 Correspondence. A review of the Veteran's DD-214 shows that he served in Southwest Asia from December 1990 to May 1991 and received the Southwest Asia Service Medal with three bronze stars and the Kuwait Liberation Medal. In addition, the Veteran's service personnel records (SPRs) include a memorandum, dated in May 1992, which confirms that he was recommended for discharge after he failed to meet the requirement for his Army Physical Fitness Test. See March 2015 DD 214 Certified Original - Certificate of Release or Discharge from Active Duty; March 2015 Military Personnel Record. A review of the service treatment records (STRs) shows a March 1990 enlistment report of medical examination that notes the Veteran's spine and other musculoskeletal system to be normal. In May 1990, the Veteran reported that he had been experiencing back pain for two weeks, and a screening note of acute medical care, dated 16 days later, shows that the Veteran continued to report lower back pain. On the latter occasion, the Veteran indicated that his lower back pain manifested in his fifth week of training during a two mile run and denied a history of direct trauma. The assessment was myalgia. The Veteran also sought treatment for back pain in July 1990. At that time, he continued to deny a history of direct trauma to his back and indicated that his pain manifested after he slept on a cot in the field. The assessment was mild mechanical lower back pain. However, the Veteran's spine and other musculoskeletal system was noted to be normal on his November 1991 and April 1992 reports of medical examination, and the Veteran denied recurrent back pain on the corresponding reports of medical history. See July 1992 STR Medical; March 2015 Medical Treatment Record Government Facility. A review of the post-service treatment records shows that the Veteran underwent a VA examination for joints in September 1992. During the examination, the Veteran endorsed symptoms related to his right shoulder and right ankle but did not report any symptoms related to his lower back. See September 1992 VA examination. The Veteran was afforded a VA environmental agents registry examination in November 2014. During the examination, the Veteran endorsed back pain and body aches and reported that he was stationed in the Persian Gulf from December 1990 to May 1991. He stated that his body aches, which manifested in 1991, may be related to his service. In addition, the examiner noted that the Veteran had a past medical history of lumbago. See October 2017 CAPRI. A March 2015 letter from MetroHealth Broadway Health Center shows that the Veteran was diagnosed with degenerative joint disease. See March 2015 Third Party Correspondence. The Veteran underwent a VA examination for back conditions in June 2015. The examiner diagnosed the Veteran with degenerative disc disease. During the examination, the Veteran reported that he had been experiencing intermittent back pain since service. He further stated that he had a history of developing back pain after sleeping and indicated that he had previously been diagnosed with lumbago. After performing an examination and reviewing the evidence of record, the examiner opined that it was less likely than not that the Veteran's diagnosed degenerative disc disease was related to his complaints of pain and lumbago during service. In support of his opinion, the examiner noted that the Veteran's STRs were silent for any diagnosed back disabilities, other than pain and lumbago. To this end, the examiner found that it was more likely that the Veteran's current lower back disability was related to normal age progression, deconditioning, and his occupation. See June 2015 C&P examination. In support of his claim, the Veteran submitted a private medical opinion from Dr. Megan McNamara, dated in December 2021. Dr. McNamara stated that the Veteran had been a patient under her care since September 2021; she also indicated that she reviewed the Veteran's medical records in the computerized patient record system and noted the circumstances and events of his service prior to providing her opinion. To this end, Dr. McNamara found that it was highly likely that the Veteran initially injured his back during training, and that he subsequently exacerbated the initial injury by performing routine activities, to include carrying heavy objects off a truck, during service. In support of her opinion, Dr. McNamara found that the Veteran's lumbar radiculopathy was caused by a "pinched nerve," which in turn led him to experience lower back pain that radiated down his left leg. To this end, she explained that the Veteran's pinched nerve was caused by arthritis and a bulging disc in his back. Dr. McNamara further explained that, pursuant to a review of the medical literature and personal experience, it was known that back pain could be exacerbated by lifting heavy objects. To this end, she noted that the Veteran's back pain worsened to the point that he was unable to complete a physical fitness test at the end of his active duty service, and opined that it was highly likely that his diagnosed lumbar radiculopathy was a direct result of his active duty service. See December 2021 Medical Treatment Record Government Facility. In addition, the Veteran submitted a nexus statement from Dr. McNamara, dated in December 2021. Following a review of the Veteran's post-service treatment records, Dr. McNamara opined that the Veteran's current disability, back pain diagnosed as lumbar radiculopathy, was caused by or the result of training and heavy lifting during service. In support of her opinion, Dr. McNamara noted that the Veteran did not have a diagnosis of back pain prior to entering service. She further stated that the Veteran injured his back during a training exercise, and as such, explained that his back injury had been exacerbated by his activities in service. See December 2021 Medical Treatment Record Non-Government Facility. Following a review of the evidence of record, the Board finds that a remand is warranted to obtain an addendum medical opinion to determine the nature and etiology of the Veteran's lower back disability. To this end, the Board finds the June 2015 VA examination inadequate because the examiner did not provide rationale for his finding that it was more likely that the Veteran's current lower back disability was related to normal age progression, deconditioning, and his occupation. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). The Board further notes that none of the medical opinions currently associated with the claims file have addressed whether the Veteran's lower back disability was caused or aggravated beyond its natural progression by his service-connected right ankle disability. Thus, the Board finds that a remand is necessary to obtain an addendum medical opinion to determine the nature and etiology of the Veteran's claimed lower back disability. The Board further notes that the Veteran has identified multiple treatment records pertinent to his claimed lower back disability that have not been associated with the claims file. To this end, the Veteran reported that he received treatment from a chiropractor, Dr. Heidi Williams, in or around 2007. See December 2017 Medical Treatment Record Non-Government Facility. In addition, he testified that he received acupuncture treatments from a non-VA provider and underwent massage therapy for his lower back disorder during the November 2021 Board hearing. See November 2021 Hearing Transcript, pages 15-16. The Board further notes that a December 2015 internal medicine outpatient note indicates that the Veteran received primary care at MetroHealth Broadway Health Center, and in the December 2021 private medical opinion, Dr. McNamara indicated that the Veteran had been a patient under her care since September 2021. See October 2017 CAPRI; December 2021 Medical Treatment Record Non-Government Facility; December 2021 Medical Treatment Record Government Facility. However, the Board finds that, with the exception of the March 2015 letter from MetroHealth Broadway Health Center and Dr. McNamara's December 2021 private medical opinion and nexus statement, no medical records related to the abovementioned treatment or from the abovementioned providers has been associated with the claims file. Thus, the Board finds that a remand is also required to obtain these records. Lastly, during the November 2021 Board hearing, the Veteran testified that he began receiving treatment for his lower back disorder at a VA hospital in Brecksville, Ohio in 1992, immediately after he was discharged from active duty service, and indicated that he continued to receive care at that facility until it closed. He further reported that he has continued to receive treatment for his lower back disorder at VA through the present. See November 2021 Hearing Transcript, page 9. However, the Board notes that the only VA treatment records currently associated with the Veteran's claims file are dated from December 2013 to December 2016, and that no unavailable records response has been received. See October 2017 CAPRI. As such, the Board finds that a remand is also warranted to obtain these records. The matter is REMANDED for the following action: 1. With any necessary identification of sources by the Veteran, request all VA treatment records not already associated with the file from the Veteran's VA treatment facilities, and all private treatment records from the Veteran not already associated with the file. Specifically, attempts should be made to obtain the following treatment records: (a.) All treatment records from the VA hospital in Brecksville, Ohio dated from 1992 until the facility closed in or around 2011, to include any archived medical records. (b.) VA treatment records from the Veteran's VA treatment facilities dated prior to December 2013 and from December 2016 to the present. (c.) Private treatment records relating to acupuncture and massage therapy for the Veteran's lower back disability. (d.) Private treatment records Dr. Heidi Williams dated in or around 2007. (e.) Private treatment records from MetroHealth Broadway Health Center dated from 2015 to the present. (f.) Private treatment records from Dr. Megan McNamara dated from September 2021 to the present. If any treatment records are unavailable, issue a formal finding of unavailability and notify the Veteran so that he can submit any medical records in his possession. 2. After completion of the above development, obtain an opinion from an appropriately qualified examiner to determine the nature and etiology of the Veteran's claimed lower back disability. It is up to the discretion of the examiner as to whether an in-person examination is necessary. The examiner should provide the following opinions: (a.) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed lower back disability, to include degenerative disc disease and lumbar radiculopathy, had its onset during service or is otherwise etiologically related to the Veteran's active duty service, to include as due to wear and tear from lifting and offloading heavy items, to include meals ready-to-eat, unit gross rations, and cookware, from trucks, during service. Please explain why or why not. (b.) The examiner should opine as to whether it is at least as likely as not (50 percent or greater probability) that any diagnosed lower back disability was (i) caused or (ii) aggravated by his service-connected right ankle disability. Please explain why or why not. The examiner should observe that permanent aggravation is not required. If aggravation is found, the examiner should identify, to the extent possible, the baseline level of disability prior to the aggravation and determine what degree of additional impairment is attributable to the Veteran's service-connected right ankle disability. S. HENEKS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Justis, 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.