Citation Nr: 18132217
Decision Date: 09/06/18	Archive Date: 09/06/18

DOCKET NO. 15-46 349
DATE:	September 6, 2018
REMANDED
Entitlement to service connection for low back disorder is remanded.
REASONS FOR REMAND
1. Entitlement to service connection for a low back disorder is remanded.
The Veteran asserts that he began having low back pain in service due to his duties as an engine man, including lifting heavy equipment and heavy tool bags.
The record shows in-service back complaints and post-service treatment for back pain.  The Board notes that a November 2005 post-deployment assessment reflects complaints of back and a 2011 VA treatment record reflects onset of back pain a few years earlier.  A November 2013 VA treatment record shows that the Veteran experienced several lower back collapses in addition to his low back pain.  A July 2014 MRI study shows mild congenital stenosis of the mid to lower lumbar spine.
Based on a review of the record, the Board finds that VA’s duty to assist requires a VA examination in this matter.  38 C.F.R. § 3.159.  Duenas v. Principi, 18 Vet. App. 512 (2004); McClendon v. Nicholson, 20 Vet App. 79 (2006) (the Secretary must provide a VA medical examination when there is competent evidence of a current disability or persistent or recurrent symptoms of a disability, and evidence establishing that an event, injury, or disease occurred in service or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but insufficient competent medical evidence on file for a decision on the claim).
The matter is REMANDED for the following action:
1. Ask the Veteran to complete a VA Form 21-4142 for any healthcare providers that treated his back condition.  Make two requests for the authorized records from, unless it is clear after the first request that a second request would be futile.
2. Obtain the Veteran’s VA treatment records for the period from 2010 to the Present.
3. Then, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any back disability.  The examiner must opine on the following: 
(a.) Whether it is at least as likely as not related to an in-service injury, event, or disease, including his military duties as an engine mechanic with heavy lifting of equipment and bags.
(b.) If arthritis or degenerative disease is shown, whether it at least as likely as not (i) began during active service, (ii) manifested within one year after discharge from service, or (iii) was noted during service with continuity of the same symptomatology since service.
4. Ensure that the VA medical opinion obtained includes a complete rationale for the conclusions reached.  The medical opinion must support the conclusions reached with an analysis that is adequate for the Board to consider and weigh against other evidence of record; medical opinions must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.  If an opinion cannot be expressed without resort to speculation, ensure that the clinician so indicates and discusses why an opinion is not possible, to include 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.
 
C.A. Skow
Acting Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	K.M. Walker, Associate Counsel

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