BVA9503446 DOCKET NO. 92-22 356 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for residuals of a low back injury. 2. Entitlement to service connection for residuals of a groin injury. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Theresa M. Catino, Associate Counsel INTRODUCTION The veteran served on active military duty from December 1973 to May 1974. He also had several periods of active duty for training with the United States Army Reserve, including one period from October 1989 to November 1990. REMAND In October 1993, the Board of Veterans' Appeals (Board) remanded the case to accord the veteran additional VA examinations with regard to his low back and groin conditions. In this prior remand, the Board specifically requested that the examiners render opinions as to whether any low back and groin disabilities that the veteran may presently have are causally related to the injury that the veteran sustained in October 1989 while he was on active duty for training. Significantly, however, the examiners did not provide this information. Furthermore, in a January 1995 statement, the veteran's representative pointed out that the Board's prior instructions were not carried out fully and requested that the case be remanded again to comply with the Board's initial instructions. Recently, the United States Court of Veterans Appeals (Court) has upheld the provisions of 38 C.F.R. Part 4, § 4.2, which provide that, if an examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes. Ardison v. Brown, 6 Vet.App. 405, 407 (1994); Abernathy v. Principi, 3 Vet.App. 461, 464 (1992). In the present case, the examinations conducted pursuant to the Board's October 1993 remand are inadequate for the purposes of evaluating the nature, extent, and etiology of any current low back and groin disability that the veteran may have. Also pursuant to the Board's prior remand, the veteran submitted in December 1993 the names of physicians from whom he had received post-service treatment for his low back and groin conditions. A review of the claims folder appears to indicate that the RO did not attempt to obtain all of these medical records. The Court has held that there is a continuing obligation on the VA to assist the veteran in developing the facts of his claim throughout the entire administrative adjudication. This obligation includes the duty to obtain records regarding the veteran's medical history. Murincsak v. Derwinski, 2 Vet.App. 363, 373 (1992). VA has a duty to assist the veteran in the development of facts pertinent to his claim. 38 U.S.C.A. § 5107(a) (West 1991); 38 C.F.R. § 3.103(a) (1991). This duty to assist includes the duty to develop facts when the record before the Board is clearly inadequate. EF v. Derwinski, 1 Vet.App. 324 (1991); Littke v. Derwinski, 1 Vet.App. 90 (1990). The development of facts includes a "thorough and contemporaneous medical examination, one which takes into account the records of prior medical treatment, so that the evaluation of the claimed disability will be a fully informed one." Green v. Derwinski, 1 Vet.App. 121, 124 (1991). The Board concludes that further assistance to the veteran is required. Accordingly, the case is REMANDED to the RO for the following: 1. The veteran should be contacted and requested to furnish a complete list of all medical personnel and facilities from which he has received treatment for his low back and groin conditions since his separation from service. The Board is particularly interested in records of any treatment that the veteran may have received from Dr. David Berndt at the Davie Medical Center at 5930 S.W. 64 Avenue, Davie, Florida 33314, from Dr. Chris Theodoran at 1875 Lititz Pike, Lancaster, Pennsylvania 17601, and at Lancaster Community Hospital, Lancaster, Pennsylvania, including reports of the studies conducted there in November 1989. After obtaining the appropriate releases from the veteran where necessary, the health care providers should be contacted and requested to provide all treatment records in their possession pertaining to the veteran. If these records are unavailable, that fact should be annotated in the claims folder. Any available records should be associated with the claims folder. 2. Following the above, the veteran should be accorded a VA genitourinary examination to determine the nature, extent, and etiology of any groin disability, including questionable bowel and bladder symptoms and impotence, that the veteran may have. The veteran's claimed erectile dysfunction should be evaluated by Rigiscan, if indicated. The examiner should review the report of the January 1994 urodynamic study and express an opinion concerning the etiology of any abnormality shown by that study. The examination should be conducted in accordance with the diagnostic procedures outlined in the VA Physician's Guide for Disability Evaluation Examinations. The report of examination should include a detailed account of all manifestations of pathology found to be present. All necessary tests should be conducted, and the examiner should review the results of any testing prior to completion of the report. The examiner must express an opinion as to whether there is any present disability found on examination and, if there is, whether it was caused by, or is in any way related to, the injury that the veteran sustained in October 1989 while he was on active duty for training. The claims folder and a copy of this remand must be made available to and reviewed by the examiner prior to the examination. The examiner should review all of the pertinent medical evidence in the claims folder, including the service medical records, and provide complete rationale for all conclusions reached. 3. Thereafter, the veteran should be accorded VA orthopedic and neurology examinations to determine the nature, extent, and etiology of any low back disability that the veteran may have. The examinations should be conducted in accordance with the diagnostic procedures outlined in the VA Physician's Guide for Disability Evaluation Examinations. The reports of examination should include a detailed account of all manifestations of joint pathology found to be present. All necessary tests and X-rays should be conducted, and the examiners should review the results of any testing prior to completion of the report. Special attention should be given to the presence or absence of pain, any limitation of motion, instability, and weakness. The examiners must express opinions as to whether there is any present low back disability found on examination and, if there is, whether it was caused by, or is in any way related to, the injury that the veteran sustained in October 1989 while he was on active duty for training. The claims folder and a copy of this remand must be made available to and reviewed by the examiners prior to the examinations. The examiners should review all of the pertinent medical records in the claims file, including the service medical records, and provide complete rationale for all conclusions reached. 4. The RO should review the examination reports and determine if they are adequate for rating purposes and in compliance with this Remand. If not, they should be returned for corrective action. 5. Thereafter, the RO should formally adjudicate the issues of entitlement to service connection for a low back disability and a groin disability. Following completion of these actions, and, if the decision remains unfavorable, the veteran and his representative should be provided with a supplemental statement of the case and afforded a reasonable period of time in which to respond. Thereafter, the case, in accordance with the current appellate procedures, should be returned to the Board for completion of appellate review. The purpose of this REMAND is to obtain clarifying evidence. No action is required of the veteran until further notice is issued. WILLIAM J. REDDY Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1993).