Citation Nr: 1501972 Decision Date: 01/14/15 Archive Date: 01/20/15 DOCKET NO. 09-33 197 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUE Entitlement to service connection for a low back disorder, to include myofascial lumbar syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD Dan Brook, Counsel INTRODUCTION The appellant is a Veteran who served on active duty from February 1995 to January 2003. This matter comes before the Board of Veterans' Appeals (Board) from a December 2008 rating decision of the Waco, Texas, Regional Office (RO) of the Department of Veterans' Affairs (VA). In February 2013, the case was remanded for further development. In November 2014, a Board videoconference hearing was held before the undersigned; a transcript of the hearing is of record. FINDING OF FACT The Veteran is reasonably shown to have developed his current myofascial lumbar syndrome during service. CONCLUSION OF LAW Resolving reasonable doubt in the Veteran's favor, the criteria for entitlement to service connection for myofascial lumbar syndrome are met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.303 (2014). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran is claiming service connection for a low back disability. Generally, service connection is granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service in the line of duty. 38 U.S.C.A. § 1110; 38 C.F.R. §3.303. The Veteran's service treatment records show that he was seen for complaints of back pain in September 1997. At that point, he noted that he had initially injured his back one month previously but it had subsequently improved. Then, two days previously he was jumping down from a vehicle when he felt a 'pop' and suffered a resurgence of pain. The diagnosis was back strain and the Veteran was prescribed bedrest for 24 hours, Motrin and Flexeril and was given a 2 week profile. A subsequent February 2000 physical therapy evaluation shows that the Veteran was complaining of chronic low back pain with the initial injury approximately two years previously. He was noted to be in some apparent discomfort, to have guarded range of motion in all planes, to have decreased lumbar lordosis and to have a bilateral positive straight leg raise. There was tenderness to palpation along the paraspinal ligaments. The Veteran was assessed as having chronic low back pain that was probably musculoskeletal in origin. He was enrolled in back school. A May 2000 provider's note then shows a diagnosis of chronic low back pain. It was noted that an orthopedic referral and consultation with the physical examination section was necessary regarding the maximum duration of his temporary profile and the possible need to consider a Medical Board evaluation. April, May and June 2000 profile reports and progress notes show that the Veteran was experiencing recurrent low back pain and that his light duty profile was continued until July 2000 to accommodate his ongoing physical therapy. In a July 2000 report of medical history, the Veteran noted that he was taking parafon forte and flexeril for his chronic low back pain. He also noted that he did not consider his injury minor because the problem had been ongoing for about 2 1/2 years. In a July 2001 report of medical history, the Veteran indicated that he had had problems with his back in the past year but not recently. At an April 2009 VA examination, the examiner diagnosed the Veteran with myofascial lumbar syndrome. X-rays showed 6 lumbar vertebra. The examiner indicated that a review of the service treatment records noted a single entry in September 1997 when the Veteran was diagnosed with a back strain. The examiner opined that it was less likely than not that the current back problem was related to a single episode in service approximately 12 years previously and more likely than not due that the problem was due to the effects of intercedent lumbar strains, musculoskeletal deconditioning due to physical inactivity and a genetic predisposition to developing spine problems. The Veteran subsequently received a VA examination in April 2013 by the same VA examiner but the examiner did not have the Veteran's claims file available. Then, in May 2013, after noting that he had reviewed the claims file and the prior VA examination reports, he opined that the single documented episode of lower back pain in the service treatment records in 2000 was less likely than not related to the Veteran's current myofascial lumbar syndrome. Rather, this syndrome was more likely than not due to the effects of intercedent lumbar strains, musculoskeletal deconditioning due to physical inactivity and a genetic predisposition to developing spine problems. At his November 2014 Board hearing, the Veteran testified that during the time period from 2000 to 2003 and up until the present, his back had continued to bother him. He noted that from January 2003 to when he was first seen for VA medical care for back pain in 2007 or 2008, he simply took Aleve for pain and tried to strengthen his core muscles. The service treatment records show that the Veteran did experience disability manifested by chronic low back pain during service. Also, although the July 2001 report of medical history indicates that the Veteran's back stopped bothering him for a time, he has testified that he was having problems with it at the time of separation and has continued to have problems ever since. The Board does not find a basis in the record for finding this testimony not credible. Also, the opinions provided by the VA examiner may not be afforded any probative value as he was under the mistaken impression that the Veteran had suffered a single acute manifestation of low back pathology rather than chronic symptomatology. Consequently, resolving any reasonable doubt in the Veteran's favor, it is established that his current, chronic myofascial low back syndrome first became manifest during service. Accordingly, service connection for this disability is warranted. 38 C.F.R. §§ 3.102, 3.303. ORDER Service connection for myofascial lumbar syndrome is granted. ____________________________________________ P. M. DILORENZO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs