92 Decision Citation: BVA 92-26148 Y92 BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 DOCKET NO. 92-53 970 ) DATE ) ) ) THE ISSUE Entitlement to service connection for a low back disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. H. Tousley, Associate Counsel INTRODUCTION The veteran had active military service from July 1968 to December 1990. This matter came before the Board of Veterans' Appeals (Board) from an appeal of a rating decision in July 1991 by the Department of Veterans Affairs (VA) regional office (RO) in Phoenix, Arizona. The veteran submitted a notice of disagreement in September 1991. The RO issued a statement of the case in October 1991. The veteran submitted a substantive appeal in November 1991. The case was docketed at the Board in January 1992. The veteran's representative, the Disabled American Veterans, submitted additional written argument in April 1992. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that he has a chronic low back disability that began during service. He asserts that he has experienced mild to extreme pain in his back for almost 20 years. He contends that he cannot do any heavy lifting, bending, or sitting the wrong way for fear of hurting his back again. He states that he only sought medical treatment during service when he had extreme back pain because he wanted to stay at his job as an air traffic controller. DECISION OF THE BOARD In accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), following review and consideration of all evidence and material of record in the veteran's claims file, and for the following reasons and bases, it is the decision of the Board that the evidence supports a grant of service connection for a low back disorder. FINDINGS OF FACT 1. The RO has obtained all evidence necessary for an equitable disposition of the veteran's claim. 2. The veteran received treatment during service on mulitple occasions for low back strain. 3. Degenerative joint disease of the lumbosacral spine was shown within one year after separation from service. CONCLUSION OF LAW A low back disability was incurred while in active military service. 38 U.S.C.A. §§ 1110, 5107 (West 1991); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (1991). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board finds that the veteran's claim is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991). We are satisfied that all the relevant facts have been properly and sufficiently developed for an equitable disposition of this claim. The service medical records reveal the veteran was conservatively treated on several occasions for episodes of low back pain that were often diagnosed as a lumbosacral strain. In reference to lumbosacral strain: The true joints of the spine are the apophyseal joints formed by the superior and the inferior articular processes of the posterior neural arch. During flexion, extension, and rotation of the spine, gliding motions take place between the apposed flat facets, which are covered with hyaline cartilage. The articulation is surrounded by a ligamentous capsular structure that is loose enough to permit motion but becomes taut at the extremes of each movement. Like other ligaments it is subject to stretching and tearing, particularly by hyperextension, as a result of which the facets subluxate on each other. 2 Turek, Orthopedics Principles and Their Application, at 1512 (4th ed. 1984). Predisposing factors encourage tearing of the capsule and subluxation include the following:...Chronic occupational strains require excessive bending and lifting. Id. At the outset, tearing of ligaments and subluxation are manifest by local symptoms of low back pain accentuated by motion that stretched the ligaments, namely, hyperextension. Later, as the nerve root is compressed, sciatica and neurological findings referrable to the fifth lumbar nerve root become prominent. Eventually, symptoms of localized degenerative arthritis are super imposed. Id. at 1513. Clinical Picture. A history is often given of repeated episodes of acute low back pain caused by forceful hyperextension. Between attacks, hyperextension movement of the back increased pain whereas flexion reduces it....As time goes on symptoms of nerve root irritation appear, including sciatica, paresthesias, numbness over the dorsomedial aspect of the foot, and weakness of dorsiflexion of the large toe....Id. On examination,...[l]ocalized tenderness is observed about the lumbosacral junction. In the acute stage the back muscles are in spasm, and motions are restricted in all directions....An increased lumbar lordosis and any rounding of the dorsal spine should be noted. The straight leg raising test may accentuate the low back pain at the extreme point of the maneuver, because the capsular structures are stretched....Id. at 1513-114. Chronic Stage....Arduous occupational activities are prohibited....Exercises [Williams] are aimed at developing the flexor muscles of the lumbosacral spine. Id. at 1515. The pertinent regulation provides: Service connection connotes many factors but it basically means that the facts, shown by evidence, establish that a particular injury or disease resulting in a disability was incurred coincident with service in the Armed Forces....38 C.F.R. § 3.303(a) (1991). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings of a diagnosis including the word "Chronic." 38 C.F.R. 3.303(b) (1991). Service medical records reveal the veteran experienced repeated traumas to the low back during the early 1970's. The first episode of low back pain for which he received treatment was in May 1971. In August 1971, he received conservative treatment for low back pain after falling while waterskiing and after falling down a flight of stairs. His next episode of low back pain was in April 1972 after falling on a step. He could not bend over due to low back pain in March 1973 after lifting the tongue of a horse trailer. In May 1973 he fell off a horse and in August 1973 he fell down a flight of stairs. Each time he was grounded from his duties as an air traffic controller and treated conservatively. In September 1973, he displayed on examination a positive straight leg raising on the left, paravertebral muscle spasm in the lumbosacral area, and decreased sensation over the dorsum area of the left foot after a co-worker pulled his chair out from under the veteran. He was briefly hospitalized at the end of September 1973 and in May 1974 for persistent low back pain. The service medical records show he then began to sometimes experience low back pain without any significant trauma to the back. He felt low back pain in August 1974 after bending over a table. By August 1976, he complained of radiating pain into the left leg. On examination, he exhibited positive straight leg raising, bilaterally, and decreased ankle and knee jerks. The veteran did not receive treatment for low back pain again until February 1982 when he reported that he had experienced low back pain for three weeks after moving some furniture. He described it as a dull, nagging pain. He related at the examination for physical therapy where he was instructed in the use of Williams exercises that he had experienced episodes of low back pain since 1970 that usually resolved themselves in 3 to 6 days, but that his pain was increased by prolonged walking or sitting. He sought treatment in February 1984 where there was noted paraspinal muscle spasm on the left and decreased deep tendon reflexes, bilaterally. He reported a sudden onset of low back pain radiating into the left buttock after bowling in March 1988. There was detected numbness of the left big toe and positive straight leg raising, bilaterally. The last reported episode of treatment for low back pain was in January 1989 when he related he had experienced pain for 12 hours after twisting his back while shaving. A VA examination for disability determination purposes in March 1991 noted multiple disorders including "history of low back injury, no residuals noted except mild pain at times..." Outpatient medical records from September 1991 from a service medical facility indicate that the veteran received conservative treatment for complaints of low back pain that had lasted for four days. An X-ray showed decreased lordosis of the lumbosacral spine with mild anterior spurring. The diagnoses were lumbar muscle strain and degenerative joint disease of the lumbosacral spine. Although the active service medical records fail to reveal a diagnosis of a chronic lumbosacral strain, an overall review of these records indicate the clinical findings support a determination that the veteran initially injured the supporting structures of the lumbosacral spine that predisposed him to subsequent lumbosacral strains. The veteran initially experienced episodes of low back pain associated with significant in-service incidents of trauma to the back. At that time, he displayed the typical symptomatology of acute lumbosacral strains such as paravertebral muscle spasm and pain on motion of the back. Gradually, though, the episodes of low back pain occurred unrelated to any significant trauma and his pain became exacerbated by prolonged sitting or walking. He increasingly began to display signs of nerve root involvement as evidenced by findings of pain on straight leg raising and decreased sensation in the left foot. Within a year after service, service department examiners did diagnose lumbar muscle strain, early degenerative changes in the lumbosacral spine and lordosis of the spine were found, findings reflective of a progressive, chronic low back disorder. The numerous reports of grounding of the veteran during the 1970's from his duties as an air traffic controller because of treatment for his low back pain and his efforts to return to duty as soon as possible supports his contention that he often did not seek treatment for chronic low back pain because he did not want to miss additional time from his duties. The reported clinical findings are consistent with a determination that the veteran has a chronic lumbosacral strain with degenerative joint disease of the lumbosacral spine that began while in service. Thus, the evidence establishes service connection for a low back disability. ORDER Entitlement to service connection for a low back disability is granted. BOARD OF VETERANS' APPEALS WASHINGTON, D.C. 20420 WARREN W. RICE, JR. ROBERT D. PHILIPP FRANCIS F. TALBOT (CONTINUED ON NEXT PAGE) NOTICE OF APPELLATE RIGHTS: Under 38 U.S.C.A. § 7266 (West 1991), a decision of the Board of Veterans' Appeals granting less than the complete benefit, or benefits, sought on appeal is appealable to the United States Court of Veterans Appeals within 120 days from the date of mailing of notice of the decision, provided that a notice of disagreement concerning an issue which was before the Board was filed with the agency of original jurisdiction on or after November 18, 1988. Veterans' Judicial Review Act, Pub. L. No. 100-687, § 402 (1988). The date which appears on the face of this decision constitutes the date of mailing and the copy of this decision which you have received is your notice of the action taken on your appeal by the Board of Veterans' Appeals.