Citation Nr: 21072722 Decision Date: 12/06/21 Archive Date: 12/06/21 DOCKET NO. 17-05 763A DATE: December 6, 2021 ORDER Entitlement to service connection for mild degenerative arthritis of the spine (previously claimed as back pain) is granted. FINDING OF FACT Resolving reasonable doubt in the Veteran's favor, his current back disability had onset in service and has continued since service. CONCLUSION OF LAW The criteria for service connection for mild degenerative arthritis of the spine (previously claimed as back pain) have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1970 to March 1974. In August 2021, the Veteran testified at a virtual hearing before the undersigned. In a September 2015 rating decision, the Regional Office (RO) reopened the claim based on new and material evidence and the Board will not overturn the RO finding that the claim is reopened. Entitlement to service connection for mild degenerative arthritis of the spine (previously claimed as back pain) The Veteran asserts that his currently diagnosed degenerative arthritis of the spine had its onset in service and therefore service connection is warranted. Specifically, the Veteran has reported, and the evidence shows, that he injured his back in service and has continued to suffer from chronic back pain ever since. A review of the Veteran's service treatment records (STRs) shows that in September 1971, the Veteran sought treatment with complaints of back pain after lifting heavy furniture. On examination, the Veteran had paralumbar muscle spasm and limited range of motion (ROM). The impression was acute lumbosacral sprain. Two days later the Veteran still had limited ROM. On examination there was less spasm and a bit better ROM. The examiner found the Veteran was able to go back to work but prescribed three days of physical therapy. On September 22, 1971 the Veteran reported feeling better but still had low back pain and complained about the amount of lifting required for his job. The treatment note shows a possible referral to orthopedics may be necessary if the Veteran continued to complain about low back pain and his job duties. An October 6, 1971 treatment note reflects the veteran had continued back pain and a prescription for Valium was refilled. A week later, on October 13, 1971 the Veteran complained of lumbosacral pain and the impression was noted as lumbosacral myositis. In November 1971, the Veteran again sought treatment for ongoing right-sided lumbosacral pain that had progressed with radiation to right sciatica. The examination was positive for spasm, right lumbosacral pain. The impression was lumbosacral myositis. On December 1, 1971, the Veteran was put on a profile until January 1972. The note states that a final decision would be made at that time. A February 16, 1972 treatment note reflects the Veteran had received treatment for three months with little improvement and he was being referred to Keesler AFB for further tests and treatment. On February 28, 1972, the Veteran complained of back pain after reportedly pushing a refrigerator. He was found to have right paraspinal spasm with movement to the left, forward flexion to 30 degrees straight and 45 degrees to the right. The impression was lumbosacral strain, and his profile was continued. An undated Keesler AFB consult for low back pain shows the Veteran's back condition had been ongoing since October 1971 with no improvement. He was described as having low back pain and right buttock pain that was exacerbated by heavy lifting, leaning laterally to the right, turning to the right, or lying on his back. It was improved by sitting or lying on his left side. The back pain had been treated with physical therapy, analgesics, Valium, and a profile change. Previous findings were noted as negative SLR and moderate spasm. X-rays showed no spondylolisthesis, spondylosis, or evidence of pathology. The impression was no neurosurgical diagnosis and that he had a probable pulled ligament. In June 1972, the Veteran was given a consult for physical therapy for moist heat treatments every other day for three weeks for chronic low back pain. A June 30, 1972 physical therapy note shows the Veteran received four treatments of moist head before going on leave. He was instructed to return to see the doctor if the condition was still present after returning from leave. An August 28, 1972 physical therapy consult notes a back injury in 1971 with recurrent back pain and muscle strain treated with moist heat therapy three times a week. The provisional diagnosis was sprained back and muscle tears. The plan shows the Veteran was to do Williams exercises for chronic lumbosacral sprain. On September 11, 1972 it was noted that the Veteran was a no show for three days and he was discharged from physical therapy. On the Veteran's Report of Medical History, dated November 1973, the Veteran checked YES for recurrent back pain. The Veteran also wrote that he was informed by the doctor at Keesler Medical Hospital that he would have knee and back problems until he died and there wasn't anything the doctors could do. In block 25, the examining physician at separation noted low back pain and chronic muscle pains in the physician's summary. The November 1973 Report of Medical Examination also shows the physician's summary lists low back pain and chronic muscle pains as significant history. A June 2015 VA nonservice-connected pension examination reflects a diagnosis of lumbar degenerative joint disease. The examiner noted multiple STRs documenting evaluation for low back strain. The Veteran reported chronic low back pain of varying intensities. He also reported receiving pain medication, using heating pads and TENs units from the 1970's through 2004. The Veteran stated in the mid 2000's he had physical therapy, used pain patches, and was prescribed Gabapentin. An August 2015 VA examiner noted a diagnosis of lumbosacral strain, but also noted that x-rays show arthritis. The examiner opined it was less likely than not the claimed condition was incurred in or caused by the claimed in-service injury, event or illness. The rationale provided was that the 1971 back sprain in service had resolved and the Veteran now has mild degenerative arthritis of the spine. As the August 2015 VA examiner did not review the Veteran's claims file an addendum opinion was requested. A June 2018 VA back opinion found it is less likely than not that the current diagnosis of mild degenerative arthritis of the spine was incurred in or caused by the in service injury, event, or illness. The rationale provided was that the medical science does not support a link between lumbar strain and development of degenerative arthritis. The examiner also stated a lumbar strain is a soft tissue injury and does not involve the bones nor joint spaces, and a lumbar strain does not cause, lead to, progress into nor otherwise develop into degenerative arthritis. Lastly, the examiner stated as it is not caused by lumbar strain there is no evidence to support any aggravation. The Board notes that the June 2018 VA examiner did not address the in-service diagnosis of lumbar myositis or the Veteran's reports of ongoing symptomatology since separation from service. A December 2017 private physician statement from Columbus Orthopaedic Clinic and Outpatient Center reflects that the Veteran's back issues stem from the in-service back injury in the 1970's. The physician stated the Veteran suffered disc injuries that are now chronically herniated, calcified, and degenerative and are the reason he has been hurting over the past 40 years. Lastly, the physician stated the Veteran's current pain is directly related to the injury he sustained in the Air Force. The Board notes that the STRs do not show the Veteran suffered a disc injury at the time of the injury or at any time during service and it is unclear if that is the physician's interpretation of the medical records given the in-service diagnosis of lumbar myositis. During the August 2021 virtual hearing, the Veteran testified that he initially injured his back in service in 1971. He stated, and the STRs reflect, that he continued to have back pain throughout service and reported recurrent or chronic back pain at the time of his separation. The cause and chronicity of symptomatology have been repeated in the Veteran's statements submitted in support of his appeal. At the VA examinations the Veteran reported the onset and history of his back pain, including the course of treatments since service. Based on the medical and lay statements above, the Board finds that the evidence establishes that the Veteran injured his back in service that was characterized as lumbar strain, chronic back pain, muscle tears, and lumbar myositis. The evidence also establishes that during the current appeal period, the Veteran's back disability has been diagnosed as degenerative arthritis of the thoracolumbar spine, lumbar strain, and lumbar degenerative joint disease. Thus, there is probative evidence of a nexus under 3.303(b), between service and the currently-diagnosed degenerative arthritis of the Veteran's thoracolumbar spine. The Board recognizes that there are unfavorable VA opinions of record, however each of those opinions or addendums either did not adequately address pertinent factual information and/or disregarded the lay assertions regarding continuity of symptoms since service. Each opinion has been found to be inadequate and therefore the Board affords them little to no probative value and need not be considered further. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Veteran is competent to report the ongoing back symptoms that he has had since service, even if he may not be competent to provide a diagnosis for such symptoms. Therefore, considering the totality of the evidence, the Board finds that the evidence is at least in equipoise on the question of a nexus between the Veteran's service and the degenerative arthritis of his lumbar spine. Resolving reasonable doubt in the Veteran's favor, the claim for service connection for a low back disability to include degenerative arthritis of the lumbar spine is granted. 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. Mitchell, 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.