Citation Nr: 21073308 Decision Date: 12/08/21 Archive Date: 12/08/21 DOCKET NO. 13-31 192 DATE: December 8, 2021 ORDER Entitlement to service connection for low back pain is granted. FINDING OF FACT The probative evidence of record establishes that the Veteran's low back pain is aggravated beyond its natural progression by his service-connected acquired psychiatric disability. CONCLUSION OF LAW The criteria for service connection for low back pain are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from November 1982 to August 1995. This matter is on appeal from an October 2011 rating decision. In July 2016, the Veteran testified before the undersigned Veterans Law Judge via video conference. In September 2018, the Board of Veterans' Appeals (Board) remanded the Veteran's claim to obtain an examination to address the Veteran's contentions. Due to inadequate medical opinions, the Board remanded the Veteran's claim in May 2020, December 2020, and July 2021. The claim has now returned to the Board. 1. Entitlement to service connection for low back pain As noted in the May 2020 Remand, the Veteran testified to having diffuse pains all over his body and applied for service connection for fibromyalgia. Further, the theory of whether the Veteran's muscle pain was caused or aggravated by his service-connected PTSD and associated symptomology was raised by the record. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. Thus, in order to establish that a Veteran has a disability that was caused or aggravated by a service-connected condition, two elements must be established. First, probative evidence must link the two conditions together. Second, the evidence must establish that the condition actually worsened. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis As noted in the December 2020 Remand, the Board could not locate a diagnosis related to the Veteran's claim of muscle pain, but the Veteran asserts that he is limited by muscle pain. Thus, a consideration of whether the Veteran's undiagnosed pain is so debilitating that it can result in functional impairment is required. See Saunders v. Wilkie, 886 F.3d 1356 (2018) (where the evidence shows that symptoms reach the level of a functional impairment of earning capacity, a disability for VA compensation purposes exists, even if there is no underlying diagnosis). The Board finds that the Veteran has a diagnosis of low back pain and the first element of service connection has been met. Shedden, supra. The December 2020 Board decision denied the Veteran's claim of low back pain, but addressed the diagnoses of lumbosacral strain and arthritis. It did not address the separate diagnosis of widespread pain and specially remanded the claim. However, clinicians have found that the Veteran's pain is localized in his back. Turning to whether the Veteran's low back pain was caused or aggravated by his posttraumatic stress disorder (PTSD) disability, a VA clinician rendered an opinion in August 2021. The clinician explained as follows: "It is possible that PTSD can exacerbate existing pain syndrome. In this case it may exacerbate his back pain attributed to his lumbar spine disease." The clinician continued: "The relationship between PTSD and chronic pain states is well documented for many decades. Chronic pain syndromes frequently have an associated PTSD factor which has been shown to worsen this. 'PTSD hyperarousal has been associated with increased pain perception and dissociation with decreased pain perception. Also, the nature of the traumatic event may play a role in how PTSD affects pain sensitization.' This is a far more possible explanation for his pain than Fibromyalgia." The Board notes that the use of words such as "can" or "may" tend to weaken the strength of an opinion. However, here the Board finds the opinion to be sufficient: the examiner cited research in support of his opinion even though the clinician did not state that it is at least as likely as not that the Veteran's back pain was aggravated beyond its natural progression. Further, the clinician states that PTSD "is a far more possible explanation" of the Veteran's pain. Thus, the Board gives the examiner's opinion probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). One possible interpretation of the clinician's opinion is that the Veteran's diagnosis is "chronic pain syndrome" rather than "back pain." If the diagnosis were chronic pain syndrome, then it would be analyzed under the Veteran's existing PTSD diagnosis. However, the probative evidence of record does not demonstrate that the Veteran's PTSD rating can account for the Veteran's chronic pain, as opposed to a sleep impairment (which might also worsen the Veteran's back pain). Thus, the Board confirms that the diagnosis is back pain and not chronic pain syndrome. Turning to the baseline level of severity, while the examiner did not address this, the Board finds that without the increased pain related to the Veteran's PTSD, the Veteran would not have painful range of motion. To the extent that he would have pain due to his non-service-connected lumbosacral strain and arthritis conditions, the Board finds that his range of motion became limited and painful because it was aggravated by his PTSD. Thus, the weight of the evidence is for the claim for service connection for low back pain. Accordingly, the claim is granted. Bethany L. Buck Veterans Law Judge Board of Veterans' Appeals Attorney for the Board I. M. Hitchcock 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.