Citation Nr: 21014738 Decision Date: 03/15/21 Archive Date: 03/15/21 DOCKET NO. 16-15 097A DATE: March 15, 2021 ORDER Service connection for low back pain or strain is granted. Service connection for left knee pain or strain is granted. FINDING OF FACT The Veteran’s current low back pain or strain and left knee pain or strain had their onset during active duty, including while deployed to Iraq in a combat zone. CONCLUSIONS OF LAW 1. The criteria for service connection for low back pain or strain are met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102 3.303, 3.304. 2. The criteria for service connection for left knee pain or strain are met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 2003 to September 2007. This matter is before the Board of Veterans’ Appeals (Board) on appeal from an October 2015 rating decision. The Board remanded the case in October 2018 for additional development. The Board also remanded the issue of service connection for a groin condition; however, that was claim granted in full upon remand. Service Connection 1. and 2. Service connection for low back pain or strain; service connection for left knee pain or strain The Veteran contends that he has low back and left knee disabilities due to service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. Generally, service connection requires three elements: (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). In adjudicating such claims, reasonable doubt that exists because of an approximate balance of positive and negative evidence concerning any point will be resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Veteran had two deployments from August 2005 to March 2007, including to Iraq, with notations in the unofficial service report of hostile fire or imminent danger pay and combat zone or a combat operation. It is unclear if the Veteran engaged in combat with the enemy. See 38 U.S.C. § 1154(b); 38 C.F.R. § 3.304(d). However, he has not asserted that he had specific injuries during combat, only that he had low back pain and left knee pain that began during his training and deployment to Iraq. See May 2015 claim; August 2019 VA examinations. Pain or other symptoms of the claimed conditions that result in functional impairment of earning capacity may establish a disability without an underlying diagnosis. See Saunders v. Wilkie, 886 F.3d 1356, 1367-69 (Fed. Cir. 2018). For Veterans who had Persian Gulf War service in the Southwest Asia theater of operations, symptoms due to an undiagnosed illness or medically unexplained chronic multisymptom illness (MUCMI) may be service-connected on a presumptive basis if they manifest to a compensable degree after such service, even if there is no other link to service. 38 U.S.C. § 1117, 1118; 38 C.F.R. § 3.317. It is unclear whether there is an underlying diagnosis for the Veteran’s back and left knee pain, as no imaging studies have been conducted, and VA treatment records note only chronic low back pain and arthralgia for the knees. The August 2019 VA examiner stated a diagnosis of low back strain in 2005 and left knee strain in 2006 based on the Veteran’s reports of symptoms or conditions beginning in service. These are not truly current diagnoses, only notations as to his reported history. Nevertheless, the Board resolves reasonable doubt in the Veteran’s favor to find a current disability with consideration of Saunders and his Southwest Asia service. The Veteran is competent to describe the nature and timing of his injuries or symptoms during service and ongoing symptoms since service, as well as not seeking treatment and instead self-medicating his conditions. Although there is some potentially conflicting evidence, the Board resolves reasonable doubt in his favor and finds him credible as to having had low back and left knee symptoms that began during service and continued since that time for a present disability. The Veteran’s service treatment records do not reflect specific back or knee treatment, except for once in 2005 for back pain that appears related to coughing from strep throat. He denied problems in pre-deployment and post-deployment evaluations in 2005 and 2006. Then, in evaluation reports in July 2007 and August 2007 shortly before his separation from service, the Veteran reported that since his last evaluation he had developed back and knee pain (and other problems) for which he did not seek treatment. In a Report of Medical History form, the Veteran also checked back and knee pain and gave explanations for them (and other problems). However, he crossed off the knee and back explanations, as well as the “yes” dot in favor of a “no” dot for knee problems, with his initials. The crossed-out items described low back pain with standing or sitting for too long and sometimes with sleep in the mornings, and knee pain and popping after runs or long walks and sometimes in the mornings. The examiner commented that the Veteran had multiple musculoskeletal issues that were minor, or self-resolving conditions, that were treated at BAS level with no specialist treatment, and there was no interval history and no sequelae from known issues. When asked about the significance of the Veteran having crossed out items during a 2019 VA examination, the Veteran stated that he did not remember the event. Nevertheless, it appears that the Veteran had low back and left knee pain that developed after his 2006 evaluation during his last deployment, but at the time of his 2007 examination shortly thereafter he believed the conditions had resolved. However, subsequent evidence suggests persistent recurring symptoms. There are VA treatment records from April 2008 to May 2008 with no relevant complaints, and records from November 2012 through July 2020. Records in November 2012 noted chronic intermittent low back pain and arthralgias in the knees (and other areas), and the Veteran reported some injuries to the ankles in service but no specific knee or back injuries. A July 2013 record also noted chronic low back pain that was intermittent and aggravated by prolonged standing or sitting; intermittent numbness in the left lower extremity from the knee down to the foot approximately three times a year since falling while in Afghanistan; and polyarthralgia in the knees (and other joints) that is intermittent. The assessment just noted these reports with no specific diagnosis. A February 2014 record stated that the Veteran was followup from the 2013 treatment, and the chronic low back pain and intermittent numbness in the left lower extremity were noted as resolved, but the knee condition was not mentioned. After that time, VA treatment records through July 2020 continued to note chronic low back pain and arthralgias in the problem lists, but there was no specific treatment for the back or knees. The Board remanded this matter in 2018 for VA examinations. For both the back and the left knee, the reports reflect that the Veteran “developed insidious onset of pain” during service. They note periods of injury during training for the back for which the Veteran did not seek treatment, and that for the knee he went to a clinic and was given NSAIDs. For both the back and left knee, the Veteran reported that he continued to have pain when he separated from service, he only self-medicated and used a heat pad for the back, and he now has constant back and knee pain with flare-ups. These reports are generally consistent with the notations in VA treatment records and for his claim. The lack of treatment alone does not negate symptoms. The 2019 examiner gave negative nexus opinions for both the back and left knee, essentially noting that the Veteran had crossed out his reports of back and knee problems in the 2007 separation reports and there was no medical documentation of ongoing symptoms or a nexus to service. These opinions are inadequate because they did not consider the competent and credible lay reports of ongoing symptoms. In summary, the Board resolves reasonable doubt in the Veteran’s favor to find that his current low back strain or pain and left knee strain or pain have existed since service, with persistent and recurring manifestations since service in Iraq. This is sufficient to show a nexus to service, and the appeal is granted. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Wheatley 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.