Citation Nr: 21022710 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 14-11 945 DATE: April 19, 2021 ORDER Entitlement to service connection for a back disability is granted. FINDING OF FACT The Veteran’s back disability is etiologically related to an in-service injury. CONCLUSION OF LAW The criteria for service connection for a back disability have been met. 38 U.S.C. §§ 1131, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active naval service from April 1984 to March 1989. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2011 rating decision issued by a Department of Veterans’ Affairs (VA) Regional Office (RO). In December 2017, the Veteran testified in a hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding has been associated with the Veteran’s claims file. This issue was previously remanded by the Board in April 2018 and July 2020 for further development. The case has now been returned to the Board for further appellate action. Service Connection – Back Disability The Veteran has contended that her back disability is related to her active duty service. Specifically, the Veteran reported that she injured her back during service from falling on ice and was treated for that injury during active duty. Service treatment records confirm that the Veteran was treated between October and December 1984 for complaints of low back pain determined at that time to be the result of a low back strain. The Veteran was again treated for a back injury in 1986 after a reported fall. The diagnosis at that time was a muscle contusion. Again, in January 1988, the Veteran reported low back pain. The treating physician at that time reported it as a pulled muscle and diagnosed it as a muscle sprain. However, at the time of the Veteran’s separation examination, she indicated “no” in response to experiencing recurrent back pain. Nevertheless, the Veteran has reported that she first experienced symptoms associated with a back disability during service and that those symptoms have continued since that time. Not only are these assertions corroborated by the Veteran’s service treatment records, but they are confirmed through numerous third party affidavits and private medical records. Moreover, the Board finds the Veteran to be credible in her reporting of experiencing ongoing back pain continuing since her active duty service. Heuer v. Brown, 7 Vet. App. 379 (1995); Falzone v. Brown, 8 Vet. App. 398 (1995); Caldwell v. Derwinski, 1 Vet. App. 466 (1991). In support of the Veteran’s claim, affidavits from her son, former spouse, and close friend were submitted. All of which affirm the Veteran’s continued and consistent assertions of experiencing low back pain ever since service. In addition, the Veteran herself has submitted written descriptions of her chronic low back pain and detailed the ongoing treatment that she sought after her separation from service. Likewise, she candidly testified about the onset of her symptoms in service and the continuous nature of those symptoms ever since separation from active duty. The Board is mindful that earlier reported symptoms which lead to a later diagnosis of those same symptoms may, in some cases, establish the necessary medical nexus for service connection. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (establishing that lay evidence may be competent insofar as describing symptoms from an earlier time which support a later diagnosis by a medical professional). Such is the case in the facts presented here, where the Veteran has described her earlier symptoms beginning with the numerous documented accounts in service, which are later diagnosed as a lumbosacral strain in 2008. The Board has considered the VA examination reports of record. Most recently, a December 2020 report provided a negative nexus opinion. However, the Board finds that the opinion is based upon an inaccurate recitation of the medical history. In providing the rationale for the negative nexus opinion, the examiner cited solely to the service treatment record in 1986 with the diagnosis of a low back contusion and found that service treatment records are otherwise silent for follow-up regarding any additionally reported back problems. As detailed above, there were several reports and numerous occasions of treatment for low back pain in service. As such, the VA medical opinion is inadequate and of little probative value. Furthermore, the private treatment records, although they do not date back to 1989 due to the unavailability of such dated records, do provide more historical context to the Veteran’s claim. In July of 2008, medical records confirm that the Veteran had been experiencing chronic low back pain. These same reports are consistent throughout the ensuing years of treatment shown within the private treatment records. In 2008, the Veteran received injections for pain management of her low back condition. Treatment records from 2010-2013 all reflect that she continued to receive progressively more aggressive treatments, including the surgical placement of a pain pump. A June 2013 private medical record makes note that the Veteran’s medical history “is significant for chronic low back pain…” See June 11, 2013, Private Treatment Record. In sum, the Veteran has competently and credibly reported that her back pain had its onset and has continued since service. While there is a VA medical opinion of record against the claim, the Board finds that opinion to be inadequate. Accordingly, the Board finds that the evidence for and against the claim is at least in equipoise. Therefore, reasonable doubt must be resolved in favor of the Veteran and entitlement to service connection for a disability of the thoracolumbar spine is warranted. 38 U.S.C. § 5107 (2018); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Sutherell, Associate 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.