Citation Nr: 21027394 Decision Date: 05/05/21 Archive Date: 05/05/21 DOCKET NO. 13-15 989 DATE: May 5, 2021 ORDER Entitlement to service connection for a low back disorder, to include a lumbar strain, is denied. FINDINGS OF FACT 1. The Veteran's low back disorder was not demonstrated in service and is not shown to be related to an in-service occurrence or event. It has not been shown to be related to any active duty. Arthritis was first shown years post-service. 2. The evidence shows that it is less likely than not that the Veteran's low back condition was caused and/or aggravated by his service-connected knee strain. He was first service connected for a right knee sprain, and later for a left knee strain. CONCLUSION OF LAW The criteria for service connection for a low back disorder have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107 (West 2019); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served with the United States Marine Corps from June 1974 to June 1976. This matter was previously remanded in August 2020, May 2019, and September 2017, to obtain VA examinations and opinions, to determine the nature and etiology of the Veteran's low back disorder. Most recently, the Board found that that its previous remand directives were not substantially complied with. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Agency of Original Jurisdiction (AOJ) was directed to obtain an addendum opinion by an orthopedist rather than a Nurse Practitioner. The examiner was directed to opine whether each diagnosed low back disorder since 2009 is at least as likely as not related to an in-service injury or disease; and, if not, whether any disorder was secondary to, or aggravated by, his service-connected knee strain. The case has returned to the Board for review. Service Connection Generally, service connection may be granted for disability arising from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection for a disability requires evidence of: (1) The existence of a current disability; (2) the existence of the disease or injury in service, and (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). See also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). Service connection may also be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. In such an instance, the Veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); see Allen v. Brown, 7 Vet. App. 439, 448 (1995). Certain chronic diseases, such as degenerative arthritis, may be presumed to have been incurred in service if demonstrated within 1 year following separation from qualifying service. 38 U.S.C. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Entitlement to service connection for a low back disorder. The Veteran contends that his low back disorder is related to his time in-service. The Veteran also initially contended that his low back disorder is proximately related to his service-connected right knee strain. While this issue was in appellate status a left knee strain was also service connected. Both are rated 10 percent disabling. Service Treatment Records (STRs) do not reveal any complaints, diagnoses, or treatments for a low back disorder, though they do note an injury of the Veteran striking his right knee. At an examination prior to separation, the Veteran's low back was noted as normal with no findings of arthritis, bone, or joint deformities diagnosed. The examinations reveal no findings of any disorders associated with the Veteran low back during his period of Marine Corps service. In an April 2016 VA back conditions examination, the examiner diagnosed the Veteran with degenerative joint disease of his lumbar spine with an onset of 2009. The examiner opined that it is less likely than not that the Veteran's low back disorder is related to his service-connected right knee strain. VA outpatient treatment records reveal a reported history of chronic low back pain since 2016, attributed by the Veteran to field training and the wearing of a rucksack, field maneuvers, and lifting heavy equipment. The Veteran also reported in April 2013 falling on his back after stepping in a hole. The Veteran started treatment with chiropractic care in April 2016. The contemporaneous VA examination is documented as decreased lumbar spine flexion with pain, as well as reduced hip flexion strength, with no radicular symptoms. April 2016 VA x-ray findings note degenerative changes of the lumbar spine with bilateral L5 pars defect with minimal grade 1 anterolisthesis of L5 on S1. A November 2017 medical examiner opined that the lumbar spine degeneration was due to age-related osteoarthritis and was not service connected. December 2019 VA Examination of the Lumbar spine noted diagnosis of degenerative arthritis since April 2016 and spondylolysis since April 2016, with chiropractic treatment beginning in 2009. The December 2019 medical examiner did not feel that the back pathology was service connected, noting that the service treatment records were silent for lumbar spine injury or pain, with no nexus to the knee condition. After a thorough review of the record, the January 2021 VA Medical Examiner opined post-remand that the claimed low back disorder was less likely than not (less than 50 percent probability) incurred in or caused by an in-service injury, event, or illness. The examiner stated that degenerative changes of the Veteran's lumbar spine and his previously diagnosed spondylolisthesis are consistent with common age-related changes of the lumbar spine and are less likely than not service connected. The Board notes that the Veteran's STRs, to include his entrance and discharge physical examinations, are silent for low back pain or low back injury. There is no documentation of treatment of low back pain or degenerative changes of the lumbar spine for several decades after the Veteran's discharge from military service. The examiner noted that although it is medically reasonable for the Veteran to have experienced some temporary low back pain associated with the use of his lumbar spine musculature during military training activities, this muscle ache would not be expected to produce permanent injury to his lumbar spine that would manifest decades later, and this muscle strain would not be expected to produce permanent damage to his lumbar spine. Further, the Veteran's imaging studies are consistent with age-related changes of his lumbar spine and are not more severe than would be commonly expected in someone of his age. There is no indication of aggravation from his service-connected knee condition. The January 2021 examiner finally opined that the claimed condition of lumbar spine degenerative changes and spondylolisthesis is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected knee strain. The conditions of lumbar spine degenerative changes and spondylolisthesis and knee strain are not medically related. The lumbar spine degenerative changes and spondylolisthesis is a separate entity entirely from the knee strain and unrelated to it. The examiner's review of medical literature failed to demonstrate a causal relationship. A nexus has therefore not been established. In the examiner's view, mild arthritis of the right knee (and an anterior knee contusion from military service) would not be expected to produce degenerative changes of the lumbar spine. There is no medical connection between the two conditions. Conclusion To summarize, the Veteran's STRs do not reveal any complaints or treatments for a low back disorder related to service or for many years post-service. See Mason v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000) (the passage of many years between discharge from active service and the medical documentation of a claimed disability is evidence against a claim of service connection). This premise is further evidenced by the fact that the Veteran did not submit a compensation and pension application for his service-related low back disorder until many years after separation from service. The Board reviewed the Veteran's lay statements asserting that the onset of his low back disorder was caused by his time in-service. Lay people are competent to report on matters observed or within their personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, the Veteran was competent to provide statements of symptoms which were observable to his senses. However, the Board must emphasize that the Veteran was not competent to interpret accurately clinical findings pertaining to a low back disorder as this requires highly specialized knowledge and training. 38 C.F.R. § 3.159 (a)(1). See also Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The foregoing summary of the treatment record reveals no possibility for service connection for a low back disorder on a direct or secondary basis. Although the Veteran contends that his low back disorder is related to service, his STRs do not report any complaints, diagnosis, or treatments for a low back disorder. He specifically denied any low back pain at his examination prior to separation and no pertinent abnormalities were found. Furthermore, the April 2016 examiner noted that the Veteran's low back disorder is less likely than not related to the Veteran's time in-service. The examiner explained that there is no evidence in the record or medical literature that supports a causal relationship between the Veteran service-connected knee disorder and the onset of his lower back disorder. Moreover, the examiner noted that it was not until 2009 that the onset of the Veteran's degenerative joint disease of his lumbar spine was first diagnosed. The Veteran is not documented in the available records to have undergone care for his lumbar spine until several decades after his military service. Lastly, as a pathology for a low back disorder was not shown to be related to the Veteran's time in-service, or secondary to his service connected knee disorders, the Board concludes that the clinical evidence does not support the Veteran's contentions for a granting of service connection on a direct or secondary basis. Based on this evidence, the Board finds service connection is not warranted. The Board has considered the benefit-of-the-doubt doctrine; however, the Board does not perceive an approximate balance of positive and negative evidence. The preponderance of the evidence is against the claim, the doctrine is not applicable, and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Omosegbon, Babalakin O. 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.