Citation Nr: 22015238 Decision Date: 03/16/22 Archive Date: 03/16/22 DOCKET NO. 16-20 043 DATE: March 16, 2022 ORDER Service connection for a low back disorder is denied. FINDINGS OF FACT 1. The Veteran served on active duty from April 1968 to April 1970. 2. A back strain was shown during service but symptoms were not shown to be chronic; a current low back disorder, diagnosed as degenerative disc disease (DDD) with arthritis, was not shown to a compensable degree within one year of service and symptoms were not continuous since service. A current low back disorder is not causally or etiologically related to service. CONCLUSION OF LAW A low back disorder was not incurred in service and is not presumed to have been incurred in service. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107 (2012); 38 C.F.R. §§ 3.159, 3.303, 3.307, 3.309 (2021). REASONS AND BASES FOR FINDINGS AND CONCLUSION Turning to the relevant laws and regulations, service connection may be granted on a direct basis as a result of disease or injury incurred in service based on nexus using a three-element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred in or aggravated by service. See 38 C.F.R. §§ 3.303(a), (d); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009). Service connection may be granted on a presumptive basis for diseases listed in 38 C.F.R. § 3.309 under the following circumstances: (1) where a chronic disease or injury is shown in service and subsequent manifestations of the same disease or injury are shown at a later date unless clearly attributable to an intercurrent cause; or (2) where there is continuity of symptomatology since service; or (3) by showing that the disorder manifested itself to a degree of 10 percent or more within one year from the date of separation from service. See 38 C.F.R. § 3.307. Turning to the medical evidence, an August 2013 VA examiner diagnosed lumbosacral DDD and a lumbosacral strain. As such, a current disorder has been shown and the first element of service connection is met. As to in-service incurrence, the Veteran contends that he pulled a muscle in his low back while moving telephone poles in 1969. The service treatment records (STRs) reflect a strained muscle in the back during September 1969. He was placed on limited duty and reported that he felt better 3 days after the injury. At the time of the April 1970 separation examination, he reported a history of back trouble; however, the examiner noted a normal clinical evaluation of the spine. In sum, the medical evidence supports the in-service incurrence of a low back injury which was not chronic in nature. As to nexus, the August 2013 VA examiner opined it was less likely than not that a lumbosacral disorder was incurred in or caused by complaints of low back pain during service. The examiner noted that the separation examination did not indicate a chronic back condition. He concluded that the in-service injury resolved without residuals and that a current low back disorder was more likely due to events or injuries that occurred after service. In a June 2021 opinion, a VA examiner opined that lumbosacral DDD was less likely as not incurred in or caused by service. The examiner reviewed the STRs and post-service medical records and noted that the Veteran reported that he was feeling better 3 days after his in-service strained back muscle, left infrascapular region. Further, she explained that the separation examination noted a normal examination of the spine and did not mention any pathology of the back. The examiner also indicated that lumbar DDD was a work-related injury and was treated under Worker's Compensation. Specifically, she noted that the Veteran experienced an industrial injury at work after separation from service, in approximately 1975. In addition, the June 2021 VA examiner noted that the Veteran's in-service injury was a strained muscle of the left infrascapular region, which would correspond which an injury in the thoracic spine area, not the lumbosacral area. Importantly, she explained that the evidence did not support a persistent back condition in the infrascapular or thoracic region as a result of the strained muscle in 1969. As such, she concluded that a current lumbosacral spine disability was less likely than not related to service. Accordingly, the medical evidence does not support service connection on a direct basis. As to presumptive service connection, the August 2013 VA examination report reflected that arthritis was documented based on diagnostic testing; however, arthritis was not documented in the medical records until the August 2013 VA examination. Further, there were no complaints of low back pain until approximately 1975 at the earliest. As such, arthritis of the lumbar spine was not diagnosed in service and did not manifest within one year of separation. As to continuity of symptomatology, post-service treatment records show that the Veteran sought treatment for low back pain in 1980, approximately 10 years after separation from service. An October 1980 treatment note, which diagnosed an extruded disc, indicated that the Veteran's back pain began five years prior, in approximately 1975. As such, this supports an onset of low back pain five years after separation from service. Further, the available evidence suggests that the Veteran's symptoms of low back pain began in 1975 due to an industrial work injury in which he sought Worker's compensation. VA requested authorization to obtain these private treatment records related to Worker's compensation but has determined that these records could not be located and further attempts to obtain them would be futile. As such, the medical evidence does not support presumptive service connection. The Board finds that the August 2013 examination and June 2021 medical opinion were adequate for evaluation purposes. Specifically, August 2013 examiner reviewed the claims file, interviewed the Veteran, and conducted a physical examination. The June 2021 examiner conducted a full review of the file, including the Veteran's contentions. There is no indication that the examiners were not fully aware of the Veteran's past medical history or that they misstated any relevant fact, including reviewing the Veteran's lay statements regarding his in-service injury. Moreover, the examiners have the requisite medical expertise to render medical opinions regarding the etiology of the disorder and had sufficient facts and data on which to base the conclusion. Further, there is no contradicting medical evidence of record. Therefore, the Board finds the VA examiners' opinions to be of great probative value. The Board has considered the Veteran's lay statements that his disorder was caused by service. He is competent to report symptoms because this requires only personal knowledge as it comes to him through his senses. However, he is not competent to offer an opinion as to the etiology of his current disorder due to the medical complexity of the matter involved. Such competent evidence has been provided by the service records, clinical evidence, and examinations obtained and associated with the claims file. Here, the Board attaches greater probative weight to the clinical findings than to his statements. In light of the above, the preponderance of the evidence is against the claim for service connection and there is no doubt to be otherwise resolved. As such, the appeal is denied. Finally, the Veteran has not raised any other issues, nor have any other issues been reasonably raised by the record, for the Board's consideration. See Doucette v. Shulkin, 28 Vet. App. 366, 369-370 (2017) (confirming that the Board is not required to address issues unless they are specifically raised by the claimant or reasonably raised by the evidence of record). L. HOWELL Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Kokolas, 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.