LUMBOSACRAL STRAIN

J. PARKER · 2026 · Case ID: A26040034

MIXED

Summary

The veteran, who served from September 2000 to March 2010, appeals the denial of service connection for lumbosacral strain, bilateral lower extremity radiculopathy, and left hip strain as secondary to lumbosacral strain. The Board granted service connection for lumbosacral strain, finding that symptoms began in service and continued post-service, despite a negative initial VA examination that failed to consider all evidence. The Board also granted service connection for left and right lower extremity radiculopathy as secondary to the service-connected lumbosacral strain, based on a VA examiner's opinion that identified the back condition as the likely cause. The claim for left hip strain as secondary to lumbosacral strain was remanded. The Board found the VA examiner's opinion for the hip strain to be inadequate, as it relied on an inaccurate assumption of no chronicity of symptoms and failed to address aggravation. The case was remanded for a new opinion on whether the hip strain was caused by or aggravated by the service-connected lumbosacral strain.

Rationale

Evidence of onset of back pain in service in 2005; Chronicity of symptoms noted in service treatment records; Favorable post-service treatment records indicating onset five years prior; Inaccurate VA examination due to failure to consider all evidence

Special Benefit

NO SPECIAL BENEFIT

Docket No.

250724-572052

Full Decision Text

Citation Nr: A26040034
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 250724-572052
DATE: April 29, 2026

ORDER

Service connection for lumbosacral strain is granted.

Service connection for left lower extremity (LLE) radiculopathy is granted.

Service connection for right lower extremity (RLE) radiculopathy is granted.

REMANDED

Service connection for left hip strain as secondary to lumbosacral strain is remanded.

FINDINGS OF FACT

1. The evidence shows current diagnoses of lumbosacral strain and bilateral lower extremity radiculopathy.

2. The current lumbosacral strain was incurred in service.

3. The current LLE and RLE radiculopathy disorders were caused by the service-connected lumbosacral strain.

CONCLUSIONS OF LAW

1. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for lumbosacral strain have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303.

2. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for left lower extremity radiculopathy have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310.

3. Resolving reasonable doubt in the Veteran's favor, the criteria for service connection for right lower extremity radiculopathy have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran, who is the Appellant, served on active duty from September 2000 to March 2010.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2025 rating decision from the Regional Office (RO). In the July 24, 2025, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement (NOD)), the Veteran elected the Evidence Submission docket; therefore, the Board may only consider evidence submitted prior to the May 2005 rating decision, or within 90 days of the July 24, 2025 substantive appeal to the Board (i.e., March 2024 NOD). 38 C.F.R. § 20.303.

With regard to service connection for lumbosacral strain and bilateral lower extremity radiculopathy, the Board finds that the duties to notify and assist in this case have been rendered moot by the grant of service connection for lumbosacral strain and LLE and RLE radiculopathy, which is a full grant of the benefits sought on appeal. Service connection for left hip strain is remanded for additional development.

Service Connection

Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (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.

Service connection may be established, on a secondary basis, for disability that is proximately due to or the result of a service-connected disease or injury. See 38 C.F.R. § 3.310. Secondary service requires evidence demonstrating that the disability is either (1) proximately due to or the result of a service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310.

1. Service connection for lumbosacral strain

The Veteran appeals for service connection for lumbosacral strain. He contends that back pain began during service, and that X-rays during service in 2008 show vertebral fractures between L5/S1. See January 2008 Claim.

The evidence in this case shows a current
310. Secondary service requires evidence demonstrating that the disability is either (1) proximately due to or the result of a service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310.

1. Service connection for lumbosacral strain

The evidence in this case shows a current diagnosis of lumbosacral strain. See January 2025 VA Examination Report.

After a review of all the lay and medical evidence of record, the Board finds that the evidence is at least in relative equipoise on the questions of whether symptoms of lumbosacral strain began during service and have been continuous since service. The April 2000 service enlistment examination report indicates that there were no complaints or abnormalities noted in the spine. During service in March 2005 the Veteran reported chronic back pain for one week following physical training. Tenderness on palpation, muscle spasm, and painful motion in the lumbar spine were noted upon examination, and the diagnosis was backache. In an October 2005 post-deployment assessment, following a tour in Iraq, the Veteran reported a history of problems with back pain during and after deployment. Lumbar back strain remained an active problem in 2007. See April 2000, March 2005, October 2005, February 2007 service treatment records.

Post-service treatment records show that when seeking initial post-service treatment for low back pain in 2012 the Veteran reported an onset of back pain that began about five years prior, that is, at least since 2007 during service. The Veteran reported that he saw a chiropractor in 2008 who took some x-rays and declined to treat the Veteran due to noted abnormalities in his spine at that time. The Veteran reported he was scared to address his back issues at that time, so he did not seek additional treatment. However, he endorsed continued episodes of back pain that were starting to affect his quality of life. The private examiner in 2012 reviewed radiographic imaging of the lumbar spine dated August 15, 2008 and reported on findings including grade 1 isthmic spondylolisthesis of L5 on S1 with mild disc space narrowing. Diagnostic impression was chronic mechanical low back pain, grade 1 isthmic spondylolisthesis L5-S1, and lumbar disc disease. See August 2012 private treatment records.

During an October 2012 VA mental health visit the Veteran reported some adjustment anxiety after being diagnosed with a "broken back" by a private doctor, and the Veteran linked his back problems to the military. See October 2012 VA treatment record.

During the January 2025 VA back examination, the Veteran reported an onset of back pain during service in 2005 while in Iraq when he jumped out of truck with heavy gear and felt back pain instantly. The Veteran reported that the back pain slowly progressed with worsening pain since then. See January 2025 VA Examination Report.

The VA examiner in January 2025 opined that the current back disability is less likely than not incurred in or related to service. The examiner reasoned that there is a lack of substantiating evidence supporting a nexus between the current diagnosis of lumbosacral strain and military service. The examiner reasoned that, without chronicity during service or after service, a post-service event, illness, or injury is a more likely etiology. The examiner inaccurately assumed there is an overall lack of service treatment records, back complaints, and evidence of chronicity of care noted in the claims file. Id.

It does not appear that the VA examiner in January 2025 accessed the entire claims file especially service treatment record evidence of onset of back pain and treatment of the back during service. The service treatment records show initial signs and symptoms of back pain in 2005, including during the deployment to Iraq, and that "lumbar back strain" was also included on the Veteran's active problem list in February 2007. The VA examiner also did not consider favorable post-service evidence that shows that, when the Veteran first sought treatment for back pain two years after service separation (i.e., 2012), he reported a history of onset of back pain five years prior that had progressively worsened over time, indicating symptoms of back pain since at least 2007 during service. As such
2025 accessed the entire claims file especially service treatment record evidence of onset of back pain and treatment of the back during service. The service treatment records show initial signs and symptoms of back pain in 2005, including during the deployment to Iraq, and that "lumbar back strain" was also included on the Veteran's active problem list in February 2007. The VA examiner also did not consider favorable post-service evidence that shows that, when the Veteran first sought treatment for back pain two years after service separation (i.e., 2012), he reported a history of onset of back pain five years prior that had progressively worsened over time, indicating symptoms of back pain since at least 2007 during service. As such, the Board finds the January 2025 VA medical opinion to be of little probative value as it is based on an inaccurate factual assumptions of no back complaints during service and no chronicity of symptoms during or after service, which is inconsistent with the service treatment records, as well as credible lay histories provided by the Veteran for the purposes of treatment within two years of service separation.

Resolving reasonable doubt in the Veteran's favor, the Board finds that symptoms of low back pain began during service and continued since service separation, which symptoms were later diagnosed as lumbosacral strain, thus tending to show direct service onset or direct service incurrence. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a), (d). The Board is granting the service connection claim based on evidence, including that pertinent to service, which establishes that symptoms of a low back disability (later diagnosed as lumbosacral strain with disc herniations) began in service, so were "incurred in" service. The grant of direct service connection renders all other theories of service connection moot.

2. Service Connection for Left Lower Extremity Radiculopathy

3. Service Connection for Right Lower Extremity Radiculopathy

The evidence shows a current diagnosis of right and left lower extremity radiculopathy. See January 2025 VA Examination Report.

After reviewing all the evidence, both lay and medical, the Board finds that the evidence is in relative equipoise on the question of whether the LLE and RLE radiculopathy were caused by the service-connected low back disability. Private treatment records dated April and May 2022 show that the Veteran endorsed lumbar spine pain with radiation to the entire leg of the bilateral lower extremities. During the January 2025 VA examination, the VA examiner diagnosed bilateral lower extremity radiculopathy and identified lumbosacral strain as the likely cause of the bilateral lower extremity radiculopathy. See April 2022, May 2022 private treatment records; see also January 2025 VA Examination Report.

Based on the above, and resolving reasonable doubt in favor of the Veteran, service connection for the LLE and RLE radiculopathy disabilities, as secondary to the service-connected low back disability, is warranted. 38 U.S.C. § 5107; 38 C.F.R. §§ 3.102, 3.310. The grant of secondary service connection renders moot other theories of service connection.

REASONS FOR REMAND

4. Service Connection for Left Hip Strain as Secondary to Lumbosacral Strain is Remanded.

The Veteran appeals for service connection for left hip strain as secondary to the service-connected lumbosacral strain, contending that he has developed significant hip pain secondary to the back disability.

In January 2025, the VA examiner diagnosed left hip strain and opined that it is less likely than not that the left hip strain was caused by or the result of the lumbosacral strain. The rationale provided was that there is an overall lack of service treatment records, hip complaints, chronic diagnosis, and evidence of chronicity of care noted in the claims file at this time. However, the evidence need not show initial onset or complaints of left hip pain in service under the causation or aggravation theory of secondary service-connection. 38 C.F.R. § 3.310(a). Moreover, the RO did not obtain an opinion on the question of whether the left hip strain was aggravated (worsened in severity) by the now service-connected lumbosacral strain. 38 C.F.R. § 3.310(b). On remand, the RO should obtain an addendum opinion with supporting rationale on the theory of secondary service connection.

Service connection for left hip strain is REMANDED for the following action:

Return the VA medical opinion report to the VA examiner who provided the medical opinion in January 2025. If the original VA examiner is unavailable, a new examiner
aggravation theory of secondary service-connection. 38 C.F.R. § 3.310(a). Moreover, the RO did not obtain an opinion on the question of whether the left hip strain was aggravated (worsened in severity) by the now service-connected lumbosacral strain. 38 C.F.R. § 3.310(b). On remand, the RO should obtain an addendum opinion with supporting rationale on the theory of secondary service connection.

Service connection for left hip strain is REMANDED for the following action:

Return the VA medical opinion report to the VA examiner who provided the medical opinion in January 2025. If the original VA examiner is unavailable, a new examiner may be assigned to address the requested opinion. The relevant documents in the record should be reviewed by the examiner, and a detailed history of relevant symptoms should be obtained from the record. A rationale for all opinions and a discussion of the facts and medical principles involved should be provided.

The examiner should offer opinions:

a) Is it at least as likely as not that the current left hip strain was caused by the service-connected lumbosacral strain?

b) Is it at least as likely as not that the current left hip strain was aggravated by (increased in severity by) the service-connected lumbosacral strain?

J. PARKER

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board S. Moore

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.

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