LUMBOSACRAL STRAIN

TIFFANY DAWSON · 2026 · Case ID: A26040659

MIXED

Summary

The Veteran, who served in the United States Army from November 2008 to May 2009, with subsequent service in the Army National Guard and Army Reserve, appeals the denial of service connection for multiple conditions. The Board granted service connection for a low back disability (lumbosacral strain) and asthma. The Veteran's lay statements indicated onset of back pain during basic training, which was corroborated by service treatment records showing treatment for back pain and tenderness. The Board found the VA examiner's opinion against service connection for the back was inadequately reasoned, and resolving doubt in the Veteran's favor, granted service connection. For asthma, the Veteran reported shortness of breath during active duty for training, supported by service records noting complaints of chest tightness and a commander's notation that the respiratory symptoms were incurred in the line of duty. The Board found the VA clinician's opinion linking the current asthma to service was well-supported. The Board remanded claims for hypertension, a psychiatric disorder (depression, anxiety, stress), skin disorders (melasma, hydradenitis suppurativa), left foot disorder (pes planus), IBS, left knee disorder, and left and right shoulder disorders. Remand was necessary due to duty to assist errors, specifically the failure to obtain complete service records for National Guard/Reserve service and the lack of VA examinations for the remanded conditions. The Board noted that for the remanded conditions, any evidence submitted that the Board could not consider would be handled by the AOJ in the supplemental claim process.

Rationale

Favorable finding of current disability by AOJ; Lay statements of onset in service corroborated by STRs; VA examiner's opinion against service connection was inadequately reasoned; Benefit of the doubt resolved in Veteran's favor

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210126-137214

Full Decision Text

Citation Nr: A26040659
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 210126-137214
DATE: April 30, 2026

ORDER

Entitlement to service connection for a low back disability, diagnosed as lumbosacral strain, is granted.

Entitlement to service connection for asthma is granted.

REMANDED

Entitlement to service connection for hypertension is remanded.

Entitlement to service connection for a skin disorder, diagnosed as melasma and hydradenitis, is remanded.

Entitlement to service connection for an acquired psychiatric disorder, claimed as depression, anxiety, and stress, is remanded.

Entitlement to service connection for a left foot disorder is remanded.

Entitlement to service connection for irritable bowel syndrome (IBS) is remanded.

Entitlement to service connection for a left knee disorder manifested by pain, to include as secondary to service-connected right knee disability, is remanded.

Entitlement to service connection for a left shoulder disorder is remanded.

Entitlement to service connection for a right shoulder disorder is remanded.

FINDINGS OF FACT

1. The Veteran's lumbosacral strain occurred during active service, with continuing symptoms since such time.

2. The Veteran's asthma onset during a period of active duty for training.

CONCLUSIONS OF LAW

1. The criteria for service connection for lumbosacral strain have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for asthma have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active duty service in the United States Army from November 2008 to May 2009, with additional periods of service in the Army National Guard and Army Reserve. See DPRIS Response associated with claims file May 27, 2020.

The rating decisions on appeal were issued in September 2020 (psychiatric, left foot, hypertension, IBS, left knee, left and right shoulders, and skin disorders) and October 2020 (back and asthma) and constitute initial decisions; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.

In the January 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held in October 2024; a transcript is associated with the record. Therefore, the Board may only consider the evidence of record at the time of the September 2020 and October 2020 agency of original jurisdiction (AOJ) decisions on appeal, as well as any evidence submitted by the Veteran, or her representative, at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims for service connection for lumbosacral strain and asthma, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claims of entitlement to service connection for hypertension, a psychiatric disorder, and for skin, musculoskeletal, and gastrointestinal disorders, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection

Service connection generally requires (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) competent evidence of a causal relationship, or nexus, between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163,
claims of entitlement to service connection for hypertension, a psychiatric disorder, and for skin, musculoskeletal, and gastrointestinal disorders, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection

Under 38 U.S.C. § 5107 (b), the VA shall consider all information and lay and medical evidence of record in a case before the Secretary with respect to benefits under laws administered by the Secretary. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990).

1. Entitlement to service connection for a low back disability.

As an initial matter, in the October 2020 rating decision, the AOJ favorably found that the evidence established that the Veteran had a current low back disability diagnosed as lumbosacral strain. Pursuant to 38 C.F.R. § 3.104(c), the Board is bound by this favorable finding absent clear and unmistakable evidence to the contrary. Thus, the question before the Board is whether the Veteran's current disability had its onset in, or is otherwise etiologically related to, service. For the following reasons, service connection for a low back disability is warranted.

The Veteran contends she developed a low back disability which began in basic training with symptoms of low back pain associated with marching and rucking with heavy gear. May 2020 VA Form 21-526EZ; October 2020 Back Conditions Disability Benefits Questionnaire (DBQ).

The Board observes that, as a lay person, the Veteran is competent to report on matters observed or within her personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, she is competent to provide statements of the above symptoms she personally experienced which are observable to her senses.

Moreover, the Board finds the Veteran's statements of onset of back pain in basic training are supported by the available service department records. Specifically, the service treatment records (STRs) reflect the Veteran reported experiencing back pain for multiple days during basic training after she first started wearing her individual body armor (IBA). STR received July 25, 2020, date of service (DOS) January 16, 2009. At that time, the Veteran was noted by the treating physician to have tenderness to palpation and rated her pain as 6 out of 10, on the scale of 1 to 10 with 10 being the worst pain imaginable. The Veteran was given a prescription for both topical pain relief ointment and nonsteroidal antiinflammatory medication and work restrictions prohibiting wearing IBA or a ruck sack for the following three days.

The Board finds the October 2020 VA-contracted examiner's opinion arguing that the Veteran's low back disability is less likely than not related to her active service is not supported by an adequate rationale, as this clinician's report fails to address the Veteran's lay statement reflecting onset of back pain in service with continuation of symptoms since such time, further corroborated by the STRs which document the Veteran's medical treatment for her back symptoms in January 2009 during basic training.

Here, the Board finds the Veteran's STRs document the onset of back pain in service; moreover, the Board finds the Veteran has competently and credibly stated that the back pain that onset in service has continued since service. Therefore, the Board resolves reasonable doubt in the Veteran's favor to find that service connection for low back disability is warranted.

2. Entitlement to service connection for asthma.

As an initial matter, in the October 2020 rating decision, the AOJ favorably found that the evidence established that the Veteran has a current asthma disability. Pursuant to 38 C.F.R. § 3.104(c), the Board is bound by this favorable finding absent clear and unmistakable evidence to the contrary. Thus, the question before the Board is whether the Veteran's current disability had its onset in, or is otherwise etiologically related to, service. The persuasive weight of the
pain that onset in service has continued since service. Therefore, the Board resolves reasonable doubt in the Veteran's favor to find that service connection for low back disability is warranted.

2. Entitlement to service connection for asthma.

As an initial matter, in the October 2020 rating decision, the AOJ favorably found that the evidence established that the Veteran has a current asthma disability. Pursuant to 38 C.F.R. § 3.104(c), the Board is bound by this favorable finding absent clear and unmistakable evidence to the contrary. Thus, the question before the Board is whether the Veteran's current disability had its onset in, or is otherwise etiologically related to, service. The persuasive weight of the evidence establishes that the Veteran's asthma onset in, and has continued since, active service.

The Veteran contends she developed a respiratory disorder which began in basic training with shortness of breath, and has continued since such time. May 2020 VA Form 21-526EZ; August 2020 Respiratory Conditions DBQ. The Board observes that, as a lay person, the Veteran is competent to report on matters observed or within her personal knowledge. See Layno v. Brown, 6 Vet. App. 465, 470 (1994). Therefore, she is competent to provide statements of the above symptoms she personally experienced which are observable to her senses.

Moreover, the Board finds the Veteran's statements of onset of asthma during active duty are supported by the available service department records. Specifically, STRs reflect the Veteran's complaints of chest tightness with exertion and trouble breathing with shortness of breath during a two-week period of active duty for training in June 2010. STR-Dental associated with claims file July 25, 2020, DOS June 12, 2010. At that time, the Unit Commander noted the Veteran had been in active duty for training status from June 5th to June 19, 2010, and that her respiratory symptoms were considered to have been incurred in the line of duty. Id., DA Form 2173. A follow-up evaluation was scheduled to determine the Veteran's fitness for duty as the Veteran had been identified with a past history of exercise induced asthma or airway hyperactivity; this resulted in a permanent profile for asthma requiring the Veteran to be permitted to have an albuterol inhaler at all times and to use the medication before exercise. Id., DOS March 13, 2011, and July 2011 DA Form 3349.

The August 2020 VA-clinician noted the above history and opined that the Veteran's current asthma disability had onset during active duty and continued since such time, identifying the March 2011 asthma consultation request and the May 2011 pulmonary function testing as supporting evidence in favor of a nexus. August 2020 Respiratory Conditions and Medical Opinion DBQ. While the examining physician excluded an earlier 2009 incidence of bronchitis/laryngitis during basic training as related to the Veteran's current asthma disability in an addendum report, the evidence supports that the Veteran's current asthma disability, which was first treated in June 2010 and subsequently evaluated from March to July 2011, is etiologically related to the Veteran's June 2010 period of active duty service. In so finding, the Board notes the examining physician's rationale is well-supported by probative weight of the evidence of record, including the Veteran's testimony and the June 2010 report of the Veteran's Unit Commander which identifies the Veteran's respiratory disorder as having occurred during the June 2010 period of active duty for training. As such, entitlement to service connection for asthma is warranted.

REASONS FOR REMAND

Under the AMA, the Board may only remand an issue for the correction of (1) duty to assist errors occurring prior to the date of the AOJ decision on appeal (i.e., pre-decisional duty to assist errors) and (2) AOJ errors in satisfying a regulatory or statutory duty, if correction of such error would have a reasonable possibility of aiding in substantiating the appellant's claim. See 38 C.F.R. § 20.802(a).

For the reasons identified herein, the Board finds remand is warranted to correct duty to assist errors that occurred prior to the rating decisions on appeal.

Entitlement to service connection for melasma and hydradenitis.

Entitlement to service connection for hypertension.

For the reasons identified herein, the Board finds remand is warranted to correct duty to assist errors that occurred prior to the rating decisions on appeal.

Entitlement to service connection for melasma and hydradenitis.

Entitlement to service connection for hypertension.

The Veteran has described onset of hyperpigmentation and hypertension in service. While there is evidence of relevant diagnoses in 2013, the Board is unable to determine the character of the Veteran's service at the relevant times. Moreover, the Board observes that the Veteran's service department records appear to be incomplete.?For example, on the May 2020 VA Form 21-526EZ, the Veteran reported that she served in the Army Reserve through January 2017, and the available evidence associated with the claims file confirms the Veteran was assigned to the Army Reserve July 2014 for a period of service through January 2017; however, these records also indicated the Veteran had additional service in the Army National Guard of California from July 2008 through July 2014. DPRIS Response associated with claims file May 27, 2020. Nevertheless, the AOJ does not appear to have made attempts to obtain the Veteran's service department records from her National Guard service, nor has the AOJ conducted sufficient development to identify the Veteran's specific periods of ACDUTRA or INACDUTRA for her National Guard and Army Reserve service.

As the VA has a?duty to assist?claimants in obtaining evidence needed to substantiate a claim, including military records and "relevant records pertaining to the claimant's active military, naval, air, or space service that are held or maintained by a governmental entity," the AOJ's failure to attempt to obtain these records, or to make a formal finding if reasonably certain such records do not exist or further efforts to obtain them would be futile, constitutes a?pre-decisional duty to assist error. 38 U.S.C. § 5103A; 38 C.F.R. § 3.159 (c) (2), (3).

Entitlement to service connection for an acquired psychiatric disorder.

Entitlement to service connection for a left shoulder disorder.

Entitlement to service connection for a right shoulder disorder.

Entitlement to service connection for a left knee disorder.

Entitlement to service connection a left foot disorder.

Entitlement to service connection for IBS.

The Veteran contends she developed disorders of the left and right shoulders, left knee, and left foot, as well as IBS and an acquired psychiatric disorder, a result of her active duty service. May 2020 VA Form 21-526EZ. In addition to remanding for the AOJ to conduct development to identify the Veteran's specific periods of ACDUTRA or INACDUTRA regarding her National Guard and Army Reserve service, remand is necessary for the AOJ to obtain relevant VA examinations to determine the nature of etiology of the Veteran's related symptoms.

The Veteran describes onset of symptoms including severe anxiety and depression "while on active duty" at Fort Irwin. May 2020 VA Form 21-526EZ. Evidence of record prior to the rating decision on appeal includes STRs which noted diagnosis of a mood disorder with the Veteran reporting "high job stress" including unit and drill stress in August 2013. The Veteran was also prescribed antidepressant medication in February 2014.?? The evidence of record prior to the rating decision on appeal also include the lay statement of the Veteran's spouse, who described witnessing the Veteran's mental health struggles "to this day". The available STRs similarly document the Veteran's complaints of joint pains and gastrointestinal symptoms during this period.

Nevertheless, the Veteran has not been afforded VA examinations for her contended psychiatric, musculoskeletal and gastrointestinal disorders, nor has an opinion been obtained to determine the nature or etiology of the symptoms described by the evidence of record. The Secretary is required to provide a medical examination or opinion regarding the Veteran's claimed disability "if the information and evidence of record does not contain sufficient competent medical evidence to decide the claim" and (1) the record contains competent evidence of a current diagnosed disability or persistent or recurrent symptoms of disease; (2) the evidence establishes that the veteran suffered an in-service event, injury or disease; (3) and the evidence indicates that the claimed disability or symptoms may be associated with the established in-service event, injury or disease or with another service-connected disability. See?38 C.F.R. § 3.159?(c)(4); see also?McLendon?v. Nicholson, Vet. App.?79, 85-86 (2006).

In this case, the low threshold of the?McLendon?standard has been met.
of record does not contain sufficient competent medical evidence to decide the claim" and (1) the record contains competent evidence of a current diagnosed disability or persistent or recurrent symptoms of disease; (2) the evidence establishes that the veteran suffered an in-service event, injury or disease; (3) and the evidence indicates that the claimed disability or symptoms may be associated with the established in-service event, injury or disease or with another service-connected disability. See?38 C.F.R. § 3.159?(c)(4); see also?McLendon?v. Nicholson, Vet. App.?79, 85-86 (2006).

In this case, the low threshold of the?McLendon?standard has been met. As the evidence of record includes lay evidence of various symptoms that may be etiologically related to the Veteran's military service, the AOJ erred in not scheduling the Veteran for VA examinations to determine the nature and etiology of her contended psychiatric, musculoskeletal and gastrointestinal disorders. McLendon, 20?Vet. App.?79, 81?(2006).

The matters are REMANDED for the following actions:

1. Attempt to obtain the complete service department records of the Veteran, to include the records pertaining to the Veteran's Army National Guard of California service from July 2008 through July 2014. Attempt to clearly identify any periods of ACDUTRA and INACDUTRA during the Veteran's National Guard and Army Reserve service through January 2017. Document all attempts to verify this service in the claims file.

Provide notification as required by 38 C.F.R. § 3.159 if any such records are unavailable and inform the Veteran to afford the Veteran an opportunity to submit any copies in her possession.

2. Thereafter, forward the record and a copy of this Remand to a VA clinician for completion of an addendum medical opinion addressing the etiology of the Veteran's hypertension. If the?clinician determines?that a new examination is necessary to provide the requested opinion, such examination should be scheduled. The clinician should address the following:

Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) the Veteran's hypertension disability onset during, or is etiologically related to, the Veteran's periods of active service.

A complete rationale should be provided.

3. Forward the record and a copy of this Remand to a VA clinician for completion of an addendum medical opinion addressing the etiology of the Veteran's skin disability diagnosed as melasma and hydradenitis suppurativa. If the?clinician determines?that a new examination is necessary to provide the requested opinion, such examination should be scheduled. The clinician should address the following:

Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) the Veteran's skin disability, diagnosed as melasma and hydradenitis suppurativa, onset during a period of the Veteran's active service, or is etiologically related to a period of the Veteran's active service.

In so opining, the examining clinician should specifically address the evidence of record, including the Veteran's lay statement describing onset discoloration over her arms and face while serving at Fort Irwin, complaints of "rash for last few days" as noted in the June 2010 DA Form 2173, and including service treatment records documenting worsening facial rash on March 28, 2013, spreading skin discoloration as noted on August 21, 2013, and hyperpigmentation as noted in the May 2013 treatment records of Lancaster Rheumatology associated with claims file June 2, 2020 and July 25, 2020.

4. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's contended acquired psychiatric disability, claimed as depression, anxiety and stress. The examiner must review the entire claims file, including a copy of this remand.

The examiner is asked to provide a response to the following:

(a.) Identify any psychiatric disorders that have existed since the date of the Veteran's claim in May 2020 (even if now asymptomatic or resolved). The examiner should address the lay statements of the Veteran reporting symptoms including depression and anxiety, and the Veteran's spouse's statement which described witnessing the Veteran's mental health struggles "to this day".

(b.) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that any acquired psychiatric disability diagnosed had its onset in service, within a year of service, or is otherwise related to service.

The examining clinician should specifically address the service treatment records which noted diagnosis of a mood disorder with the Veteran reporting "high job stress" including unit and drill stress in August
have existed since the date of the Veteran's claim in May 2020 (even if now asymptomatic or resolved). The examiner should address the lay statements of the Veteran reporting symptoms including depression and anxiety, and the Veteran's spouse's statement which described witnessing the Veteran's mental health struggles "to this day".

5. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's contended left and right shoulder disabilities. The examiner must review the entire claims file, including a copy of this remand.

The examiner is asked to provide a response to the following:

(a.) Please?identify?any current left and right shoulder disability since the date of the Veteran's claim by either (1) diagnosis or (2) functional impairment.?

(b.) As to any left and right shoulder disability diagnosed above, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such disability had its onset in service or is otherwise related to service.

In so opining, the examining clinician should specifically address the evidence of record, including the Veteran's lay statement describing onset of bilateral shoulder strain after basic training in 2008 and 2009 where she was required to carry heavy weight on her back for long durations of time, and including service treatment records documenting diagnosis of right shoulder impingement syndrome in May 2011, and continuing joint pain as noted in the consultation record dated October 2013 of Lancaster Rheumatology.

6. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's contended left knee disability. The examiner must review the entire claims file, including a copy of this remand.

The examiner is asked to provide a response to the following:

(a.) Please?identify?any current left knee disability since the date of the Veteran's claim by either (1) diagnosis or (2) functional impairment.?

(b.) As to any left knee disability diagnosed above, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such disability had its onset in service or is otherwise related to service.

7. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's contended left foot disability, claimed as pes planus. The examiner must review the entire claims file, including a copy of this remand.

The examiner is asked to provide a response to the following:

(a.) Please?identify?any current left foot disability since the date of the Veteran's claim by either (1) diagnosis or (2) functional impairment.?

(b.) As to any left foot disability diagnosed above, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such disability had its onset in service or is otherwise related to service.

In so opining, the examining clinician should specifically address the Veteran's lay statement describing onset of symptoms of bilateral knee pain during service.

8. Schedule the Veteran for a VA examination to determine the nature and etiology of the Veteran's contended gastrointestinal disability, claimed as irritable bowel syndrome (IBS). The examiner must review the entire claims file, including a copy of this remand.

The examiner is asked to provide a response to the following:

(a.) Please?identify?any current gastrointestinal disability since the date of the Veteran's claim by either (1) diagnosis or (2) functional impairment.?

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(b.) As to any gastrointestinal disability diagnosed above, whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that such disability had its onset in service or is otherwise related to service.

In so opining, the examining clinician should specifically address the evidence of record, including the Veteran's lay statement describing onset of symptoms of IBS during service, and including service treatment records documenting Veteran's report of diarrhea with decreased appetite for two weeks as documented in March 2009, and history of diarrhea/constipation as noted in the May 2013 treatment records of Lancaster Rheumatology associated with claims file June 2, 2020 and July 25, 2020.

Tiffany Dawson

Veterans Law Judge

Board of Veterans' Appeals

Att

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