Backpain question

[bruinboy]

I am confused... I have a complaint of backpain on my exit physicial. I stated that I had a serious back spasm for about a week in medical record .... I continue to have back pain so I filed a claim. Recently I had a C&P for lower back pain and spasm.  Can this service connect? This Veteran describes a clinical picture of occasional lumbar muscle spasm/strain, with no objective evidence that is had its onset in service.However, his X-rays show diffuse degenerative spondylosis which could be triggering the spasms. The radiologic abnormalities may be nothing more than simple wear and tear of the spine, but the likelihood is that the process began more than 12 months ago, i.e. began while he was in service. THerefore, it is at least as likely as not that his LBP had its onset while in service

[iceturkee]

is back pain well documented in your service medical record? if it isn't, its my guess thats why the examiner opined least likely.

[bruinboy]

it says "at least as likely as not"  not "least likely"  .... the test said 50% or more likely from the service. I only have one incidence of back injury documented though... that is why I asked

[TALON II FE]

I think it is SC, "...at least as likely as not...".  Now, whether  they are going to give you anything above a 0%, that may not happen, but you will be SC and that is huge since spines don't tend to heal well from my experience.  Keep getting documentation of continued treatment when you have flare ups to support an increase later, if that's warranted.  Good Luck!

[iceturkee]

2 hours ago, bruinboy said:

it says "at least as likely as not"  not "least likely"  .... the test said 50% or more likely from the service. I only have one incidence of back injury documented though... that is why I asked

sorry i misread that. the examiner opined in your favor. that said, i'm concerned about only one entry in your military medical record. i got denied for service connection for my lower back because i had only 2 entries in my medical record. that was before examiners were opining least as likely or least likely. talon might be correct, you may get only 0 percent.

what was your range of motion during your c&p?

[bruinboy]

 

[ ] Review of available records (without in-person or video telehealth
examination) using the Acceptable Clinical Evidence (ACE) process
because the existing medical evidence provided sufficient information on which
to prepare the DBQ and such an examination will likely provide no
additional relevant evidence.
[ ] Review of available records in conjunction with a telephone interview
with the Veteran (without in-person or telehealth examination) using the
ACE process because the existing medical evidence supplemented with a
telephone interview provided sufficient information on which to prepare
the DBQ and such an examination would likely provide no additional
relevant evidence.
[ ] Examination via approved video telehealth
[X] In-person examination
Evidence review
---------------
Was the Veteran's VA claims file (hard copy paper C-file) reviewed?
[ ] Yes [X] No
If no, check all records reviewed:
[X] Military service treatment records
[ ] Military service personnel records
[X] Military enlistment examination
[X] Military separation examination
 
[ ] Military post-deployment questionnaire
[ ] Department of Defense Form 214 Separation Documents
[X] Veterans Health Administration medical records (VA treatment
records)
[ ] Civilian medical records
[ ] Interviews with collateral witnesses (family and others who have
known the Veteran before and after military service)
[ ] No records were reviewed
[ ] Other:
1. Diagnosis
------------
Does the Veteran now have or has he/she ever been diagnosed with a
thoracolumbar spine (back) condition?
[X] Yes [ ] No
Thoracolumbar Common Diagnoses:
[ ] Ankylosing spondylitis
[X] Lumbosacral strain
[ ] Degenerative arthritis of the spine
[ ] Intervertebral disc syndrome
[ ] Sacroiliac injury
[ ] Sacroiliac weakness
[ ] Segmental instability
[ ] Spinal fusion
[ ] Spinal stenosis
[ ] Spondylolisthesis
[ ] Vertebral dislocation
[ ] Vertebral fracture
Diagnosis #1: Minimal lumbar spondylosis - DDD + DJD
Date of diagnosis: 3/8/2016
2. Medical history
------------------
a. Describe the history (including onset and course) of the Veteran's
thoracolumbar spine (back) condition (brief summary):

 

 Veteran seen today for an original evaluation of his low back and an opinion as to whether it was caused by or is due to his military service (2/2008-2/2015, ).
Review of VBMS and CPRS reveal:
1/18/2007 VA PCP Initial -   male presents to the clinic with
no medical problems at this time. he says he is okay
11/1/2012 STR Note -
7/10/2013 STR Note - ROS: No back pain.
12/19/2013 PHA - ROS: No back pain.
9/26/2014 RAD Med Hx - Yes- Recurrent back pain or any back problem.
Q#29: Had back spasm and lower back pain in July 2015; not seen.
10/27/2014 STR Note - ROS: No back pain.
3/5/2015 VA PCP Initial - HX of  PTSD, depression, anxiety d/o presents to establish care. (no mention of back complaints)
8/21/2015 VA PCP Initial - CHIEF COMPLAINT: Evaluation and Management of tinnitus. bilateral chronic knee pain, worse with running. 
10/14/2015 VA PCP -  need motrin for bilateral knee pain and lower back ache... My knee pain gets worst with increased activity and cold. Had this symptom for over a year now. My lower back aches also.

 

Today the Veteran reports that he first noticed back pain w  2013-2014. The pain resolved spontaneously with ice. Then in 2014, July or August, he was running and stepped on something and landed hard and shortly thereafter developed a spasm of his low back. He needed to keep the back straight/arched to alleviate the pain. He did not seek treatment for the back, until he informed PT and PCM that his pain had resolved. The spasm lasted one week, it resolved when his SGT allowed him to not do PT. The naproxen given him for the knee helped the back. Heapplied heat. Then in 1/2015 he drove over 300 miles and after which he developed LBP when running, this time lasting 2-3 days. He did stretching, took OTC ibuprofen. It resolved before he went for medical attention. In May 2015, when driving from California to New York he developed low back stiffness and achiness which lasted about 5 days. In 10/2015 while running he developed some LBP, called his PCP, but it resolved so he cancelled the appointment. The pain aggavates when he runs over 25 minutes, only once in 3 months which resolved with hot bath. Currently he has no back pain. When he does have the pain it is across the low back L>R, not over the spine itself, no radiation, no incontinence, no ED, no assistive devices, no medications except when it hurts, no MD directed bed rest. Worst pain was 4/10, usually 2-3/10. He is a student with no specific activity restrictions, but it hurts to sit too long.

 

b. Does the Veteran report flare-ups of the thoracolumbar spine (back)?
[ ] Yes [X] No
c. Does the Veteran report having any functional loss or functional
impairment of the thoracolumbar spine (back) (regardless of repetitive use)?
[X] Yes [ ] No
If yes, document the Veteran's description of functional loss or
functional impairment in his or her own words.
See Q2a
 
3. Range of motion (ROM) and functional limitation
--------------------------------------------------
a. Initial range of motion
[ ] All normal
[X] Abnormal or outside of normal range
[ ] Unable to test (please explain)
[ ] Not indicated (please explain)
Forward Flexion (0 to 90): 0 to 80 degrees
Extension (0 to 30): 0 to 30 degrees
Right Lateral Flexion (0 to 30): 0 to 30 degrees
Left Lateral Flexion (0 to 30): 0 to 30 degrees
Right Lateral Rotation (0 to 30): 0 to 30 degrees
Left Lateral Rotation (0 to 30): 0 to 30 degrees
If ROM is outside of normal range, but is normal for the Veteran (for
reasons other than a back condition, such as age, body habitus,
neurologic disease), please describe:
stiff muscles
If abnormal, does the range of motion itself contribute to a
functional loss? [ ] Yes (please explain) [X] No
Description of pain (select best response):
No pain noted on exam
Is there evidence of pain with weight bearing? [ ] Yes [X] No
Is there objective evidence of localized tenderness or pain on palpation
of the joints or associated soft tissue of the thoracolumbar spine
(back)?
[ ] Yes [X] No
b. Observed repetitive use
Is the Veteran able to perform repetitive use testing with at least three
repetitions? [X] Yes [ ] No
Is there additional loss of function or range of motion after three
repetitions? [ ] Yes [X] No
c. Repeated use over time
Is the Veteran being examined immediately after repetitive use over time?
[ ] Yes [X] No
If the examination is not being conducted immediately after
repetitive use over time:
[ ] The examination is medically consistent with the Veteran's
statements describing functional loss with repetitive use over
time.
[ ] The examination is medically inconsistent with the Veteran's
statements describing functional loss with repetitive use over
time. Please explain.
[X] The examination is neither medically consistent or inconsistent
with the Veteran's statements describing functional loss
with repetitive use over time.
Does pain, weakness, fatigability or incoordination significantly limit
functional ability with repeated use over a period of time?
[ ] Yes [X] No [ ] Unable to say w/o mere speculation
d. Flare-ups
No response provided
e. Guarding and muscle spasm
Does the Veteran have guarding or muscle spasm of the thoracolumbar spine
(back)? [ ] Yes [X] No
f. Additional factors contributing to disability
In addition to those addressed above, are there additional contributing
factors of disability? Please select all that apply and describe: None
 

 

4. Muscle strength testing
--------------------------
a. Rate strength according to the following scale:
0/5 No muscle movement
1/5 Palpable or visible muscle contraction, but no joint movement
2/5 Active movement with gravity eliminated
3/5 Active movement against gravity
4/5 Active movement against some resistance
5/5 Normal strength
Hip flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Knee extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle plantar flexion:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Ankle dorsiflexion:
 
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Great toe extension:
Right: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
Left: [X] 5/5 [ ] 4/5 [ ] 3/5 [ ] 2/5 [ ] 1/5 [ ] 0/5
b. Does the Veteran have muscle atrophy?
[ ] Yes [X] No
 

 

5. Reflex exam
--------------
Rate deep tendon reflexes (DTRs) according to the following scale:
0 Absent
1+ Hypoactive
2+ Normal
3+ Hyperactive without clonus
4+ Hyperactive with clonus
Knee:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Ankle:
Right: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
Left: [ ] 0 [ ] 1+ [X] 2+ [ ] 3+ [ ] 4+
 

 

6. Sensory exam
---------------
Provide results for sensation to light touch (dermatome) testing:
Upper anterior thigh (L2):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Thigh/knee (L3/4):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Lower leg/ankle (L4/L5/S1):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
Foot/toes (L5):
Right: [X] Normal [ ] Decreased [ ] Absent
Left: [X] Normal [ ] Decreased [ ] Absent
7. Straight leg raising test
----------------------------
Provide straight leg raising test results:
Right: [X] Negative [ ] Positive [ ] Unable to perform
 
Left: [X] Negative [ ] Positive [ ] Unable to perform
 

 

8. Radiculopathy
----------------
Does the Veteran have radicular pain or any other signs or symptoms due to
radiculopathy?
[ ] Yes [X] No
 

 

9. Ankylosis
------------
Is there ankylosis of the spine? [ ] Yes [X] No
 

 

10. Other neurologic abnormalities
----------------------------------
Does the Veteran have any other neurologic abnormalities or findings related
to a thoracolumbar spine (back) condition (such as bowel or bladder
problems/pathologic reflexes)?
[ ] Yes [X] No
 

 

11. Intervertebral disc syndrome (IVDS) and episodes requiring bed rest
-----------------------------------------------------------------------
a. Does the Veteran have IVDS of the thoracolumbar spine?
[ ] Yes [X] No
 

 

12. Assistive devices
---------------------
a. Does the Veteran use any assistive device(s) as a normal mode of
locomotion, although occasional locomotion by other methods may be
possible?
[ ] Yes [X] No
 

 

13. Remaining effective function of the extremities
---------------------------------------------------
Due to a thoracolumbar spine (back) condition, is there functional
impairment
of an extremity such that no effective function remains other than that
which
would be equally well served by an amputation with prosthesis? (Functions of
the upper extremity include grasping, manipulation, etc.; functions of the
lower extremity include balance and propulsion, etc.)
[X] No
 

 

14. Other pertinent physical findings, complications, conditions, signs,
symptoms and scars
-----------------------------------------------------------------------
a. Does the Veteran have any other pertinent physical findings,
complications, conditions, signs or symptoms related to any conditions
listed in the Diagnosis Section above?
[ ] Yes [X] No
 
b. Does the Veteran have any scars (surgical or otherwise) related to any
conditions or to the treatment of any conditions listed in the Diagnosis
Section above?
[ ] Yes [X] No
c. Comments, if any:
No response provided
 

 

15. Diagnostic testing
----------------------
a. Have imaging studies of the thoracolumbar spine been performed and are
the
results available?
[X] Yes [ ] No
If yes, is arthritis documented?
[X] Yes [ ] No
b. Does the Veteran have a thoracic vertebral fracture with loss of 50
percent or more of height?
[ ] Yes [X] No
c. Are there any other significant diagnostic test findings and/or results?
[X] Yes [ ] No
If yes, provide type of test or procedure, date and results (brief
summary):
2/25/2016 X-rays L-Spine - Very minor degenerative spondylosis.
 

 

16. Functional impact
---------------------
Does the Veteran's thoracolumbar spine (back) condition impact on his or
herability to work?
[ ] Yes [X] No
 

 

17. Remarks, if any:
--------------------
This Veteran describes a clinical picture of occasional lumbar muscle
spasm/strain, with no objective evidence that is had its onset in service.
However, his X-rays show diffuse degenerative spondylosis which could be
triggering the spasms. The radiologic abnormalities may be nothing more than
simple wear and tear of the spine, but the likelihood is that the process
began more than 12 months ago, i.e. began while he was in service.
THerefore,
it is at least as likely as not that his LBP had its onset

 

while in service.

Edited April 11, 2016 by bruinboy

[bruinboy]

looks like 10 percent service connect because my forward flexion is less than 85? Waht do you guys think?