BVA9505207 DOCKET NO. 91-55 284 ) DATE ) ) On appeal from the decision of the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUES 1. Entitlement to service connection for a disability manifested by chest pains. 2. Entitlement to service connection for a low back disability. ATTORNEY FOR THE BOARD Joseph Horrigan, Counsel INTRODUCTION The veteran served on active duty from August 1980 to August 1989. This matter came before the Board of Veterans' Appeals (Board) from a November 1989 rating action of the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The case was remanded by the Board in March 1991, November 1992, and December 1993. It is before the Board for further appellate consideration at this time. For reasons made evident below, the issue of entitlement to service connection for a disability manifested by chest pains is discussed in the REMAND section of this decision. CONTENTIONS OF APPELLANT ON APPEAL The veteran contends that she developed a chronic low back disorder as a result of injuries sustained during service. DECISION OF THE BOARD In accordance with the provisions of 38 U.S.C.A. § 7104 (West 1991), following review and consideration of all the evidence and material of record in the veteran's claims folder, and for the following reasons and bases, it is the decision of the Board that the evidence favors the veteran's claim for service connection for mechanical low back pain. FINDING OF FACT The veteran developed chronic low back disability while on active duty. CONCLUSION OF LAW The veteran has mechanical low back pain which was incurred in service. 38 U.S.C.A. § 1131, 5107, 7104 (West 1991); 38 C.F.R. § 3.303(b) (1994). REASONS AND BASES FOR FINDING AND CONCLUSION The Board finds that the veteran's claim for service connection for low back disability is "well grounded" within the meaning of 38 U.S.C.A. § 5107(a). That is, the veteran's claim is plausible. On examination prior to entrance onto active duty, no abnormality of the spine was found and, in the report of medical history, the veteran answered no in regard to back pain. The service medical records show that the veteran was seen on several occasions in November 1981 with complaints of dull, tight aching in the lower back with no radiation into the legs and tenderness in the thoracic spine. A whiplash injury two years earlier was noted. An X-ray was normal. The impressions were myalgia and paraspinous muscle strain/sprain. In early December 1981, the veteran was described as asymptomatic. The veteran was again seen in November 1983 for bilateral back pain which was worse on bending. There was no radiculopathy or trauma reported. A previous episode was reported which resolved spontaneously. The assessment was mechanical low back pain. In July 1984, she was seen with complaints of low back pain of one day's duration. The assessments included questionable muscle spasm. In March 1987, the veteran was seen with complaints which included back pain, headaches and shoulder pain. Findings included mid thoracic muscle spasms. The assessment included headache/back pain. Later in March 1987, the veteran fell and sustained a sacral and coccyx contusion. An X-ray was negative, with no fracture of the coccyx seen. A whole body bone scan of March 1988 showed no focal abnormalities in the thoracic spine. The veteran was seen in October 1988 with complaints of back, leg, and hip pain. Low back pain radiating into the left leg and foot with occasional numbness was reported. The assessment was low back pain with radiculopathy L5-S1. When seen later that month with complaints of left hip pain, the assessment was L5-S1 disc protrusion. The veteran was placed on physical profile with no lifting more than 5 pounds. In March 1989, it was noted that the veteran was seeking a waiver from moving heavy objects and had a history of a slipped disc. She was seen in July 1989, with complaints of back pain radiating to the "spine." The assessment was rhomboid muscle strain. On examination prior to separation from service, the spine was evaluated as normal. In the report of medical history, the veteran answered in the negative regarding recurrent back pain. On VA examination in October 1989, the veteran complained of a lower back problem which prevented her from lifting anything heavy. No limitation of motion , swelling or atrophy in any joint was reported. No back disability was diagnosed. On VA examination in October 1990, the veteran again had complaints regarding the lower back with an inability to lift or bend at times. Evaluation revealed some tenderness over the lumbar sacral spine. No gross abnormalities were noted on neurological examination. The diagnoses included history of "slipped disc lower back" moderately symptomatic. During a VA neurological examination of May 1993, the veteran gave a history of developing pain in the low back after performing heavy lifting during service. The pain occasionally would radiate into the left leg and was exacerbated by heavy lifting, bending, prolonged sitting, or standing. She had been told that she may have a slipped disc. Evaluation revealed 5/5 motor strength without evidence of drift or atrophy. Reflexes were 1+ and symmetric and plantar reflexes were flexor. No cortical release signs were noted. There was no dysmetria or dystaxia in the extremities and gait, including tandem, was normal. Sensory examination was intact and the Romberg was negative. An X-ray of the lumbar spine showed good alignment with a transitional type 5th lumbar vertebra. The height of the vertebral bodies and disc spaces were well maintained. There was a slight exaggeration of the lumbosacral angle with no evidence of a spondylolisthesis. It was the examiners impression that the veteran had a chronic low back syndrome with mild evidence of an L5 radiculopathy characterized by some mild mechanical signs on the left. No focal motor, sensory or reflex abnormalities were delineated. In late May 1993, the veteran was treated by the VA for complaints of pain in the low back, and right leg. A history of a slipped disc 7 years earlier was reported. On evaluation, the veteran was noted to limp on the right leg. There was tenderness to palpation in the low back with full range of motion. Straight leg raising on the right was positive for pain in the low back and right thigh. The assessment was questionable muscular pain, questionable herniated disc. On VA orthopedic examination in September 1994, the veteran gave a history of lifting injuries with severe pain in the low back while on active duty. She was treated with physical therapy, rest, and exercises with some improvement. In 1987, she fell and sustained a bruised coccyx which remained painful for many months. She reported that she could not stand or sit for prolonged periods without low back pain located in the lumbosacral area to the right of the midline and radiation into the legs or paresthesia of the feet. She had been told she had slight disc protrusion. On evaluation, she had 70 degrees of forward flexion in the lumbosacral spine with 30 degrees of hyperextension, 35 degrees of lateral bending bilaterally, and 30 degrees of bilateral rotation. Straight leg raising was possible through a full range bilaterally and deep tendon reflexes were equal and active throughout. Circumferences at mid calf and mid thigh were equal and toe and heel walking was accomplished without difficulty. X-rays, the most recent of which was performed in September 1994, were reviewed and showed no evidence of fracture, dislocation or subluxation. There was a slight decrease in disc space between L5 and S1 but no degenerative changes or osteophytes were noted. It was the examiner's opinion that the veteran gave a history of multiple back injuries and apparently mechanical low back pain. At the time of the examination, there was no evidence of radiculopathy, localized weakness or reflex changes. The above evidence demonstrates that the veteran had considerable treatment for low back complaints during service. Some of the episodes involved complaints of pain which were largely confined to the low back area while on other occasions complaints and findings were reported that indicated radiculopathy in the area of L5-S1. At least one inservice traumatic injury to the area is documented and the possibility of disc pathology involving L5-S1 was indicated. The same pattern of low back complaints and symptomatology has persisted since discharge from service with the veteran complaining of low back pain and occasional complaints indicative of radiculopathy at the L5 disc and some abnormalities at this level have been reported on X-ray. Although a precise diagnosis of the veteran's low back disability has not been rendered, the evidence indicates that the veteran probably incurred chronic low back disability during active duty for which service connection is warranted. Accordingly, service connection is established for the diagnosis offered at the most recent orthopedic rating examination, mechanical low back pain. ORDER Service connection for mechanical low back pain is granted. REMAND During service, the veteran was seen on several occasions for complaints of chest wall pain but evaluations revealed no more than muscle strain. An electrocardiogram performed during service showed an incomplete right bundle branch block. Since discharge from service the veteran has continued to complain of chest pains and electrocardiograms have repeatedly demonstrated a right bundle branch block. An electrocardiogram of December 1991 also was reported to show findings indicative of right atrial hypertrophy and an electrocardiogram of May 1993 showed T-wave abnormalities possibly indicative of inferior ischemia. A study of November 1993 showed ventricular arrhythmias, occasional unifocal premature ventricular contractions, and supraventricular arrhythmias with paroxysmal atrial fibrillation. The most recent electrocardiogram was reported to show only a right bundle branch block but a chest X-ray of September 1994 showed what appeared to be a moderate increase in the heart shadow. Recent treatment records show that the veteran's complaints of chest wall pain are of two types; one of musculoskeletal origin and one possibly cardiac in origin. Possible mitral valve prolapse has also been reported. In its remand of December 1993, the Board instructed the RO to afford the veteran an examination by a cardiologist to ascertain the nature and etiology of any organic heart disease. It also instructed the RO to obtain all clinical records documenting the veteran's treatment since May 30, 1991. Apparently, the requested cardiology examination was not performed and the RO only requested records from the VA Medical Center in Miami since May 30, 1993. It also appears that relevant records from a VA outpatient clinic and a private hospital may be available, but are not currently in the claims folder. In addition, while the veteran was afforded an orthopedic examination in September 1994, the examiner did not address the veteran's chest wall complaints as requested in the December 1993 remand. In view of the foregoing, and given the duty to assist the veteran in the development of his claim under the provisions of 38 U.S.C.A. 5107(a) (West 1991), this case is remanded to the RO for the following development: 1. The RO should obtain all clinical records reflecting treatment from May 30, 1991, to May 30, 1993, for chest pains and/or cardiovascular symptoms at the VA Medical Center in Miami, Florida, as well as the report of the Doppler echocardiogram performed at the Oakland Park VA Outpatient clinic on April 27, 1993. All records obtained should be associated with the claims folder. 2. After obtaining any necessary authorization, the RO should obtain a copy of the report of the angiogram performed at the North Broward Medical Center in September 1989 as well as copies of all clinical records documenting the veteran's treatment for chest pains in the Emergency Room of that facility in May 1990. All records obtained should be associated with the claims folder. 3. Then, the veteran should be afforded VA examination by a cardiologist to ascertain the nature and etiology of any organic heart disease. All necessary special studies should be performed and all pertinent clinical findings reported in detail. The claims folder must be made available to the examiner prior to the evaluation so that the pertinent clinical records can be reviewed in detail. The examiner should express her/his opinion, with complete rationale regarding the medical probability that any organic heart disease found is related to the veteran's inservice symptomatology. 4. Then, the veteran should be afforded VA examination by an orthopedist to ascertain the nature and etiology of any chest wall disability. All necessary special studies should be performed and all pertinent clinical findings reported in detail. The claims folder must be made available to the examiner prior to the evaluation so that the pertinent clinical records can be reviewed in detail. The examiner should express her/his opinion, with complete rationale regarding the medical probability that any musculoskeletal disability involving the chest is related to the veteran's inservice symptomatology. 5. After completion of the above, and any further development deemed appropriate, the RO should review the veteran's claim of entitlement to service connection for disability manifested by chest pains. If the benefit sought is not granted, the veteran and her representative should be provided a supplemental statement of the case and afforded a reasonable opportunity to respond. Thereafter, the case should be returned to the Board for further consideration, if appropriate. By this remand, the Board intimates no opinion as to the outcome warranted in this case. No action is required of the veteran until she is so informed by the RO. BARBARA B. COPELAND Member, Board of Veterans' Appeals The Board of Veterans' Appeals Administrative Procedures Improvement Act, Pub. L. No. 103-271, § 6, 108 Stat. 740, ___ (1994), permits a proceeding instituted before the Board to be assigned to an individual member of the Board for a determination. This proceeding has been assigned to an individual member of the Board. Under 38 U.S.C.A. § 7252 (West 1991), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Veterans Appeals. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (1994).