Citation Nr: 0001225 Decision Date: 01/14/00 Archive Date: 01/27/00 DOCKET NO. 94-35 692 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUE Entitlement to an increased rating for lumbosacral strain, currently evaluated as 20 percent disabling. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant INTRODUCTION The veteran served on active duty from February 1981 to August 1987. This case comes before the Board of Veterans' Appeals (Board) from a rating decision rendered in July 1992 by the Atlanta, Georgia, Regional Office (RO) of the Department of Veterans Affairs (VA). FINDINGS OF FACT 1. All evidence necessary for an equitable disposition of the veteran's claim has been developed. 2. Lumbosacral strain is manifested primarily by "significantly reduced" range of motion and by complaints of increased pain. It has been found to be moderate in severity. CONCLUSION OF LAW The criteria for an increased rating for lumbosacral strain are not met. 38 U.S.C.A. § 1155 (West 1991); 38 C.F.R. Part 4, §§ 4.40, 4.45, 4.71a, Diagnostic Code 5295 (1999). REASONS AND BASES FOR FINDINGS AND CONCLUSION Initially, the Board finds that the veteran's claim for an increased rating for service-connected lumbosacral strain is well grounded within the meaning of 38 U.S.C.A. § 5107(a) (West 1991); that is, he has presented a claim that is plausible. See Proscelle v. Derwinski, 2 Vet. App. 629 (1992). He has not alleged that any records of probative value that may be obtained, and which have not already been sought or associated with his claims folder, are available. The Board accordingly finds that the duty to assist the veteran, as required under 38 U.S.C.A. § 5107(a) (West 1991), has been satisfied. Service connection for lumbosacral strain was granted by the Atlanta RO in March 1989 following review of evidence that included the veteran's service medical records and the report of a March 1988 VA examination. The RO found that back problems were shown in service, and that lumbar strain was noted on VA examination. A 10 percent rating was assigned. This rating was increased to 20 percent in May 1991 by the Board; the RO thereafter assigned an effective date of August 6, 1987, the day following the veteran's separation from service, for this 20 percent rating. The veteran currently contends that his lumbosacral strain is more severe than as reflected by the 20 percent rating assigned therefor, and that an increased evaluation is warranted. After a review of the record, however, the Board finds that his contentions are not supported by the evidence, and that his claim fails. The severity of a service-connected disability is ascertained by the application of diagnostic criteria set forth in VA's Schedule for Rating Disabilities, 38 C.F.R. Part 4 (Schedule). Under the criteria set forth in Diagnostic Code 5295 of the Schedule, the 20 percent rating currently in effect for lumbosacral strain contemplates muscle spasm on extreme forward bending and loss of lateral spine motion in the standing position. A rating greater than 20 percent (that is, a 40 percent rating) would be appropriate under Diagnostic Code 5295 for lumbosacral strain that is severe in nature, as would be manifested by listing of the whole spine to the opposite side, positive Goldthwaite's sign, marked limitation of forward bending in the standing position, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space, or some of these symptoms accompanied by abnormal mobility on forced motion. The criteria for an increased rating are not satisfied. The report of the most recent clinical evaluation of the veteran's lumbosacral spine, undertaken by VA in January 1998, shows that he complained of mid-back pain that was aggravated by activity. It also shows that he evidenced "some" back pain when sitting down or getting up, and that he exhibited what was described by the examiner as "significant loss of motion in the back"; flexion was possible to only 25 degrees, as compared to full or normal flexion of 95 degrees. However, the veteran did not indicate that his mid-back pain had, according to the examination report, any "radiating features," and there was no loss of sensation in the lower extremities. There was a normal lumbar lordosis, and no paravertebral guarding. The report indicates a clinical diagnosis of moderate residuals in the back. The report of a radiographic study of the lumbar spine, conducted in January 1998 pursuant to that examination, shows that the spine and sacroiliac joints were normal, and indicates a diagnosis of normal lumbar spine. In brief, while the clinical evidence indicates the presence of what has been identified on examination as moderate impairment, it does not demonstrate that the veteran's lumbosacral strain is of such severity as to warrant an increased rating. Although there was significant (or "marked") limitation of forward bending, the record does not show that any of the other criteria for an increased rating are manifested; that is, the evidence does not show that there is, at this time, listing of the whole spine to the opposite side, positive Goldthwaite's sign, loss of lateral motion with osteoarthritic changes, or narrowing or irregularity of joint space. The Board notes that the Court has held that, when ascertaining the severity of a service-connected orthopedic disability, VA is required to consider the level of resultant functional impairment; see 38 C.F.R. §§ 4.40 and 4.45 (1999). See also DeLuca v. Brown, 8 Vet. App. 202 (1995). The report of the January 1998 examination indicates that the veteran complained of persistent pain, evidenced pain when sitting down and standing up, exhibited impaired lumbosacral movement, and became fatigued because of pain, he had no abnormality in his gait, was able to dress and undress without difficulty, and "did not appear to be in pain." It must also be noted that the provisions of 38 C.F.R. § 4.40 stipulate that a claim of functional impairment must be supported by adequate pathology. In that regard, the Board must emphasize that the examination report, in addition to indicating that the veteran's gait was normal, and that he dressed and undressed without any difficulty, also shows that the musculoskeletal system was normal, in that there was a normal lumbar lordosis, no paravertebral guarding, and a normal lumbosacral spine radiographically. While there appears to be some degree of functional impairment, the Board nonetheless finds that such impairment is adequately compensated by the current 20 percent rating, as reflected by the examiner's finding that the veteran's back residuals are moderate. In brief, the Board concludes that the preponderance of the evidence is against the veteran's claim for an increased rating for service-connected lumbosacral strain. The claim, accordingly, fails. ORDER An increased rating for lumbosacral strain is denied. M. S. SIEGEL Acting Member, Board of Veterans' Appeals