Citation Nr: 1753629 Decision Date: 11/22/17 Archive Date: 12/01/17 DOCKET NO. 11-27 468 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a low back disorder, to include as secondary to service-connected knee and left hip disabilities. REPRESENTATION Appellant represented by: The American Legion WITNESSES AT HEARING ON APPEAL The Veteran and her husband ATTORNEY FOR THE BOARD B. Rideout-Davidson, Counsel INTRODUCTION The Veteran had a period of active duty for training from November 1983 to July 1984 and served on active duty from June 1985 to August 1985 and from November 1986 to February 1988. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2010 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. The Veteran testified at a hearing before the undersigned Veterans Law Judge at the RO in May 2015. A transcript of that hearing has been associated with the claims file. In September 2015 and August 2016, the Board remanded the case for further development. That development was completed. and the case has since been returned to the Board for appellate review. This appeal was processed using the Veterans Benefits Management System (VBMS) paperless claims processing system. Accordingly, any future consideration of this Veteran's case should take into consideration the existence of this electronic record. FINDING OF FACT The Veteran's current low back disorder is related to her service-connected knee disabilities. CONCLUSION OF LAW The low back disorder is proximately due to, the result of, or aggravated by a service-connected disability. 38 U.S.C. § 1110 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION Given the favorable disposition to grant the Veteran's claim for service connection, the Board finds that all notification and development actions needed to fairly adjudicate this aspect of the appeal have been accomplished. There is no prejudice to the Veteran. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted on a secondary basis for disability which is proximately due to or the result of service-connected disease or injury, or for additional disability resulting from the aggravation of a nonservice-connected disability by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); 38 C.F.R. § 3.310. In this case, the Veteran's service treatment records do not document any complaints, treatment, or diagnosis of a back disorder. In August 2003, the Veteran was afforded a VA examination for her left knee disorder, and an awkward gait was noted. At a VA medical appointment in March 2006, the Veteran's medical provider stated that he suspected that the Veteran's low back pain was due to a leg length discrepancy following her knee replacement surgery. In April 2006, the Veteran was diagnosed with a lumbar strain and was fitted for heel lifts. At an appointment in August 2006, the Veteran's provider subsequently noted that her low back pain had improved with use of the shoe lifts. In December 2009, a VA medical opinion was obtained in connection with the Veteran's low back claim. The VA examiner reviewed the claims file and opined that there was no evidence in the medical literature to support a causal relationship or material aggravation of one joint injury resulting in an injury to the spine. Thus, absent any medical evidence in the literature and a lack of consensus among medical experts, the examiner found that it was unlikely that the Veteran's spine disorder was due to her left knee disorder. The Veteran's VA medical records show that she has reported that her chronic knee pain has exacerbated her back pain at various times throughout the appeal period, to include at appointments in November 2010 and December 2010. During these appointments, the Veteran's statements were generally recorded as medical history. However, at an appointment in December 2010, the medical assessment for the visit was also reported as chronic knee pain that was making the Veteran's back pain worse. X-rays from December 2010 revealed a narrowing of disc space and the possibility of a disc bulge. VA medical records then show a car accident, with neck, back and shoulder pain/injury in March 2011. At a VA medical appointment in May 2013, the provider appeared to be reviewing knee x-rays in connection with the Veteran's reports of low back pain, although no etiology opinion was directly expressed. The Veteran also submitted several medical opinions from her private doctor, Dr. S.L. (initials used to protect privacy), including statements dated in May 2015, June 2015, and September 2015. In these statements, Dr. S.L. opined that, over time, the Veteran began compensating for her deteriorating left knee, which then compromised her low back. She opined that the Veteran's low back disorder was a direct result of the left knee disability. An additional VA medical opinion was obtained in December 2015. At that time, the VA examiner opined that the standard of medical care did not support a direct causal relationship in which knee pain resulted in back pain. The examiner also noted that there was a January 2010 VA medical record noting back pain following sweeping and a March 2011 notation regarding a lumbar strain following a motor vehicle accident, which were the more likely causes of the back disorder. However, the December 2015 VA examiner did not address the Veteran's altered gait. Following the most recent remand, another VA medical opinion was obtained in October 2016. After a review of the records, the examiner opined that the standard of medical care did not support a direct causal relationship in which left knee, right knee, or hip pain, to include an altered gait resulting from these disabilities, would cause back pain. The examiner again cited to the January 2010 sweeping injury and the March 2011 motor vehicle accident as more likely causes of the back disorder. The Board finds that the medical evidence cited above permits application of the reasonable doubt doctrine. The VA medical opinions did not find that the Veteran's low back disorder was caused by her service-connected knee disorders; however, Dr. S.L. provided a contrasting medical opinion with rationale, and the Veteran's VA medical records contain statements linking the low back disorder to the knee disorders. In fact, medical records associated with the file following the August 2016 remand show that the Veteran's VA medical doctors specifically linked the low back pain to a leg length discrepancy caused by her knee disorder. The Board finds that the opinions of Dr. S.L., the VA healthcare providers, and the VA examiners place the evidence of record at least in equipoise as to whether the Veteran's service-connected knee disabilities caused or aggravated the current low back disorder. Resolving all reasonable doubt in the Veteran's favor, the Board finds that the criteria for service connection for a low back disorder are met. See 38 U.S.C.A. § 5107(b); 38 C.F.R. §§ 3.102. 3.310. ORDER Service connection for a low back disorder is granted. ____________________________________________ J.W. ZISSIMOS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs