Citation Nr: 18140314 Decision Date: 10/02/18 Archive Date: 10/02/18 DOCKET NO. 15-05 913 DATE: October 2, 2018 ORDER Entitlement to service connection for a right shoulder disability as secondary to service-connected right total knee arthroplasty is granted. Entitlement to service connection for right hip disability as secondary to service-connected right total knee arthroplasty is granted. REMANDED Entitlement to service connection for a lumbar spine disability, to include as secondary to service-connected disease or injury, is remanded. FINDINGS OF FACT 1. A right shoulder disability is attributable to the Veteran’s service-connected right total knee arthroplasty. 2. A right hip disability is attributable to the Veteran’s service-connected right total knee arthroplasty. CONCLUSIONS OF LAW 1. A right shoulder disability is proximately caused by service-connected right total knee arthroplasty. 38 C.F.R. §§ 3.102, 3.310. 2. A right hip disability is caused by service-connected right total knee arthroplasty. 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1975 to June 1978. A hearing in this matter was held in Salt Lake City, Utah in May 2018. The transcript is of record. Service Connection Generally, to establish service connection a Veteran must show: “(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 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 is also warranted for disability which is proximately due to or the result of a service-connected disease or injury. When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Any increase in severity of a non-service connected disease or injury that is proximately due to or the result of a service connected disease or injury, and not due to the natural progress of the nonservice connected disease or injury will be service connected. However, VA will not concede that a non-service-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). 1. Entitlement to service connection for a right shoulder disability, to include as secondary to right knee The Veteran seeks service connection for a right shoulder disability. At his May 2018 hearing, as well as in numerous written statements, the Veteran testified that he suffered a fall in January 2012 as a result of medications prescribed for his service-connected right knee. The Veteran asserts that his right shoulder disability was caused by the fall. Medical records consistently attribute the Veteran’s fall to buckling of his right knee. A September 2018 VA examination provided an opinion regarding whether the Veteran’s fall was caused by the medication for his right knee. The examiner opined that it was less likely than not that the medication led to the fall, as dexamethasone is not known to cause weakness or dizziness as reported by the Veteran. Further, contemporaneous medical records attribute the fall to buckling of the right knee. No opinion was rendered as to whether that buckling was due to the service-connected disability. Buckling of the right knee is consistent with the Veteran’s service-connected disability. Therefore, the Board finds that the Veteran’s fall was due to his service-connected right knee. An MRI of the right shoulder from July 2010 showed moderate osteoarthritic changes. The humeral head was normally located, and the biceps tendon was normal in morphology and signal intensity. An MRI from March 2012, two months after the Veteran’s fall, showed acromioclavicular osteoarthritis, biceps tendinopathy, glenolabral instability, subluxation of the biceps tendon within the intraarticular segment, and splitting of the subscapularis tendon. The Veteran received VA examinations in August 2013 and June 2018. The August 2013 examiner noted diagnoses of right shoulder rotator cuff injury and bilateral degenerative arthritis. The examiner stated that there were no other imaging results or findings. The examiner opined that the Veteran’s right shoulder disabilities were less likely than not related to his knee condition because the Veteran had “significant shoulder pathology” before the fall, and his disabilities were a normal progression of those conditions present prior to the fall. The June 2018 VA examiner noted diagnoses of right glenohumeral joint osteoarthritis and right shoulder impingement. The examiner opined that the Veteran’s disabilities were at least as likely as not due to his right total knee arthroplasty. To support his conclusion, the examiner noted that the Veteran’s March 2012 MRI results, specifically the biceps tendon and rotator cuff injuries and glenolabral instability are more consistent with trauma than with progression of his preexisting arthritis. The Board finds that the June 2018 VA opinion has greater probative weight. The August 2013 opinion provided only a vague assertion of “significant shoulder pathology” prior to the fall and did not address either the July 2010 or March 2012 MRI findings in detail. Meanwhile, the June 2018 examiner addressed the March 2012 findings and explained their relation to the Veteran’s fall as well as to his right shoulder condition prior to the fall. Therefore, the Board finds that the Veteran’s right glenohumeral joint osteoarthritis, tendinopathy, instability and right shoulder impingement are proximately due to the Veteran’s service-connected right knee. Medical records   corroborate the Veteran’s account of the fall and that it was due to buckling of his right knee. Further, the most probative medical opinion indicates that his current right shoulder disabilities are due to the fall or were aggravated by the fall. We find the opinion regarding natural progress to be unconvincing. 2. Entitlement to service connection for right hip disability to include as secondary to right knee The Veteran seeks service connection for a right hip disability. He asserts it is due to his May 2013 right total knee arthroplasty surgery. The Veteran received VA examinations for his right hip in October 2014, January 2015, May 2016, and June 2018. The October 2014 examiner noted diagnoses of bilateral hip arthritis and a right hip labrum tear. The examiner opined that the Veteran’s arthritis was not likely related to the Veteran’s right knee, but that the labrum tear was as likely as not related to positioning during surgery on the right knee. In explanation, the examiner stated that the total knee arthroplasty requires repeated repositioning of the lower extremity which could cause moderate stress on the hip, leading to a labrum tear. The January 2015 examiner noted that the Veteran had a labral tear of the right hip and “snapping hip syndrome.” The examiner opined that both conditions were less likely than not related to the Veteran’s right knee replacement surgery. The rationale provided was that there was no record of any unusual complications during his knee surgery, and medical literature does not document a connection between labral tears of the hip and total knee replacement surgery, and that the MRI described the mild labral tear as degenerative, not traumatic. Further, snapping hip syndrome is most often the result of chronic tightness in the muscles and tendons surrounding the hips, but can also be caused by labral tears. On a general medical examination in May 2016, the examiner noted a diagnosis of gluteus medius tear/chondrolabral junction tear secondary to total knee arthroplasty. The examiner stated that although the Veteran was originally thought to have a labral tear, arthroscopic right hip surgery in May 2015 showed a tear at the chondrolabral junction. Another hip examination was conducted in June 2018. The examiner noted diagnoses of gluteus medius tear, acetabular labrum tear, snapping hip syndrome, and gluteus minimus tendinitis, and stated that all disabilities were at least as likely as not due to the right total knee arthroplasty. To support this opinion, the examiner noted that there is no documentation of the tears prior to his knee surgery in 2013, and that the manipulation of the lower extremity required for the right knee arthroplasty could conceivably result in such injuries. The Board finds that the most probative evidence weighs in favor of a finding that the Veteran’s gluteus medius tear, acetabular labrum tear, snapping hip syndrome, and gluteus minimus tendinitis are secondary to his service-connected right total knee arthroplasty. The Veteran had no documented complaints of right hip pain prior to the surgery, and his condition worsened immediately after the surgery. Three of four VA examinations relate the right hip to the surgery, asserting that the manipulation required could cause a tear of the right hip. The only medical opinion that asserted otherwise was offered prior to the 2015 hip surgery revealing that the tear was in the chondrolabral junction, and therefore relied on incomplete facts. Both opinions offered subsequent to that surgery attribute the right hip disabilities to the total right knee arthroplasty. REMANDED Entitlement to service connection for a lumbar spine disability is remanded.   REASONS FOR REMAND 1. Entitlement to service connection for a lumbar spine disability is remanded. The Board cannot make a fully-informed decision on the issue of service connection for a lumbar spine disability because no VA examiner has opined whether the Veteran’s current lumbar spine degenerative disc disease (DDD) and degenerative joint disease (DJD) are directly related to his service, to include his service as a paratrooper. In his June 2018 VA examination, the examiner raised the possibility that the Veteran’s DDD and DJD are attributable, at least in part, to the impact from the jumps he completed as a paratrooper. However, no direct opinion was provided as to whether his DDD and DJD are at least as likely as not due to his active service, and several other potential causes were also listed. The matter is REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any lumbar spine disability. The examiner must opine whether it is at least as likely as not related to a service including jumps completed as a paratrooper. The examiner should also opine whether it is at least as likely as not (1) proximately due to any service-connected disability, or (2) aggravated by any service-connected disease or injury.   2. Thereafter, readjudicate the issues on appeal. If the determination remains unfavorable to the Veteran, he and his representative should be furnished a supplemental statement of the case. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A. Creegan, Associate Counsel