Citation Nr: 18140986
Decision Date: 10/09/18	Archive Date: 10/09/18

DOCKET NO. 09-19 869
DATE:	October 9, 2018
ORDER
Entitlement to service connection for left knee osteoarthritis is granted. 
Entitlement to service connection for low back osteoarthritis is granted. 
REMANDED
Entitlement to a total disability based upon individual unemployability (TDIU) is remanded. 
FINDING OF FACT
The Veteran’s service-connected right knee disorder caused his left knee osteoarthritis and low back osteoarthritis.
CONCLUSION OF LAW
The criteria for service connection for left knee osteoarthritis and low back osteoarthritis, as secondary to a service-connected right knee disorder, have been met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.
REASONS AND BASES FOR FINDINGS AND CONCLUSION
The Veteran had active service from January 1967 to May 1967.
This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2007 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA).
Service Connection
Secondary Service Connection
Service connection on a secondary basis is merited if there is (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical evidence establishing a nexus (i.e., link) between the service-connected disability and the current disability.  Wallin v. West, 11 Vet. App. 509, 512 (1998).
Merits – Left Knee and Low Back
Medical providers have repeatedly diagnosed the Veteran with left knee osteoarthritis and low back osteoarthritis during the pendency of the appeal.  These diagnoses satisfy the first prong of both secondary service connection claims.
VA has service connected the Veteran’s right knee disorder, most recently rating it as 30 percent disabling since December 2017 after he had his knee replaced.  This satisfies the second prong of both secondary service connection claims.
The appeals turn on the third prong of both secondary service connection claims – medical nexus.  The Veteran contends that his right knee disorder caused him to develop left knee osteoarthritis and low back osteoarthritis because of his altered gait.  VA examined him for compensation purposes in April 2009 and April 2017.  The VA examiners diverged on the question of whether an altered gait could cause osteoarthritis.  The 2009 examiner stated that "change in gait or alteration of posture is not identified as a risk factor for the development of osteoarthritis."  The 2017 examiner, while of similar mindset, acknowledged that in some situations, e.g., "major muscle or nerve damage" or the "shortening of the injured lower extremity," where there is "an obvious lurching type gait (a significant limp)" osteoarthritis can result.  Using this framework, a consistent picture of the Veteran's disability appears.  
VA and private treatment records trace the deterioration of the Veteran’s right knee over time and the development of an antalgic gait.  First, a September 2004 VA compensation examiner observed, when the Veteran claimed service connection for his right knee disorder, that "the veteran walked with a limp and it appeared that he was shifting his weight [from the right leg] to the left leg."  Second, an April 2008 private record from Dr. S.M. notes the Veteran "has crepitus throughout the range of motion of his right knee, positive patella grind test, mild effusion," and a "start up limp when he gets off the examination table."  Third, a July 2015 private treatment record from Dr. R.S. shows an antalgic gait with reduced range of motion with pain.
Because of the divergent opinions regarding altered gait and its relationship to osteoarthritis, the undersigned will afford the Veteran the benefit of the doubt on this question and will assume that it does.  Given the foregoing paragraph, the increasing pain in the Veteran’s right knee severely limited his mobility and consistently altered his gait.  Accordingly, the undersigned finds it is at least as likely as not that the Veteran’s right knee disorder, and by extension his altered gait, at least as likely as not caused the development of the left knee osteoarthritis and low back osteoarthritis.
REASONS FOR REMAND
The grants of service connection are intertwined with the TDIU issue.  The Board may not review the TDIU issue until VA implements the grants above.
The matter is REMANDED for the following action:
Implement the grants of service connection above.  Determine what, if any, additional development is needed regarding the TDIU issue and then readjudicate it.

 
KELLI A. KORDICH
Veterans Law Judge
Board of Veterans’ Appeals
ATTORNEY FOR THE BOARD	M. Sopko, Counsel