Citation Nr: 18142997 Decision Date: 10/18/18 Archive Date: 10/17/18 DOCKET NO. 16-15 483 DATE: October 18, 2018 ORDER Entitlement to service connection for low back disability to include, as secondary to the service connected left knee and ankle sprain/strain is granted. REMANDED Entitlement to service connection for right hip disability to include, as secondary to the service connected left knee and ankle sprain/strain is remanded. Entitlement to service connection for right leg shortening to include, as secondary to the service connected left knee and ankle sprain/strain is remanded. FINDING OF FACT The Veteran’s currently diagnosed L5-S1 disc herniation and degenerative disc disease aggravation is attributable to his service connected left knee and ankle sprain/strain disability. CONCLUSION OF LAW The criteria for entitlement to service connection for low back disability as secondary to the service connected left knee and ankle sprain/strain has been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310(b) (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran’s is a Gulf War Era Veteran who served on active duty in the United States Marine Corps from June 1996 to June 2000. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). Duty to Notify and Assist Neither the Veteran nor his representative identified any other shortcomings in fulfilling VA’s duty to notify and assist. Scott v. McDonald, 789 F. 3d 1375 (Fed. Cir. 2015). The Board thus finds that further action is unnecessary under 38 U.S.C. § 5103A and 38 C.F.R. § 3.159. The Veteran will not be prejudiced because of the Board’s adjudication of the claims below. 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 incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315–16 (Fed. Cir. 2009). In a December 2003 MRI Lumbar Spine Report mild degenerative disk disease at L4-L5 and L5-S1 with desiccation and loss of T2 disk signal was reported. Disk bulging at L4-L5 and moderate sized central disk herniation was also reported. Although, the Veteran has a current low back disability, he has provided only lay statements that he injured his back on March 28, 1999 and on October 28, 1999 while on active duty. He reported that he performed extended forced marches over long distances carrying heavy equipment and reported an unspecified injury during an initiation ceremony at sea. The Veteran’s military medical service records do not show evidence of treatment for a low back injury. In a March 2000 discharge physical examination medical history questionnaire, the Veteran denied any recurrent back pain or injury, and the examiner noted no spine abnormalities. Private records in February 2006 note that the Veteran sustained a low back injury while lifting at his civilian job for the Postal Service. Imaging studies showed a disc bulge with impingement at L5-S1. Several private physicians as cited below note that the Veteran sustained back injuries in 2003 and 2006. As the weight of evidence shows that a lumbar spine disability did not manifest until many years after service and as there is no competent evidence of proximate causation by any injury or disease in service, the criteria for direct service connection have not been met. A disability may be service connected on a secondary basis by demonstrating that the disability is either (1) proximately due to or the result of an already service connected disease or injury, 38 C.F.R. § 3.310(a) or (2) aggravated by an already service connected disease or injury, 38 C.F.R. §3.310(b) (2017). A letter from Dr. Joseph Long was submitted by the Veteran in 2006 stating “the knee injury in 1998, in my opinion, is a probable cause of his current lower back condition.” In an April 2013 letter from Dr. Terry Green, Dr. Green noted that the Veteran originally sustained a herniated disc in December 2003 but steadily worsened over the past 10 years. The physician opined that the Veteran’s “current disability with his left knee and left ankle is the primary reason that has caused his lower back to sustain this current chronic condition.” In a May 2013 letter from Dr. James Clark, Dr. Clark stated that the Veteran’s current disability of left knee and ankle has caused the Veteran “to favor one side of his body that has focused excessive use of his right side. This effects his twisting, bending, kneeling, and hip alignment. In turn, has added excessive pressure to his lower back.” The Veteran underwent a VA back examination in October 2013. The advanced practice nurse (APN) noted that the Veteran’s subjective symptoms and demonstrated function were exaggerated and inconsistent with clinical observations and concurrent imaging studies showing a normal lumbar spine and did not correlate with the Veteran’s history and current employment with the Postal Service loading and unloading trucks and sorting mail. The APN did not provide an opinion on causation or aggravation by the left knee. In a December 2013 addendum, the APN noted that the Veteran was without a lumbar spine diagnosis attributable to service. The Board finds that the weight of competent evidence, specifically the opinions of the private physicians, shows that service connection secondary to the service-connected left knee is warranted. Therefore, entitlement to service connection for low back disability secondary to the service connected left knee and ankle sprain/strain is granted. REASONS FOR REMAND 1. Entitlement to service connection for right hip disability to include, as secondary to the service connected left knee and ankle sprain/strain is remanded. In an April 2013 letter from Dr. Terry Green, Dr. Green stated that the Veteran’s “current disability with his left knee and left ankle has caused him to adjust the way he bends, twists, and shifts his weight. It has also adjusted his hips alignments...” In an August 2013 letter from Dr. Joseph Long, Dr Long stated that the Veteran’s “service connected disability of his left knee and left ankle has severely adjusted the way he twists and bends. His hip alignment has changed with this disability and in my opinion…” Dr. Long goes on to state that the Veteran “will have hip pain and stiffness with these current disabilities and will continue to worsen as time goes on.” Although the medical evidence provided by the Veteran indicate that the persistent or recurrent symptoms of a disability may be associated with another service connected disability, the evidence of record otherwise lacks a diagnosis of a right hip disability. Therefore, a VA examination is needed to allow the Board to make a fully-informed decision. 2. Entitlement to service connection for right leg shortening to include, as secondary to the service connected left knee and ankle sprain/strain is remanded. In a December 2003, a private chiropractor noted that the Veteran had a short right leg. The extent of the shorter leg was not quantified. A letter from Dr. Joseph Long was submitted by the Veteran in 2006 stating that the Veteran’s leg length inequality with the one leg being shorter than the other, “is caused by pelvic misalignment causing pelvic unleveling.” In a May 2013 letter from Dr. James Clark, Dr. Clark stated the Veteran’s current disability of left knee and ankle has caused the Veteran’s “right leg to become shorter than his left leg, due to his hips adjusting to the weight shifting.” Although the medical evidence provided by the Veteran indicate that the right leg shortening may be associated with another service connected disability, the evidence of record otherwise lacks a specific assessment of the severity of the shorter leg and rationale how it was proximately caused or aggravated by the left knee and ankle disabilities. Therefore, a VA examination is needed to allow the Board to make a fully-informed decision. The matters are REMANDED for the following action: 1. Schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any right hip pain and right leg shortening. Determine whether the Veteran has a current right hip diagnosis. If so, opine whether it is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability. Include a discussion regarding any conflicting medical evidence. (Continued on the next page)   Determine the extent of the Veteran’s right leg shortening. Determine whether the Veteran has a current diagnosis of right leg shortening disability. If so, opine whether it is at least as likely as not (1) proximately due to service-connected disability, or (2) aggravated beyond its natural progression by service-connected disability. Include a discussion regarding any conflicting medical evidence. J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD C. NeSmith, Associate Counsel