Citation Nr: 18159829 Decision Date: 12/20/18 Archive Date: 12/20/18 DOCKET NO. 17-07 348 DATE: December 20, 2018 ORDER Entitlement to service connection for a lumbar spine disability, as secondary to service-connected left knee disability, is denied. REMANDED Entitlement to service connection for a right knee disability, as secondary to service-connected left knee disability is remanded. FINDING OF FACT The Veteran’s lumbar spine disability is not caused by or made worse by the service-connected left knee disability. CONCLUSION OF LAW The criteria for service connection for a lumbar spine disability, as secondary to a service-connected left knee disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty, including from April 1975 to April 1977. This matter is before the Board of Veterans’ Appeals (Board) on appeal of January 2016 rating decision of the Boise, Idaho, Regional Office (RO) of the Department of Veterans Affairs (VA). Entitlement to service connection for a lumbar spine disability, as secondary to service-connected left knee disability is denied. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, 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”-the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may also be granted on a secondary basis for a disability if it is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show that a current disability exists and that the current disability was either proximately caused or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board has reviewed the Veteran’s service treatment records (STRs) and post-service medical records. The Veteran’s STRs are silent for treatment or complaints for a lumbar spine disability. The Veteran was afforded a VA examination in December 2015. He reported a lot of heavy lifting early in his career. He stated that he had back problems for 20 years or more. He noted not recalling any specific injury or incident at onset, just that it could occur with bending. He noted an achy pain in his lower back. A diagnosis of degenerative arthritis of the spine was provided. The VA examiner noted that back complaints were not found in the Veteran’s STRs. Back complaints first appeared in post medical records in 1999, associated with bending and after working on a roof. The Veteran had left side radiation into the buttocks, but radiculopathy was not described. Assessment was disk disease, with “recurrent disk derangement” noted in 2004. Episodes of back pain were recorded on most annual visits thereafter. The VA examiner opined that the condition claimed was less likely than not incurred in or caused by the claimed in-service injury, event or illness. Evidence of significant back complaint or injury was not found in the STRs, and medical records show onset of back pains about 20 years after separation. No nexus was found for direct service connection for this condition. In the Veteran’s notice of disagreement, he stated all the years of limping at the time, due to his service-connected left knee, had caused his lower back to have more pain. The Veteran was afforded a VA examination in November 2016. He reported that his back hurt when he walked, sat, or laid in bed. The VA examiner opined that the condition claimed was less likely than not proximately due to or the result of the Veteran’s service-connected left knee condition. The examiner then described a detailed list of documented instances of treatment between June 1999 and February 2016 to underscore the absence of notation of left knee issues in reference to treatment for the low back, and vice versa. Thus, it appeared that the chronic low back pain had its onset in 1999 or earlier, and this was long before his left knee was symptomatic enough to be mentioned in the medical record, or symptomatic enough to cause back pain. Therefore, it was less likely than not that the Veteran’s back condition (degenerative joint disease (DJD)) is secondary to his service-connected left knee DJD or total knee replacement. Additionally, since 1999, the low back DJD/pain seems to be described in basically the same terms in all office notes, particularly when comparing the recent ones (after the left knee became symptomatic) to the earlier notes going back to 1999. Therefore, it is less likely than not the Veteran’s left knee DJD/replacement has aggravated his lumbar DJD beyond its natural progression. The Veteran has not asserted that his claimed lumbar spine disability is related to active duty. Rather, the Veteran contends that his lumbar spine disability is related to his service-connected left knee disability. In addition, there is no medical evidence which relates the Veteran’s current lumbar spine disability to active duty. After the review of the record, the Board finds that the November 2016 VA medical opinion regarding secondary service connection weighs against a finding of a relationship between the Veteran’s lumbar spine disability and his service-connected disability. The opinion provided by the VA examiner is persuasive evidence, which opposes rather than supports the claim, because the opinion accurately reflects the evidence of record and the thorough examination, and provides a detailed discussion of all relevant facts. The examiner’s opinion offered a rationale and a plausible explanation for concluding that the Veteran’s lumbar spine disability was not the result of his service-connected left knee disability. Furthermore, the record contains no medical opinion to the contrary. Accordingly, service connection for the Veteran’s lumbar spine disability on a secondary basis is not warranted. See 38 C.F.R. § 3.310. The Veteran is certainly competent, as a lay person, to report symptoms of which he has personal knowledge, such as back pain, and the Board finds his account credible. Layno v. Brown, 6 Vet. App. 465, 469 (1994). However, as a lay person he is not competent to establish a medical diagnosis or show a medical etiology merely by his own assertions as such matters require medical expertise. See 38 C.F.R. § 3.159(a)(1). The specific issue in this case, the relationship between the Veteran’s lumbosacral pain and service-connected disability, is a complex medical issue and thus is outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). As a lay person, the Veteran does not have the education, training, or experience to offer a medical diagnosis or an opinion as to the onset or etiology of this disability. See Kahana v. Shinseki, 24 Vet. App. 428 (2011). In light of the foregoing, the Board finds that the preponderance of the evidence is against the Veteran’s claim of service connection for a lumbar spine disability because the persuasive medical evidence does not show that the lumbar spine disability is either caused or aggravated by the service-connected left knee disability. As such, the benefit-of-the-doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection is not warranted. REMANDED ISSUE Entitlement to service connection for a right knee disability, as secondary to service-connected left knee disability is remanded. Regarding the issue of service connection for right knee disability, to include as secondary to service-connected left knee disability, a review of the record shows that the Veteran’s original claim, received in 2015, was for direct service connection. Subsequently, in January 2017, in the Veteran’s substantive appeal, he noted that his right knee disability was due to his service-connected left knee disability. The Veteran was afforded a VA examination in December 2015. The VA examiner opined that the Veteran’s diagnosed right knee disability was less likely than not incurred in or cause by the claimed in-service injury, event or illness. The Veteran’s claims file, however, does not reflect that an opinion has been associated with his file regarding secondary service connection of the Veteran’s claimed disability and his service-connected left knee disability. As such, a secondary causation opinion is necessary to fully and fairly adjudicate this issue. The matter is REMANDED for the following action: Return the Veteran’s claim folder to the examiner who conducted the December 2015 VA knee and lower leg conditions examination for an addendum opinion. If an additional examination is deemed necessary, one should be scheduled. If the prior examiner is not available, the file must be forwarded to another examiner to obtain the requested opinion. The examiner is asked to specifically address the following question: is it at least as likely as not (50 percent or greater probability) that the claimed right knee disability was caused or aggravated by the Veteran’s service-connected left knee disability? If aggravation is found, the examiner should provide the baseline manifestations of the Veteran’s claimed right knee disability prior to aggravation by the service-connected left knee disability. A complete rationale must be provided for all opinions expressed and conclusions reached. A. C. MACKENZIE Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD A-L Evans, Counsel