Citation Nr: 20021446 Decision Date: 03/25/20 Archive Date: 03/25/20 DOCKET NO. 16-51 033 DATE: March 25, 2020 ORDER Service connection for a lumbar spine disability, to include as secondary to bilateral knee disabilities, is granted. FINDING OF FACT The Veteran’s low back disability is aggravated by his knee disabilities. CONCLUSION OF LAW The criteria for service connection for a lumbar spine disability, to include as secondary to bilateral knee disabilities, have been met. 38 U.S.C. §§ 1101, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1980 to January 1988. This appeal is before the Board of Veterans’ Appeals (Board) from a November 2012 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Atlanta, Georgia. In January 2020, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript is included in the claims file. Entitlement to service connection for a lumbar spine disability, to include as secondary to bilateral knee disabilities The Veteran claims service connection for a lumbar spine disability as secondary to his service-connected bilateral knee disabilities. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Service treatment records reflect that in October 1985 the Veteran reported pain in his back, arms, and legs for the prior two days. No back diagnosis was given and there is no indication of follow-up treatment. No abnormality was noted at his November 1987 separation examination. Private treatment records reflect that in August 2004 the Veteran reported back pain after injuring his back 3 days prior. X-rays were negative. He was diagnosed with a lumbar strain. In May 2005 he reported back discomfort. X-rays showed no changes. He was diagnosed with low back pain. In April 2011 he reported low back pain on his left side since the prior day after bending over to pick something off the floor. He reported having similar problems in the past. He was diagnosed with low back pain. He reported back pain again in October 2011. In December 2011 he reported 5-6 years of lumbar pain and pain at the left of the spine in the lumbar region. X-rays showed mild degenerative disc disease of the lumbar spine. In his January 2012 claim, the Veteran reported that he has started to have more frequent back pain because of his weak knees. Specifically, he stated that his inability to bend his knees without pain has caused significant back pain. Private treatment records include a February 2012 record in which the Veteran’s physician opined that his knee pain causes him to strain his back muscles. No rationale was given. The Veteran underwent a VA examination in March 2012. He reported low back problems beginning in about 2006. He recalled no specific injury. He reported that the condition came and worsened over time. He stated his belief that the back problem worsened because of his bad knees. X-rays showed thoracic spondylosis and lumbar spondylitic changes with degenerative disc disease. The examiner diagnosed a lumbar strain and degenerative disc disease with degenerative arthritis of the thoracolumbar spine. The examiner opined that the disability was less likely than not caused by the Veteran’s knee disabilities. This opinion was based on the rationale that there was no loss of motion with only lumbar tenderness with very mild arthritis on x-rays. The examiner further noted that although there was record of back pain in service, it was a single instance of treatment and subsequent examinations were normal. The Veteran underwent another VA examination in July 2012. He reported that symptoms began in 2002. He stated that his symptoms began with his knees and that because he could not bend them it caused a strain in his back and arthritis through repetitive abnormal use. The examiner diagnosed a lumbar strain and lumbar degenerative arthritis. The examiner opined that the disability was less likely than not related to service. This opinion was based on the rationale that there was only one instance of treatment in service with no diagnosis and no order of x-rays, and there was no established longitudinal trend of subjective complaints and objective findings since. Private treatment records reflect that in November 2012 an MRI showed bulging disc and facet hypertrophy with mild central canal stenosis at L4-5, as well as left paracentral disc protrusion and anular tear with moderate central canal stenosis at L5-S1. In March 2015 the Veteran reported back, hip, thigh, and knee pain for the prior 3-4 years. In November 2016 his treating physician stated that his known moderate knee degenerative joint disease may be altering his gait and could be a factor in ongoing low back pain. Later that month, the Veteran reported to his treating orthopedist that he fell repeatedly while in service and subsequently experienced lower back pain. In December 2016, the orthopedist opined that his low back pain was as likely as not caused by his service-related knee injuries. This opinion was based on the rationale that his knee disabilities caused an antalgic gait which contributed to his back pain. In December 2019, the Veteran reported low back pain due to an in-service left knee injury. His physician opined that his current lumbar disability and low back pain are more likely than not indirectly due to his knee disabilities. This opinion was based on the rationale that his knee problems led to alteration of gait, which has resulted in chronic lumbar pain and dysfunction due to aggravation of the degenerative changes in his lumbar spine. The physician stated that his was also due to the aggravation of his knee and foot disabilities by his work for the United States Postal Service. The Board finds that the evidence is at least in equipoise as to whether the Veteran’s low back disability has been aggravated by his knee disabilities. The July 2012 VA examination only addressed direct service connection, which the Veteran has not claimed. While the March 2012 VA examiner opined against secondary service connection based on causation, no opinion was given as to secondary service connection based on aggravation. In contrast, multiple private treatment providers have opined that his knee disabilities caused an altered gait which in turn caused or aggravated his back pain. Of these opinions, the most probative is the December 2019 opinion which gave a detailed and specific rationale explaining how the initial knee disabilities worsened to the point that they aggravated his back pain and arthritis. For these reasons, the Board finds that the evidence is at least in equipoise as to whether the Veteran’s low back disability has been aggravated by his knee disabilities. Service connection is therefore granted. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Gallagher, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.