Citation Nr: 20022589 Decision Date: 04/01/20 Archive Date: 04/01/20 DOCKET NO. 18-11 107A DATE: April 1, 2020 ORDER Entitlement to service connection for degenerative arthritis of the lumbar spine, to include as secondary to service-connected right knee disability, is denied. REMANDED Entitlement to service connection for left knee arthritis, to include as secondary to service-connected right knee disability, is remanded. Entitlement to service connection for a stomach condition, to include esophagitis, acid reflux, hiatal hernia and gastric erosion, and to include as secondary to service-connected right knee disability, is remanded. FINDING OF FACT The Veteran’s degenerative arthritis of the lumbar spine is neither proximately due to nor aggravated beyond its natural progression by his service-connected right knee disability and is not otherwise related to an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for arthritis of the lumbar spine, to include as secondary to service-connected right knee disability, have not been met. 38 U.S.C. § 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1984 to May 1985. In June 2019, the Board of Veterans Appeals (Board), in pertinent part, remanded the above captioned claims for further development. As previously addressed in the June 2019 Board remand, the Veteran filed a timely June 2018 notice of disagreement (NOD) in response to a June 2019 decision regarding his claim for dependency benefits. A statement of the case (SOC) has still not been issued regarding the matter, however, the NOD has been acknowledged by the Regional Office (RO). Because the NOD has been acknowledged, a remand for an issuance of an SOC pursuant to Manlincon v. West, 12 Vet. App. 238 (1999) is not necessary. Service Connection Entitlement to service connection for degenerative arthritis of the lumbar spine, to include as secondary to service-connected right knee disability Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). 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. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Service connection may be granted for any disease initially diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Secondary service connection is warranted where a disability is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Briefly, the threshold legal requirements for a successful secondary service connection claim are: (1) Evidence of a current disability for which secondary service connection is sought; (2) a disability for which service connection has been established; and (3) competent evidence of a nexus between the two. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). The Veteran is service connected for right knee traumatic arthritis. He reports that his lumbar spine began hurting due to shifting weight from the right knee. Therefore, he contends this disability is secondary to his service-connected right knee traumatic arthritis. The question for the Board is whether the Veteran has a current disability that is proximately due to or the result of, or is aggravated beyond its natural progress by service-connected disability. The Board concludes that, while the Veteran has a current diagnosis of arthritis of the lumbar spine, the preponderance of the evidence is against finding that the Veteran’s arthritis of the lumbar spine is proximately due to or the result of, or aggravated beyond its natural progression by his service-right knee disability. 38 U.S.C. § 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). While the Veteran believes his degenerative arthritis of the lumbar spine is proximately due to or the result of/aggravated beyond its natural progression by service-connected right knee disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the December 2019 VA medical examiner who examined the Veteran and reviewed his claims file, and found that the evidence did not indicate a progression beyond the natural course of complications of lumbar spine degenerative changes to include fractures, bone death, joint bleeding or back surgery resulting from a right knee patella chondromalacia with traumatic arthritis or its treatment. In support of that opinion, the examiner highlighted the fact that the examination results showed the Veteran maintained a normal gait and stance. See December 2019 VA examination opinion. The Veteran’s postservice treatment records similarly show that apart from one instance in October 2018 where he was noted to have an antalgic gait, he has been subsequently (to include as recently as June 2019) noted to have a normal gait pattern with no limp. Significantly, the Veteran’s postservice treatment records do not indicate that his degenerative arthritis of the lumbar spine is etiologically related to his service-connected right knee disability. Service connection may also be granted on a direct basis, but the preponderance of the evidence is also against finding that the Veteran’s degenerative arthritis of the lumbar spine is related to an in-service injury, event, or disease. 38 U.S.C. § 1131; Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a), (d). The Veteran’s available service treatment records are silent for any lumbar spine complaints, findings, treatments or symptoms. Furthermore, the March 2014 VA examiner opined that the Veteran’s mild degenerative arthritis in his low back “was much more compatible” with his age and occupation than his service. See March 2014 VA examination. To the extent the Veteran believes his degenerative arthritis of the lumbar spine is related to an in-service injury, event, or disease, he is not competent to provide a nexus opinion in this case. This issue is also medically complex, as it requires knowledge of the interaction between multiple organ systems in the body/interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Consequently, the Board gives more probative weight to the VA examiners’ reports and opinions previously addressed. REASONS FOR REMAND Entitlement to service connection for left knee arthritis and a stomach condition, to include esophagitis, acid reflux, hiatal hernia and gastric erosion to include as secondary to service-connected right knee disability are remanded. The Veteran is service connected for right knee traumatic arthritis. He reports that his left knee began hurting due to shifting weight from the right knee. Therefore, he contends this disability is secondary to his service-connected right knee traumatic arthritis. Furthermore, the Veteran contends that his stomach condition, to include esophagitis, acid reflux, hiatal hernia and gastric erosion is caused or aggravated by the medication he is required to take for his service-connected right knee disabilities. The June 2019 Board remand requested that the Veteran be afforded VA examinations to adequately address his secondary causation theories of entitlement for these disabilities. In satisfaction of the Board’s remand, VA examinations were performed in December 2019. However, in rendering the medical opinions, the examiner essentially provided only objective findings related to the claimed disabilities without specifically addressing whether the disabilities were caused or aggravated by his service-connected right knee disability, and did not provide adequate rationale for the opinions provided. Relating to the Veteran’s left knee degenerative arthritis, the examiner concluded the available records failed to show a left knee degenerative arthritis that was aggravated beyond a natural course by a right knee traumatic arthritis. In support of that opinion, the examiner stated the Veteran had a “stable arthritis left knee with normal gait” and “no evidence of left knee weakness, laxity or ankylosis” as well as no surgical history due to right knee arthritis with chondromalacia. See December 2019 Medical Opinion. However, the examiner does not provide any reasoning for his medical opinion beyond reporting the clinical findings related to the Veteran’s left knee. He also does not adequately address any possible aggravation of the Veteran’s left knee disability by his service-connected right knee. Moreover, the examiner was specifically asked to address the article cited in the September 2018 correspondence from the Veteran’s attorney if the examiner did not find a secondary relationship between the Veteran’s knees. However, the examiner’s rationale does not include any mention of this article. See June 2019 Board Remand. Lastly, relating to the Veteran’s stomach conditions, the VA examiner found that the available evidence did not indicate progression beyond the natural course or complications including ulceration, scarring, dysphagia or malnutrition resulting from a right knee patella chondromalacia with traumatic arthritis or its treatment pertaining specifically to the Veteran’s degenerative arthritis of the right knee. See December 2019 VA Medical Opinion. However, the examiner provided no explanation for the rationale of this opinion and did not address the question of aggravation. Therefore, the opinion is conclusory and incomplete. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s left knee arthritis is at least as likely as not related to/proximately due to the service-connected right knee disability OR aggravated beyond its natural progression by service-connected right knee disability. The examiner is asked to provide clear and supporting rationale for the opinion rendered. Furthermore, if a negative causal connection is found, the examiner should address the article cited in the September 2018 correspondence from the Veteran’s attorney (“Osteoarthritis” Mayo Clinic). 2. Obtain an addendum opinion from an appropriate clinician regarding whether the Veteran’s stomach condition, to include esophagitis, acid reflux, hiatal hernia and gastric erosion is at least as likely as not related to/proximately due to service-connected disability, OR aggravated beyond its natural progression by service-connected right knee disability. The examiner is asked to provide clear and supporting rationale for the opinion rendered, and must specifically address the effects of the medication prescribed to treat the Veteran’s right knee disability on his stomach. A. ISHIZAWAR Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Churchwell, 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.