Citation Nr: 20060331 Decision Date: 09/14/20 Archive Date: 09/14/20 DOCKET NO. 16-00 049 DATE: September 14, 2020 ORDER Entitlement to service connection for lumbar spine degenerative disc disease is denied. Entitlement to service connection for left hip osteoarthritis is denied. Entitlement to service connection for left knee osteoarthritis is denied. Entitlement to service connection for right foot osteoarthritis is denied. Entitlement to service connection for left foot osteoarthritis is denied. FINDINGS OF FACT 1. The Veteran has lumbar spine degenerative disc disease that was incurred years after his separation from service, did not result from an in-service injury or event, and neither resulted from nor was aggravated by his service-connected disabilities. 2. The Veteran has left hip tendonitis that was incurred years after his separation from service, did not result from an in-service injury or event, and neither resulted from nor was aggravated by his service-connected disabilities. 3. The Veteran has left knee osteoarthritis that was incurred years after his separation from service, did not result from an in-service injury or event, and neither resulted from nor was aggravated by his service-connected disabilities. 4. The Veteran has right foot osteoarthritis that was incurred years after his separation from service, did not result from an in-service injury or event, and neither resulted from nor was aggravated by his service-connected disabilities. 5. The Veteran has left foot osteoarthritis that was incurred years after his separation from service, did not result from an in-service injury or event, and neither resulted from nor was aggravated by his service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for lumbar spine degenerative disc disease are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309(a), 3.310 (2019). 2. The criteria for service connection for left hip osteoarthritis are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309(a), 3.310 (2019). 3. The criteria for service connection for left knee osteoarthritis are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309(a), 3.310 (2019). 4. The criteria for service connection for right foot osteoarthritis are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309(a), 3.310 (2019). 5. The criteria for service connection for left foot osteoarthritis are not met. 38 U.S.C. §§ 1110, 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a), 3.309(a), 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty from February 1977 through June 1978. The record reflects that the Veteran has been represented in this appeal by a private attorney, J. Michael Woods, per a May 2016 VA Form 21-22a appointment. In a May 2020 letter, Mr. Woods moves to withdraw representation of the Veteran under 38 C.F.R. § 20.608. Although Mr. Woods provides no specific reasons for his withdrawal, he explains that continued representation of the Veteran would be “impossible, impractical, or unethical.” He states that disclosure of the specific reasons for his withdrawal would also be unethical. Notably, a copy of the letter was mailed to the Veteran at his known address. The Veteran has provided no reply to Mr. Woods’ letter. The Board is satisfied with the May 2020 motion. In the absence of a timely reply from the Veteran, the Board recognizes Mr. Woods’ withdrawal as the Veteran’s representative. 38 C.F.R. § 20.608 (b). The Veteran has not appointed a new representative. Service Connection 1. Entitlement to service connection for lumbar spine degenerative disc disease, left hip tendonitis, and left knee osteoarthritis. The Veteran contends in his January 2016 claim that he is entitled to service connection for disorders in his lumbar spine, left hip, and left knee. The Veteran theorizes, through arguments raised by the Veteran’s former representative in a March 2018 brief, that each claimed condition resulted from or was aggravated by an altered gait caused by his service-connected right ankle disability. Thus, he argues primarily that service connection for the claimed disorders are warranted on a secondary basis under 38 C.F.R. § 3.310. As discussed in detail below, the disposition as to each of the Veteran’s claim turns on the relative weight to be afforded to the concurring VA examiners’ negative opinions expressed in February 2016 and August 2019 and an opposing February 2018 favorable opinion rendered by Dr. H.S. For the reasons also given below, the Board is persuaded by the negative opinions given by the VA examiners and finds that the Veteran is not entitled to service connection for claimed disorders in his lumbar spine, left hip, and left knee on either a direct or secondary basis. Service treatment records show that the Veteran did not report or seek treatment during service for any symptoms or impairment associated with his back, left hip, or left knee. There is no mention in the service treatment records of any noted abnormalities or clinical findings in those joints. Relative to the Veteran’s lumbar spine and left hip, the post-service VA and private treatment records show that the Veteran has not sought regular treatment for those joints. Notably, a September 1996 treatment record from Fort Hamilton Hughes Memorial Hospital notes that the Veteran was mentioning occasional left knee pain. However, the record notes no specific findings or diagnoses relating to the Veteran’s left knee. Records for subsequent VA and private treatment reflect no treatment specifically for the Veteran’s left knee, nor do they show any findings or express any opinions related to the left knee. The VA treatment records and private treatment records from Dr. C.F., Dr. H.A., and Dr. R.K. reflect that the Veteran has been followed through the present for ongoing pain and instability in his right ankle. Although those records reflect various findings and complaints that appear to be contemplated by VA as part of the rating that has been assigned for the Veteran’s right ankle disability, the records note no findings related to a separate right foot disorder, nor do they reflect any specific findings or opinions related to the Veteran’s spine, left hip, left knee, and left foot. A series of VA examinations conducted in February 2016 revealed diagnosed disorders in the Veteran’s lumbar spine, left hip, and left knee. A spine examination showed decreased thoracolumbar spine motion and pain during palpation over the area of the spine. X-rays revealed intervertebral disc space narrowing at multiple disc levels in the Veteran’s spine. The examiner diagnosed thoracolumbar spine degenerative disc disease. Notably, the Veteran reported during the spine examination that he first noticed his back pain while working on a production line, a job that required him to twist and lift repetitively. A left hip examination revealed decreased motion in the hip joint. The examiner diagnosed left hip tendonitis. A left knee examination indicated pain during weight bearing and during palpation over the knee joint. X-rays revealed minimal narrowing of the medial compartment in the left knee. The examiner also diagnosed left knee osteoarthritis. In relation to all three diagnoses, the examiner opined that it is less likely as not that the disorders were incurred during service or caused by the Veteran’s right ankle disability. The examiner explained that the mechanism of a joint or the spine developing arthritis or other chronic condition due to overcompensation for another joint injury by limping has never been proven. Indeed, the examiner states, a review of the medical literature does not suggest that there is a nexus between residuals associated with a right ankle fracture and lumbar spine degeneration, left hip tendonitis, or left knee degeneration. The February 2016 examiner’s negative opinions are rebutted in the record by a February 2018 private opinion from Dr. H.S. Dr. H.S.’ opinion is accompanied by his curriculum vitae and a copy of a March 2004 paper entitled, “Discussion paper prepared for The Workplace Safety and Insurance Appeals Tribunal,” which purports to support Dr. H.S.’ opinion. Dr. H.S. opines that the disorders in the Veteran’s knees, hip, and back are more likely than not caused and permanently aggravated by gait instability caused by the Veteran’s service-connected right ankle disability. Apparently paraphrasing and quoting directly from the March 2004 paper, Dr. H.S. notes that limping causes a shift in the body’s center of gravity toward the affected leg which in turn causes lateral bending of the trunk toward that side. When weight is transferred to the good leg, repositioning of the center of gravity in the mid-line is in part due to the pull of the paralumbar and abdominal muscles. The increased muscle pull increases the force transmitted across the lumbar discs, facet joints, hip, knees, and ankle due to mechanical leverage. This in turn, can cause or aggravate degenerative change of the disc and facet joints. Dr. H.S. adds that the Veteran has used a cane to ambulate due to instability in his right ankle and that he has had gait problems favoring his left leg for many years. The Board acknowledges that the Veteran has had an altered gait for many years due to his service-connected right ankle disability. An October 1996 right ankle examination noted that the Veteran’s right ankle remained in an everted position even while at rest and that the Veteran walked with a limp with the right foot held in an everted position. Still, Dr. H.S.’ reliance on the March 2004 paper is misplaced and his favorable opinion is due limited probative weight. The Board has carefully reviewed the March 2004 paper that serves as the basis for Dr. H.S.’ opinion. At the outset, the Board points out that the author of the paper acknowledges in his conclusion that the clinical data relating to the existence of a relationship between a limp and the development of injuries in other joints is “limited and inconclusive.” In that regard, the author’s admonishment appears to be consistent with the February 2016 VA examiner’s observation that the existing medical literature has not proven that arthritis or other chronic condition can result from limping. Cast in that light, it does not appear that the March 2004 paper reflects principles that are generally accepted by the medical community. Accordingly, the Board does not accept the March 2004 paper as being authoritative and serving as a sound basis for Dr. H.S.’ offered rationale. Second, the Board observes that the paper attempts to discuss primarily the effect that limping might have on the spine. Indeed, the biomechanics considered by the author of the paper and which were cited by Dr. H.S. in his opinion contemplates the altered motion that might result from a spine disorder. Although the author engages in some discussion of the effect of an altered gait on the knee joints, he conducts that discussion strictly from the perspective of an altered gait that has resulted from a spine injury. Even if one were to accept the March 2004 paper as being authoritative, which the Board does not for the reason given above, it must be recognized that the opinions expressed in the March 2004 paper do not directly pertain to the Veteran’s specific type of gait. Indeed, the author points out that the type of altered gait is important to consider and even engages in a lengthy discussion as to the different types of altered gait. For this reason also, the probative weight to be assigned to the March 2004 paper, and therefore Dr. H.S.’ opinion and rationale, is limited. Following receipt of Dr. H.S.’ opinion, the Veteran’s claims file was again submitted to the February 2016 examiner for review and an opinion as to whether the Veteran’s lumbar spine, left hip, and left knee disorders either resulted from or was aggravated by the Veteran’s right ankle disability. The examiner maintained his opinion that it is less likely than not that the degeneration in the Veteran’s spine and left knee and left hip tendonitis resulted from the Veteran’s right ankle disability. As rationale, the examiner reiterated that the February 2016 examiner’s conclusion that the mechanism of one joint or the spine developing arthritis by overcompensation of another joint injury has never been proven. Rather, the examiner concludes, the conditions in the Veteran’s spine, left knee, and left hip are likely due to non-service-connected risk factors such as age and obesity. The examiner reiterated also that the conditions in the Veteran’s spine, left hip, and left knee are not aggravated by the Veteran’s right ankle disability. In that regard, the examiner opined that there is no evidence in the record that indicates that there has been any aggravation of the degeneration in the Veteran’s spine and left knee and of the Veteran’s left hip tendonitis. In relation to the spine, the examiner observed that the Veteran was reporting back pain during spine examinations in 1978 and 1979 which he attributed to lifting injuries. The examiner states that the subsequent examinations and treatment records do not indicate subsequent permanent worsening or aggravation. In regard to the Veteran’s left hip, the examiner notes simply that there is no evidence showing aggravation or worsening of the Veteran’s left hip tendonitis. Indeed, the evidence shows that the Veteran’s left hip condition was first diagnosed during the February 2016 examination and subsequent treatment records mention no complaints or findings that would indicate any progression or worsening of that condition. Regarding the Veteran’s left knee, the examiner noted that initial complaints of occasional left knee pain were reported by the Veteran during September 1996 treatment and that the subsequent evidence does not indicate progression since that time. Indeed, the evidence since September 1996 does not appear to document any progression or worsening of the Veteran’s left knee. In contrast to Dr. H.S.’ opinion, the negative opinions and rationale given by the VA examiner appear to reflect the principles and opinions held by the medical community, and, are consistent with the evidence in the record. For these reasons, the Board is persuaded by the examiner’s opinions. The preponderance of the evidence shows that the Veteran has degenerative arthritis in his lumbar spine and left knee and tendonitis in his left hip that were incurred years after his separation from service, did not result from an in-service injury or event, and neither resulted from nor were aggravated by the Veteran’s right ankle disability. The Veteran is not entitled to service connection for lumbar spine degenerative disc disease, left hip tendonitis, or left knee osteoarthritis. To that extent, this appeal is denied. 2. Entitlement to service connection for right and left foot osteoarthritis. The Veteran also contends in his January 2016 claim that he is entitled to service connection for disorders in both of his feet. The Veteran theorizes again through his former representative’s March 2018 brief that the conditions in his feet resulted from or was aggravated by an altered gait caused by his service-connected right ankle disability. Subject to the same, the Board observes that the service treatment records include a March 1977 record that notes that the Veteran had mild bilateral pes planus. The Veteran also reported at that time that he was wearing shoe inserts and that they did provide relief. Given the same, the Veteran’s claim is construed as asserting entitlement to service connection for bilateral foot disorders on both a direct and secondary basis. The post-service treatment records show that the Veteran has remained under regular and ongoing treatment for residual symptoms and impairment associated with his service-connected right ankle fracture. Those symptoms are contemplated by the disability rating already assigned for the Veteran’s right ankle disability. In addition to the residuals associated with the Veteran’s right ankle disability, the treatment records show that a February 2013 right foot MRI revealed degenerative changes in the Veterans’ tarsal and metatarsal articulations. During a February 2016 examination, the Veteran reported that he began receiving right foot pain eight years ago. He stated that he had been told previously that he had arthritis in his foot. On examination, the examiner noted pain in both of the Veteran’s feet, although there were no findings of pes planus, neuroma, hammer toes, hallux valgus, hallux rigidus, pes cavus, or malunion or nonunion of the tarsal or metatarsal bones. The MRI noted the findings from the 2013 bone scan. X-rays conducted during the examination showed arthritis in both feet. The examiner diagnosed degenerative arthritis in both feet but opined that it is less likely than not that the diagnosed disorders were incurred during service or caused by the Veteran’s service-connected right ankle injury. The examiner explained that the mechanism of one joint developing arthritis or other chronic conditions by overcompensation for another joint injury through limping has never been proven. Moreover, the examiner noted that the medical literature does not show a medically understood nexus that links the two conditions. The examiner cites that there are several other non-service-connected risk factors including age and generalized arthritis in multiple joints that are principle factors responsible for the development of the Veteran’s bilateral foot degeneration. Dr. H.S.’ February 2018 letter provides no opinion in relation to the degeneration in the Veteran’s feet. Nonetheless, the Veteran was afforded a new examination in August 2019. The Veteran reported that he had been having right foot pain and that he had been diagnosed previously with a Morton’s neuroma. He described having ongoing right foot pain and locking in his right midfoot. He denied having any symptoms in his left foot. Again, a physical examination of the Veteran’s feet revealed no evidence of pes planus, neuroma, hammer toes, hallux valgus, hallux rigidus, pes cavus, or malunion or nonunion of the tarsal or metatarsal bones. Still, tenderness was present during palpation over the ball of the right foot and midfoot. Tenderness was also present along every metatarsal. No abnormalities were observed in the Veteran’s left foot. Again, the examiner noted that the November 2013 bone scan showed degeneration in both of the Veteran’s feet. The examiner again diagnosed arthritis in both feet. Although the examiner noted the in-service findings of pes planus in the Veteran’s feet, the examiner stated that the Veteran does not have a current diagnosis for pes planus. The examiner states that the arches in the Veteran’s feet appeared to be normal and explained that there is not a universally agreed upon longitudinal plane at which a foot transitions from a “normal” arch to a “flat” arch. Moreover, the examiner observes, the Veteran did not disclose a history of pes planus when asked about the history of his foot condition, nor do the orthopedic and podiatric treatment records in the claims file note any findings or diagnoses for pes planus. Based on the foregoing, the examiner opined that the weight of the evidence does not support a current pes planus diagnosis. Regarding the degeneration in the Veteran’s feet, the examiner opined that it is less likely than not that the condition is related etiologically to the Veteran’s active duty service. The examiner observes that arthritis was first diagnosed more than 35 years after the Veteran was separated from service, and moreover, the Veteran has multiple risk factors for development of osteoarthritis including age, obesity, and decades of ambulating on his feet. The examiner also reiterated that it is less likely than not that the Veteran’s bilateral foot osteoarthritis is proximately due to or the result of the Veteran’s right ankle disability. As rationale, the examiner explained again that there is no anatomic or physiologic nexus to connect the two conditions and added that there is no anatomic or physiologic nexus whereby osteoarthritis in one joint is caused by osteoarthritis in another joint. Also, the examiner repeated that there is no credible peer-reviewed medical literature that supports the conclusion that limping is a causative etiology of osteoarthritis. The examiner opined also that the Veteran’s bilateral foot osteoarthritis has not undergone any aggravation. The examiner explained that there is nothing in the record that suggests that the Veteran’s osteoarthritis was aggravated beyond its natural progression. The negative opinions and rationale given by the VA examiner are consistent with the evidence in the record, and also, appear to be consistent with accepted principles and opinions held by the medical community. Moreover, they are not contradicted by other evidence in the record. For these reasons, the Board is persuaded by the examiner’s opinions. The preponderance of the evidence shows that the Veteran has degenerative osteoarthritis in his feet that began years after his separation from service, did not result from an in-service injury or event, and neither resulted from nor were aggravated by the Veteran’s right ankle disability. Although the evidence indicates that bilateral pes planus was diagnosed for the Veteran during service, the evidence shows that the Veteran has not had pes planus in either foot at any time during the appeal period. The Veteran is not entitled to service connection for right and/or left foot osteoarthritis. To that extent also, this appeal is denied. MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board D.S. Lee 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.