Citation Nr: 21000941 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 13-17 605 DATE: January 6, 2021 ORDER Entitlement to service connection for a lumbar spine disorder, to include as secondary to the service-connected right knee disability, is denied. FINDING OF FACT A lumbar spine disorder did not manifest during service, was diagnosed more than one year after service, is etiologically not related to service, and is not secondary to the service-connected right knee degenerative joint disease. CONCLUSION OF LAW A lumbar spine disorder did not manifest during service, may not be presumed to have been incurred therein, is unrelated to service, and was not caused or aggravated by the service-connected right knee degenerative joint disease. 38 U.S.C. §§ 1110, 1112, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from May 1969 to August 1970. Entitlement to service connection for a lumbar spine disorder, to include as secondary to the service-connected right knee disability. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for arthritis if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309(a). 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, as distinguished from merely isolated findings or a diagnosis including the word “chronic.” Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disorder. 38 C.F.R. § 3.310(a). Secondary service connection may be found in certain instances in which a service-connected disability aggravates another condition. Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310(b). The Veteran contends that his lumbar spine disorder is secondary to his service-connected right knee degenerative joint disease. See, e.g. December 2011 claim. As will be discussed further below, as arthritis in the lower back was not manifested in service or for more than one year after service, it follows that service connection for a lumbar spine disorder on a presumptive basis is not warranted pursuant to 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307, 3.309(a). Service treatment records do not document complaints, findings or treatment for a low back disorder. After service, a July 2012 VA x-ray shows disc space narrowing at L5/S1 as well as L3/L4. On VA back examination in July 2012, the Veteran reported that his back started hurting 10 years earlier, which he believed was due to his knee. The examiner opined that it is less likely than not that the Veteran has a back disability that was incurred in or caused by service or that is proximately due to or the result of the Veteran’s service-connected disability based on the determination that the Veteran did not have a specific back condition resulting in a disability. The examiner pointed out that imaging studies revealed only a minimal amount of arthritis type changes consistent with his age. The examiner found that the slight short leg type limp resulting from a knee brace was not causing the exaggerated biomechanical changes of side to side and vertical displacement of the center of gravity that would cause early or increased degenerative changes of the vertebrae. VA treatment records in November 2014 show the Veteran had low back pain all the time. During the June 2016 Board hearing, the Veteran testified that his back started hurting many years ago. The Veteran indicated that a doctor may have told him that his back pain could be related to his knee because the knee pain shoots up in his back. On VA back examination in October 2016, the examiner opined that the Veteran was not diagnosed with a back disability. Accompanying x-ray shows stable study of lumbar spine with minimal degenerative changes and no significant progression. The examiner opined that it is less likely than not that the Veteran has a back disability that was incurred in or caused by service as the evidence does not show the presence of a permanent residual or chronic disability of the lumbar spine. The range of motion exam was within the range of normal for someone the Veteran’s age and poor general physical conditioning. Imaging studies revealed only a minimal amount of arthritis type changes that are expected for someone of the Veteran’s age and poor general physical conditioning. The examiner further stated that medical evidence shows that arthritis of the knee does not result in arthritis changes in the spine. The examiner concluded that a review of the claims file and examination reveals no biomechanical condition or process originating from the right knee that would cause arthritis of the spine. On VA examination in October 2020, the diagnosis was degenerative arthritis of the spine. After reviewing the claims folder and examining the Veteran, the examiner in an accompanying opinion noted that service treatment records do not show treatment for a back disability. She pointed out that VA treatment records in July 2014 document the Veteran’s complaints of back pain. A July 2012 x-ray shows disc space narrowing in the lumbar spine. The examiner opined that the Veteran’s back disability was less likely than not incurred in or caused by service or is proximately due to or the result of the Veteran’s service-connected right knee disability. The examiner noted that the Veteran’s service treatment records show that the Veteran fell in 1969 from a ladder and fractured his right knee cap. She pointed out that the Veteran was able to work for Norfolk Southern railroad for 39 years before retiring and his duties included being a car repairman. The examiner found it significant that the evidence shows the Veteran reported back pain around 2014, which is approximately 45 years after his in-service knee injury. She explained that while the Veteran developed right knee osteoarthritis, arthritis is not a disease that spreads from one joint to another. Medical literature fails to show such a relationship. Degeneration forms vertebral osteophytes, facet joint osteoarthritis, and disc space narrowing. Specifically, spine osteoarthritis is the presence of disc degeneration and osteophyte formation which occurs with the aging process. The etiology of spine osteoarthritis is likely secondary to multifactorial pathogenesis. Its etiology includes genetic predisposition, epigenetics, dietary changes, sex, and ethnicity differences. Age, muscle strength, physical activity, and work-related habits are factors in the development of osteoarthritis. Together these factors contribute to a low-grade inflammatory state and potential degenerative changes. Overtraining of muscles with abnormal joint movements can lead to injury, changes to joint alignment, worsening arthritis. The examiner stated that an account has to be given for other contributing factors in the Veteran’s condition, such as age and obesity, as well as the minimal changes noted on repeat radiology exams. In other words, his spine is showing signs of arthritis that is expected for someone his age. The examiner further stated that given that the most recent x-rays of his lumbar spine only show minimal degenerative changes that would occur with the natural aging process, the low back disorder to specifically include arthritis is less likely than not related to the history of right knee patella fracture. The examiner opined that it is less likely as not that the Veteran’s back disability is aggravated beyond its natural progression by the service-connected right knee disability based on the rationale that arthritis occurs over time and can affect any articular surface. It is more likely to affect weight-bearing joints, to include the spinal column. The spinal cord consists of two facet joints (zygapophyseal joints), and one intervertebral disc, all of which are potential origins for back pain. The three components comprise a spinal motion segment, which facilitates degeneration over time. This is a key factor in the Veteran’s case as it wasn’t until many years later, around 2014, that his complaints of low back pain were documented. His original injury occurred in 1969, approximately 45 years before his documented complaints of back problems. The examiner reiterated that degeneration forms vertebral osteophytes, facet joint osteoarthritis, and disc space narrowing. Osteoarthritis of the spine is the presence of disc degeneration and osteophyte formation. She concluded that given that the most recent x-rays of the lumbar spine only show minimal degenerative changes that would occur with the natural aging process, the Veteran’s low back disability, confirmed as arthritis, has not been aggravated beyond its natural progression. The Board finds the October 2020 opinion to be probative as it was based on medical principles and applied to the facts of the case. Nieves-Rodriquez v. Peake, 22 Vet. App. 295 (2008). The examiner considered the nature of the Veteran’s low back disorder in proffering the opinion. The opinion is uncontroverted by the other competent evidence of record. As a lay person, the Veteran is competent to report symptoms pertaining to his low back disorder. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the etiology of the Veteran’s low back disorder falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). The Veteran’s low back disorder is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding its etiology. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Veteran has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that the Veteran received any special training or acquired any medical expertise in evaluating such disorder. Accordingly, the lay evidence does not constitute competent medical evidence and lacks probative value. As the lay evidence is not competent, the matter of whether it is credible is not reached.   Arthritis is included among the chronic diseases under 38 U.S.C. § 1101 and 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). To the extent that the Veteran is asserting continuity of symptomatology, his assertions are outweighed by the evidence of record discussed above. Accordingly, because the preponderance of the evidence is against the claim of service connection for a lumbar spine disorder, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Mac, 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.