Citation Nr: 21066172 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 20-11 546 DATE: October 28, 2021 ORDER Service connection for a low back disability is granted. REMANDED Service connection for a left shoulder disability is remanded. FINDING OF FACT The evidence is in relative equipoise as to whether the Veteran's low back disability was caused or aggravated by her service-connected bilateral knee disabilities. CONCLUSION OF LAW The criteria for service connection for a low back disability have been met. 38 U.S.C. §§ 1110, 5107; 38C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service in the United States Army from April 1998 to November 2000. The Veteran seeks service connection for a low back disability as secondary to gait changes from her service-connected bilateral knee disabilities. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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 (nexus). Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection can also be established on a secondary basis for a disability which is proximately due to, or the result of a service-connected disability. 38 C.F.R. § 3.310. The Board finds that the evidence is in relative equipoise and will grant service connection for a low back disability as secondary to the service-connected bilateral knee disabilities. Evidence that is supportive of the secondary service connection theory of the claim includes a private physical therapist's (Dr. S.C.) September 2018 and March 2021 opinions. To this end, Dr. S.C. indicated that he had treated the Veteran on multiple occasions for back and knee pain since 2018. Dr. S.C. collectively opined that the years of military service had played a role in her pain experience. According to Dr. S.C., a precipitating event was the diagnosis and management of her bilateral knee injuries during her active duty career. Dr. S.C. concluded that years of biomechanical adjustment and compensation may have played a role in her spine and ultimately lead to symptoms in that area. Other evidence that is supportive of the claim includes a December 2020 VA physician's assistant (PA) opinion. The VA PA opined that the Veteran's degenerative disc disease and osteoarthritis of the spine were likely caused by overcompensation from her bilateral knee injuries and disabilities, that led her to favor one side when walking for the last few decades that altered her biomechanics and ultimately led to her back problems. See December 2020 VA treatment report. The Board notes that the VA physician's assistant physically evaluated the Veteran's knees at the December 2020 visit, but not her spine. In rendering the favorable opinion, the VA PA stated that it was "our opinion," thus, it appears that she was providing an opinion after having consulted and collaborated with the VA orthopedic department. See December 2020 VA treatment report. Although the is a medical opinion that concluded that service connection was not warranted, the Board finds that the evidence of record is in relative equipoise as to whether the Veteran's low back disability was caused by gait disturbances and biomechanical problems caused by her service-connected bilateral knee disabilities. Accordingly, service connection for a low back disability is granted. REASONS FOR REMAND The Veteran seeks service connection for a left shoulder disability. She contends that it is caused by gait disturbances and biomechanical problems caused by her service-connected bilateral knee disabilities. The Board finds that prior to further appellate review of the claim, a new VA examination is necessary to determine the exact nature and diagnosis of the Veteran's left shoulder disability. There is conflicting evidence as to whether or not the Veteran currently has a left shoulder disability. To this end, a March 2020 VA examiner concluded, after an examination of her shoulders, that the Veteran did not have a left shoulder disability. The examiner indicated that the Veteran had presented to the examination with complaints of right shoulder pain. The examiner further opined that he was unable to rule out the cervical spine as a factor and believed it to be a contributing factor to her shoulder pain. The examiner indicated that the Veteran had undergone had extensive imaging and operative reports that suggest a degenerative nature of her lumbar spine and shoulder. However, he ultimately concluded that the Veteran did not have a left shoulder disability. Conversely, a December 2020 VA physician's assistant's opinion that the Veteran's degenerative disc disease and osteoarthritis of the back, neck and shoulders are likely caused by the overcompensation from her bilateral knee injuries and disabilities leading her to favor one side when walking for the last few decades altering her biomechanics and ultimately leading to her shoulder problems. The VA PA did not examine the left shoulder at the December 2020 visit, nor were x-rays provided to support her diagnosis of osteoarthritis (OA) of the left shoulder. The Board questions the diagnosis of OA of the left shoulder in light of an absence of arthritis at the March 2020 examination, nine (9) months previously. As such, the Board finds that a new VA examination is necessary to determine the exact nature and diagnosis of any left shoulder disability, to include its relationship to her service-connected bilateral knee disabilities. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination of the left shoulder. The examiner should answer the following questions: a) Does the Veteran have either a diagnosable left shoulder disability, or does she experience pain in her left shoulder that causes functional impairment of earning capacity? Why or why not? b) If yes, is it at least as likely as not (50 percent or greater) that any current left shoulder disability either began during or was otherwise caused by the Veteran's active service? Why or why not? c) If yes, is it at least as likely as not (50 percent probability or greater) that any diagnosed left shoulder disability is directly caused or aggravated (made worse) by biomechanical alterations caused by her service-connected bilateral knee disabilities. Why or why not? In providing the opinions, the examiner is requested to address the March 2020 VA examiner's conclusion that the Veteran did not have a left shoulder disability and December 2020 VA PA's conclusion that the Veteran had OA of the shoulders that is likely caused by the overcompensation from her bilateral knee injuries and disabilities leading her to favor one side when walking for the last few decades altering her biomechanics and ultimately leading to her shoulder problems. MATTHEW W. BLACKWELDER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Carole Kammel, 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.