Citation Nr: A21016465 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 190701-22846 DATE: October 6, 2021 ORDER Entitlement to service connection for a low back disability, to include as secondary to a service-connected knee disability, is granted. FINDING OF FACT Resolving all reasonable doubt in his favor, the Veteran's low back disability is proximately due to his service-connected knee disabilities. CONCLUSION OF LAW The criteria for entitlement to service connection for a low back disability, to include as secondary to a service-connected knee disability, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from April 1970 to January 1978. A Department of Veterans Affairs (VA) Regional Office (RO) issued a rating decision in June 2019, which constitutes an initial decision; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. In his July 2019 VA Form 10182, Decision Review Request: Board Appeal, the Veteran elected the Hearing docket. In April 2021, the Veteran testified before the undersigned at a hearing. A transcript of his testimony has been associated with the claims file. Because he selected the Hearing docket, the Board of Veterans' Appeals (Board) may only consider the evidence of record at the time of the RO decision on appeal, as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). This matter has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.800(c). Service Connection Generally, the Veteran alleges that he has a low back disability that has developed due to service-connected knee disabilities. More specifically, he reports that his knee problems have caused severe pain and altered the way that he walks, which has in turn caused low back pain. He does not allege, nor does the evidence indicate, that his low back disability had its onset during his active service. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Secondary service connection may also be established for a nonservice-connected disability which is aggravated by a service-connected disability. In such an instance, the veteran may be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439, 448 (1995). Here, the RO determined in the rating decision on appeal that the Veteran had been diagnosed with degenerative arthritis of the lumbar spine. The Board is bound by this favorable finding. As such, the chief question for the Board is whether the Veteran's low back disability was caused or aggravated by his service-connected bilateral knee conditions. To that end, the Veteran submitted an April 2019 private medical opinion from Dr. M.L., his chiropractor, which stated that his low back disability was at least as likely as not a result of his bilateral knee condition. More specifically, Dr. M.L. stated that the Veteran's knee pain was a direct result of his military service and, upon learning of his progressively worsening back pain, she believed that his back pain was directly correlated with his knee pain. She stated that, as a chiropractor, she has studied many cases where patients have lower extremity problems and then later develop low back problems as a direct result of their lower extremity issues. Citing findings of numerous peer-reviewed healthcare journals, Dr. M.L. reported that studies had proven that back pain developed as a result of compromised lower extremity mechanics, which caused pain and eventual degenerative joint disease. Additionally, she explained, the altered gait associated with the knee is directly suggestive of altered biomechanics, which lead to low back pain over time. She also stated that biomechanical problems with either the back or the knee can directly influence the other body part, because the musculoskeletal, nerve, and vascular structures of the body serve an open chain circuit to both the back and knee. After indicating that she had reviewed the Veteran's health records and evidence-based research, she opined that his low back pain was directly related to his service-connected knee problems. The Board finds Dr. M.L.'s opinion to be thorough, based on a review of the Veteran's health records, and supported by medical literature. As a chiropractor, she is competent to render an opinion on the etiology of his low back condition, and her opinion is supported by a detailed rationale. As such, the Board finds that her opinion is entitled to significant probative weight. The Board acknowledges that the record contains negative nexus opinions from November 2018 and June 2019 VA medical examiners. Nonetheless, the Board finds that these medical opinions are entitled to little, if any, probative weight. For instance, the November 2018 VA examiner stated that there was no medical evidence that the Veteran's knee condition could cause his back condition because the knee and back conditions were separate, distinct conditions, and his degenerative arthritis was related to the normal aging process. In rendering this opinion, however, the November 2018 VA examiner failed to address whether the knee condition aggravated the back condition. An adequate medical opinion regarding secondary service connection must address causation and aggravation separately. See El Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (indicating that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b)). Moreover, the November 2018 VA examiner declined to address the Veteran's lay statements regarding the onset of his back pain. An opinion is inadequate if it does not consider all relevant evidence of record, including lay evidence. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Likewise, the June 2019 VA medical opinion states that there was no medical evidence that the Veteran's back issue was at least as likely as not due to or the result, or that it had been permanently aggravated by, his service-connected knee disabilities. The June 2019 VA examiner reiterated that the back and knee conditions were separate and distinct conditions, and that "significant gait disturbance" was noted in the medical record that would have been anticipated to cause a chronic back condition. Notably, the June 2019 VA examiner addresses Dr. M.L.'s April 2019 nexus opinion. However, the June 2019 VA examiner's opinion is also flawed. To that end, the examiner states that Dr. M.L.'s opinion is "mere speculation" with "no significant medical evidence" to support it but does not explain why this is so. An opinion that is conclusory or that does not provide a sufficiently detailed rationale is inadequate. Stefl v. Nicholson, 23 Vet. App. 320 (2007). Furthermore, the June 2019 VA examiner states that there was no significant gait disturbance in the Veteran's medical record but declined to address medical evidence showing that the Veteran had an antalgic gait, such as a September 2010 VA examination report. An opinion based on an inaccurate factual premise is entitled to no probative weight. Reonal v. Brown, 5 Vet. App. 458 (1993). Last, although the VA examiner nominally addressed whether the Veteran's back condition had been aggravated by his knee disabilities, the VA examiner applied the wrong standard regarding aggravation. In this regard, the examiner opined that the Veteran's back condition was not permanently aggravated by his knee disabilities. As the Court of Appeals for Veterans Claims recently ruled, however, aggravation need not be permanent for secondary service connection to be granted. Ward v. Wilkie, 31 Vet. App. 233 (2019) (holding that 38 C.F.R. § 3.310(b) does not require for there to be permanent worsening of a disability, but rather that there has been worsening, no matter how incremental, beyond the natural progression of the condition). Accordingly, the probative value of the November 2018 and June 2019 VA medical opinions is minimal at best. Dr. M.L.'s medical opinion, on the other hand, is more probative. Resolving all reasonable doubt in favor of the Veteran, the Board finds that the evidence indicates that his low back disability at least as likely as not resulted from his service-connected knee disabilities. As such, service connection is granted. M. Tenner Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E. Rademacher, Associate 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.