Citation Nr: 21068917 Decision Date: 11/15/21 Archive Date: 11/15/21 DOCKET NO. 16-08 515 DATE: November 15, 2021 ORDER Entitlement to service connection for a lumbar spine condition, to include as secondary to service-connected bilateral knee conditions, is granted. FINDING OF FACT The Veteran's lumbar spine condition is secondary to his service-connected bilateral knee conditions. CONCLUSION OF LAW The criteria for entitlement to service connection for a lumbar spine condition, to include as secondary to service-connected bilateral knee conditions, 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 had active duty service in the United States Air Force from July 1980 to February 1991. In March 2021, the Board remanded the above issue for additional development. The case has since returned to the Board for appellate review. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. To establish entitlement to service-connected compensation benefits, 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may be granted for any disease initially diagnosed after service 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). For veterans with 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases, including organic diseases of the nervous system such as sensorineural hearing loss, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. Pursuant to 38 C.F.R. § 3.303(b), where a chronic disease such as sensorineural hearing loss is shown as such in service, subsequent manifestations of the same chronic disease are generally service connected. If a chronic disease is noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required. Entitlement to service connection based on chronicity or continuity of symptomatology pursuant to 38 C.F.R. § 3.303(b) applies only when the disability for which the Veteran is claiming compensation is due to a disease enumerated on the list of chronic diseases in 38 U.S.C. § 1101(3) or 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for a lumbar spine condition, to include as secondary to service-connected bilateral knee conditions, is granted. The Veteran alleges that his currently diagnosed lumbar spine condition is caused by his service-connected bilateral knee disabilities. He contends that he has had significant low back pain after his knees locked up and he fell in December 2007 or January 2008. See September 2009 Physical Therapy Consult; see also March 2010 VA examination report. Additionally, the Veteran contends that his gait, combined with weight gain due to his service-connected knee and ankle conditions, caused or aggravated his back problems and that he did not have any back issues until he had knee and ankle issues. See February 2016 Form 9. The Board agrees that entitlement to service connection for a lumbar spine condition secondary to service-connected bilateral knee disabilities is warranted. Since service connection is being granted on this theory of entitlement, the Board will not address any other theories of service connection. At the outset, there is no dispute that the Veteran has a current lumbar spine disability. See November 2010 Lumbar Spine MRI; see also January 2013 Back (Thoracolumbar Spine) Conditions Disability Benefits Questionnaire. Indeed, at the January 2013 VA examination, he was specifically diagnosed with degenerative disc disease and osteoarthritis of the spine, with muscle spasms. Therefore, the first element of service connection, a diagnosis, has been met. Additionally, the Board notes that the Veteran is service connected for bilateral knee disabilities. Thus, this element of secondary service connection is met. Turning to a nexus, the record contains VA opinions in March 2010, January 2013, and June 2021 that all conclude that the Veteran's lumbar spine condition is less likely than not (less than 50 percent probability) proximately due to, the result of, or aggravated beyond its normal progression by any of the Veteran's service-connected disabilities. In March 2010, the VA examiner concluded that the Veteran's lumbar spine condition is not caused by or related to his bilateral knee condition, as there is no nexus with which to connect these conditions. However, no rationale was offered in support of this conclusion. See March 2010 VA examination. As a result of a January 2013 VA examination, the VA examiner opined that Veteran's back conditions are not secondary to his service-connected right and left knees as there is no anatomic or physiologic basis by which to connect the conditions. The VA examiner then offered remarks detailing the history of the Veteran's back condition. See January 2013 VA examination. In June 2021, the examiner concluded that the Veteran's lumbar condition was less likely than not proximately due to, the result of, or aggravated beyond its natural progression by any of his service-connected conditions. Specifically, the June 2021 VA examiner concluded that the Veteran's lumbar spine condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected disabilities, to specifically include his bilateral knee disabilities based on altered gait or overcompensation. The examiner reasoned that there is a lack of information in the evidence and medical literature to support the theory that his lumbar condition was aggravated beyond its natural progression by his service-connected bilateral knee disabilities based on altered gait or overcompensation. The examiner was unable to establish a nexus with current available evidence. As to the relationship between the Veteran's lumbar spine condition and the Veteran's right knee disabilities, the June 2021 VA examiner concluded that the Veteran's lumbar spine condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected residuals of right knee surgery. The examiner reasoned that there was a lack of information in the evidence of record and medical literature to support a direct causal relationship between the Veteran's lumbar spine condition and residuals of right knee surgery. There was also a lack of medical evidence to support pain and arthritis in one area causing pain or arthritis in another area. Therefore, the June 2021 VA examiner concluded that a nexus has not been established. The examiner also concluded that the Veteran's lumbar spine condition was not aggravated beyond its natural progression by his service-connected residuals of right knee surgery. The examiner reasoned that there is a lack of information in the evidence of record and medical literature to support the theory that his lumbar condition was aggravated beyond its natural progression by his service-connected residuals of right knee surgery. Therefore, the Veteran was unable to establish a nexus with the current available evidence. The June 2021 VA examiner also concluded that the Veteran's lumbar spine condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition of degenerative joint disease, right knee. The examiner reasoned that there was a lack of information in evidence and medical literature to support a direct causal relationship between the Veteran's lumbar spine condition and degenerative joint disease, right knee (flexion). There was also a lack of medical evidence to support pain and arthritis in one area causing pain and arthritis in another area. Therefore, the examiner was unable to establish a nexus with the available evidence. The examiner also concluded that the Veteran's lumbar spine condition was not aggravated beyond its natural progression by his service-connected connected degenerative joint disease of the right knee. The examiner reasoned that there was a lack of information in evidence of record and medical literature to support the theory that his lumbar condition was aggravated beyond its natural progression by his service-connected degenerative joint disease of the right knee. The examiner was unable to establish a nexus with current available evidence. The June 2021 VA examiner then concluded that the Veteran's lumbar spine condition is less likely than not (less than 50 percent probability) proximately due to or the result of Veteran's service-connected right knee replacement. The examiner reasoned that there is a lack of information in the evidence to support a direct causal relationship between the Veteran's lumbar spine condition and the Veteran's right knee replacement. The examiner noted that there is no clear evidence from a review of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis, or shortening of the injured limb resulting in length discrepancy of more than 5cm so that the individuals gait pattern has been altered to the extent that clinically there is an obvious Trendelenburg gait. Therefore, the examiner was unable to establish a nexus with current available evidence. The June 2021 VA examiner also concluded that the Veteran's lumbar spine condition is less likely than not (less than 50 percent probability) proximately due to, the result of, or aggravated beyond its natural progression by the Veteran's service-connected total right knee replacement. The examiner reasoned that there is a lack of information in evidence and medical literature to support that his lumbar condition was aggravated beyond its natural progression by the service-connected total right knee replacement. There was also a lack of medical evidence to support the theory that his right knee pain led to lower back pain. The examiner was therefore unable to establish a nexus with current available evidence. The Board finds the March 2010, January 2013, and June 2021 opinions inadequate. The Board notes that the March 2010, January 2013, or June 2021 opinions address the December 2011 and October 2012 opinions, discussed in greater detail below, that link the Veteran's lumbar spine condition to his service-connected bilateral knee disabilities. In addition, while the March 2010 and January 2013 VA opinions were provided following an examination of the Veteran and review of the evidence of record, the Board notes that the March 2010 and January 2013 VA examiners did not provide any rationale regarding their conclusions that the Veteran's lumbar spine disability was not related to his bilateral knee condition. As no rationale was provided to rebut the Veteran's contentions, the Board finds the Marcy 2010 and January 2013 VA opinions inadequate. As to the June 2021 VA opinions regarding secondary service connection, the June 2021 VA examiner based the opinions primarily on a lack of documented medical evidence and, as such, is inadequate. See Buchannan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) (finding that the VA examiner's conclusion was improperly predicated on a lack of documentation in the medical record). Conversely, the record also contains two opinions in December 2011 and October 2012 in support of his service connection claim. In December 2011, a VA provided opined that the Veteran has myofascial pain in the lumbar back that is likely secondary to altered mechanics due to knee pathology. See December 2011 VA treatment records. In October 2012, the Veteran's private physician stated that he believed with a reasonable degree of medical certainty that the Veteran has developed right hip strain, right lumbar strain, and right trochanter bursitis as direct flow-through injuries related to his right knee osteoarthritis. See October 2012 Statement. While the December 2011 VA provider and October 2012 private physician did not provide additional rationale for their opinions, the Board notes that the providers both based their conclusions following an examination of the Veteran and reviewing his medical records. Accordingly, the December 2011 VA and October 2012 private opinions are probative, as they are based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Given the probative December 2011 and October 2012 opinions, the Board finds that a nexus has been established between the Veteran's lumbar spine condition and his service-connected bilateral knee conditions. As such, service connection for a lumbar spine condition is warranted, and the claim is granted. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. E. Grossman, 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.