Citation Nr: 21077350 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 18-20 365 DATE: December 29, 2021 ORDER Entitlement to service connection for thoracolumbar strain (lumbar spine disability) secondary to bilateral knee disabilities, on a causation basis, is granted. Entitlement to service connection for right hip strain, secondary to bilateral knee disabilities, on a causation basis, is granted. Entitlement to service connection for irritable bowel syndrome (IBS) with urinary incontinence, secondary to lumbar spine disability on a causation basis, is granted. REMANDED Entitlement to service connection for right big toe disability is remanded. FINDINGS OF FACT 1. The evidence is at least evenly balanced as to whether the Veteran's lumbar spine disability was caused by his service connected bilateral knee disabilities. 2. The evidence is at least evenly balanced as to whether the Veteran's right hip strain was caused by his service connected bilateral knee disabilities. 3. The evidence is at least evenly balanced as to whether the Veteran's IBS with urinary incontinence was caused by his now service connected lumbar spine disability. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for lumbar spine disability secondary to service connected bilateral knee disabilities, on a causation basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. 2. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for right hip strain secondary to service connected bilateral knee disabilities, on a causation basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. With reasonable doubt resolved in favor of the Veteran, the criteria for entitlement to service connection for IBS with urinary incontinence secondary to service connected lumbar spine disability, on a causation basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1970 to April 1972. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) which denied service connection for lumbar spine disability, right hip strain, IBS, and right big toe disability. The Veteran filed his notice of disagreement in October 2013, was issued a statement of the case in February 2018, and in April 2018 perfected his appeal to the Board. In September 2021, the Veteran appeared at a virtual Board hearing before the undersigned Veterans Law Judge. A copy of the transcript is of record. SERVICE CONNECTION Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, air, or space service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for disability proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (b). Lumbar Spine, Right Hip, and IBS with Urinary Incontinence The Veteran's wife testified that the Veteran has severe back pain and has to sleep with pillows under his back, and a towel around his neck. She stated that she believes his back pain is related to his knee pain and has worsened over the years. The Veteran's wife testified that the Veteran's right hip strain is due to his right knee disability. She stated that he cannot walk or exercise due to his hip pain, and that the pain would make it difficult for the Veteran to work. The Veteran's wife stated that the Veteran has a restricted diet due to IBS, and wakes up several times in the night to go to the bathroom. She stated that the Veteran's private physician indicated that the IBS and urinary incontinence were due to his back disability. A January 1995 letter from the Veteran's private physician reflects that the Veteran reported intestinal problems, but fewer problems with bladder function. A June 2011 letter from the Veteran's physician Dr. D. Jockers indicates that the Veteran's spinal issues may likely have been caused by a surgical problem which occurred on his left knee in 1971. The physician stated that the Veteran has been under his care for the last 3 months for spinal issues, and explained that the body is designed to operate with a kinetic chain that links one joint to another, thus when lower extremity injuries occur, they often lead to injuries at more proximal regions along the kinetic chain. He stated that a knee injury can commonly cause abnormal pelvic posturing that can be further enhanced with improper gait mechanics, and that his process can then lead to a compensatory curvature in the lumbar region. The physician reported that the Veteran's right hip has shifted anterior and that he has a mild left lumbar scoliosis which seems to suggest that his left knee injury may have caused the right knee to alter its gait pattern which could have created an anteriorly rotated right hip and compensatory scoliosis formation. The physician added that poor spinal biomechanics in the lumbo-pelvic region often creates abnormal function in the nervous system, causing abnormal healing and organ function. He stated that the nerve supply in the lower back region ties into the bowels and prostate among other areas. The physician noted that the Veteran has suffered with IBS and frequent urination over the last 30 years, therefore the Veteran's back disability may have contributed to his IBS and frequent urination. July 2012 private medical treatment records reflect a diagnosis of active IBS, and the Veteran denied incontinence and urinary frequency. In a January 2013 letter, the Veteran's spouse reported that the Veteran has been told by a number of chiropractors that his problems with his knees have negatively impacted his gait causing his spinal column to get out of proper alignment, and that this improper alignment has triggered right hip problems. She also stated that the Veteran suffers with IBS which causes intestinal pain, spasm, and irritation, and prevents him from eating many kinds of foods. May 2013 private treatment records reflect a diagnosis of lumbar subluxation. An August 2013 disability benefits questionnaire (DBQ) reflects that the Veteran has a diagnosis of thoracolumbar strain with the Veteran reporting that it began after his meniscectomy. The Veteran also reported frequent urination and irritable bowel. The examiner opined that the Veteran's lumbar spine disability was less likely than not (less than a 50 percent probability) due to his serviced connected disability, stating that there is no documented medical record of examination supporting the Veteran's claimed condition. He stated that the lumbar spine disability diagnosed is less likely than not related to the post-operative knee condition as there is no direct pathophysiology between the two conditions. He also noted that there is no specialist evaluation to support the claim, nor any documented treatment for the condition supporting the etiology. Another August 2013 DBQ reflects a diagnosis of right hip strain with the Veteran reporting onset of symptoms in 1970. The examiner opined that the Veteran's right hip strain was less likely than not incurred in, or caused by an in-service event, injury, or illness, and less likely than not proximately due to, or the result of his service connected knee disability. The examiner stated that there was no documented medical examination of record to support the claimed condition, and that there is no direct pathophysiology between the Veteran's knee condition and hip strain. The Board notes that in this opinion, the examiner erroneously opined as to the Veteran's lumbar spine disability, but based on the context of the DBQ, the examiner intended to opine as to the Veteran's right hip strain. A separate August 2013 DBQ reflects that the Veteran does not have a diagnosis of an intestinal condition, but he reported a diagnosis of spastic colon from January 1977, with symptoms he states began in 1974 or 1975. The Veteran reported taking probiotics to treat his intestinal condition. The physician reported that there is no diagnosis as there is no pathology to render a diagnosis. The examiner opined that the Veteran's intestinal disability was less likely than not (less than a 50 percent probability) incurred in, or caused by service, or proximately due to, or the result of his service connected lumbar spine disability. The examiner stated that there is no medical evidence to support the claim. A final August 2013 DBQ reflects that the Veteran has been diagnosed with a condition of the bladder, or urethra of the urinary tract. The examiner reported a diagnosis of chronic kidney disease/renal insufficiency that is at least as likely as not a complication of hypertension and diabetes mellitus. The Veteran reported that his condition began in 1971 and became worse after knee surgery. He reported current symptoms of frequent urination. The examiner noted that there is no diagnosis of urinary incontinence as there is no pathology to render a diagnosis. The examiner opined that the Veteran's urinary tract disability was less likely than not (less than a 50 percent probability) incurred in, or caused by the claimed in-service injury, event, or illness, or proximately due to, or the result of the Veteran's service connected lumbar spine disability, stating that there is no medical evidence to support the claim. In an undated letter, the Veteran's nephew, a physician and nurse, stated that the Veteran's 1971 meniscectomy negatively affected the Veteran's gait and damaged his other knee. He reported that the Veteran's chiropractor explained that a misaligned spine has a negative impact on the nerves that run through the spinal column to the organs and tissues, and as a result, the Veteran can experience urinary incontinence and intestinal problems. For the following reasons, the Board finds the evidence at least evenly balanced that entitlement to service connection for lumbar spine disability, and right hip strain secondary to bilateral knee disabilities, and IBS with urinary incontinence secondary to lumbar spine disability is warranted. While the August 2013 DBQs indicate that the Veteran's lumbar spine, right hip, and IBS with urinary incontinence are less likely than not due to service connected disabilities, the examiner concluded that there is no direct pathophysiology between a right hip strain or lumbar spine disability, and a knee condition, and based his opinions as to all three disabilities primarily on a lack of medical documentation which is an impermissible basis upon which to find that the disabilities are not related to a service connected disability. Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). The opinions are thus afforded little probative value. Alternately, the Veteran's private treating physician Dr. D. Jockers reported that the Veteran's lumbar spine and right hip issues may likely have been caused by his knee disabilities. He also explained how the Veteran's IBS with urinary incontinence may be related to his lumbar spine disability. The private physician provided a thorough rationale to support his findings based on an accurate characterization of the evidence stemming from providing treatment to the Veteran for months. Therefore, his opinion is afforded significant probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Additionally, the Veteran's nephew, a medical professional, reiterated the Veteran's private physician's conclusion that a back misalignment can cause urinary incontinence and intestinal problems, and the Veteran's spouse relayed that a number of contractors have indicated that the Veteran's knee issues could cause his back disability, which could then cause hip issues. The Veteran's spouse is competent to relate what was told to her by medical professionals regarding a nexus, and there is no indication that she lacks credibility. Jandreau v. Nicholson, 492 F. 3d 1372, 1377, n.4 (Fed. Cir. 2007). There are both positive and negative medical nexus opinions of record, with the private physician's opinion being afforded more probative weight considering the thorough rationale provided. The evidence is thus at least evenly balanced as to whether the Veteran's lumbar spine disability and right hip strain were caused by his service connected knee disabilities, and whether his IBS with urinary incontinence were caused by his lumbar spine disability. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for lumbar spine disability and right hip strain secondary to bilateral knee disabilities, and IBS with urinary incontinence secondary to lumbar spine disability, each on a causation basis, is warranted. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. REASONS FOR REMAND In a July 2012 letter, the Veteran reported irritation, aches, soreness, and pain in his right big toe. He stated that the weakness of his left knee and ankle causes him to overwork and overuse his right knee, negatively affecting his right knee and right big toe, causing deterioration and degeneration. Unfortunately, the Board cannot make a fully informed decision on the issue of entitlement to service connection for right big toe disability because no VA examiner has opined whether the Veteran's disability is related to his service connected bilateral knee disabilities. VA must provide a medical examination or obtain a medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing that certain diseases manifested during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran's service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006); see also 38 U.S.C. § 5103A (d)(2) (2012); 38 C.F.R. § 3.159 (c)(4)(i) (2018). The third prong, which requires that the evidence of record "indicate" that the claimed disability or symptoms "may be" associated with the established event, disease, or injury, is a low threshold. McLendon, 20 Vet. App. at 83. The Veteran has provided competent lay evidence of persistent or recurrent symptoms of a disability as he has reported aches, soreness, and pain in his right toe, and has indicated that his pain may be associated with his service connected knee disabilities. As the evidence is insufficient to make an informed decision on the claim, a remand for a medical opinion is warranted. The matter is thus REMANDED for the following action: Obtain an opinion from an appropriate clinician to determine the nature and etiology of the Veteran's right big toe disability. If an examination is deemed necessary, one should be conducted, to include via telehealth if feasible. The clinician should opine as to whether the Veteran's right big toe disability is at least as likely as not (at least a 50 percent probability) either (a) caused or (b) aggravated by his service connected bilateral knee disabilities. If aggravation is found, the baseline level of disability should be identified to the extent possible. The clinician is advised that the Veteran is competent to report symptoms and treatment, and these reports must be considered when formulating the requested opinion. All opinions expressed must be accompanied by a complete rationale. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Maddox, 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.