Citation Nr: 21006525 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 10-31 386 DATE: February 4, 2021 ORDER Service connection for a cervical spine disorder is denied. FINDING OF FACT A cervical spine disorder is not caused or aggravated by the Veteran’s service-connected left knee disability. CONCLUSION OF LAW The criteria for service connection for a neck disorder have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1983 to July 1986. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a rating decision issued in November 2010 by a Department of Veterans Affairs (VA) Regional Office. In July 2014, the case was remanded in order to afford the Veteran her requested Board hearing. Thereafter, in January 2018, she testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In April 2018, October 2019, and September 2020, the Board remanded the case for additional development, and it now returns for further appellate review. Entitlement to service connection for a cervical spine disorder, claimed as secondary to service-connected left knee disability. As an initial matter, the Board observes that the evidence does not show, nor does the Veteran contend, that her cervical spine disorder is directly or presumptively related to her military service. See Robinson v. Shinseki, 557 F.3d 1355, 1361 (2008) (claims which have no support in the record need not be considered by the Board as the Board is not obligated to considered “all possible” substantive theories of recovery. Where a fully developed record is presented to the Board with no evidentiary support for a particular theory of recovery, there is no reason for the Board to address or consider such a theory). Rather, the Veteran claims that her service-connected left knee gives out, which has caused her to fall and injury her neck. In this regard, in documents of record and at the January 2018 Board hearing, the Veteran, her spouse, her father-in-law, and friends reported that she fell multiple times in 2009 and 2010, to specifically include in August 2009, September 2009, February 2010, and August 2010. With respect to the fall that occurred in February 2010, the Veteran reported that her left knee gave out and, as a result, caused injury to the cervical spine, thereby causing or aggravating such disorder. Specifically, she stated that her neck disorder became more of a problem and progressively more painful since the February 2010 fall. In this regard, service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303(a), 3.310. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). As an initial matter, the Board finds that evidence of record reflects that the Veteran has a current diagnosis of degenerative disc disease of the cervical spine, as shown by a February 2012 VA examination and VA and private treatment records. She is also service-connected for a left knee disability, characterized as chondromalacia with instability and limitation of flexion and extension of the left knee. Thus, the remaining inquiry is whether the Veteran’s service-connected left knee disability caused or aggravated her cervical spine disorder. In this regard, an August 2009 private treatment record reflects the Veteran’s report of a fall on level ground and a finding of local tenderness to palpation over the left ankle, left foot, right fight, left knee, left iliac crest, pelvis, lower back, left shoulder, face, and anterior neck. A September 2009 private treatment record reveals that the Veteran reported neck pain for three weeks after a fall. Neck pain and myalgia were assessed. A VA treatment record dated the same month reflects the Veteran’s report that she fell at the mall the prior week and injured her left side, shoulder, and neck due to her knee giving out. In March 2010, a private treatment record reflects a diagnosis of cervical degenerative disc disease and, in a contemporaneous record, it was noted that the Veteran complained of neck pain that was cervical in nature and radiated to the back of the head. In this regard, she reported that she first noticed such pain in August 2009, and had experienced three falls since such time that were secondary to knee dislocation. In an April 2010 VA treatment record, the Veteran reported that she fell a few times in August 2009, causing shoulder pain and, in October 2010, she indicated that she experienced left shoulder pain and immobility that had gotten worse since another fall about one month ago. She stated that, after the fall, she noticed numbness and tingling from the neck down the elbow, though this had gotten better. In February 2011, the Veteran reported pain and reduced range of motion in her left shoulder and cervical spine since February 2010. She stated that, in February 2010, her knee buckled, and she broke her fall by catching herself on the car door with her left arm. A June 2013 VA treatment record reflects that the Veteran reported that she had fallen three times in the last five or six years because she was having more problems with the left knee. She stated that she fell twice in 2009 and again in 2010 where she almost dislocated her left shoulder and hurt her left hip, left ankle, back, and jaw. In September 2010, the Veteran was afforded a VA examination so as to determine whether her cervical spine disorder is related to the falls caused by her service-connected left knee disability. At such time, she reported that her neck pain had its onset as a result of a fall that occurred in August 2009. Specifically, the Veteran indicated that her knee gave out and she fell onto a hard floor, injuring her neck, left ankle, left hip, left hand, left wrist, left elbow, and jaw. She further stated that she fell again in August 2010 and injured the same areas. However, the examiner indicated that she could not offer an opinion as to whether the Veteran’s cervical spine disorder was the result of such falls due to her left knee instability without resorting to mere speculation. In this regard, she explained that the Veteran had multiple somatic complaints with little objective evidence. The Veteran was afforded another VA examination in February 2012, at which time, she reported that her left knee gave out in August 2009 and she fell on her side, injuring her neck. She further indicated that she fell and injured her neck again in February 2010 due to her left knee giving out. The VA examiner opined that the Veteran’s cervical spine disorder, diagnosed as mild degenerative cervical spine disease, was less likely than not proximately due to or a result of her service-connected left knee disability. As rationale, she explained that X-rays showed a diagnosis of mild degenerative cervical spine disease, which is age-related and not related to trauma. However, as the February 2012 VA examiner did not offer an opinion as to whether the Veteran’s cervical spine disorder was aggravated by her left knee disability, the Board remanded the claim in April 2018 in order to obtain such an opinion. In April 2019, a VA examiner reviewed the record and opined that the Veteran’s cervical spine disorder was less likely than not aggravated beyond its natural progression by falls due to her service-connected left knee disability. In support thereof, she stated that radiological studies in 2012 revealed only mild degenerative cervical spine disease, which is more related to the natural process of aging rather than a fall due to a knee disorder. The examiner further reported that degenerative cervical spine disease happens over a period of years, and would not happen from a fall from a knee disorder. Thus, she concluded that, after a review of the research literature, there was no causal relationship between a fall due to knee disorder and degenerative cervical spine disease. However, as the examiner’s rationale only addressed causation, the Board again remanded the case in October 2019 in order to obtain another addendum opinion addressing aggravation. In November 2019, a VA examiner reviewed the record and opined that the Veteran’s cervical spine disorder was less likely than not aggravated beyond its natural progression by falls due to her service-connected left knee disability. As a rationale for the opinion, she referenced a September 2010 VA examination and MRI as a baseline for the Veteran’s cervical spine disorder prior to the claimed aggravation and found that, while there had been an increase in the severity of such disorder as evidenced by a July 2013 MRI, such was unrelated to falling secondary to her left knee disability and instead was due to aging and normal wear and tear. The examiner further indicated that she was unable to find medical literature that states that degenerative disc disease of the cervical spine is caused by falls. Finally, she noted the Veteran’s report that her cervical spine disorder became more of a problem and became progressively more painful since a February 2010 fall, but again stated that she was unable to find medical literature that indicates degenerative disc disease of the cervical spine is caused by falling and noted that the 2010 MRI was negative for any signs associated with falling; rather, such only showed degenerative disc disease related to aging and normal wear and tear. However, the September 2010 VA examination and MRI used as a baseline for the severity of the Veteran’s cervical spine disorder prior to the alleged aggravation occurred after most of the Veteran’s falls that she alleges caused or aggravated her cervical spine disorder, to include her most severe fall in February 2010. Furthermore, while the examiner relied upon the cited medical literature for her finding that falls do not cause degenerative disc disease of the cervical spine, she did not address whether falls aggravate such a disorder. Finally, while she cited the Veteran’s report that her cervical spine disorder became more of a problem and became progressively more painful since a February 2010 fall, she did not comment upon it despite being directed to do so in the October 2019 remand. Therefore, in September 2020, the Board again remanded the claim in order to obtain an addendum opinion that adequately addressed whether the Veteran’s cervical spine disorder is aggravated by her left knee disability. In November 2019, a VA examiner reviewed the record and opined that the Veteran’s cervical spine disorder is less likely than not caused by, the result of, or secondary to any falls that she attributes to her service-connected left knee disability, to include those described as occurring in 2009 and 2010 and any subsequent falls. Furthermore, he found that the Veteran’s cervical spine disorder has not been and is not likely to be aggravated by any falls that she attributes to her service-connected left knee disability. In this regard, the examiner observed that the Veteran is service-connected for instability of the knee, but the actual condition is lateral subluxation of the left patella and the actual knee joint (the femoral - tibial joint) is not unstable. He further noted that the Veteran complained of chronic neck and back pain on a February 2010 primary care visit, and an MRI done in September 2010 revealed no acute or trauma related changes; rather, such only showed chronic degenerative changes. Further, intervertebral disc spaces were described as grossly normal, and the findings of disc osteophyte complex with bilateral uncinate degenerative changes at C56 and C67 are the sites that age-associated degenerative changes are found earliest and most commonly. The examiner explained that the natural progression of cervical spine disease is that it typically manifests first in the lower part of the neck and with time progresses in a cephalad direction, which pattern is present in the Veteran as the July 2013 MRI does show progressive enlargement of the disc osteophyte complexes at C5-6, as well as developing facet hypertrophy at more cephalad levels. The examiner further explained that, had a fall caused an injury to the cervical spine, there would be focal changes associated with the injury. The progression, both of the MRI findings and the Veteran’s symptoms, is consistent with the natural progression of the disease. He found that such did not support the Veteran’s contention that her cervical spine disorder is a result of a single, or a series of, acute injuries causing an aggravation to her cervical spine disease. Thus, the examiner opined that the Veteran’s cervical spine disorder was not aggravated by the falls she attributes to her service-connected left knee disability. The Board accords great probative weight to the February 2012 VA examiner’s opinion that the Veteran’s cervical spine disorder is not caused by her service-connected left knee disability, and September 2020 VA examiner’s opinion that her cervical spine disorder is caused by, related to, or aggravated by such service-connected disability. In this regard, such opinions considered all of the pertinent evidence of record, to include the statements of the Veteran and relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). Notably, there is no medical opinion to the contrary. The Board also considered the Veteran’s and other lay statements of record that assert that her cervical spine disorder is caused or aggravated by her service-connected left knee disability, to include as a result of falls caused by such service-connected disability; however, as lay people, they do not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, while the Veteran, her friends, and her family are competent to report that they witnessed instability and falls due to the giving way of the left knee, and her subsequent reports of neck pain, the etiology of her cervical spine disorder, diagnosed as degenerative disc disease, involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, ascertain the etiology of such disorder, to include whether such may be caused or aggravated due to injuries caused by falls, requires knowledge of the spine, to include disc degeneration, and the impact trauma may have on such disorder. Consequently, the etiology of the Veteran’s cervical spine disorder may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Thus, the Veteran’s, her family, and her friends opinions as to the etiology of her cervical spine disorder is not competent evidence and, consequently, is afforded no probative weight. Based on the foregoing, the Board finds that the Veteran’s cervical spine disorder is not caused or aggravated by her service-connected left knee disability. Thus, service connection for such disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim for service connection for a cervical spine disorder. As such, that doctrine is not applicable in the instant appeal, and her claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dawn A. Leung, 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.