Citation Nr: 21008391 Decision Date: 02/16/21 Archive Date: 02/16/21 DOCKET NO. 10-34 247 DATE: February 16, 2021 ORDER Entitlement to service connection for a cervical spine disability secondary to service-connected knee or low back disabilities is denied. FINDING OF FACT The Veteran’s cervical spine disability is not secondary to service-connected bilateral knee and/or low back disabilities and is not otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a cervical spine disability due to service or service-connected disabilities are not met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served from August 1977 to December 1981. This matter is on appeal to the Board of Veterans’ Appeals (Board) from a June 2009 rating decision. The claim was initially claimed as a “back disability,” and the Veteran was granted service connection for a low back disability in a February 2017 rating decision. His claim was subsequently reframed as a cervical spine disability, and he contends that it is secondary to his now service-connected low back disability, or to his service-connected bilateral knee disabilities. The claim was remanded by the Board in August 2012, February 2017, and March 2018 decisions. The Board finds the most recent March 2018 remand directives have been complied with. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. Where a condition is claimed as “secondary” to a service-connected disability, the evidence must show that the condition is proximately due to, or the result of, or aggravated beyond its natural progression by, any service-connected disability or disabilities. 38 U.S.C. §§ 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310 (a). In September 2009 correspondence, the Veteran stated his back problems are due to the pain and adjustment his body must make to accommodate his knees. His pain causes his stride and gait to change, which puts pressure on his back due to improper alignment. In a May 2015 letter drafted by a private physician, Dr. S, it was noted that a May 2009 record shows altered gait mechanics, altered posture, and abnormal stride. Dr. S explained that research finds that walking with a limp or antalgic gait can cause back pain and aggravate pre-existing back pain. Because each type of limp causes exaggerated bending and rotation of the trunk, this could accelerate the aging process and cause back symptoms. Dr. S stated he could say “with certainty the antalgic gait caused by the service-connected bilateral knee conditions aided in the development of permanently aggravate[d] spinal problems.” Medical articles supporting Dr. S’s conclusion were included. The letter does not differentiate between the Veteran’s low back and neck disability. There have been several VA opinions and addendums rendered throughout the pendency of the claim. In an April 2009 VA examination, degenerative disc disease (DDD) of the cervical spine was listed as a diagnosis based on recent X-ray findings. He had full range of motion (ROM). The examiner opined it was less likely than not that the Veteran’s back condition was proximally due to or the result of the bilateral knee condition. He stated his opinion was based on review of the service treatment records (STRs) and the Veteran’s history. Review of the STRs did not show any treatment for back pain, and the Veteran reported onset of back pain 3 to 4 years prior. Another examination was conducted in September 2012; however, it appears to be the same examination report from April 2009. As such, an addendum opinion was obtained from a new examiner in April 2015. The Veteran was not physically examined, but the claims file was reviewed. Regarding the Veteran’s cervical spine disability, the examiner found it was less likely than not related to service or his knee disabilities. He reasoned the STRs showed no treatment for a neck disability, and there is no documentation in chronicity since service. There is no anatomical or biological plausibility to establish a nexus between bilateral knee pain and cervical spine DDD diagnosed decades later. The Veteran was diagnosed with C3-5, C6-7 DDD in April 2009; the examiner explained this is consistent with the expected normal age-related changes of the spine in a then 51-year-old male. There was also no documentation of aggravation beyond natural progression. A new in-person VA examination was conducted in August 2017. The listed diagnoses were cervical strain and myofascial pain syndrome. The Veteran reported his neck pain began 10 to 15 years prior that gradually worsened. He stated that certain movements in the back, such as twisting his trunk, will aggravate his neck. Pain on movement with abnormal ROM was indicated; there was no abnormal gait or abnormal spinal contour. He reported using a brace occasionally and a cane. The examiner opined the cervical disability was less likely than not related to service. She determined there was a baseline severity prior to aggravation, as the Veteran reported a 4 to 5 out of 10 pain level that increases to a 5 to 6 out of 10 with twisting movements of the back. Thus, she concluded it was at least as likely as not that the cervical disability was aggravated beyond natural progression by the back because twisting the back increases the pain. An addendum opinion was obtained in February 2018 to clarify whether the opinion was supported by the medical evidence rather than only the Veteran’s statements. The Veteran was re-interviewed for this opinion. The examiner indicated there are trigger points in the medical evidence, albeit temporary if treated, that show palpation can radiate up to the neck. She indicated there seemed to be a relation to the lower back. Another addendum opinion was obtained in March 2018 to request identification of the date aggravation existed, if aggravation is indeed found, and also provide a clear statement on whether it is at least as likely as not that the Veteran’s cervical spine disability is caused by the back or knee conditions. The examiner stated it was less likely than not that the neck disability is caused by the back or knee disabilities given the history, review of the files, and physical examination. As to aggravation, the examiner stated that per medical evidence, back aggravating neck symptoms did not seem to be permanent. VA examination by a new examiner was conducted in December 2018. The listed diagnosis was cervical strain. The Veteran reported intermittent pain and stiffness that increased with extreme cold or heat. He had normal ROM and no abnormal gait or spinal contour. The examiner stated there were no objective signs of a permanent neck disability, only subjective data from the Veteran supporting a neck condition that is intermittent. On examination, the Veteran was able to perform ROM without pain. According to the Veteran, the day of examination was a good day as he was not having a flare-up; when he experiences a flare-up, he cannot turn his neck. The examiner concluded the Veteran’s claimed cervical disability was less likely than not related to service or his back and knee disabilities. According to the examiner, objective examination is normal and symptoms were only subjective. The examiner also noted conflicting statements from the Veteran, first reporting a neck disability 10 to 15 years ago and at the examination reporting 5 to 6 years ago. Neck symptoms appeared to be temporary rather than permanent. As the examiner’s opinion that there was no objective evidence of a cervical spine disability conflicted with objective X-ray findings of DDD of the cervical spine, the examiner was asked to provide an addendum opinion in August 2020. The examiner clarified that although there were no objective findings on the date of examination, the Veteran stated the pain was intermittent and chronic, and this is consistent with chronic treatment in the medical records and a previous X-ray supporting a diagnosis of DDD of the cervical spine. Therefore, the examiner opined that the increased manifestations of neck strain are due to the low back disability. She provided definitions of back pain and neck pain from a Johns Hopkins website. She opined there is no medical evidence supporting a connection between the knee disabilities and the neck condition, as they are completely separate conditions. Finally, she opined there is no direct connection to service as the Veteran’s complaints started over 30 years after service. Due to the lack of rationale supporting her opinion regarding the neck and back nexus, another addendum opinion was obtained in September 2020. Additionally, she was asked to opine on additional functional limitation after repetitive use over time and during flare-ups. The examiner stated her estimation of decreased ROM under such conditions, and again stated that the cervical spine was normal on the date of examination. According to the examiner, the diagnosis of cervical strain is derived only from subjective data. She did not clarify her nexus rationale. A final addendum opinion was obtained by a new VA examiner in November 2020. The examiner reviewed the claims file prior to rendering her opinion. Regarding a diagnosis, the examiner clarified that the correct diagnosis should be DDD, which was confirmed by X-ray in 2009. She noted that DDD can certainly cause intermittent spasms and strain in the neck; thus, the previous diagnosis of cervical strain can be confirmed as manifestation of his underlying DDD diagnosis. Regarding causation or aggravation due to the back or knees, the examiner explained that DDD of the cervical spine is, by definition, a degenerative process due to wear and tear over time. Degeneration of the joints develop independently. Though the Veteran may have degeneration in other joints, the degeneration does not cause or affect the degenerative process in other joints. Further, mechanics associated with the Veteran’s knees and back do not establish a persistently abnormal gait or alignment that would in any way affect the alignment or progression of cervical disorder (the Veteran’s gait is repeatedly documented as normal in the records with only periodic abnormal gait). Clinically, the Veteran’s cervical disability has clearly not progressed significantly since 2009, given that his recent examination indicated normal function at baseline, so there is no evidence of aggravation due to any cause. Thus, the Veteran’s back and knee disabilities less likely than not caused or affected his DDD of the cervical spine. In support of her opinion, the examiner included several notations in the records from 2005 to 2018; there were 4 notations of abnormal gait among 10 notations of normal gait. The probative value of medical opinion evidence is based on the medical expert’s personal examination of the patient, the physician’s knowledge and skill in analyzing the data, and the medical conclusion that the physician reaches. Guerrieri v. Brown, 4 Vet. App. 467, 470-71 (1993). Whether a physician provides a basis for his or her medical opinion goes to the weight or credibility of the evidence in the adjudication of the merits. See Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998). Other factors for assessing the probative value of a medical opinion are the physician’s access to the claims folder and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000); Nieves-Rodriguez, 22 Vet. App. 295 (2008). There are several inconsistencies and varying opinions of record. While some opinions seem to suggest a link between the neck and lower back, due to the insufficiencies and inconsistencies between the August 2017 VA examination and the subsequent two addendums, as well as the December 2018 VA examinations and subsequent two addendums, the Board affords the findings in each low probative value. Regarding the April 2015 private opinion by Dr. S, while Dr. S does not refer specifically to the cervical spine, he does indicate that an abnormal gait can cause spinal problems, and he provides medical literature to support this statement. However, while Dr. S states that the abnormal gait caused by the knee disabilities aided in the causation of the spinal disabilities, it is unclear whether this is a probability of 50 percent or greater. On the other hand, while the November 2020 examiner, Dr. W, acknowledged that an abnormal gait can cause or aggravate spinal disabilities, she determined that the evidence did not support this in the Veteran’s case. While neither Dr. S nor Dr. W personally examined the Veteran, the Board affords Dr. W’s conclusion more weight as it is based on several notations throughout the record rather than on one particular record. See Willis v. Derwinski, 1 Vet. App. 66 (1991) (While the conclusions of a physician are medical conclusions that the Board cannot ignore or disregard, the Board is free to assess medical evidence and is not compelled to accept a physician’s opinion). Moreover, not only is Dr. W’s rationale clear and logical, but it is consistent with the evidence of record. Most treatment records indicate a normal gait, but there are indications of an antalgic gait, and the Veteran has stated several times he uses a cane. However, of the records that do indicate an antalgic or abnormal gait, most indicate it is slight or mild. The previous VA examinations found no abnormal gait or spinal contour. Thus, this is consistent with Dr. W’s finding that the evidence does not establish a persistently abnormal gait or alignment that would in any way affect the alignment or progression of a cervical disability. While Dr. W indicates the Veteran’s cervical disability had not significantly progressed since 2009, there is an August 2019 X-ray that shows progression of moderate to severe DDD. However, the same record indicates a non-antalgic gait, and subsequent records throughout 2020 indicate a normal gait. The August 2019 record reflects that the Veteran’s worsening pain is secondary to the cervical spine DDD, which, as Dr. W explains, is an independent degenerative process unrelated to degeneration of other joints. In consideration of all the evidence, the Board finds Dr. W’s opinion to be highly probative. The evidence does not weigh in favor of the Veteran’s claim. While the Board acknowledges the Veteran’s contentions that his neck is related to his back or his neck, there is nothing in the record to suggest he is competent to render a complex medical opinion such as etiology. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Layno v. Brown, 6 Vet. App. 465, 470 (1994) (“Generally, lay testimony is not competent to prove that which would require specialized knowledge or training”). Similarly, while not contended by the Veteran, the evidence weighs against a finding of direct service connection. While the Veteran’s treatment records reflect neck pain, they do not provide evidence bearing on a nexus to service or his service-connected disabilities. In sum, the criteria for entitlement to service connection are not met. The Board has considered the benefit-of-the-doubt rule; however, since a preponderance of the evidence is against the Veteran’s claim, the benefit-of-the-doubt rule is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. L.M. BARNARD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Carroll, 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.