Citation Nr: 21024348 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 18-14 701 DATE: April 22, 2021 ORDER Entitlement to service connection for a lumbar spine disability as secondary to a service-connected right knee disability is granted. FINDING OF FACT The Veteran’s lumbar spine disability is proximately due to, or aggravated by his service-connected right knee disability. CONCLUSION OF LAW The criteria for service connection for lumbar spine disability as secondary to right knee disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from April 1968 to March 1969.  This matter comes before the Board of Veterans’ Appeals (Board) on appeal from the January 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran initially filed a claim for right knee disability, left knee disability secondary to right knee disability, and lumbar spine disability. In response to the January 2016 rating decision denying service connection for the three disabilities, the Veteran filed a notice of disagreement in September 2016 which appealed only the right knee and spine disabilities. The Board remanded the claim of right knee disability and lumbar spine disability in December 2019 and October 2020 as the issue of lumbar spine disability was inextricable intertwined with the right knee claim. In December 2020, the AOJ granted service connection for right knee disability, leaving the issue of lumbar spine disability as the only issue on appeal. The Veteran testified before the undersigned Veterans Law Judge in a May 2019 Board videoconference hearing, the transcript of which is included in the record. The Board has limited the discussion below to the relevant evidence required to support its findings of fact and conclusions of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record.  See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016).     Service Connection – Pertinent Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Only chronic diseases listed under 38 C.F.R. § 3.309(a) are entitled to the presumptive service connection provisions of 38 C.F.R. § 3.303(b). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted on a secondary basis for a disability which is proximately due to, aggravated by, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to establish service connection on a secondary basis, there must be (1) evidence of a current disability (2) evidence of a service-connected disability; and (3) medical evidence establishing a link between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material favorable to the claimant. Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990).  Competency of evidence differs from weight and credibility.  Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted.  Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994).   When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Analysis The Veteran contends that his lumbar spine disability manifested as a result of his antalgic gait stemming from his right knee disability. As an initial matter, the Veteran has been diagnosed with degenerative arthritis of the lumbar spine and lumbar spine spondylosis without myelopathy. See January 2021 VA Examination Report; April 2015 VA Treatment Record. Moreover, the Veteran was granted service connection for his right knee disability. Therefore, the Veteran meets the first and second elements for a claim for secondary service connection. Therefore, the claim hinges on whether there is competent evidence of a nexus between his current disability and the service-connected disability. Turning to the evidence, in a June 1997 private report related to a 1996 employment-related injury, Dr. D.F.F. stated that the Veteran had sensitivity in the right sacroiliac joint area, and with his continued symptoms, he requested an magnetic resonance image (MRI) of the left knee, right hip, and sacroiliac joint to rule-out degenerative, arthritic disease of the right hip and sacroiliac joint area. In another narrative report in September 1997, Dr. D.F.F. stated that both his right hip and sacroiliac joint were involved with increased discomfort which had developed over the last several months, which Dr. D.F.F. believed was secondary to putting more pressure on his left lower extremity for pivoting, twisting and stress motions because of his constant right lower extremity and sacroiliac joint involvement. See September 1997 Private Treatment Record. A September 2006 private treatment record noted that the Veteran had an antalgic gait, with positive single-leg hop. See September 2006 Private Treatment Record. An April 2010 private MRI scan revealed evidence of moderately advanced degenerative disc disease with loss of height and signal in the L2-3, L3-4, and L4-5 discs with slight diffuse disc bulging at all three levels and hypertrophic osteoarthritis in the apophyseal joints but no focal disc protrusion. See April 2010 Private MRI. In an April 2015 VA pain clinic note, the Veteran reported mid-low back pain for several years starting in the 1990s due to bilateral knee issues/pain and described the pain as constant and shooting. He was diagnosed with bilateral lumbar facet syndrome and lumbosacral spondylosis without myelopathy. See April 2015 VA Treatment Record. The Veteran was provided a VA examination for compensation purposes in December 2015 for his lumbar spine disability. The examiner found the service treatment records (STRs) did not indicate a primary right knee disability that could be considered to be orthopedic in nature and his lumbar spine disability was noted to be degenerative in nature and long after service and was far more likely related to a combination of age and wear and tear over the course of his civilian career. The examiner further stated that it would require speculation in any account to determine that any particular right knee injury would secondarily lead to a degenerative osteoarthritis or disc disease in the lumbar spine. However, the examiner did opine that the Veteran’s current lumbar spine diagnoses are not related in any way to his right knee cellulitis. In a June 2016 buddy statement, the spouse of the Veteran’s neighbor stated that she had known the Veteran since 1975 and she saw him limping and his gait seemed to suffer on and off. In December 2016 correspondence to VA, the Veteran stated that he inquired with a VA orthopedic surgeon regarding the relationship between his right knee and his lumbar spine, to which the VA orthopedist responded it was possible. The Veteran also asked the VA physician who performed his lumbar and cervical spine injections of the relationship between his right knee and lumbar spine and the VA physician stated that an altered gait could have led to shifting the hips out of alignment which could result in back and spinal issues. See December 2016 Correspondence to VA. A November 2018 VA treatment record noted the Veteran presented with a history of chronic low back pain, possibly caused by chronic inflammatory responses from muscle imbalances and abnormal arthrokinematics, which could cause muscular guarding and restrictive circulation in the thoracic and lumbar spine resulting in the pain the Veteran was experiencing. See November 2018 VA Treatment Record. In a May 2019 private medical opinion, Dr. P.A.M., an internist who treated the Veteran from October 2017 to November 2018, opined the Veteran’s chronic back pain was undoubtedly the result of chronic biomechanical imbalance stemming from his right knee pain. See May 2019 Private Medical Opinion. Another private medical opinion was provided by Dr. P.A.M. in February 2020, which stated the Veteran has chronic back issues resulting from biomechanical imbalance stemming from chronic right knee arthritis that began in 1968. See February 2020 Private Medical Opinion. A VA medical opinion was again obtained in January 2021. The examiner noted the report of an antalgic gait and that he favored his right side but found no evidence of a leg length discrepancy causing a Trendelenburg gait to which to opine that the Veteran’s lumbar degenerative arthritis was due to the right knee. Instead, the examiner found the records supported a disc bulge and spondylosis, or age-related wear and tear. In addition, the examiner found the February 2014 imaging showed a partially lumbarized S1, which was congenital and resulted in a shorter distance between the facet and sacral promontory, and according to medical research, “lumbosacral transitional vertebrae (LSTV) are increasingly recognized as a common anatomical variant associated with altered patterns of degenerative spine changes.” Therefore, the examiner opined that his lumbar spine disability was not related to his right knee disability. See January 2021 VA Examination Report. In a March 2021 private medical opinion, Dr. C.F.S, a Doctor of Chiropractic, opined that the Veteran’s chronic low back pain was a result of a chronic imbalanced gait due to the service-connected right knee injury. Dr. C.F.S. further explained that a compromised lower extremity injury could cause altered biomechanical function to the lumbar spine resulting in chronic long-term deterioration. See March 2021 Private Medical Opinion. In his May 2019 Board hearing, the Veteran testified that he left Camp Lejeune with an abnormal gait which persisted since then; that his right knee led to back problems; he has good days and bad days with his abnormal gait; and he would need to walk different when his knee bothered him. See May 2019 Hearing Transcript, page 18, 19, 21. On review of the evidence, both lay and medical, and providing the Veteran with the benefit of the doubt, the Board finds that the preponderance of the evidence weighs in favor of a nexus in this case. Evidence against the claim includes the December 2015 and January 2021 VA opinions. However, the December 2015 VA medical opinion is contradictory. The examiner, despite stating it would require speculation to determine if the right knee injury would lead to a degenerative osteoarthritis or disc disease in the lumbar spine, opined unequivocally there was no relation. As such, the Board assigns the opinion no probative value. The Board finds the January 2021 VA opinion with regard to causation adequate and probative. However, to the extent that it did not address whether the lumbar spine was aggravated by the right knee disability, it is inadequate. See El-Amin v. Shinseki, 26 Vet. App. 136 (2012). Evidence in support of the claim includes the May 2019, February 2020 and March 2021 private medical opinions. Both Dr. Dr. P.A.M. and Dr. C.F.S. provided statements in support of the claim, reasoning that the biomechanical imbalance stemming from the Veteran’s right knee caused his chronic back pain. Both medical opinions are competent and supported by reasoning. The Board has also considered the statements from Dr. D.F.F.’s to the effect that the Veteran’s sacroiliac sensitivity was related to the disability in the right knee. While the narrative reports were related to a workers’ compensation claim, his recommendations were for treatment of disabilities related to his injured right knee. Although no reasoning was provided, the statement tends to lean in favor of the claim and is supportive of the other private medical opinions of record. The Board also considered the Veteran’s lay statements and testimony about the onset, duration, and severity of his low back pain. The Veteran, while not competent to opine to the etiology of his lumbar spine disability, is competent to relay observable symptoms, such as his abnormal gait began upon separation from service, that his low back began to hurt a few months after separation from service, and that he would change his walk when his knee was painful. The Board finds his statements competent and credible. Moreover, his medical records, both VA and private, support his report of intermittent antalgic gait. For the foregoing reasons, the Board finds that the preponderance of the evidence is in favor of the service connection claim for a lumbar spine disability on a secondary basis. Accordingly, the appeal is granted. S. B. MAYS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Moldawer, 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.