Citation Nr: 21027527 Decision Date: 05/06/21 Archive Date: 05/06/21 DOCKET NO. 17-04 907A DATE: May 6, 2021 ORDER Entitlement to service connection for a low back disability, to include as secondary to a service-connected left knee disability is granted. FINDING OF FACT It is as likely as not that the Veteran's low back disability is proximately due to or related to his military service, to include as secondary to a service-connected left knee disability. CONCLUSION OF LAW With resolution of reasonable doubt in the Veteran's favor, the criteria for service connection for a low back disability as secondary to a service-connected left knee disability have been met. 38 U.S.C. §§ 1110, 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 July 1973 to July 1976. A Board of Veterans' Appeals (Board) hearing was held in February 2020 via videoconference. A transcript of the hearing is contained within the claims file. The Board remanded this matter in April 2020 for further evidentiary development. The case returned to the Board for appellate review. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence 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 also be established on a secondary basis for disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310 (a). Secondary service connection may also be established for a disorder which is aggravated by a service-connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310 (b); Allen v. Brown, 8 Vet. App. 374 (1995). In order to prevail on the issue of secondary service connection, the record must show: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); see also Allen, supra. The Veteran is seeking entitlement to service connection for a back disability, to include as secondary to his service-connected left knee disability. Specifically, the Veteran contends that he began having back pain during his military service while operating forklifts and that his back disability was further aggravated by his service-connected left knee disability. See February 2020 Hearing Transcript. The Board concludes, resolving reasonable doubt in his favor, that the Veteran has a current back disability, that is as likely as not related to his military service. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). The November 2020 VA examiner confirmed the Veteran's back diagnoses. Thus, there is evidence of a current back disability. Service connection has been established for left knee degenerative arthritis status post replacement surgery. A temporary 100 percent disability rating was assigned from August 1, 2011 to August 31, 2011 and a 30 percent disability rating is assigned from October 27, 2011. The remaining question is whether there is a medical nexus between the Veteran's currently diagnosed back disability and his service-connected left knee disability. The Veteran's VA treatment records indicate that his back disability is related to his left knee disability. Additionally, the Veteran's private physician submitted a letter in April 2017 and February 2021, and he was afforded a VA examination in November 2020. A December 2011 VA physical therapy evaluation states that the Veteran has been performing some knee exercises that are causing undue mechanical stresses to his low back. The evaluation further stated that because of the extent of his left knee disability, the Veteran has likely been overusing his low back for underweighting his lower left extremity and for performance of his knee exercises in physical therapy. The April 2017 private letter states that the Veteran has chronic back pain that is likely related to his chronic knee pain. However, no particular rationale was provided to support this opinion. Pursuant to the April 2020 Board remand, the Veteran was afforded a VA examination in November 2020. The November 2020 examiner confirmed the veteran's back diagnoses as lumbosacral strain, degenerative arthritis of the spine, and intervertebral disc syndrome. The November 2020 VA examiner provided a negative nexus opinion with the rationale that there is no objective evidence in the claims file supporting any historical back injury or illness. The examiner further provided that arthritis in one joint does not cause arthritis in another joint. While the examiner provided three back diagnoses, a nexus opinion was solely provided for the arthritis diagnoses. Additionally, the examiner does not adequately address the aggravation prong of secondary service connection. These errors significantly diminish the probative value of the November 2020 VA opinion. The March 2021 letter from the Veteran's private physician noted review of medical records and current literature. The physician opined that it is at least as likely as not that the Veteran's spinal and knee disabilities are causally related. The physician provided the rationale that it is well-established that chronic gait disturbance contributes to dysfunction in other joints of the lower extremities and the spine. The physician further provided that the November 2020 VA opinion is contradictory to established medical literature which does recognize a causal link between chronic, altered gait mechanics from degenerative disease in one part of the body and degenerative disease in another. The Board finds this opinion well-reasoned and thoroughly considered the Veteran's complete medical history and is accordingly afforded high probative value. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (a factor for assessing the probative value of a medical opinion includes the thoroughness and detail of the opinion). Upon review of the record, the Board finds the evidence to at least be in equipoise as to whether the Veteran's current back disability is related to his service-connected left knee disability. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for a back disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. MICHAEL D. LYON Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Frazier, Associate Attorney 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.