Citation Nr: 21042159 Decision Date: 07/12/21 Archive Date: 07/12/21 DOCKET NO. 15-06 733A DATE: July 12, 2021 ORDER Service connection for obstructive sleep apnea (OSA) is denied. Service connection for degenerative disc disease (DDD) of the lumbar spine is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that service connected chronic obstructive pulmonary disease (COPD) or service connected cardiomyopathy with congestive heart failure (CHF) caused or aggravated obesity and the preponderance of the evidence is against finding that obesity caused or aggravated OSA or DDD of the lumbar spine. 2. The preponderance of the evidence is against finding that OSA was incurred during service; OSA first manifested many years after service and is unrelated to any in-service event, including any asbestosis exposure; and is not cause or aggravated by service connected COPD or service connected cardiomyopathy with CHF. 3. The preponderance of the evidence is against finding that DDD of the lumbar spine was incurred during service; arthritis of the lumbar spine first manifested many years after service and is not cause or aggravated by service connected bilateral pes planus or by service connected COPD or service connected cardiomyopathy with CHF. CONCLUSIONS OF LAW 1. The criteria for service connection for OSA have not been met. 38 U.S.C. §§ 1101, 1110, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for DDD of the lumbar spine have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the Army from July 1979 to October 1983. His military occupational specialty (MOS) was a machinist. These matters come before the Board of Veterans' Appeals (Board) on appeal from rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The matters now before the Board were remanded for additional development in July 2018, following which a February 2019 rating effectuated the Board's grant of service connection for COPD. Subsequently, a February 2020 rating granted service connection for cardiomyopathy and CHF. The matters on appeal were again remanded in March 2020, and November 2020. The Veteran is also service connected for bilateral pes planus. Pursuant to the November 2020 remand, which noted the possibility that the Veteran may have received private treatment for OSA prior to establishing VA care in 2008, the RO sent the Veteran letter in December 2020 and March 2021 requesting information as to all private care providers and offering to assist him in obtaining such records. However, there was no response. Also, updated VA clinical records have been obtained, as have additional VA medical opinions, as requested in the November 2020 Board remand. Accordingly, the Board finds that there has been substantial compliance with that remand. Stegall v. West, 11 Vet. App. 268, 271 (1998); D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Service Connection Establishing service connection generally requires (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) 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); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curium, 78 F.3d 604 (Fed. Cir. 1996) (table); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a), (d). Service connection may be granted for any disease diagnosed after discharge, when the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). However, not every manifestation of joint pain during service will permit service connection for arthritis first shown as a clear-cut clinical entity at some later date. 38 C.F.R. § 3.303(b). Certain chronic diseases, such arthritis, will be presumed related to service, absent an intercurrent cause, if shown as chronic in service; or, if manifested to a compensable degree within a presumptive period following separation from service; or, if noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection will be granted on a secondary basis for disability that is proximately due to or the result of, or permanently aggravated by, an already service-connected condition. 38 C.F.R. § 3.310(a) and (b). This requires (1) evidence of a current disability; (2) a service-connected disability; and (3) evidence establishing a nexus between the service-connected disability and the claimed disability. Wallin v. West, 11 Vet. App. 509, 512 (1998). Obesity is not a disability for purposes of VA benefits; hence, it cannot be service connected on a direct basis. See Marcelino v. Shulkin, 29 Vet. App. 155, 158 (2018). However, indirect secondary service connection can be granted with obesity acting as an "intermediate step." See VAOPGCPREC 1 2017 (Jan. 6, 2017). Specifically, a grant is warranted (1) if the service-connected disability caused the Veteran to become obese, (2) if obesity was a substantial factor in causing a subsequent disability, and (3) if the subsequent disability would not have occurred but for obesity. Id. A layperson is generally incapable of opining on matters requiring medical knowledge. Routen v. Brown, 10 Vet. App. 183, 186 (1997), aff'd sub nom., Routen v. West, 142 F.3d 1434 (Fed. Cir. 1998). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Reasonable doubt will be favorably resolved if there is an approximate balance of favorable and unfavorable evidence but if the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Ortiz v. Principi, 274 F.3d 1361, 1365-66 (Fed. Cir. 2001) (holding that an approximate balance of evidence is more favorable than the evidence being in equipoise, i.e., equally balanced). Obesity It is undisputed that the Veteran now has OSA and lumbar DDD, and it is asserted that either the Veteran's service connected COPD or cardiomyopathy, caused him to become obese which led to his development of the claimed OSA and lumbar DDD. However, for the following reasons the Board finds that obesity is not an intermediate step between the service connected disorders and the claimed OSA and lumber DDD. 38 U.S.C. §§ 1101, 1110, 1113, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. Service treatment records (STRs) show that, in a May 1979 Report of History at service entrance, the Veteran reported not exercising or running enough. A June 1982 Health Questionnaire for Dental Treatment noted that he smoked cigarettes. A June 2011 VA outpatient treatment (VAOPT) record shows that a lumbosacral MRI revealed an impression of a long history of chronic low back pain with lumbar DDD and lumbar radiculopathy significant tobacco history, diabetes, and morbid obesity in addition to multiple other medical problems. Morbid obesity and dietary changes were discussed. His morbid obesity was also contributing and causing his low back pain. See VA CAPRI records entered in VBMS November 17, 2014. Records from the Social Security Administration (SSA) reflect that a Physical Residual Functional Capacity Assessment in March 2006 found that he had COPD, hypertension, and heart failure. He was obese, being 68 inches in height and weighing 295 lbs. He slept with a CPAP machine, but reported feeling better since he had stopped smoking and lost weight. These records include a discharge summary of hospitalization in October 2005 with final diagnoses that included OSA and obesity-hypoventilation syndrome with chronic hypoxia and morbid obesity. A January 2006 sleep study at the Center for Sleep Disorders yielded a diagnosis of severe OSA. A January 2006 Office Visit from The Chattanooga Heart Institute reflects the Veteran was not exercising and was having difficulties with dietary indiscretions. His problem list included cardiomyopathy, sleep apnea, obesity, COPD, and diabetes. In January 2007, as to his cardiomyopathy and obesity, he was given counseling on dietary modification and aerobic training. A November 2006 office note from S. A. Chitty, M.D. noted that, in addition to an assessment of severe OSA, the Veteran had obesity hypoventilation syndrome, which was improving with weight loss but there was a concern that he had gained weight but some of this was simply due to being depressed about the death of his mother. A September 2012 record from the Pulmonary and Critical Care Medicine Clinic of the Erlanger Medical Center reported that the Veteran had OSA, and had used a CPAP device since 1995. As to the claim for service connection for OSA, multiple VA medical opinions have been obtained. Pursuant to the March 2020 Board remand, in April 2020 a VA medical opinion was obtained after a review of the records. It was opined that the claimed OSA was less likely as not proximately due to or aggravated by obesity. The rationale was that the STRs showed that there was no evidence of the diagnosis or treatment for sleep apnea or a diagnostic polysomnography while on active duty. Observed snoring, unrestful sleep, gasping, trouble sleeping, shallow breathing, and insomnia were not pathognomic for sleep apnea. Rather, sleep apnea was diagnosed by polysomnography. Insomnia was not a sign of sleep apnea and the two were mutually exclusive. Insomnia was a sleep disorder where people had trouble sleeping. They might have difficulty falling asleep, or staying asleep as long as desired. Insomnia was typically followed by daytime sleepiness, low energy, irritability, and a depressed mood. In contrast, people with sleep apnea had no trouble falling or staying asleep. According to a 2020 Journal of Obesity article and a large majority opinion in an UpToDate literature search, many conditions were associated with obesity, a high body mass index (BMI) was a corollary of certain conditions. However, the data available could not confirm that a high BMI caused the claimed diseases. Risk factors for OSA included obesity, craniofacial abnormalities, and upper airway soft tissue abnormalities. Other factors often partially or fully explained links of BMI and health, such as exercise, nutrition, insulin resistance, and weight stigma. Obesity could increase the risk, but could not be shown to have causality. Genetic and involuntary environmental contributions to body weight outweighed voluntary lifestyle choices. It was further stated that obesity was the best documented risk factor for OSA. The prevalence of OSA progressively increased as the BMI and associated markers (e.g., neck circumference, waist-to-hip ratio) increased. Craniofacial and upper airway soft tissue abnormalities each increased the likelihood of having or developing OSA. Examples of such abnormalities include an abnormal maxillary or short mandibular size, a wide craniofacial base, tonsillar hypertrophy, and adenoid hypertrophy. (UpToDate 2015). As to the low back it was also opined that it was less likely than not proximately due to or aggravated by the service connected heart condition or the nonservice connected obesity. The rationale was that the conditions were not medically related. The claimed disorder was a separate entity entirely from the service connected condition and unrelated to it. The medical literature did not support a medical relationship and, so, a nexus was not established. It was further stated that the service connected heart conditions and nonservice connected obesity did not preclude all forms of exercise. For example, paraplegics exercised and maintained appropriate BMI. Obesity was most commonly caused by a combination of excessive food intake, lack of physical activity, which was a personal choice. Obesity was a medical condition in which excess body fat has accumulated to the extent that it might have a negative effect on health. With respect to the impact of COPD and heart disease upon exercising, the Veteran's obesity and obesity hyperventilation syndrome did not preclude all forms of exercise. For example, paraplegics exercised and maintained appropriate BMI. Obesity was most commonly caused by a combination of excessive food intake and a lack of physical activity, which was a personal choice. According to a recent 2020 Journal of Obesity article and a large majority opinion in UpToDate literature search, many conditions were associated with obesity, and BMI was a corollary of certain conditions. However, the data available could not confirm that BMI caused the diseases. Other factors often partially or fully explain links of BMI and health, such as exercise, nutrition, insulin resistance, and weight stigma. Obesity could increase risk, but could not be shown to have causality. Genetic and involuntary environmental contributions to body weight outweighed the voluntary lifestyle choices. Another VA medical opinion was obtained in January 2021 as to obesity, and it was stated that obesity was less likely than not proximately due to or the result of Veteran's service connected COPD and service connected cardiovascular disease. Citing to medical literature, the rationale was that there was no anatomic or pathophysiological basis for the obesity to be due to the service connected heart and COPD disabilities. The heart condition (CHF and cardiomegaly) and the respiratory condition of COPD would have some potential to limit the amount of aerobic exercise that the Veteran would able to perform continuously. However, there was no direct link between these conditions and the development of obesity since the research had shown the three sessions of ten minutes of exercise had the same benefits as one 30 minute session. Weight gain was determined by genetic and metabolic factors, caloric intake, and caloric expenditure. There were alternative methods of exercise such as pool based aerobics that accommodate co-morbid conditions such as the Veteran's heart and respiratory problems. Diet and nutritional practices could also be utilized to manage not only the heart problems but also minimize weight gain. Lifestyle coaching and use of behavioral management techniques had also been found to be effective at preventing and/or treating obesity. There was no established medical nexus for the etiology of the Veteran's obesity to be proximately due to or caused by his service connected heart and COPD disabilities. The Board must weigh the conflicting medical evidence and may favor the opinion of one competent medical expert over another. See Wood v. Derwinski, 1 Vet. App. 190, 193 (1991) and Owens v. Brown, 7 Vet. App. 429, 433 (1995). The Board acknowledges the clinical notes suggesting a connection between the Veteran's obesity and his lumbar DDD. However, the Board finds that the opinions expressed which address the matter of obesity were rendered after a review of the entire evidentiary record, unlike the clinical notations, and are extensive in scope and addressed the matter of obesity in detail, and in fact in far greater detail than the favorable clinical notations. In sum, the VA opinions are persuasive and are given greater probative value. Unfortunately, the weigh against the claims for service connection for OSA and lumbar DDD by virtue of obesity as an intermediate step between those claimed disorders and the service connected COPD and cardiomyopathy with CHF. For example, there is evidence that a sedentary lifestyle, which the evidence shows can lead to obesity, was noted even at service entrance. Also, even emotional factors, such as depression due to the death of a family member, may have had an impact on obesity. Similarly, he has had a history of smoking tobacco. In sum, the evidence shows that the service connected COPD and cardiomyopathy with CHF do not by themselves preclude activity or exercise which could combat obesity. Accordingly, the Board finds that the preponderance of the evidence demonstrates that the Veteran's obesity was not caused or aggravated by service connected COPD or cardiomyopathy with CHF. Moreover, the preponderance of the evidence does not establish that obesity due to the foregoing was a substantial factor in causing OSA or lumbar DDD, and the preponderance of the evidence does not establish that OSA or lumbar DDD would not have occurred but for obesity. 1. Service connection for OSA It is contended that the Veteran developed OSA due to service connected COPD or, alternatively, it is due to in-service exposure to asbestos. See a May 2015 statement by the Veteran. For the following reasons, the Board finds that OSA is not of service origin, is not due to asbestos exposure, and was not caused or aggravated by service connected COPD or cardiomyopathy with CHF. The STRs are negative for OSA. A November 1982 Report of History reflects that he denied having or having had frequent trouble sleeping. He was not given an examination at service discharge. A September 2012 record from the Pulmonary and Critical Care Medicine Clinic of the Erlanger Medical Center it was reported that the Veteran had OSA, and had used a CPAP device, since 1995. A July 2016 VA Respiratory Condition Disability Benefits Questionnaire (DBQ) yielded an opinion that the Veteran's COPD, which was diagnosed in 2005, was at least as likely as not made worse by military service and exposure to airborne asbestos, as well as metal particulates and dust. This was consistent with a July 2016 private physician's opinion. A July 2018 Board decision granted service connection for COPD, conceding probable asbestos exposure. Pursuant to the July 2018 Board remand, the Veteran was examined and a VA medical opinion was obtained in December 2019, at which time his records were reviewed. It was reported that his OSA had started around 1991. It was opined that the Veteran's OSA was less likely than not due to inservice asbestos exposure. The rationale was that records indicated that the Veteran had been diagnosed with severe OSA. However, there were no studies that suggested a causal link between OSA and asbestos exposure. Pursuant to the March 2020 Board remand, in April 2020 a VA medical opinion was obtained after a review of the records. It was opined that the claimed OSA was less likely as not incurred in or caused by an inservice injury, event, or illness. The rationale was that a review of the STRs showed that there was no evidence of the diagnosis or treatment for sleep apnea or a diagnostic polysomnography while on active duty. Observed snoring, unrestful sleep, gasping, trouble sleeping, shallow breathing, and insomnia were not pathognomic for sleep apnea. Rather, sleep apnea was diagnosed by polysomnography. Insomnia was not a sign of sleep apnea and the two were mutually exclusive. It was also opined that while sleep apnea was known to be a risk factor for heart disease (hypertension cardiomyopathy, etc.,), heart conditions were not a risk factor for the development of sleep apnea. Also, it was opined that OSA was less likely than not proximately due to or aggravated by service connected COPD. The two conditions were not medically related. OSA was a separate entity entirely from the service connected COPD and unrelated to it. COPD is a disease of the lung parenchyma, and not upper airway abnormalities (characteristic of OSA). The medical literature did not support a medical relationship. A nexus had not been established. The most important risk factor for COPD was cigarette smoking and the amount and duration of smoking contributed to disease severity. With enough smoking, almost all smokers will develop measurably reduced lung function. Pursuant to the November 2020 Board remand additional medical opinions were obtained in January 2021. An addendum opinion in January 2021 stated that OSA was less likely than not incurred in or caused by military service. The rationale was that there was no objective evidence to support an etiology for the OSA as incurred in or caused by the reports of frequent trouble sleeping during service. Citing to medical literature, it was stated that sleep disturbance could be caused by a number of problems, e.g., insomnia, anxiety, PTSD, depression, chronic pain, alcohol or drug abuse, side effects of OTC medications (such as ephedrine or other stimulants), irregular work schedules, snoring, and sleep apnea. While interrupted sleep was the common denominator due to all of these conditions, the pathophysiological mechanism which disrupted the sleep pattern was not shared. OSA was characterized by narrowing or collapse of the pharyngeal airway during sleep and it was caused by anatomical variations in the craniofacial features and/or neck. Given these specific features of OSA and because there were numerous conditions which were similar to sleep apnea, e.g., a diagnosis of Primary Snoring, a sleep study was the definitive test to measure and diagnose sleep apnea. The lay statements submitted by the Veteran were considered; however, they were insufficient to establish an etiology for the sleep apnea due to service. While the Veteran was deemed competent to report a history of symptomatology, he was not capable of diagnosing those symptoms or establishing an etiological basis for the symptoms. The history of snoring, gasping, trouble sleeping, and unrestful sleep were not diagnostic of OSA. Snoring could be related to other disorders which were independent of OSA. In this case, the Veteran had a sleep study in 1995, approximately 12 years after service. The weight of the objective evidence did not support an onset of OSA during service. Another opinion in January 2021 was that the OSA was not at least as likely as not aggravated beyond its natural progression by service connected COPD or the service connected cardiomyopathy and CHF. The rationale was that the medical record showed that the OSA was well managed with the CPAP device. There was no objective evidence of any aggravation of OSA due to or caused by the service connected COPD or service connected cardiomyopathy and CHF. In analyzing the evidence, and addressing first the matter of asbestos exposure, despite medical opinions that the Veteran's COPD is consistent with exposure to asbestos or other particulates, no radiologic studies are of record which have been assessed as reflecting findings indicative of asbestos exposure. More to the point, the only opinion addressing whether asbestos exposure leads to OSA is negative. In fact, the evidence shows that OSA does not result from disability of the lungs, but is due to abnormality of the upper airway tract. As with the addendum opinion in January 2021, the Board has considered the Veteran's lay statements but finds them to be insufficient to establish an etiology for the sleep apnea due to service, or in fact an etiology related to service connected COPD, which affects that lungs rather than the upper airway tract, or cardiomyopathy. While the Veteran was deemed competent to report a history of symptomatology, he is not capable of diagnosing those symptoms or establishing an etiological basis for the symptoms. Specifically, snoring, gasping, trouble sleeping, and unrestful sleep are not diagnostic of OSA. In this case, there are no favorable medical opinions linking the Veteran's OSA to military service, including any possible asbestos exposure, or by means of causation or aggravation to his service COPD or cardiomyopathy with CHF. Moreover, the unfavorable medical opinions were rendered after a review of the evidence and reflect a sound basis for the opinions which were reached. Accordingly, service connection for OSA is not warranted. There is no doubt to be resolved. 2. Service connection for DDD of the lumbar spine It is contended that the Veteran's lumbar DDD had its onset during and had continued since service and, alternatively, the it is due to his service connected bilateral pes planus. For the following reasons, the Board finds that the lumbar DDD did not manifest until many years after service and is unrelated to his military service and unrelated to his service connected bilateral pes planus, COPD, and cardiomyopathy with CHF. The STRs show that a November 1982 Report of History reflects that the denied having or having had recurrent back pain. He did not undergo an examination at service discharge. A June 2011 VAOPT record shows that a lumbosacral MRI revealed an impression of a long history of chronic low back pain with lumbar DDD and lumbar radiculopathy significant tobacco history, diabetes, and morbid obesity in addition to multiple other medical problems. See VA CAPRI records entered in VBMS November 17, 2014. Pursuant to the July 2018 Board remand, the Veteran was examined and a VA medical opinion was obtained in December 2019, at which time his records were reviewed. It was noted that the Veteran reported having had the onset of low back pain during service, which had continued thereafter. It was opined that it was less likely than not that his claimed chronic low back pain with lumbar degenerative arthritis and lumbar radiculopathy was service related. The rationale was that the service records were silent for any back injuries or back complaints during military service or within one year of service. It was also opined that it was less likely than not that his back condition was caused or aggravated beyond natural progression by service connected pes planus. The rationale was that there was no evidence of any significant foot deformity that would alter his gait or biomechanics enough to increase the risk for lumbar degenerative arthritis. Examples of significant foot pathology would be foot drop, amputations, foot fractures, etc. Pursuant to the March 2020 Board remand, in April 2020 a VA medical opinion was obtained after a review of the records. With respect to the claimed low back disorder, it was opined in April 2020 that the low back disorder was less likely than not incurred in or caused by inservice injury, event, or illness. The rationale was that the STRs showed no evidence of the diagnosis, treatment, or complaints of a lumbar (low back) condition while on active duty or within one year of separation. As to the low back it was also opined that it was less likely than not proximately due to or aggravated by the service connected heart condition or the nonservice connected obesity. The rationale was that the conditions were not medically related. The claimed disorder was a separate entity entirely from the service connected condition and unrelated to it. The medical literature did not support a medical relationship and, so, a nexus was not established. It was also opined that the claimed low back disorder was unrelated to service connected COPD. The rationale was that musculoskeletal conditions were not anatomically or physiologically related to lung conditions (COPD). Pursuant to the November 2020 Board remand additional medical opinions were obtained in January 2021. As to the claimed low back disorder, citing to medical literature, another opinion in January 2021 stated that the low back disorder was not at least as likely as not aggravated beyond its natural progression by service connected COPD or service connected cardiovascular disorders. The rationale was that there was no anatomic or pathophysiological mechanism for the service connected COPD or service connected cardiomyopathy and CHF to aggravate or worsen the lumbar DDD. Lumbar DDD referred to a condition in which age-related wear and tear on a spinal disc caused low back pain. The discs naturally stiffen with use and age, and there was some degree of disc degeneration in everyone as they aged. Low back pain symptoms could resolve over time or worsen if the discs ruptured, tore, or bulged. COPD as well as cardiomyopathy and CHF had no proximate relationship to the condition of the lumbar DDD. There was no established medical nexus for any aggravation. The Board acknowledges the Veteran's statements of record of having continuously had back pain since service. In making this determination, the Board takes notice that the appellant has not identified any specific injury or event during active duty. While lay persons are competent to describe observable symptomology (e.g. pain), a lay person is not competent to opine on the etiology of such symptoms given that the Veteran's lumbar spine disability was not clinically shown as incurred during service and, in fact, not until many years after service, and because he lacks the requisite medical expertise to formulate a medical opinion on whether the condition had its onset in service during service or is related, by causation or aggravation, to his service connected bilateral pes planus. These are complex medical determinations beyond the range of experience or understanding of the lay person that cannot be answered based on observation or analysis of the lay person. Rather, the nature and etiology of the lumbar DDD is an intricate and complex matter that require specialized medical education and knowledge, which a lay person does not possess, regarding the unseen and complex processes of the development of musculoskeletal disabilities. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009) Here, the only competent evidence as to the nature and etiology of the lumbar DDD are the several VA medical opinions of record. The medical opinions are to the effect that the Veteran's lumbar DDD is not of service origin and, also, is unrelated to the bilateral pes planus because there was no deformity sufficient to alter his gait such as to increase the risk for lumbar DDD. Similarly, the opinions are also to the effect that the lumbar DDD, being musculoskeletal in nature, was unrelated to his service connected COPD and his service connected cardiovascular disease, which involved different bodily systems, such that there was no nexus either by causation or aggravation. Given the above, the Board finds that the preponderance of the evidence is against finding that the Veteran's lumbar DDD had its' onset during active duty; resulted from a disease, injury or event during active duty; and is unrelated to his service connected bilateral pes planus, COPD, or cardiomyopathy with CHF either by causation or aggravation. Accordingly, service connection for lumbar DDD is not warranted. There is no doubt to be resolved. Katherine Kiemle Buckley Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Fussell, 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.