Citation Nr: A25035006 Decision Date: 04/16/25 Archive Date: 04/16/25 DOCKET NO. 240814-464522 DATE: April 16, 2025 ORDER Entitlement to service connection for right knee condition to include right knee strain, as secondary to the Veteran's service-connected left knee s/p meniscal tear and anterior cruciate ligament tear, is granted. Entitlement to service connection for gastroesophageal reflux disease (GERD), as secondary to the Veteran's service-connected left knee instability, is granted. Entitlement to service connection for low back condition to include lumbosacral strain with degenerative arthritis and intervertebral disc syndrome (IVDS), as secondary to left knee s/p meniscal tear and anterior cruciate ligament tear, is granted. Entitlement to right lower extremity radiculopathy, as secondary to the Veteran's service-connected IVDS, is granted. Entitlement to left lower extremity radiculopathy, as secondary to the Veteran's service-connected IVDS, is granted. FINDINGS OF FACT 1. The Veteran's right knee condition to include right knee strain is at least as likely as not caused by his service-connected left knee s/p meniscal tear and anterior cruciate ligament tear. 2. The Veteran's GERD is at least as likely as not caused by the medication taken to treat his service-connected left knee instability and by his weight gained due to his left knee instability. 3. The Veteran's low back condition to include lumbosacral strain with degenerative arthritis and intervertebral disc syndrome (IVDS) is at least as likely as not caused by his service-connected left knee s/p meniscal tear and anterior cruciate ligament tear. 4. The Veteran's right lower extremity radiculopathy is at least as likely as not caused by his service-connected IVDS. 5. The Veteran's left lower extremity radiculopathy is at least as likely as not caused by his service-connected IVDS. CONCLUSIONS OF LAW 1. The criteria for service connection for right knee strain due to the Veteran's service-connected left knee s/p meniscal tear and anterior cruciate ligament tear have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for GERD due to the Veteran's service-connected left knee instability have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for low back condition to include lumbosacral strain with degenerative arthritis and intervertebral disc syndrome (IVDS) due to the Veteran's service-connected left knee s/p meniscal tear and anterior cruciate ligament tear have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for right lower extremity radiculopathy due to the Veteran's service-connected IVDS have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for left lower extremity radiculopathy due to the Veteran's service-connected IVDS have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1996 to November 1996. In the August 2024 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the August 2023 agency of original jurisdiction (AOJ) supplemental claim decision on appeal. 38 C.F.R. § 20.301. If evidence was submitted after the AOJ issued the supplemental claim decision on appeal, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.301, 20.801. If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim[s], considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. The Veteran is seeking service connection for a low back condition, right knee condition, and gastroesophageal reflux disease (GERD). Establishing service connection generally requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be granted for a current disability resulting from a service-connected disability. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310. The legal threshold for establishing secondary service connection is simple "but for" causation, which is a "broad standard" that allows for multiple causes of a harm. Spicer v. McDonough, 61 F.4th 1360, 1363-64 (Fed. Cir. 2023). Analysis The August 2023 rating decision by the AOJ provided a favorable finding that the Veteran is service connected for left knee s/p meniscal tear and anterior cruciate ligament tear and left knee instability. The AOJ also provided favorable findings that the Veteran has been diagnosed with right knee strain, intervertebral disc syndrome and lumbar radiculopathy, and with gastroesophageal reflux disease (GERD). The Board is bound by these favorable findings, unless rebutted by evidence that identifies a clear and unmistakable error in the favorable finding. 38 C.F.R. § 3.104(c). 1. Secondary service connection for right knee condition to include right knee strain. The Veteran contends that his right knee condition has been caused by his service-connected left knee condition. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. Along with his August 2022 VA Form 21-526 EZ, Application for Disability Compensation and Related Compensation Benefits, the Veteran provided a statement that the pain in his left knee causes him to shift his weight back and forth to alleviate discomfort. In October 2022, the Veteran was provided with a VA medical examination. The VA examiner provided a diagnosis of right knee strain. The VA examiner also provided a medical opinion that the Veteran's right knee strain is less likely than not (less than 50 percent probability) proximately due to or the result of the left knee status-post meniscal tear and anterior cruciate ligament tear. The examiner also provided a rationale that the Veteran's records were reviewed and while the examination findings support the current, associated diagnoses of right knee strain, there is no evidence or treatment records to indicate that this is secondary to the left knee status post meniscal tear and anterior cruciate ligament tear. However, the VA examiner did not address the Veteran's August 2022 lay statement provided in support of his claim. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination must consider lay evidence of an in-service incurrence or continuity of symptomatology since service). As a result, the October 2022 VA medical opinion regarding service connection for right knee strain is insufficient and is afforded no probative value. In April 2023, the Veteran provided a medical opinion completed by C.M.B., PA-C, MPLC, who concluded that it is at least as likely as not (a 50%/50% probability) that the Veteran's right knee condition to include strain is secondary to, and/or aggravated by his service-connected left knee s/p meniscal tear and anterior cruciate ligament tear condition with associated compensatory walking strategies, biomechanical and kinematic changes. C.M.B., PA-C, MPLC provided an extensive rationale that included the assertion that due to the severity of the Veteran's service-connected left knee pathology and associated pain, he developed an antalgic gait pattern with limping that the medical literature associates with secondary biomechanical changes that cause abnormal kinetics to occur within both of the lower extremity joints, and hastened the development and progression of his right knee condition to include strain. In June 2023, the Veteran was provided with another VA medical examination. The VA examiner provided a diagnosis of right knee strain. The examiner also provided a medical opinion and concluded that the Veteran's right knee condition is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the Veteran's service-connected condition. The examiner provided a rationale that there is no evidence or treatment records to indicate that this condition is secondary to the left knee status-post meniscal tear and anterior cruciate ligament tear, and that the Veteran had reported during the exam that he had initially injured the right knee during the same incident in around 2007 when he injured the left knee. Based on the foregoing, the Board finds that the evidence is approximately balanced that the Veteran's right knee strain was caused by his service-connected left knee s/p meniscal tear and anterior cruciate ligament tear. Service connection for right knee condition to include right knee strain as secondary to the Veteran's service-connected left knee s/p meniscal tear and anterior cruciate ligament tear is warranted. 2. Secondary service connection for GERD. The Veteran contends that his GERD has been caused by the medications he takes for his left knee condition, as well as his weight gain due to his left knee condition. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. Along with his August 2022 VA Form 21-526 EZ, Application for Disability Compensation and Related Compensation Benefits, the Veteran provided a statement that his left knee injury prevents him from being active as he once was, having gone from 140 pounds when he entered the military to 175 pounds. The Veteran also stated that he has taken aspirin, ibuprofen, Advil, naproxen, and Aleve for his service-connected disability and began to get symptoms of GERD after taking these medications on a routine basis and the symptoms have continued to the present day. In October 2022, the Veteran was provided with a VA medical examination. The VA examiner provided a diagnosis of gastroesophageal reflux disease (GERD). The VA examiner also provided a medical opinion that the Veteran's GERD is less likely than not (less than 50 percent probability) proximately due to or the result of the left knee status post meniscal tear and anterior cruciate ligament tear. The examiner also included a rationale that the Veteran's records were reviewed and while the examination findings support the current associated diagnoses of GERD, there are no STRs to support chronicity of condition, or that the condition began secondary to the left knee status post meniscal tear and anterior cruciate ligament tear. Pursuant to the holding in Dalton, because the VA examiner did not address the Veteran's August 2022 lay statement provided in support of his claim, the October 2022 VA medical opinion regarding service connection for GERD is insufficient and is afforded no probative value. The VA provided an additional medical opinion in December 2022. The VA examiner concluded that it is less likely than not (less than 50 percent probability) that the Veteran's left knee condition caused weight gain and the weight gain as well as the medication taken for the left knee caused the Veteran's GERD. The examiner provided a rationale that weight gain is a multifactorial condition that is summed up with calories in greater than calories expended and that, while the Veteran's knee condition may limit some activity it didn't prevent all activity, and the Veteran could've had lifestyle changes to decrease calories. The VA examiner further provided that NSAIDs have a correlation with GERD, but the causation is unclear and limited, and based on common clinical knowledge there is no nexus between weight gain or the NSAIDS with regards to GERD. The Board finds that the December 2022 medical opinion to be speculative in its assumption that the Veteran "could've had lifestyle changes to decrease calories." See Bloom v. West, 12 Vet. App. 185 (1999) (holding that a medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty). In addition, the examiner's statement that the correlation between NSAIDs and GERD is unclear and limited also does not provide the required degree of medical certainty necessary for an adequate medical opinion. Based on the foregoing, the Board finds that the December 2022 VA medical opinion is also insufficient and is afforded no probative value. In April 2023, the Veteran provided a medical opinion completed by C.M.B., PA-C, MPLC, who concluded that it is more likely than not (greater than a 50 percent probability) that the Veteran's current GERD is secondary to, related to, and/or aggravated by his service-connected left knee instability with subsequent weight gain and chronic NSAID usage. C.M.B., PA-C, MPLC provided an extensive rationale that included the assertion that due to the persistent pain of his service-connected left knee instability, the Veteran was unable to be as active as he was before his musculoskeletal condition and subsequently began to progressively gain weight, and multiple studies have found that weight gain increases intra-gastric pressure by gravitational force of adipose tissue around the abdominal cavity by extrinsic gastric compression, which leads to gastroesophageal junction incompetence and esophageal acid clearance is compromised, facilitating the development of GERD. C.M.B., PA-C, MPLC further provided that the subgroup of patients with grades II and III esophagitis and chronic NSAID used had a significantly greater lower esophageal sphincter (LES) pressure and a less severe intra esophageal pH profile than patients without NSAID use, suggesting that NSAID use may aggravate an otherwise milder acid-related esophageal disease in a subgroup of patients. The VA provided an additional medical opinion in August 2023. The VA examiner concluded that the Veteran's GERD is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the Veteran's service-connected condition. The examiner provided a rationale that there are no STRs or any medical records to support chronicity of the condition, or that the condition began secondary to the left knee status-post meniscal tear and anterior cruciate ligament tear. As previously noted, this is inconsistent with the holding in Dalton. As a result, the August 2023 VA medical opinion regarding service connection for GERD is insufficient and is afforded no probative value. As the evidence weighs in favor of the Veteran, the Board finds that the Veteran's GERD is at least as likely as not caused by the medication taken to treat his service-connected left knee instability and by his weight gained due to his left knee instability. Service connection for GERD as secondary to the Veteran's service-connected left knee instability is warranted. 3. Secondary service connection for low back condition to include lumbosacral strain with degenerative arthritis and intervertebral disc syndrome (IVDS). The Veteran contends that his low back condition has been caused by his service-connected left knee condition. Because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board's adjudication will consider only entitlement to secondary service connection. Along with his August 2022 VA Form 21-526 EZ, Application for Disability Compensation and Related Compensation Benefits, the Veteran provided a statement that, due to pain and discomfort, his service-connected condition has caused him to walk unevenly, increasing the pain and discomfort in his lower back. In October 2022, the Veteran was provided with a VA medical examination. The VA examiner provided diagnoses of lumbosacral strain with degenerative arthritis and intervertebral disc syndrome (IVDS), as well as bilateral lumbar radiculopathy. The VA examiner also provided a medical opinion that the Veteran's lumbar radiculopathy, IVDS, lumbosacral strain, and degenerative arthritis are less likely than not (less than 50 percent probability) proximately due to or the result of the left knee status post meniscal tear and anterior cruciate ligament tear. The examiner also included a rationale that the Veteran's records were reviewed and while the examination findings support the current, associated diagnoses of lumbar radiculopathy, IVDS, lumbosacral strain and degenerative arthritis, there are no treatment records nor evidence to suggest that these conditions are from the left knee status-post meniscal tear and anterior cruciate ligament tear. Pursuant to the holding in Dalton, because the VA examiner did not address the Veteran's August 2022 lay statement provided in support of his claim, the October 2022 VA medical opinion regarding service connection for lumbosacral strain with degenerative arthritis and IVDS is insufficient and is afforded no probative value. In April 2023, the Veteran provided a medical opinion completed by C.M.B., PA-C, MPLC, who concluded that it is at least as likely as not (a 50%/50% probability) that the Veteran's lumbosacral strain with degenerative arthritis and IVDS is secondary to, and/or aggravated by his service-connected left knee s/p meniscal tear and anterior cruciate ligament tear condition with associate compensatory walking strategies, biomechanical and kinematic changes. C.M.B., PA-C, MPLC provided an extensive rationale that included the assertion that due to the severity of the Veteran's service-connected left lower extremity pathology and associated pain, he developed an antalgic gait pattern with limping and/or a transfer in his center of gravity due to unequal weight distribution in the lower extremities that the medical literature associates with secondary biomechanical changes that cause abnormal kinetics to occur within both of the lower extremity joints, and hastened the development and progression of his lumbosacral strain with degenerative arthritis and intervertebral disc syndrome condition. In June 2023, the Veteran was provided with another VA medical examination. The VA examiner provided diagnoses of IVDS and bilateral lower extremity radiculopathy. The examiner also provided a medical opinion and concluded that the Veteran's back condition is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the Veteran's service-connected condition. The examiner provided a rationale that there is no treatment records nor evidence to suggest that these conditions are from the left knee status-post meniscal tear and anterior cruciate ligament tear. As previously noted, this is inconsistent with the holding in Dalton. As a result, the August 2023 VA medical opinion regarding service connection for the Veteran's back condition insufficient and is afforded no probative value. As the evidence weighs in favor of the Veteran, the Board finds that the Veteran's low back condition to include lumbosacral strain with degenerative arthritis and intervertebral disc syndrome (IVDS) is at least as likely as not caused by his left knee s/p meniscal tear and anterior cruciate ligament tear. Service connection for low back condition to include lumbosacral strain with degenerative arthritis and IVDS as secondary to the Veteran's service-connected left knee s/p meniscal tear and anterior cruciate ligament tear is warranted. 4. Secondary service connection for bilateral radiculopathy. VA is required to adjudicate related claims for secondary service connection for disabilities that are reasonably raised during the adjudication of a claim for the primary disability. Bailey v. Wilkie, 33 Vet. App. 188 (2021); Kisor v. Wilkie, 139 S. Ct. 2400, 2415 (2019); 38 C.F.R. § 3.155(d)(2) (stating that VA will consider all lay and medical evidence in order to adjudicate entitlement to benefits for the claimed condition as well as entitlement to any additional benefits for complications of the claimed condition, including those identified by the rating criteria for that condition in 38 CFR Part 4, Schedule for Rating Disabilities). Along with his August 2022 VA Form 21-526 EZ, Application for Disability Compensation and Related Compensation Benefits, the Veteran provided a statement that after he developed his low back condition, he began to experience numbness and tingling on the left side from his low back to his calf. During the October 2022 VA back examination, the VA examiner also diagnosed bilateral lumbar radiculopathy. This diagnosis was also confirmed by the October 2022 VA peripheral nerve examination, which provided diagnoses of lumbar radiculopathy and left lower extremity superficial peroneal neuropathy. The October 2022 VA back examiner also provided a medical opinion that the likely cause of the Veteran's radiculopathy is IVDS. Although the Board notes that the October 2022 and June 2023 medical opinions regarding the Veteran's back condition indicate that the Veteran's lumbar radiculopathy was less likely than not proximately due to or the result of the left knee conditions, they are silent as to the relationship between the Veteran's lumbar radiculopathy and the Veteran's back conditions. As the evidence weighs in favor of the Veteran, the Board finds that the Veteran's bilateral lower extremity lumbar radiculopathy is at least as likely as not caused by his service-connected IVDS. As a result, service connection for bilateral lumbar radiculopathy as secondary to the Veteran's service-connected IVDS is warranted. Cynthia M. Bruce Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Merriam, Jeffrey 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.