Citation Nr: A26014257 Decision Date: 02/17/26 Archive Date: 02/17/26 DOCKET NO. 200908-108382 DATE: February 17, 2026 ORDER Service connection for a back disability, diagnosed as lumbar spine degenerative disc disease with L5-S1 disc protrusion and foraminal stenosis, is granted. FINDING OF FACT Resolving doubt in the Veteran's favor, the Veteran's back disability diagnosed as lumbar spine degenerative disc disease with L5-S1 disc protrusion and foraminal stenosis, is proximately caused by and due to his service-connected left knee disability, status post patella tendon repair. CONCLUSION OF LAW The criteria for entitlement to service connection for a back disability, diagnosed as lumbar spine degenerative disc disease with L5-S1 disc protrusion and foraminal stenosis, have been met. 38 U.S.C. §§ 1154(a), 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Army from May 1988 to July 1988, and November 1990 to April 1991. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2019 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The September 2019 rating decision constitutes an initial decision thus the modernized review system applies, also known as the Appeals Modernization Act (AMA). By way of procedural history, in December 2015, the Veteran filed a new claim for service connection for a lumbar spine condition, and in the April 2016, the RO denied service connection for lumbar spine condition. In July 2019, the Veteran filed a supplemental claim for service connection for a lumbar spine condition, and in the September 2019 rating decision, the RO confirmed and continued the denial for service connection for a lumbar spine condition, In December 2019, the Veteran filed a VA Form 20-0996, requesting a Higher Level Review (HLR) of the September 2019 rating decision, and in the April 2020 rating decision, the RO denied service connection for a lumbar spine condition. In June 2020, the Veteran filed a supplemental claim for service connection for a lumbar spine condition, and in the June 2020 rating decision, the RO In the September 2020 VA Form 10182, the Veteran appealed the September 2019 rating decision and elected the Hearing docket. Therefore, the Board may only consider the evidence of record at the time of notice of the?September 2019 agency of original jurisdiction (AOJ) decision, as well as any evidence submitted by the Veteran or his representative within 90 days following the hearing. 38?C.F.R. §?20.302(a).? The Veteran?testified at a hearing before the undersigned Acting Veterans Law Judge (VLJ) in August 2024. ? Additional evidence including the November 2024 private opinion was submitted during the 90-day period and has been considered in this decision. If evidence was associated with the claims file during a period of time when additional evidence was not allowed, the Board has not considered it in this decision. 38 C.F.R. § 20.300. If the Veteran would like VA to consider any evidence that was added to the claims file 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 related claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a supplemental claim are included in this decision. 1. Service connection for a back disability, diagnosed as lumbar spine degenerative disc disease with L5-S1 disc protrusion and foraminal stenosis, is granted. The Veteran contends that his back disability, diagnosed as lumbar spine degenerative disc disease with L5-S1 disc protrusion and foraminal stenosis, is due to his service-connected left knee disability. Specifically, the Veteran urges that he would overcompensate and use his back to reduce pressure on his knees. The Veteran further testified that his abnormal gait, and knee weakness further worsened his back conditions. See December 2015 VA Form 21-526EZ; see also August 2024 hearing transcript. In support of his claim, the Veteran submitted private medical opinions from his treating physicians from November 2018, January 2019, and November 2024. In the November 2018 private medical opinion, C.P., the Veteran's treating chiropractor for his back disability, opined that the Veteran's chronic knee issues are a contributing factor to the Veteran's lower back pain. C.P.'s rationale noted that the Veteran's knee disability caused gait changes that cause compensatory stress to the Veteran's pelvis and lumbosacral structures. C.P. further noted that the Veteran's limited ability to flex his knee, causes him to use incorrect lifting postures which place stress on the Veteran's back. C.P. opined that the Veteran's left knee pain is most likely contributing to the Veteran's perpetual lower back irritation. In the January 2019 private medical opinion, Dr. M.H., the Veteran's treating physician for his left knee disability, opined that the Veteran's left knee disability is most likely a contributing factor to the Veteran's recurrent back pain. Dr. M.H.'s rationale noted that the lower extremities work together with the hips and lumbar spine as a kinetic chain, and a condition or injury in any one area affects the biomechanics and forces placed on the other areas of the kinetic chain. In the November 2024 private medical opinion, A.G., a D.C. at the clinic treating the Veteran's back disability, opined that the Veteran's back disability is more likely than not due to his left knee disability. A.G.'s rationale provided a history of the Veteran's medical conditions, and the relationship between the Veteran's left knee and back disabilities. Specifically, A.G. opined that the Veteran's left knee disability tampered the biomechanics of the Veteran's body, and that the Veteran's left knee is now affecting the Veteran's back due to overextended musculoskeletal and nervous system interconnection, over exertion of the homeostatic condition and incorrect gait pattern. In this case, the Veteran's primary theory of entitlement is that his back disability is secondarily caused by his service-connected disabilities. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(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."? Saunders v. Wilkie,?886 F.3d 1356, 1361?(Fed. Cir. 2018) (quoting Shedden v. Principi,?381 F.3d 1163, 1167?(Fed. Cir. 2004)).? In addition to the regulations cited above, service connection is warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Further, a disability which is aggravated by a service-connected disability may be service-connected to the degree that the aggravation is shown.? 38 C.F.R. § 3.310; El-Amin v. Shinseki,?26?Vet. App.?136?(2013); Allen v. Brown,?7?Vet. App.?439?(1995).? Secondary service connection under 38 C.F.R. § 3.310(a) is warranted where a nonservice-connected disability would have been less severe but for a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the non-service-connected disability. Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) ("Put together, § 1110 plainly requires compensation when a service-connected disease or injury is a but-for cause of a present-day disability. This broad language applies to the natural progression of a condition not caused by a service-connected injury or disease, but that nonetheless would have been less severe were it not for the service-connected disability. Stated another way, § 1110 provides for compensation for a worsening of functionality-whether through an inability to treat or a more direct, etiological cause. Nothing in the statute limits § 1110 to onset or etiological causes of a worsening in functionality"). The determination as to whether the requirements for service connection are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. 38 U.S.C. § 7104 (a); Baldwin v. West, 13 Vet. App. 1 (1999); see 38 C.F.R. § 3.303 (a). In determining whether service connection is warranted for a disability, 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 the weight of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. To deny a claim on its merits, the weight of the evidence must persuasively stand against a finding that the evidence is in "approximate balance" or "nearly equal" to the evidence that supports the claim. Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). The Board must determine the value of all evidence submitted, including lay and medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). The evaluation of evidence generally involves a 3-step inquiry. First, the Board must determine whether the evidence comes from a "competent" source. The Board must then determine if the evidence is credible, or worthy of belief. Barr v. Nicholson, 21 Vet. App. 303 (2007) (Observing that once evidence is determined to be competent, the Board must determine whether such evidence is also credible). The third step of this inquiry requires the Board to weigh the probative value of the proffered evidence in light of the entirety of the record. The Board also notes that under certain circumstances, lay evidence may be sufficient to establish a nexus. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); see also Layno v. Brown, 6 Vet. App. 465, 469 (1994). Lay evidence may be competent with regard to a disease that has "unique and readily identifiable features" that are "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Turning to the evidence of record, the Veteran has a current diagnosis of lumbar spine degenerative disc disease with L5-S1 disc protrusion and foraminal stenosis. See April 2016 and September 2019 rating decisions; see also January 2016 and July 2019 VA examinations. In addition, service connection is in effect for the Veteran's primary claimed disability. Here, service connection is in effect for (1) major depressive disorder, recurrent, severe with anxious distress, with somatic disorder, persistent associated with left patella tendon repair rated as 50 percent disabling effective November 25, 2009, and rated as 70 percent disabling effective March 18, 2020; (2) obstructive sleep apnea associated with major depressive disorder rated as 30 percent disabling effective May 10, 2020; (3) migraines associated with major depressive disorder rated as 50 percent disabling effective May 31, 2020; (4) status post left patella tendon repair rated as 10 percent disabling effective April 21, 1991, and rated as 30 percent disabling effective August 18, 2020; (5) tinnitus rated as 10 percent disabling effective May 5, 2011; (6) gastroesophageal reflux disease associated with left patella tendon repair rated as 10 percent disabling effective November 20, 2020; (7) erectile dysfunction associated with major depressive disorder rated as noncompensable effective February 2, 2012; and (8) surgical scar left knee associated with left patella tendon repair rated as noncompensable effective August 6, 2017. See December 2021 code sheet. As the finder of fact, the Board finds that the first and second element of service connection can be reasonably conceded. The critical question in this case is the etiology of the diagnosed back disability. The Board is required to consider theories of entitlement to benefits that are either raised by the claimant or reasonably raised by the record. In this case, the Veteran's primary theory of entitlement is that his back disability is secondarily caused by his service-connected left knee disability. The Veteran was afforded VA examinations and subsequent medical opinions to determine the nature and etiology of his back disability in January 2016 and July 2019. During the January 2016 VA examination, the Veteran reported that his back pain has progressed over the past 10 years and related his current back pain to overcompensation from prior knee issues. The Veteran further reported in the July 2019 VA examination, that he started having back problems when he would bend more with his back to avoid the use of his legs. In the January 2016 VA examination, the examiner opined that the Veteran's back disability was less likely than not proximately due to or the result of the Veteran's left knee disability. The examiner's rationale was based on a lack of back pain in-service and noted that medical literature does not relate the back issues found on the Veteran's MRI with patella tendon problems or altered gait. Whereas, in the March 2016 VA medical opinion, the examiner opined that the Veteran's back disability was less likely than not aggravated beyond its natural progression by the Veteran's left knee disability. The examiner's rationale was based on a lack of degenerative changes in the Veteran's knees, and the amount of time between the incurrence of the Veteran's knee disability and complaints of back problems. In the July 2019 VA examination, the examiner opined that the Veteran's back disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. However, the examiner's rationale discussed secondary service connection and determined that the Veteran may have continued pain following his left knee surgical repair, but such surgery is incapable of causing back problems. While the Board acknowledges the negative nexus opinions, the Board notes that the January 2016, March 2016, and July 2019 VA examiners failed to address whether the Veteran's left knee disability altered the Veteran's biomechanics and contributed to the Veteran's back disability. Here, the negative nexus opinions failed to provide an adequate secondary assessment regarding the Veteran's back disability and effectively disregarded the Veteran's competent and credible lay account of altering his biomechanics and overcompensating the use of his back due to his knee pain. Rather, the Board accords high probative weight to the November 2018, January 2019, and November 2024 private medical opinions, and finds that service connection for a back disability is warranted based on the back disability being proximately due to his service-connected left knee disability. In reaching this determination, the Board notes that the November 2018, January 2019, and November 2024 private medical opinions were provided by the Veteran's treating provider for his back and knee disabilities, and thus familiar with the Veteran's unique medical history. The private experts also provided clear rationales, supported by medical and lay statements of record. See Nieves-Rodriguez v. Peake, 22?Vet. App.?295, 301 (2008). As such, in its role as a finder of fact, the Board finds that the competent and credible evidence shows that the Veteran's back disability is caused, at least in part, by his service-connected knee disability. See Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).? (Continued on next page) ? In light of the foregoing, the Board finds that service connection for a back disability, diagnosed as lumbar spine degenerative disc disease with L5-S1 disc protrusion and foraminal stenosis, is warranted on a secondary basis. See 38 C.F.R. § 3.310(a); 38 U.S.C. §?5107(b); see also Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).? J. Abrams Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Nettles, 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.