CERVICAL SPINE LIMITATION OF MOTION

SHAUN S. SPERANZA · 2023 · Case ID: 23030719

MIXED

Summary

The veteran, who served from August 1988 to December 1989, appeals the denial of service connection for cervical spine, right elbow, left elbow, and left shoulder disabilities. The claims were primarily based on the assertion that these conditions were secondary to his service-connected right knee disorder and associated falls. The Board reviewed multiple VA medical opinions, finding the initial opinions inadequate for failing to address aggravation and provide sufficient rationale. Subsequent opinions from January and February 2023 generally concluded that the cervical spine, elbow, and shoulder conditions were less likely than not related to or aggravated by the service-connected knee disabilities. The Board found these later opinions also inadequate, particularly regarding aggravation and addressing the veteran's lay statements about falls. Consequently, the claims for cervical spine, left elbow, right elbow, and left shoulder disabilities were denied. The case was remanded for further medical opinions on the lumbar spine and bilateral hip conditions to adequately address secondary service connection and aggravation. The claim for an earlier effective date for TDIU and for automobile/adaptive equipment were also remanded as they were inextricably intertwined with the remanded issues.

Rationale

Medical opinions found less likely than not connection to knee disorder.; No evidence of aggravation beyond natural progression.; Lay statements insufficient to establish medical etiology.

Special Benefit

TDIU; EARLIER EFFECTIVE DATE; AUTO / ADAPTIVE EQUIPMENT

Docket No.

19-04 838

Full Decision Text

Citation Nr: 23030719
Decision Date: 05/25/23 Archive Date: 05/25/23

DOCKET NO. 19-04 838
DATE: May 25, 2023

ORDER

Entitlement service connection for a cervical spine condition is denied.

Entitlement to service connection of a right elbow disability is denied.

Entitlement to service connection for a left elbow disability is denied.

Entitlement to service connection for a left shoulder disability is denied.

REMANDED

Entitlement to service connection for a lumbar spine disability is remanded.

Entitlement to service connection for a right hip disability is remanded.

Entitlement to service connection for a left hip disability is remanded.

Entitlement to service connection for a right shoulder disability is remanded.

Entitlement to an earlier effective date for TDIU prior to June 17, 2016, is remanded.

Entitlement to automobile or other conveyance and adaptive equipment or for adaptive equipment only is remanded.

FINDINGS OF FACTS

1. The Veteran's cervical spine disorder was not caused or aggravated by his service-connected knee disabilities and associated falls.

2. The Veteran's right elbow disability is not caused or aggravated beyond its natural progression by falls associated with the Veteran's right knee disabilities.

3. The Veteran's left elbow disability is not caused or aggravated beyond its natural progression by falls associated with the Veteran's right knee disabilities.

4. The Veteran's left shoulder disorder was not caused or aggravated by his service-connected knee disabilities and associated falls.

CONCLUSIONS OF LAW

1. The criteria for service connection for a cervical spine disorder as secondary to service-connected knee disabilities and associated falls have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

2. The criteria for entitlement to service connection for a right elbow disability, to include as secondary to a service-connected right knee disability, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for entitlement to service connection for a left elbow disability, to include as secondary to a service-connected right knee disability, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. The criteria for service connection for a left shoulder disorder as secondary to service-connected knee disabilities and associated falls have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2016); 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from August 1988 to December 1989.

This matter is on appeal from a July 2014 rating decision (service connection claims for left and right shoulder disabilities, degenerative disc disease of the lumbar spine, and degenerative disc disease of the cervical spine disease), a November 2016 rating decision (service connection for a left hip condition, left elbow condition, right hip condition, and right elbow condition), and a January 2019 rating decision (automobile and adaptive equipment). The Veteran testified before the undersigned Veterans Law Judge at a May 2022 Board hearing.

As a preliminary matter, the Board notes that the Veteran's appeal initially included a service connection claim for obstructive sleep apnea. However, subsequent to the September 2022 Board remand and development, the claim was granted by a January 2023 rating decision. As of date, the Veteran has not disagreed with the grant or ratings assigned by AOJ. This is considered a full grant of the benefit sought and the issue is no longer before the Board for appellate consideration. A.B. v. Brown, 6 Vet. App. 35 (1993).

Service Connection

Generally, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during military service. 38 U.S.C. §§ 1110; 38 C.F.R. § 3.303. Establishing service connection generally requires evidence showing (1) current disability; (2) in-service incurrence in or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010); 38 U.S.C. § 1110,
. App. 35 (1993).

Service Connection

Service connection may also be established on a secondary basis for a disability proximately due to or aggravated by a service-connected disease or injury. See 38 C.F.R. § 3.310; see also Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). To establish secondary service connection, a Veteran must show: (1) the existence of a present disability; (2) the existence of a service-connected disability; and (3) a causal relationship between the present disability and the service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).

Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic disease or illness manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303 (b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d).

Certain "chronic diseases" may be presumed to have been incurred during service if manifested to a compensable degree within one year of separation from active military service; however, if the evidence of the record is insufficient to establish a disease was chronic in service, and/or manifested within the specified time period, then there must be a continuity of disease symptoms shown after discharge in order to warrant service connection. 38 C.F.R. § 3.303 (b).

Cervical Spine Disorder

The Veteran contends that he developed a cervical degenerative disc disease with spondylosis due to his service-connected right knee disorder, to include his total right knee replacement.

At his October 2013 VA examination, the Veteran complained of posterior neck pain with popping and stiffness. He reported that he injured his neck when he fell several times due to his unstable right knee. The pain radiates to both upper extremities and result in numbness of his hands. X-rays revealed multilevel degenerative changes without significant neuroforaminal narrowing. Upon physical examination, the Veteran demonstrated a limited range of motion of the cervical spine. The examiner noted that the Veteran suffers from cervical degenerative disc disease with spondylosis since 1990s. Further testing revealed mild radiculopathy of the left and right upper extremities.

In a medical opinion issued in May 2014, the examiner found that the Veteran's cervical degenerative disc disease with spondylosis is less likely than not proximately due to his right knee disorder, to include his total knee replacement, as there are no verified statements to support the claim.

However, in September 2022, the Board found the May 2014 medical opinion inadequate as it failed to offer any rationale to support its conclusion. Additionally, the examiner did not offer an opinion on aggravation despite finding no nexus between the Veteran's cervical spine disorder and his service-connected right knee condition, to include total knee replacement.

Upon remand, a new medical opinion was obtained in January 2023. Pursuant to a physical examination, the examiner identified degenerative arthritis, IVDS, and radiculopathy of the cervical spine. Unlike his prior report, the Veteran indicated that his neck pain began in 2000s and that it worsened over time.

The January 2023 examiner opined that it was less likely than not that the Veteran's degenerative disease of the cervical spine is caused or related to his service-connected right knee disability, to include his right knee replacement. As rationale, the examiner explained that there was no clear evidence of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 cm (resulting in an obvious altered gait, such as the Trendelenburg gait). The level of severity is not supported based on record review history or examination. It is not unusual for two joints to share properties in the same person, but one joint's disease does not 'spread' to another or cause damage to it. Additionally, degenerative arthritis is a progressive condition, which worsens overtime. The examiner found no evidence to suggest that the Veteran's degenerative arthritis aggravated beyond its natural progression.

An addendum medical opinion was issued in February 2023, in which a different examiner offered additional explanation. This examiner reiterated that it is less likely than not that the Veteran's cervical degenerative disc disease with spondylosis resulted from his right knee disorder. The report highlighted that prior to the Veteran's October 2013 VA examination, treatment records were silent for any complaints, diagnosis, or treatment pertaining to a cervical spine condition or injury to the neck. At the October 2013 VA examination, the Veteran complained of posterior neck pain with popping and stiffness, which were due to injuries sustained during several falls related to his unstable right knee disability. X-rays revealed multilevel degenerative changes and a range of motion test showed limited motion of the cervical spine. The October 2013 examiner noted that the Veteran suffered from cervical degenerative disc disease with spondylosis since 1990s. However, there were no records of treatment for a neck injury after the falls. The February 2023 examiner indicated that cervical degenerative disc disease with spondylosis is very common due to aging and is a naturally occurring age-related phenomenon, which starts early on the second decade of life. The prevalence of cervical degenerative disc disease increases with age, which inflict 60 percent of people older than 40 years. While medical literature notes previous neck injuries to be a risk factor, it is not considered a direct cause. Additionally, the Veteran's cervical spine degenerative arthritis is a progressive condition that worsens over time. The Veteran's treatment records do not indicate that his cervical spine disorder has aggravated beyond its natural progression of arthritis. Therefore, it is less likely than not that the Veteran's cervical spine disorder is caused or aggravated by his right knee disorder, to include his right knee replacement.

The Veteran has asserted that he developed a chronic cervical spine disorder as a direct result of his service-connected knee disabilities. However, the medical evidence weighs substantially against his contention.

The Board considered the Veteran's history of falls due to the instability in left and right knees. According to a July 2014 VA examination, the Veteran reported sustaining several falls prior to his right knee replacement in May 1991, October 1995, and May 2005. Based on the Veteran's VA treatment records dating April 2015, the Veteran had an impaired gait and scored 50 points on a Morse Fall Scale, which was indicative of high risk for falls.

Nevertheless, based on the February 2023 VA examination report, the examiner found that the Veteran's cervical spine disorder manifested in 1990s and there is no medical evidence to support additional neck injury after his reported falls. Notably, the Veteran sought medical attention for various conditions throughout the years. However, the evidence does not demonstrate an abrupt onset of objective/subjective signs of cervical spine pain or increased pain immediately after a fall. While the Veteran has reported worsening symptoms throughout the years, the examiner found that it is more likely the result of the natural aging process and the progression of the degenerative disease. Anatomically, the examiner explained that in general, an injury to one joint would not cause damage to another. Therefore, it is less likely than not that the Veteran's cervical spine disorder is caused or aggravated by his service-connected knee disabilities.

To the extent that the Veteran believes that his cervical spine disability is related to his service, the Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge and experiences through his senses. Barr v. Nicholson, 21 Vet. App. 303 (2007). However, as to the etiology of a cervical spine disability, the issue of causation of such a
likely the result of the natural aging process and the progression of the degenerative disease. Anatomically, the examiner explained that in general, an injury to one joint would not cause damage to another. Therefore, it is less likely than not that the Veteran's cervical spine disorder is caused or aggravated by his service-connected knee disabilities.

To the extent that the Veteran believes that his cervical spine disability is related to his service, the Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge and experiences through his senses. Barr v. Nicholson, 21 Vet. App. 303 (2007). However, as to the etiology of a cervical spine disability, the issue of causation of such a medical condition is a medical determination outside the realm of common knowledge of any lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, although the Board has considered the lay contentions of record suggesting that the Veteran's cervical spine disorder is related to his service, the Board ultimately affords the objective medical evidence of record, which weighs against finding such a connection, greater probative weight than the lay opinion.

While the Veteran's claim may not prevail under the secondary theory of entitlement, he is not precluded from seeking service connection on a direct basis. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994).

A review of the Veteran's service treatment records showed no documentation of a complaints or diagnosis suggestive of cervical spine disorder. In fact, the Veteran was not diagnosed with a degenerative disc disease of the cervical spine until after his military service. The Veteran has not submitted any positive medical opinion to establish a positive nexus between his cervical spine condition and his service.

While there is no medical opinion of record establishing a nexus between the Veteran's cervical spine condition and his active service, the criteria have not been met to necessitate a VA examination. See McClendon v. Nicholson, 20 Vet. App. 79 (2006). Here, the evidence does not indicate or suggest a possible connection between the Veteran's cervical spine condition and his military service. Consequently, a VA examination is not warranted in this case.

The Board has also considered whether service connection may be warranted under 38 C.F.R. §§ 3.307 (a)(3), 3.309(a), as it is listed as a chronic disease. However, given that the objective evidence failed to establish that the Veteran's cervical spine condition was chronic in service, that it continued since service, or that it manifested to a degree of 10 percent within one year following discharge from service, service connection also cannot be established under this basis.

For the above reasons, the evidence for and against the claim is neither evenly balance or approximately so. Rather, the evidence weighs persuasively against the claim. The benefit of the doubt doctrine is therefore not for application and service connection on a secondary, direct, and presumptive basis, for a cervical spine condition is not warranted. See 38?U.S.C. §?5107(b), Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc) (only when the evidence persuasively favors one side or another is the benefit of the doubt doctrine not for application)

Olecranon Bursitis of the Left Elbow and Right Elbow

The Veteran contends that his left and right elbow conditions are secondary to his right knee disorder, including his right total knee replacement.

On the Veteran's October 2013 VA examination, he complained of bilateral elbow pain with on and off swelling. He indicated that the symptoms began in the 1990's following falls when his right knee gave way. The Veteran claimed that he cannot put pressure in the olecranon due to pain. A physical examination revealed a limited range of motion of the left and right elbow with pain. October 2013 x-rays revealed moderate bilateral posterior enthesophytes off the bilateral olecranon, at the expected insertion of the triceps. There was no other significant abnormality seen. The evidence does not show acute fracture or dislocation. Joint spaces were grossly preserved without significant degenerative disease.

A May 2014 medical opinion found it was less likely than not that the Veteran's olecranon bursitis of the left and right elbow is caused by his service-connected right knee degenerative disc disease to include his total knee replacement as there are no records to support the knees giving way, resulting in injury to the elbows.

In September 2022, the Board remanded the matter for additional development after finding that May 2014 medical opinion inadequate as it did not address or consider the Veteran's risk for falls and impaired gait.

A January 2023 medical
There was no other significant abnormality seen. The evidence does not show acute fracture or dislocation. Joint spaces were grossly preserved without significant degenerative disease.

A January 2023 medical opinion was obtained in January 2023, which confirmed a negative nexus between the Veteran bilateral elbow condition and his service-connected right knee disorder. As rationale, the examiner found no clear evidence of orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured lumb resulting in length discrepancy of more than 5 cm (resulting in an altered gait- as obvious as Trendelenburg gait). This level of impaired gait is not shown in the Veteran's case. While it is not unusual for two joints to share properties in the same person, but one joint's disease does not "spread" to another joint or cause damage to it. Additionally, the examiner noted that the Veteran's physical training activities are usually strenuous and repetitive allowing for joint strains. However, since service, there is no evidence of persistent problems or aggravation of the elbows beyond its natural progression. The Veteran's medical records do not show x-rays or additional doctor's visits suggestive of increased or aggravated right elbow pain. Therefore, it is less likely than not that the Veteran's bilateral elbow condition is related to or aggravated by his right knee condition.

In a medical opinion addendum dating February 2023, a different examiner added that the left and right elbow condition are not medically related to his right knee total replacement. The conditions of the elbows and of the knee are separate entities. While the Veteran stated that he fell due to his knee condition, the evidence does not demonstrate that an elbow injury resulted from the falls. As such a nexus is not established.

The Veteran's medical records document a current disability of both the left and right elbow, which has been identified as moderate bilateral posterior enthesophytes of the bilateral olecranon. However, the medical evidence does not link his bilateral elbow disabilities to his service-connected right knee conditions. Despite the Veteran's lay assertions as to the etiology of his left and right elbow disability, the Board may not rely on such statements to satisfy the nexus requirement. Although the Veteran is competent to attest to his experiences and has provided credible testimony regarding his falls, he is not competent in these circumstances to opine as to the medical etiology of his elbow disability, as he lacks medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, and 1376-77 (Fed. Cir. 2007).

The January and February 2023 medical opinions indicated that the Veteran's medical treatment records do not suggest that the Veteran's abnormal gait caused by his right knee condition caused or aggravated his bilateral elbow disabilities. The examiners suggested that the joints of the elbows and knees are of separate entities that do not share the same properties or anatomical function. Despite the Veteran's history of falls (particularly in May 1991, October 1995, and May 2005), there were no accompanying complaints suggesting a physical trauma to the elbows to imply a connection between the unstable right knee and his elbow disability.

The Veteran was not diagnosed with bilateral posterior enthesophytes of the bilateral olecranon until 2016. During this time, the Veteran's VA treatment records were silent for any reports of falls. In September 2018 and August 2017, the Veteran denied any falls over the past year. Despite the lack of falls, the Veteran was diagnosed with a bilateral elbow condition.

The objective medical findings above constitute highly probative evidence weighing substantially against the Veteran's claims. Accordingly, the Board finds that the weight of the evidence fails to establish that the Veteran's bilateral elbow conditions was caused or aggravated by the falls associated with his service-connected right knee disability. For these reasons, service connection for a right or left elbow disability secondary to a service-connected right knee disability is not warranted.

Finally, the Board notes that while the service connection may be established on a direct basis, it finds that the Veteran claim's does not prevail on a direct basis either.

Here, the probative, persuasive medical and lay evidence does not establish between the
year. Despite the lack of falls, the Veteran was diagnosed with a bilateral elbow condition.

Finally, the Board notes that while the service connection may be established on a direct basis, it finds that the Veteran claim's does not prevail on a direct basis either.

Here, the probative, persuasive medical and lay evidence does not establish between the Veteran's service and his left and right elbow condition. The evidence does not suggest that the Veteran's bilateral elbow condition is related to his active service. For example, his service treatment records were silent for any complaints or diagnosis suggestive of an elbow injury or condition. Moreover, the Veteran was not diagnosed with an elbow disability until 2016, several years after service. While not dispositive, the passage of time also weighs against the Veteran's claim. See Maxon v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).

For the above reasons, the evidence for and against the claim is neither evenly balance or approximately so. The evidence weighs persuasively against the claim. The benefit of the doubt doctrine is therefore not for application and service connection on a secondary and direct basis for a left or right elbow disability is not warranted. See 38?U.S.C. §?5107(b), Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

Left Shoulder Disability

The Veteran asserts that he developed a left shoulder disability due to falls associated with his left and right knee disabilities, to include his right knee replacement.

Post service, the Veteran complained of left shoulder pain. X-rays in October 2013 of the left shoulder revealed a cortical defect off the lateral posterior aspect of the proximal humerus. At his October 2013 VA examination, the Veteran indicated that he had been experiencing shoulder pain since the 1990s. He stated that he fell because his right knee gave way and he landed on his shoulders, resulting in a chronic condition. The Veteran was treated with physical therapy and TENS unit. There was no history of steroid injections or surgery. Due to his pain, he is not able to sleep on his side. A physical examination revealed limited range of motion in both shoulders. He was diagnosed with a left (and right) impingement syndrome of the shoulder.

A May 2014 medical opinion found a negative nexus between the Veteran's left shoulder impingement syndrome and his bilateral knee condition as there are no records to support that the knees gave way, resulting in an injury to the shoulders.

Because the May 2014 VA medical opinion was inadequate, the Board remanded the matter in September 2022 to obtain a new medical opinion.

The Veteran was afforded a new VA examination in January 2023. The examiner confirmed the Veteran's left shoulder strain and shoulder impingement syndrome. In conclusion, the examiner opined that it was less likely than not that the Veteran's left shoulder impingement syndrome was caused by or related to his service-connected left and right knee disorder (to include the right knee replacement). The examiner found no clear evidence from the review of the orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 cm (resulting in an obvious altered gait, such as the Trendelenburg gait.) The level of severity is not supported based on record review history or examination. It is not unusual for two joints to share properties in the same person, but one joint's disease does not 'spread' to another or cause damage to it. With regard to aggravation of the left shoulder, the examiner indicated that the Veteran's left shoulder impingement resulted from an overuse injury, which often improve once it is treated and the activity that caused the injury is stopped. While temporary aggravation of the left shoulder condition is possible, the examiner found no aggravation of the impingement syndrome beyond its natural progression.

In a February 2023 medical opinion addendum, a different examiner added that while the Veteran stated that he fell several times due to his knee conditions, there are no supporting treatment records to suggest a shoulder injury from a fall, resulting in his left shoulder condition. Additionally, a shoulder impingement is most likely caused by reparative overhead activities, in which such incident
. With regard to aggravation of the left shoulder, the examiner indicated that the Veteran's left shoulder impingement resulted from an overuse injury, which often improve once it is treated and the activity that caused the injury is stopped. While temporary aggravation of the left shoulder condition is possible, the examiner found no aggravation of the impingement syndrome beyond its natural progression.

In a February 2023 medical opinion addendum, a different examiner added that while the Veteran stated that he fell several times due to his knee conditions, there are no supporting treatment records to suggest a shoulder injury from a fall, resulting in his left shoulder condition. Additionally, a shoulder impingement is most likely caused by reparative overhead activities, in which such incident can rise with age. The Veteran's knee conditions, or falls would not result in a shoulder impingement. Finally, as previously stated, shoulder impingement is classified as an overuse injury, which generally improves overtime with treatment. While temporal aggravation is possible, the record does not suggest that the Veteran's left shoulder impingement syndrome is aggravated beyond its natural progression.

The Veteran's medical records document a current disability of the left shoulder. However, while he has asserted that the disability resulted as a result of falls associated with bilateral knee disabilities, the medical evidence does not support his contention. Therefore, the Board must rely on the most probative medical opinion of record.

The January 2023 and February 2023 medical opinions found no link between the Veteran's bilateral knee disabilities and his current left shoulder disabilities. In finding that the Veteran's left shoulder joint is separate from his joints of the knees, a shoulder impingement generally results from overuse of the shoulder, rather than from physical trauma. Moreover, the February 2023 examiner found that even with the Veteran's documented history of falls, there were no accompanying complaints suggesting injury to the left shoulder. Without such complaints, the record fails to suggest the Veteran's shoulder impingement syndrome directly resulted from his service-connected knee disabilities. Furthermore, the examiners also concluded that the Veteran's records failed to suggest that his shoulder disability was aggravated beyond its natural progression due to the falls associated with the knee disabilities. The January 2023 and February 2023 medical opinions constitute highly probative evidence that weighs substantially against the claim.

Other evidence does not contradict the negative nexus. While the Veteran has consistently argued for a positive nexus, his lay statements alone is insufficient to establish the required nexus in his case. He is competent to testify to his symptoms such as pain and discomfort. However, he is not competent to opine on the medical etiology of his left shoulder disability as he does not possess the prerequisite medical knowledge and training. See Jandreau, 492 F.3d 1372 (Fed. Cir. 2007).

The Board has also considered whether the Veteran's claim may prevail on a direct basis. However, the evidence does not support as such.

A review of the evidence, both medical and lay, fails to establish that the Veteran's left shoulder disability had onset in service and that it continued ever since. There is no competent medical evidence of record to suggest that the Veteran's shoulder condition is in any way related to his time on active duty. His service treatment records were silent for any complaints or diagnosis suggestive of a shoulder injury to chronic condition. By his own testimony, the Veteran specifically indicated that he developed a shoulder disability as a result of falls post service. See May 2022 Board Hearing Transcripts.

For the above reasons, the evidence for and against the claim is neither evenly balance or approximately so. The evidence weighs persuasively against the claim. The benefit of the doubt doctrine is therefore not for application and service connection on a secondary and direct basis for left shoulder disability is not warranted. See 38?U.S.C. §?5107(b), Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021).

REASONS FOR REMAND

Lumbar Spine Disorder

The Veteran contends that he developed a lumbar spine disorder as a result of his service-connected right knee disorder, to include his total right knee replacement.

At his October 2013 VA examination, the Veteran complained of back pain since the 1990's. He reported falling several times and injured his back due to the right knee giving way. There was also associated numbness of the right lower extremities. A physical examination revealed limited range of motion in his lumbar spine and pain on movement, with mild radiculopathy in the right leg. October 2013 x-rays of the lumbar spine revealed no acute fracture or dislocation. The examiner diagnosed the Veteran with degenerative disc disease of the lumbar spine.

Subsequently, a medical opinion was issued in May 2014, which found no nexus between the Veteran's degenerative disease
include his total right knee replacement.

Subsequently, a medical opinion was issued in May 2014, which found no nexus between the Veteran's degenerative disease of the lumbar spine and his service-connected right knee disability, to include his right knee replacement. The examiner reasoned that while the Veteran stated that he fell several times due to the right knee giving way, there are no records to support the Veteran's claim.

When the matter became to the Board in September 2022, the Board found the May 2014 VA medical opinion inadequate as it failed to offer any rationale for its conclusion and did not address aggravation. Thus, a new medical opinion was obtained in January 2023.

Upon a physical examination, the January 2023 examiner identified degenerative disc disease, IVDS, and bilateral lumbar radiculopathy. The Veteran told the examiner that his back pain began in the early 2000s during service. It continued to worsen over the years with symptoms of shooting pain, numbness, and tingling his legs. He indicated that the pain worsened, and that he was falling often.

The January 2023 examiner found that it was less likely than not that the Veteran's lumbar spine disorder is caused by his right knee disability. The examiner explained that there was no clear evidence from the review of the orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 cm (resulting in an obvious altered gait, such as the Trendelenburg gait. The level of severity is not supported based on record review history or examination. It is not unusual for two joints to share properties in the same person, but one joint's disease does not 'spread' to another or cause damage to it. The January 2023 examiner, however, failed to address whether the Veteran's lumbar spine disorder was aggravated beyond its natural progression by his service-connected right knee conditions.

In the February 2023, a medical opinion addendum was issued, indicating that the January 2023 medical opinion should be amended. Additionally, the February 2023 examiner acknowledged that the Veteran's assertion that his knee conditions caused the Veteran to fall due to his impaired gait. However, the examiner found no treatment records to suggest that the Veteran sustained a back injury after a fall. Rather, the Veteran's degenerative disc disease of the lumbar spine is a common condition due to aging, with other contributing factors such as diabetes mellitus and obesity. Therefore, it is less likely than not that the Veteran's lumbar spine disorder is caused by his service-connected right knee disorder, to include his right knee replacement.

The Board, however, finds that the new medical opinions, again failed to adequately address aggravation. The February 2023 examiners merely found that the Veteran's treatment records do not document a back injury due to falls. She also attributed the Veteran's lumbar spine disability to the natural aging process and possibly his obesity and diabetes. Overall, the examiner only indicated that the Veteran's medical evidence did not show that the Veteran's lumbar spine disorder is caused by his service-connected right knee disability.

Therefore, remand is necessary to obtain another medical opinion to adequately address secondary service connection.

Left and Right Hip Disorder

The Veteran asserts that he developed a left and a right shoulder disability as a result of his right knee disabilities, to include his right knee total knee replacement.

Based on an October 2013 VA treatment note, the Veteran complained of bilateral hip pain that had been present over the past 3 years. He reported that the pain worsened with movement and that pain medications brought little to no relief. A physical examination confirmed pain with internal and external rotation.

The Veteran was afforded a VA examination in October 2013. There, he complained of bilateral anterior hip pain that had been ongoing since the 1990s. He stated that he had fallen several times due to the right knee giving way, causing him to land on his hips. The examiner diagnosed the Veteran with degenerative joint disease of the bilateral hips, which had onset in 2005.

In a subsequent
knee total knee replacement.

In a subsequent medical opinion dating May 2014, the examiner found that it is less likely than not that the Veteran's bilateral hip degenerative joint disease is caused by his bilateral knee conditions, to include his right knee replacement, as there are no records to support a fall caused by his bilateral knee disabilities.

However, the Board noted that at the Veteran's July 2014 VA examination, he reported sustaining several falls prior to his right knee replacement in May 1991, October 1995, and May 2005. Based on the Veteran's VA treatment records dating April 2015, the Veteran scored 50 points on a Morse Fall Scale, which was indicative of high risk for falls. It was also noted that the Veteran had an impaired gait. Therefore, the Board remanded the matter for a new medical opinion to address the Veteran's history of falls and how it may have caused the Veteran's chronic hip disabilities. Additionally, the May 2014 examiner failed to address whether the Veteran's service-connected knee disabilities aggravated his bilateral hip disorder.

As a result, the Veteran was afforded a new VA examination in January 2023 to address the Veteran's bilateral hip condition. The examiner identified the Veteran's degenerative arthritis (other than post traumatic) and bilateral hip bursitis. The examiner opined that there was no clear evidence from the review of the orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 cm (resulting in an obvious altered gait, such as the Trendelenburg gait. The level of severity is not supported based on record review history or examination. It is not unusual for two joints to share properties in the same person, but one joint's disease does not 'spread' to another or cause damage to it. Additionally, the examiner indicated that the Veteran's degenerative arthritis of the hip is a progressive condition that generally worsens overtime. However, there is no evidence to indicate aggravation beyond its natural progression of arthritis of the hip.

Subsequently, a medical opinion addendum was issued in February 2023. The examiner reiterated that the Veteran's left and right hip condition is caused by or related to his service-connected right knee condition. As rationale, the examiner indicated the two conditions are not medically related. The examiner found no credible evidence to suggest that an injury or disease of one lower extremity (specifically his right knee condition) would have any significant impact on another lower extremity joint (left/right hip), unless the injured right knee resulted in a major muscle or nerve damage causing partial or complete paralysis of the damaged leg, and/or shortening of the injured lower extremity resulting in a limb length discrepancy of more than 4 or 5 centimeters, resulting in an altered gait or significant limp. Again, his level of abnormal gait severity is not shown by the record. Additionally, the Veteran's statements are not consistent with how the disease is known to occur. Therefore, a nexus is not established.

The Board, however, finds both January and February 2023 medical opinions inadequate. The February 2023 medical opinion is merely a restatement of the prior opinion, indicating that absent a significant gait, it is less likely that the Veteran developed a chronic left and right hip condition as a result of his service-connected knee disabilities. The examiner failed to address the Veteran's lay statements, suggesting that his right knee disabilities caused him to sustain several falls, ultimately contributing to his bilateral hip condition. The Veteran's medical treatment records have indicated that the Veteran, did in fact, sustained falls.

Next, despite finding no evidence of aggravation, the January 2023 examiner found that it was less likely than not that the Veteran's left and right hip disability was aggravated by his service-connected right knee disabilities, merely explaining that degenerative arthritis is a progressive condition that usually worsens over time. The Board finds this explanation inadequate to address aggravation. Moreover, the February 2023 addendum opinion did not
left and right hip condition as a result of his service-connected knee disabilities. The examiner failed to address the Veteran's lay statements, suggesting that his right knee disabilities caused him to sustain several falls, ultimately contributing to his bilateral hip condition. The Veteran's medical treatment records have indicated that the Veteran, did in fact, sustained falls.

Therefore, remand is necessary to obtain a new medical opinion to sufficiently address the nexus between the Veteran's bilateral hip condition and the service-connected right knee disorder.

Right Shoulder Disability

The Veteran contends that he developed a right shoulder disability as a result of falls associated with his service-connected bilateral knee disabilities, to include his right knee total replacement.

Post service, the Veteran's VA treatment records dating August 2013 noted that he complained of right shoulder pain due to a possible rotator cuff tear. MRI images found no definite rotator cuff tendon tear or tendon retraction. There was moderate degenerative change with osseous edema and synovial proliferations.

At his October 2013 VA examination, the Veteran complained of bilateral shoulder pain (worse on the right) since the 1990s. He stated that he fell because his right knee gave way and he landed on his shoulders, resulting a right shoulder disability. The Veteran was treated with physical therapy and TENS unit. There was no history of steroid injections or surgery. Due to his pain, he is not able to sleep on his side. A physical examination revealed limited range of motion in the right shoulder. He was diagnosed with a right shoulder impingement syndrome and degenerative disease of the AC joint.

Subsequently, a medical opinion was issued in May 2014, which found a negative nexus between the Veteran's right shoulder disabilities (shoulder impingement syndrome and degenerative disease of the AC joint) and his service-connected knee disabilities. As rationale, the examiner found no records to support that the knees gave way, resulting in an injury to the right shoulder.

Because the May 2014 VA medical opinion was inadequate, the Board remanded the matter in September 2022 to obtain a new medical opinion. The Veteran was afforded a new VA examination in January 2023. The examiner confirmed the Veteran's right shoulder impingement syndrome with osteoarthritis of the right AC joint. She also identified a right shoulder glenohumeral joint osteoarthritis. In conclusion, the examiner opined that it was less likely than not that the Veteran's right shoulder degenerative joint disease of the AC joint and shoulder impingement syndrome were related to his service-connected knee disabilities. The examiner found no clear evidence from the review of the orthopedic literature to suggest that an injury to one joint would have any significant impact on another or opposite uninjured joint or limb, unless the injury resulted in a major muscle or nerve damage causing partial or complete paralysis or shortening of the injured limb resulting in length discrepancy of more than 5 cm (resulting in an obvious altered gait, such as the Trendelenburg gait. The level of severity is not supported based on record review history or examination. It is not unusual for two joints to share properties in the same person, but one joint's disease does not 'spread' to another or cause damage to it. With regard to aggravation, the examiner indicated that the Veteran's degenerative arthritis of the right shoulder is a progressive condition that gradually worsens over time. However, a degenerated joint can easily tear and sustain other injuries that led to his surgery. In this particular case, the Veteran's right shoulder surgery (arthroscopy) indicates that there was aggravation of his right shoulder condition beyond its natural progression.

In a February 2023 addendum opinion, a different examiner reiterated that it is less likely than not that the Veteran's right shoulder degenerative disease of the AC is caused by or related to his service-connected left or right knee disabilities, to include his right total knee replacement. The examiner added that while the Veteran has stated that he has fallen many times due to his knee condition, there are no supporting documentation of his shoulder condition as a result of the fall. Additionally, medical literature states that arthritis of the AC joint is a common condition that occur with overhead and cross-body activities and occur in middle aged adults. Next, the Veteran's knee condition, which caused falls, would not result in a shoulder impingement. With regard to aggravation, the examiner noted that the Veteran had a
, a different examiner reiterated that it is less likely than not that the Veteran's right shoulder degenerative disease of the AC is caused by or related to his service-connected left or right knee disabilities, to include his right total knee replacement. The examiner added that while the Veteran has stated that he has fallen many times due to his knee condition, there are no supporting documentation of his shoulder condition as a result of the fall. Additionally, medical literature states that arthritis of the AC joint is a common condition that occur with overhead and cross-body activities and occur in middle aged adults. Next, the Veteran's knee condition, which caused falls, would not result in a shoulder impingement. With regard to aggravation, the examiner noted that the Veteran had a right shoulder arthroscopy of debridement of SLAP and partial rotator cuff tear with sub acromial decompression and distal clavicle resection. Degenerative arthritis is a progressive condition that gradually worsens over time. However, a degenerated joint can easily tear and sustain other injuries that lead to the surgery.

The Board finds that neither the January nor the February 2023 medical opinions are adequate. While the January 2023 examiner found that the Veteran's service-connected knee disabilities less likely caused his right shoulder degenerative joint disease of the AC joint and shoulder impingement syndrome, she stated that the Veteran's arthroscopy suggested aggravation of the shoulder disability. However, it is unclear whether the examiner found that the aggravation was caused by the knee disability. This conclusion was also echoed by the February 2023 examiner. But similar to the prior finding, the February 2023 examiner offered no clarification as to whether the Veteran's degenerative disease of the right shoulder was aggravated by the service-connected knee disabilities.

Next, while the February 2023 examiner specifically found a negative nexus between the Veteran's right shoulder impingement and falls associated with the service-connected knee disabilities, she offered no rationale to explain her conclusion. Furthermore, she did not address whether the Veteran's newly diagnosed a right shoulder glenohumeral joint osteoarthritis is related to or aggravated by the knee disabilities.

Therefore, remand is required to obtain a new medical opinion to adequately address the possible nexus between the Veteran's right shoulder disabilities and his service-connected knee disabilities.

Entitlement to an earlier effective date for TDIU prior to June 17, 2016, is remanded.

The Board finds that the claim for an earlier effective date for TDIU is inextricably intertwined with the service connection claims being remanded herein, as the outcome of these claims may impact the effective date for TDIU. See Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (issues are "inextricably intertwined" when a decision on one issue would have a "significant impact" on a Veteran's claim for the second issue). Therefore, adjudication of earlier effective date for TDIU is remanded.

Entitlement to automobile or other conveyance and adaptive equipment or for adaptive equipment only is remanded.

The Veteran's service connection claims for a lumbar spine disability and bilateral hip condition have been remanded for additional development. Because the outcome of those claims could lead to a finding of loss of use of at least one foot, the claim for automobile and adaptive equipment must also be remanded as it is inextricably intertwined with the issues being remanded.

The matters are REMANDED for the following action:

1. Obtain a medical opinion pertaining the Veteran's lumbar spine disorder. The examiner shall address the following:

(a.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's degenerative disease of the lumbar spine is caused by or related to his service-connected left and right knee conditions to include falls associated with the knee disabilities? Why or why not?

(b.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's degenerative disease of the lumbar spine is aggravated (made worse) by his service-connected left and right knee conditions to include falls associated with the knee conditions? Why or why not?

2. Obtain a medical opinion pertaining the Veteran's lumbar spine disorder. The examiner shall address the following:

(a.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left and right hip condition to include degenerative arthritis and bursitis are caused by or related to his service-connected left and right knee conditions to include falls associated with the knee disabilities? Why or why not?

(b.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left
made worse) by his service-connected left and right knee conditions to include falls associated with the knee conditions? Why or why not?

2. Obtain a medical opinion pertaining the Veteran's lumbar spine disorder. The examiner shall address the following:

(b.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's left and right hip condition to include degenerative arthritis and bursitis are aggravated (made worse) by his service-connected left and right knee condition to include to include falls associated with the knee disabilities? Why or why not?

In issuing an opinion, the examiner must consider and address whether the Veteran's falls (associated with his right knee disorder) is related to his left and right hip disabilities.

3. Obtain a medical opinion pertaining the Veteran's right shoulder disabilities. The examiner shall address the following:

(a.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's right shoulder disabilities (including shoulder impingement syndrome, degenerative disease of the AC joint, degenerative disease of the glenohumeral joint) are caused by or related to his service-connected left and right knee conditions to include falls associated with the knee disabilities? Why or why not?

(b.) Is it at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's right shoulder disabilities (including shoulder impingement syndrome, degenerative disease of the AC joint, degenerative disease of the glenohumeral joint) are aggravated (made worse) by his service-connected left and right knee conditions to include falls associated with the knee disabilities? Why or why not?

4. Once the development on the Veteran's service connection claims have been completed, adjudicate the Veteran's claim for an earlier effective date for TDIU prior to June 17, 2016.

5. Readjudicate the Veteran's claim for entitlement to automobile or other conveyance and adaptive equipment or for adaptive equipment only

SHAUN S. SPERANZA

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Yeh, Nicole

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.

Analyze in VA Law Explorer