KNEE IMPAIRMENT OF

B. MULLINS · 2025 · Case ID: 25011453

DENIED

Summary

The veteran, an Army veteran who served from May 1977 to August 1979, appeals the denial of service connection for left knee, left ankle, and lumbar spine disabilities. The veteran contended that these conditions were secondary to his service-connected right ankle disability, and also asserted direct service connection for the left ankle and spine based on in-service injuries. The Board reviewed the veteran's service treatment records (STRs), which showed only isolated, minor complaints for the left ankle and lumbar spine during service, with no treatment or complaints for the left knee. A January 1989 examination, completed for employment purposes, indicated no pre-existing back or ankle issues. The Board found this evidence weighed against presumptive service connection. For direct service connection, VA examinations in December 2024 opined that the left ankle and lumbar spine conditions were less likely than not related to service, citing the lack of chronic in-service symptoms and the presence of normal gait findings. The Board found these opinions probative and consistent with the veteran's lay assertions that symptoms began post-service. Regarding secondary claims, addendum opinions from a VA physician concluded it was less likely than not that the right ankle disability aggravated or caused the left knee, left ankle, or lumbar spine conditions. The physician noted the absence of objective evidence of gait changes or compensatory strain, citing normal gait documentation in the record and the natural progression of degenerative arthritis. The Board found the VA opinions credible and more persuasive than the veteran's lay assertions and a private opinion from Dr. C.O., whose report lacked adequate rationale and contained unverified excerpts. The Board concluded the evidence persuasively weighed against all claims, denying service connection for the left knee, left ankle, and lumbar spine disabilities.

Rationale

No in-service complaints or treatment for left knee disability.; VA examination found less likely than not related to service.; VA physician found less likely than not that right ankle disability aggravated left knee condition.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

18-23 166A

Full Decision Text

Citation Nr: 25011453
Decision Date: 09/08/25 Archive Date: 09/08/25

DOCKET NO. 18-23 166A
DATE: September 8, 2025

ORDER

The claim of entitlement to service connection for a left knee disability, to include as secondary to a right ankle disability, is denied.

The claim of entitlement to service connection for a left ankle disability, to include as secondary to a right ankle disability, is denied.

The claim of entitlement to service connection for a lumbar spine disability, to include as secondary to a right ankle disability, is denied.

FINDINGS OF FACT

1. The Veteran's left knee condition did not have onset during active duty or for many years after discharge and is not otherwise shown to be related to military service or secondary to a service-connected disability.

2. The Veteran's left ankle condition did not have onset during active duty or for many years after discharge and is not otherwise shown to be related to military service or secondary to a service-connected disability.

3. The Veteran's lumbar spine condition did not have onset during active duty or for many years after discharge and is not otherwise shown to be related to military service or secondary to a service-connected disability.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for a left knee disability, to include as secondary to a right ankle disability, have not been met. 38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for entitlement to service connection for a left ankle disability, to include as secondary to a right ankle disability, have not been met. 38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for entitlement to service connection for a lumbar spine disability, to include as secondary to a right ankle disability, have not been met. 38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran had active service with the United States Army from May 1977 to August 1979.

Procedurally, these matters come before the Board of Veterans' Appeals (Board) from a September 2016 rating decision by a Department of Veterans Affairs (VA) Regional Office, which is the Agency of Original Jurisdiction (AOJ).

In July 2019, the Board issued a decision in which it (in relevant part) denied the Veteran's request to reopen the claims for service connection for lumbar spine, left knee and left ankle disabilities, along with a right ankle disability (a condition for which service connection is now established). See May 2025 Board decision. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims (Court). In July 2020, the Veteran and the VA Secretary (collectively, as parties) filed a Joint Motion for Partial Remand (JMPR). In pertinent part, the parties requested the Court vacate the Board's July 2019 decision as to the lumbar spine, left knee, and bilateral ankle disabilities, and remand the matters for further consideration and instructions consistent with the JMPR. The JMPR stipulated that the Board failed to provide an adequate statement of reasons or bases that the VA fulfilled its duty to assist the Veteran in attempting to obtain service medical records. The Court granted the JMPR in July 2020.

Thereafter, the Board remanded these matters in December 2020 and June 2024 to ensure compliance with the JMPR. In the June 2024 remand decision, the Board determined that the AOJ had substantially complied with the development directive to attempt to obtain service medical records from Stuttgart, Germany, noting that the AOJ informed the Veteran that the records were deemed unavailable and provided the Veteran with the opportunity to submit any additional records in his possession. However, in its June 2024 remand, the Board further determined that medical examinations were warranted regarding the left and right ankle disabilities and that the left knee and lumbar spine conditions were inextricably intertwined with the ankle disability claims. In November 2024 and May 2025, the Board found additional remand required to ensure substantial compliance with the Board's previous directives, as it found the medical opinions inadequate as to the left ankle and knee and the lumbar spine. As discussed below, the Board finds that there has been substantial compliance
records from Stuttgart, Germany, noting that the AOJ informed the Veteran that the records were deemed unavailable and provided the Veteran with the opportunity to submit any additional records in his possession. However, in its June 2024 remand, the Board further determined that medical examinations were warranted regarding the left and right ankle disabilities and that the left knee and lumbar spine conditions were inextricably intertwined with the ankle disability claims. In November 2024 and May 2025, the Board found additional remand required to ensure substantial compliance with the Board's previous directives, as it found the medical opinions inadequate as to the left ankle and knee and the lumbar spine. As discussed below, the Board finds that there has been substantial compliance with its prior remand directives and that there is adequate medical opinion evidence to adjudicate these matters. 38 U.S.C. § 5103A; Stegall v. West, 11 Vet. App. 268, 270-71 (1998); 38 C.F.R. § 3.159.

Service Connection

1. The claim of entitlement to service connection for a left knee disability, to include as secondary to a right ankle disability.

See section three, below.

2. The claim of entitlement to service connection for a left ankle disability, to include as secondary to a right ankle disability.

See section three, below.

3. The claim of entitlement to service connection for a lumbar spine disability, to include as secondary to a right ankle disability.

The Veteran seeks service connection for a lumbar spine disability, as well as left ankle and knee disabilities. He primarily contends that the conditions are secondary to his now service-connected right ankle disability. See, e.g., March and July 2025 Correspondence. He has also asserted in prior filings that his left ankle and spine disabilities are related to in-service injuries. See March 2025 private medical opinion. As such, the Board's opinion below will address the Veteran's theories of direct, presumptive, and secondary service connection for the left ankle and spine and will address secondary (causation/aggravation) regarding the left knee disability. Because the evidence and theories of entitlement overlap significantly, the Board will address the claims together.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Certain chronic diseases, such as arthritis, will be presumed related to service if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); 38 C.F.R. §§ 3.303, 3.307, 3.309.

Secondary service connection is warranted when a disability is proximately due to or the result of a service-connected disease or injury, or when a service-connected disability proximately causes the worsening of a preexisting disability. 38 C.F.R. § 3.310(a)-(b). The latter is an aggravation theory that entitles a Veteran to secondary service connection when a service-connected disability triggers "[a]ny increase in severity of a nonservice-connected disease or injury" that is "not due to the natural progress of the nonservice-connected disease[.]" 38 C.F.R. § 3.310(b); see generally El-Amin v. Shinseki, 26 Vet. App. 136, 138 (2013). Service connection is not limited to "single cause and effect" but also applies to conditions that "would have been less severe were it not for the service-connected disability." Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant.
natural progress of the nonservice-connected disease[.]" 38 C.F.R. § 3.310(b); see generally El-Amin v. Shinseki, 26 Vet. App. 136, 138 (2013). Service connection is not limited to "single cause and effect" but also applies to conditions that "would have been less severe were it not for the service-connected disability." Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023).

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b). The benefit-of-the-doubt rule applies if the competing evidence is "nearly equal" or in "approximate balance" but does not apply when the evidence persuasively favors one side or the other. See Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc).

In this case, the Veteran has current disabilities of the left knee, left ankle, and lumbar spine. See June 2025 VA knee examination (diagnosing left knee strain); June 2025 VA ankle examination (diagnosing degenerative arthritis of the ankle, other than post-traumatic); June 2025 VA back examination (diagnosing degenerative arthritis of the spine/spondylosis). The Board concludes; however, that the evidence of record persuasively weighs against finding that the Veteran's left knee, left ankle, and lumbar spine conditions began during service or are otherwise related to his service or his service-connected right ankle disability.

Considering direct and presumptive service connection, the Veteran's service treatment records (STRs) include one complaint in June 1978 that he had fallen and hit the lateral aspect of his left foot against a tree. His left ankle was noted to be slightly swollen with no discoloration but with a small blood blister. He was given an ace wrap, a crutch, Tylenol, and told to elevate and ice the area. He was given an initial profile of no running or excessive standing for one day, which was extended for approximately two additional days due to the Veteran's failure to return for follow-up evaluation. No additional treatment or complaints of left ankle pain were noted in the Veteran's STRs or at his separation. Regarding his lumbar spine, the Veteran was seen in October 1978 for "lower back pains" for several days following an automobile accident. He was assessed with a "mild strain" without spasm and told to heat the area. No pain medication was given and there is no indication that he received follow-up treatment for this injury for the remainder of his service. As noted above, the Veteran does not contend that he injured his left knee during service and his STRs do not include complaint of a left knee injury, pain or impairment during service or at his discharge. The Board concludes that the lack of in-service treatment or complaint for a left knee disability and only single, isolated complaints of left ankle and back pain weigh against a finding that the Veteran had symptoms of chronic conditions consistent with presumptive service connection during his service. Additionally, at separation, the Veteran expressly denied recurrent back pain, denied foot trouble, and denied having a "trick" or locked knee.

Further, while the evidence of record contains no contemporaneous medical records for several years following the Veteran's discharge from service, the record does contain an initial "Medical Examination Record" that appears to have been completed for employment purposes in January 1989, which was signed by the Veteran. In this examination, the Veteran acknowledged a history of a fractured right ankle in 1978, but he checked a box indicating he did not have arthritis, rheumatism, bursitis or other joint injury at that time. The Veteran expressly denied back pain, stiffness, injury or abnormality. This January 1989 record included a "Special Back Examination," which did not note any "previous back injury" and showed a normal back examination. Range of motion and gait was normal with no tenderness, pain or spasm. There was no atrophy of the limbs and the Veteran had a normal straight leg raise and sciatic stretch. The Veteran denied having "any condition which might restrict full, safe, mental and physical work performance and attendance," and he was cleared for employment as a lineman for an energy company. The Board finds this contemporaneous physical examination and lay evidence to be competent and probative evidence showing that the Veteran did not have left ankle, knee, or lumbar spine disabilities or impairments for approximately a decade
1989 record included a "Special Back Examination," which did not note any "previous back injury" and showed a normal back examination. Range of motion and gait was normal with no tenderness, pain or spasm. There was no atrophy of the limbs and the Veteran had a normal straight leg raise and sciatic stretch. The Veteran denied having "any condition which might restrict full, safe, mental and physical work performance and attendance," and he was cleared for employment as a lineman for an energy company. The Board finds this contemporaneous physical examination and lay evidence to be competent and probative evidence showing that the Veteran did not have left ankle, knee, or lumbar spine disabilities or impairments for approximately a decade after his discharge from service. Accordingly, the Board finds the evidence to weigh against the claims on a presumptive basis.

Considering direct service connection for the left ankle and spine disabilities, a December 2024 VA examiner opined that the Veteran's current left ankle arthritis disability was less likely than not related to his active service, noting that the Veteran's STRs did not show a chronic ankle condition and that his separation examination was negative for the claimed disability. The clinician noted that as of September 2015, imaging of the ankle revealed only minimal osteoarthritis, which was an expected finding for a person of the Veteran's age regardless of military service, and found no other medical nexus between the diagnosed condition and the Veteran's service. A December 2024 VA examiner likewise opined that it was less likely than not that the claimed lumbar spine condition was due to the Veteran's service. The clinician noted that without chronicity of symptoms during service or after service, a post-service event, illness, or injury was a more likely etiology of the condition. The Board finds these medical opinions probative because they are based on an accurate medical history and provide explanations with clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). These opinions are also consistent with the Veteran's lay assertions that it was not until after service that his left ankle, left knee, and lumbar spine pain began. See July 2025 Correspondence.

To the extent the Veteran seeks direct or presumptive service connection, the Board acknowledges that the Veteran is competent to report having experienced symptoms of orthopedic pain and impairment; however, the Veteran is not competent to provide a diagnosis in this case or to determine that symptoms present in 1968 were early manifestations of his current conditions. The issues are medically complex and require knowledge of the interaction between multiple organ systems in the body and interpretation of diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran has not suggested that he has specialized medical training or education to provide medical opinions in this case. Consequently, the Board gives more probative weight to the VA examination opinions discussed above.

As for secondary service connection, the Board concludes that the evidence of record persuasively weighs against finding that the Veteran's left knee, left ankle, and lumbar spine disabilities are due to or the result of, or aggravated by the Veteran's service-connected right ankle disability. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310. In the Board's May 2025 remand, it determined that the existing VA examination opinions did not adequately address whether the Veteran's right ankle condition (as it existed prior to his 2022 lower leg amputation) could have aggravated his lumbar, left knee, or left ankle conditions. As directed by the Board in its May 2025 remand, the AOJ obtained addendum opinions. See July 2025 opinions. The opining VA physician concluded that it was less likely than not that the claimed secondary conditions were caused or aggravated by the right ankle disability.

Regarding the left ankle disability, the physician found no objective evidence to show that the condition had been caused by the contralateral right ankle osteoarthritis disability. The physician cited medical research showing that injury to one extremity was rarely problematic for the opposite or uninjured extremity "except when damage to the leg results in a major displacement of the center of gravity of the body while walking, significant shortening of the injured limb and the abnormal gait pattern has been present for an extended period of time." The opining physician noted that review of the Veteran's medical records did not show the presence of any such factors, as multiple medical entries described the Veteran's gait as normal. The VA physician expressly noted that they considered the Veteran's March and July 2025 lay assertions and the March 2025 private opinion of Dr. C.O. The VA physician also acknowledged the theory that compensatory body mechanics due to the right ankle osteoarthritis may have contributed to or caused left ankle degeneration. However, the VA physician emphasized that there was "no supporting documentation in the medical record indicating such a causal relationship" as the "Veteran's gait has been consistently documented as normal in multiple VA clinical encounters, and there is no objective indication of chronic biomechanical shift, altered weightbearing, or musculoskeletal compensation that would reasonably lead to contralateral joint degeneration."

The VA physician further explained that left ankle degenerative arthritis occurs due to natural aging processes and wear and tear on the joints, and that the ankle serves as a distinct joint structure that primarily involves different anatomical components compared to the knee, hip, or shoulder, where degenerative arthritis manifests. The clinician explained that the pathophysiological processes underlying degenerative arthritis do not involve direct mechanical stress or changes from ankle movement, and therefore concluded that "the presence of degenerative arthritis in the left joint does not receive aggravation from other ankle activity or conditions.

In discussing the lumbar spine condition, the VA physician emphasized that the Veteran's medical records during the relevant period showed the Veteran to have a normal (not antalgic or biomechanically altered) gait, and found no evidence of "chronic changes in gait, ambulation, weight bearing or stance that would somehow lead to right ankle osteoarthritis-related aggravation of the back problems." The physician further explained that degeneration was naturally expected to progress and to worsen due to multiple other factors (such as age and weight-bearing), and found no evidence of unnatural aggravation of the degeneration. The VA clinician provided an explanation as to why the private opinion by Dr. C.O. was not supported by the evidence of record-namely, the multiple medical treatment records documenting the Veteran's "normal gait, intact motor function, and no postural abnormalities consistent with biomechanical compensation" related to the ankle condition. The VA physician acknowledged the Board's directive to consider whether the claimed secondary conditions could have been less severe if not for the right ankle disability. The clinician stated that they considered the "possibility of subclinical biomechanical strain," but noted that "even in the absence of leg length discrepancy or Trendelenburg gait, there is insufficient medical evidence to conclude that the Veteran's spinal degeneration progressed more severely than it otherwise would have due to the right ankle condition.

The VA physician also expressly considered whether the Veteran's left knee, ankle, or lumbar spine disabilities would have been less severe if not for the service-connected right ankle condition as contemplated by Spicer, but found no indication from the evidence of record that the conditions "progressed more rapidly or severely than expected" for the Veteran considering his age and other health factors.

The Board finds the VA physician's opinions credible and probative. The opinion reports indicate that the physician fully reviewed the Veteran's claim file and considered his lay contentions (asserting the presence of gait changes) and the private medical opinion submitted in support of his claims. The VA clinician acknowledged the Veteran's theory that altered body mechanics caused or aggravated his other orthopedic conditions. The physician noted that the "medical literature is controversial regarding secondary causes of musculoskeletal biomechanical changes" and ultimately provided a reasoned rationale for their conclusion that there was no medical link between the right ankle disability and other claimed conditions by citing directly to evidence in the claims file and by explaining the medical importance of that evidence.

The Board acknowledges the Veteran's belief and assertions that his left ankle, knee, and spine conditions are linked to his right ankle injury. The Board acknowledges that in the July 2025 Correspondence, the Veteran stated that his right ankle condition "altered my gait and posture, which has caused or aggravated degenerative arthritis in my left ankle, chronic pain and swelling in my left knee as well as chronic lumbar spine pain." The Veteran stated that medical principles of "gait compensation and kinetic chain dysfunction" clearly demonstrated how chronic joint instability in his right ankle had led to "abnormal biomechanics and compensatory strain on adjacent joints and the spine." As noted above; however, the Veteran has not shown that he has specialized medical training to apply such medical principles to determine the etiology of his own conditions. Additionally, the medical evidence of record, including evidence directly submitted by the Veteran appears to contradict his lay statement. For example, multiple medical records expressly identified the Veteran as having a normal gait prior to his lower leg amputation. And, while the approximate timeframe when the Veteran asserts that he first observed changes in his gait or mechanics is not clear from his lay statements, Dr. C.O.'s private opinion indicates that the Veteran's compensatory gait changes occurred subsequent to the his right leg amputation due to peripheral artery disease, not specifically due to impairment or gait changes caused by the right ankle. Given the complex nature of the Veteran's multiple orthopedic and other health impairments, the Board finds a competent medical opinion necessary to resolve the issues on appeal. As such, the Board finds that lay evidence is not adequate to provide a nexus regarding these secondary claims.

As the Board noted in its May 2025 remand, the private opinion of Dr. C.O. does not contain adequate rationale regarding how the clinician reached any relevant medical conclusions. The Board again notes that in a March 2025 Correspondence, the Veteran submitted a statement in rebuttal to a December 2024 VA examiner's opinion. In this Correspondence the Veteran included a statement in quotation marks that he asserted was an excerpt from Dr. C.O.'s opinion with a more comprehensible rationale and medical nexus statement; however, review of Dr. C.O.'s evaluation report does not show that the language quoted by the Veteran in the March 2025 Correspondence was actually included in Dr. C.O.'s report. As such, the Board cannot rely on that quoted opinion as credible medical evidence as its source is unknown. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008), Barr v. Nicholson, 21 Vet. App. 303 (2007), Stefl v. Nicholson, 21 Vet. App. 120 (2007), Prejean v. West, 13 Vet. App. 444 (2000).]

Consequently, the Board gives more probative weight to the July 2025 VA medical evidence and other VA opinions as cited above.

In sum, the Board finds that the evidence is persuasively against the claims of entitlement to service connection for left ankle, left knee, and lumbar spine disabilities. As there is not an approximate balance of positive and negative evidence, the benefit-of-the-doubt doctrine is not applicable and service connection for the claimed conditions is not warranted. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

B. MULLINS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board C. Hart, 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.

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