KNEE IMPAIRMENT OF

Summary

The Veteran, an Air Force Veteran who served from July 1968 to December 1970, sought service connection for right knee and leg disability, left knee and leg disability, and low back disability. The Veteran claimed the right knee injury occurred in service in September 1970 due to a fall down stairs, and that the left knee and low back conditions are secondary to the right knee injury. The Board found the evidence, including the Veteran's consistent lay statements and multiple private medical opinions, established a direct service connection for the right knee condition, granting service connection for right knee meniscal tear and osteoarthritis. The Board acknowledged negative VA nexus opinions but applied the benefit of the doubt doctrine, finding the competent and credible evidence favored the Veteran. For the secondary claims, the Board found the Veteran's left knee and low back disabilities were caused by the service-connected right knee condition, despite a negative VA opinion on this point. The Board found the private medical opinions and the Veteran's consistent lay statements regarding causation more persuasive, particularly in light of recent Federal Circuit precedent on causation and aggravation. Service connection for the left knee and low back conditions was granted on a secondary basis.

Rationale

Competent and credible lay and medical evidence of record; Evidence of in-service injury; Benefit of the doubt doctrine applied

Full Decision Text

Citation Nr: 25014049
Decision Date: 11/17/25	Archive Date: 11/17/25

DOCKET NO. 16-29 911
DATE: November 17, 2025

ORDER

Service connection for right knee and right leg disability, diagnosed as a right knee meniscal tear and osteoarthritis, is granted.

Service connection for left knee and left leg disability, diagnosed as a left knee strain, is granted.

Service connection for low back disability, diagnosed as degenerative arthritis, degenerative disc disease, spinal stenosis, and right lower extremity radiculopathy, is granted. 

FINDINGS OF FACT

1. The evidence is at least in approximate balance regarding whether the Veteran's right knee disability had its onset in service. 

2. The Veteran's left knee disability is caused by or is the result of his service-connected right knee disability. 

3. The Veteran's low back disability is caused by or is the result of his service-connected right knee disability. 

CONCLUSIONS OF LAW

1. The criteria for service connection for a right knee and right leg disability, diagnosed as a meniscal tear and osteoarthritis, have been met.  38 U.S.C. §§ 1110, 1154(b), 5107(b); 38 C.F.R. §§ 3.102, 3.303.

2. The criteria for service connection for a left knee and left leg disability, diagnosed as a knee sprain, have been met.  38 U.S.C. §§ 1110, 1154(b), 5107(b); 38 C.F.R. §§ 3.102, 3.310. 

3. The criteria for service connection for a low back disability, diagnosed as degenerative arthritis, degenerative disc disease, spinal stenosis, and right lower extremity radiculopathy, have been met.  38 U.S.C. §§ 1110, 1154(b), 5107(b); 38 C.F.R. §§ 3.102, 3.310. 

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty with the United States Air Force from July 1968 to December 1970. 

This appeal comes before the Board of Veterans' Appeals (Board) from a December 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO), that adjudicated the Veteran's August 28, 2014, claim.

In a December 2018 decision, the Board denied service connection for a right knee and leg disability, a left knee and leg disability, and a low back disability.  The Veteran appealed the Board's December 2018 decision to the United States Court of Appeals for Veterans Claims (Court), which in a September 2019 order, granted the parties' joint motions for partial remand (JMPR), vacating the Board's December 2018 decision and remanding the claim for compliance with the terms of the JMPR.

In a February 2020 decision, the Board again denied service connection for a right knee and leg disability, a left knee and leg disability, and a low back disability.  The Veteran appealed the Board's February 2020 decision to the United States Court of Appeals for Veterans Claims (Court), which in a September 2020 order, granted the parties' joint motions for remand (JMR), vacating the Board's February 2020 decision and remanding the claim for compliance with the terms of the JMR.

In May 2021, May 2023, and October 2024, the Board remanded these matters for further development.  

The Board notes that, in September 2021, the Veteran requested a Board hearing, but, in January 2023, the Veteran withdrew his request for a hearing.  As such, the Board will adjudicate the appeal based on the current record.

Service Connection

The Veteran seeks service connection for a right knee and leg disability, which the Veteran contends occurred in service and has continued to worsen since service, and service connection for a left knee and leg disability and low back disability secondary to his right knee disability.  

Over the past twenty years, the Veteran has argued that his right knee and leg disability occurred in service in September 1970 due to a fall down the stairs after catching his right leg in a stair rung.  See October 2001 Statement in Support of Claim. 

In a January 2021 Brief, the Veteran's attorney argued that the evidence shows that the Veteran's right knee disability is a direct result of his military service and should be granted service connection.  Additionally, he argued that service connection for the left knee and low back disability should be granted secondary to his right knee
 and has continued to worsen since service, and service connection for a left knee and leg disability and low back disability secondary to his right knee disability.  

Over the past twenty years, the Veteran has argued that his right knee and leg disability occurred in service in September 1970 due to a fall down the stairs after catching his right leg in a stair rung.  See October 2001 Statement in Support of Claim. 

In a January 2021 Brief, the Veteran's attorney argued that the evidence shows that the Veteran's right knee disability is a direct result of his military service and should be granted service connection.  Additionally, he argued that service connection for the left knee and low back disability should be granted secondary to his right knee disability. 

In an April 2023 Brief, the Veteran's attorney further argued that the Veteran's file contains supportive nexus opinions regarding his right knee and low back disabilities.  The attorney argued that the August 2014 nexus opinion was from the Veteran's physician, who treated the Veteran for many years, and that, further, the Veteran's nexus opinions are supported by the Veteran's service treatment records. 

Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service.  38 U.S.C. § 1110; 38 C.F.R. § 3.303(a).  Disorders diagnosed after discharge will be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d). 

Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). 

Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).  Service connection on a secondary basis is warranted for any incremental increase in disability, regardless of its permanence.  See Ward v. Wilkie, 31 Vet. App. 233 (2019). 

Proximate cause under 38 C.F.R. § 3.310(a) is defined as a cause that directly produces an event without which the event would not have occurred.  VAOPGCPREC 1-2017, at 9-10 (Jan. 6, 2017); see also Carter v. McDonough, 46 F.4th 1356, 1360 (Fed. Cir. 2022) (citing Ollis v. Shulkin, 857 F.3d 1338, 1344 (Fed. Cir. 2017)) (defining proximate cause in terms of foreseeability, so that legal responsibility is limited to causes which are so closely connected with the result).  

When there are potentially multiple causes of harm, an action is considered to be a proximate cause of the harm if it is a substantial factor in bringing about the harm and the harm would not have occurred but for the action.  The action just has to be a legal cause; it does not have to be the sole or even predominant cause.  Carter, 46 F.4th at 1360-61.  In essence, proximate cause requires that the event, injury or service-connected disability played a role in the development of the secondary condition.

A determination of proximate cause is one of fact, for determination by adjudication personnel.  See Walsh v. Wilkie, 32 Vet. App. 300, 303 (2020).

In March 2023, the United States Court of Appeals for the Federal Circuit (Federal Circuit) issued a decision that addressed the issue of causation in 38 U.S.C. § 1110.  Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).  The Federal Circuit explained that the phrase "resulting from" in the statute refers to "but-for" causation (which is broad, undisputedly broader than proximate causation) and is not limited to a single cause and effect, but rather contemplates multi-causal links, including action and inaction.  Id. at 1363-64.  The Federal Circuit held secondary service connection is warranted where a nonservice-connected disability would have been less severe but-for a service-connected disability,
 issued a decision that addressed the issue of causation in 38 U.S.C. § 1110.  Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023).  The Federal Circuit explained that the phrase "resulting from" in the statute refers to "but-for" causation (which is broad, undisputedly broader than proximate causation) and is not limited to a single cause and effect, but rather contemplates multi-causal links, including action and inaction.  Id. at 1363-64.  The Federal Circuit held secondary service connection 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 nonservice-connected disability.  Id.  "Thus, for "aggravation of nonservice-connected disabilities," it is enough to show that "but for" the service-connected disability the incremental-increase in severity of a nonservice-connected disease or injury would not have occurred.  Id. 

Finally, the Federal Circuit further held that 38 C.F.R. § 3.310(b), which addresses the aggravation prong of secondary service connection, is inconsistent with 38 U.S.C. § 1110 and is therefore unlawful to the extent that VA applied it to reject the Veteran's theory of compensation.  Id. 

It is clear from the Federal Circuit's holding that causation and aggravation can be established without demonstrating a direct pathological link between the claimed disability and service-connected disabilities.  Id. 

Certain chronic diseases, including arthritis, will be presumed related to service, absent an intercurrent cause, 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 (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease.  38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).  

The Board additionally notes that, if the Board requires assistance in understanding or interpreting the underlying medical text evidence, it may seek clarification from the medical expert who wrote the opinion or from another source.  However, the Board is capable of interpreting medical text evidence on its own and is also able to interpret medical opinion evidence.  McCray v. Wilkie, 31 Vet. App. 243, 249 (2019). 

In McCray, the Court highlighted that, when evaluating medical text evidence and medical opinion evidence as to an unsettled medical question, it must bear in mind the reasonable doubt doctrine.  Id.  at 258 (citing Quirin v. Shinseki, 22 Vet. App. 390, 395 (2009)).  Further, the Court noted that a medical principle need not reach scientific consensus to adequately support a grant of VA benefits.  Id. at 258 (citing Wise v. Shinseki, 26 Vet. App. 517, 532 (2014)). 

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 has been found to be competent regarding 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). 

The Board is charged with the duty to assess the credibility and weight given to evidence.  Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001).  Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability.  Id. at 1076; see also 38 U.S
 to assess the credibility and weight given to evidence.  Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001).  Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit (Federal Circuit), citing its decision in Madden, recognized that that Board had inherent fact-finding ability.  Id. at 1076; see also 38 U.S.C. § 7104(a) (West 2002).  Moreover, the Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence.  Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992).  

Determinations as to service connection will be based on review of the entire evidence of record, to include all pertinent service, medical and lay evidence, with due consideration to VA's policy to administer the law under a broad and liberal interpretation consistent with the facts in each individual case.  38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a).

When the evidence is in approximate balance in the Veteran's favor or nearly equal 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990); Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (en banc). 

1. Service connection for a right knee and right leg disability is granted. 

As noted above, the Veteran seeks service connection for a right knee and leg disability, which the Veteran contends occurred in service and has continued to worsen since service.  Specifically, the Veteran has argued that his right knee and leg disability occurred in September 1970 during service, when he injured his knee during a fall down steps.  

In a February 2005 Statement, the Veteran reported that, since the onset of his problems in his right leg/knee in September 1970, he has continuously suffered with pain, swelling, stiffness, limited motion, locking, and falls due to his bilateral knee condition. 

Here, as explained below, the Board finds that all three elements of service connection are established by the competent and credible lay and medical evidence of record as to a right knee and leg disability.  38 U.S.C. § 1110; 38 C.F.R. § 3.303; Shedden, 381 F.3d at 1166-67.  Thus, service connection for a right knee and leg disability is warranted.  

In a November 2024 VA examination, the VA examiner diagnosed the Veteran as having right knee meniscal tear and osteoarthritis.  The examiner noted that the date of onset of the Veteran's knee disability was 1968 and indicated that the Veteran reported that, during service, his right leg became caught in a rung of stairs, causing him to fall and injure his right knee, which has caused him problems since the fall.  

The Board further notes that the Veteran's service treatment records (STRs) document that the Veteran was treated for weakness and numbness in his right knee after walking up a set of stairs and that, six days later, the Veteran sought follow-up care and the examiner noted that the Veteran's symptoms persist and that the Veteran experiences an eight to ten inch band of diminished sensation in the area of the right knee.  See September 1970 STR notes.  Additionally, the Veteran's June 1976 United States Air Force Reserves enlistment examination notes a scar on the Veteran's right knee. 

In a May 2002 Lay Statement, an individual with knowledge of the Veteran's disability stated that the Veteran has complained about problems with his legs and knees since his discharge from service, especially his right knee and leg.  The individual further reported that the Veteran has fallen on occasion as a result of the problems he has due to his knees and legs and has witnessed him fall. 

The Board finds that the Veteran has a current disability and that there is evidence of an in-service injury.  Thus, the remaining question is whether there is a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  

The Veteran has also
 States Air Force Reserves enlistment examination notes a scar on the Veteran's right knee. 

In a May 2002 Lay Statement, an individual with knowledge of the Veteran's disability stated that the Veteran has complained about problems with his legs and knees since his discharge from service, especially his right knee and leg.  The individual further reported that the Veteran has fallen on occasion as a result of the problems he has due to his knees and legs and has witnessed him fall. 

The Board finds that the Veteran has a current disability and that there is evidence of an in-service injury.  Thus, the remaining question is whether there is a causal relationship between the present disability and the disease or injury incurred or aggravated during service.  

The Veteran has also submitted several private medical opinions in support of this claim.  

In a February 2006 examination, a private examiner diagnosed the Veteran as having internal derangement right knee with cruciate injury initially and probably lateral meniscal tear initially dating back to service.  During the examination, the Veteran reported that, in 1969 during service, he went through the steps and felt something pop with immediate effusion in his right knee.  

In an August 2014 examination, a private examiner diagnosed the Veteran as having osteoporosis in both knees with pain in joint of lower leg and degenerative disc disease and arthritis of the spine.  The examiner stated that, having reviewed the Veteran's limited military records, the examiner believes that it is probable that his injuries sustained in the military have contributed to existing orthopedic problems.  In a separate August 2014 opinion, the examiner opined that, after reviewing the Veteran's service medical records, it is their opinion that the Veteran's bilateral knee and back conditions are related to his military service. 

In an August 2017 letter, a private examiner stated that the Veteran continues to have problems with his right knee.  The examiner stated that they reviewed the Veteran's military service medical records and that his right knee continues to worsen and persist to the present time.  The examiner opined that the Veteran's problem began when the Veteran fell down a flight of stairs hyperextending his right knee in 1970 while serving in the United States Air Force. 

And, in a July 2021 opinion, a private examiner stated that the Veteran is currently being treated for chronic pain of his lower back and right knee.  The examiner stated that the Veteran's pain is related to osteoarthritis as well as previous trauma sustained with the Air Force in 1970. 

The Board further finds that the Veteran's consistent lay statements constitute competent and credible evidence that the Veteran's right knee and leg disability occurred in service and has persisted since then.  See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007); Barr, 21 Vet. App. at 310; 38 C.F.R. § 3.159 (a)(2).  

The Board acknowledges the negative VA nexus opinions of record.  However, the Board notes that the competent and credible lay and medical evidence is at least approximately balanced in favor of the Veteran, and benefit of the doubt doctrine applies.  See Lynch, 21 F.4th 776.  

The Board, as finder of fact, concludes that the Veteran indicates that he first noticed his right knee pain during service as set forth above.  The Board resolves any doubt in the Veteran's favor and finds that his right knee and leg disability was incurred in service.  

In light of the foregoing, and after resolving all reasonable doubt in the Veteran's favor, the Board finds that direct service connection for a right knee and leg disability, diagnosed as right knee meniscal tear and osteoarthritis, is warranted.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102.

2. Service connection for a left knee and left leg disability is granted. 

3. Service connection for a low back disability is granted. 

As noted above, the Veteran seeks service connection for a left knee and leg disability and low back disability, which he contends are caused by his now-service-connected right leg disability.  The Veteran has consistently reported that his left knee/leg and back disabilities are caused by overcompensation from the Veteran's original right knee injury and due to falls caused by the right knee/leg injury. 

Throughout the appeal, the Veteran has reported that, during service, his right leg became caught in a rung of stairs, causing him to fall and injure his right knee and low back, which has caused him problems since the fall.  The Veteran further reported that his left knee started to bother him over time and was not injured while in service.  See May 2024 and November 2024 VA examinations. 

In a February 2002 Statement,
 he contends are caused by his now-service-connected right leg disability.  The Veteran has consistently reported that his left knee/leg and back disabilities are caused by overcompensation from the Veteran's original right knee injury and due to falls caused by the right knee/leg injury. 

Throughout the appeal, the Veteran has reported that, during service, his right leg became caught in a rung of stairs, causing him to fall and injure his right knee and low back, which has caused him problems since the fall.  The Veteran further reported that his left knee started to bother him over time and was not injured while in service.  See May 2024 and November 2024 VA examinations. 

In a February 2002 Statement, the Veteran stated that the original injury to his right knee and leg in service has caused abnormal wear and tear on his left knee and leg, as he has been trying to compensate for the problems with his opposite leg.  In a subsequent September 2004 Statement, the Veteran stated that his right knee has continued to give him problems and has caused him to fall on occasion.  He further reported that, due to his falls, he has sustained injuries to his left leg, lower back, right shoulder, and his neck.  

Alternatively, the Veteran contends that his back disability began in service and has continued since then due to the same accident causing his right knee disability.  See November 2024 VA examination.  

For the reasons discussed below, the Board finds that entitlement to service connection for the Veteran's left knee and leg disability and low back disability caused by his now service-connected right knee and leg disability is warranted.  

As the Board is granting the Veteran's claims for service connection on a secondary basis theory of entitlement based on causation, no other theories of entitlement will be addressed herein. 

The Veteran meets the first criteria of secondary service connection - the Veteran has a current disability.  

In a May 2024 VA knee and lower leg examination, the VA examiner diagnosed the Veteran with a left knee strain and patellofemoral pain syndrome.  

In a separate May 2024 VA back examination, the VA examiner diagnosed the Veteran as having degenerative arthritis, degenerative disc disease, and spinal stenosis.  

In a November 2024 VA knee and lower leg examination, the VA examiner diagnosed the Veteran as having left knee strain, and in a separate back examination, the examiner diagnosed the Veteran as having spinal stenosis and right lower extremity radiculopathy.  

As the Veteran is already service connected for a right knee and leg disability, the remaining question for the Board is whether the Veteran's left knee and leg disability and low back disability are caused by, the result of, or aggravated by his service-connected right knee and leg disability. 

Several opinions regarding the etiology of the Veteran's left knee disability and low back disability have been obtained.  

In a June 2024 VA opinion, the examiner opined that the Veteran's back disability is less likely than not due to the Veteran's right knee disability, reasoning that, while one knee joint's pain may cause short term limping, which causes more stress on the contralateral joint, it would not result in substantial back pain.  The examiner cited an August 2014 Discussion Paper, Symptoms in the Opposite or Uninjured Leg, which states that an injury to one lower extremity could have an impact on the opposite uninjured limb if damage to the leg results in major displacement of the center of gravity of the body while walking, significant shortening of the injured limb, or abnormal gait pattern for an extended period of time. 

In an August 2014 private examination, a private examiner diagnosed the Veteran as having osteoporosis in both knees with pain in joint of lower leg and degenerative disc disease and arthritis of the spine.  The examiner stated that, having reviewed the Veteran's limited military records, the examiner believes that it is probable that his injuries sustained in the military have contributed to existing orthopedic problems.  

In a separate August 2014 opinion, the examiner opined that, after reviewing the Veteran's service medical records, it is their opinion that the Veteran's bilateral knee and back conditions are related to his military service.  

And, in a July 2021 private opinion, a private examiner stated that the Veteran is currently being treated for chronic pain of his lower back and right knee.  The examiner stated that the Veteran's pain is related to osteoarthritis, as well as previous trauma sustained with the Air Force in 1970. 

The Board acknowledges the negative VA opinions of record but finds that the medical evidence shows that the Veteran's left knee and low back disabilities are caused by his service-connected right knee and leg disability.  

The Board further interprets the June 2024 VA opinion to support the finding that the Veteran's left knee and leg disability was
 their opinion that the Veteran's bilateral knee and back conditions are related to his military service.  

And, in a July 2021 private opinion, a private examiner stated that the Veteran is currently being treated for chronic pain of his lower back and right knee.  The examiner stated that the Veteran's pain is related to osteoarthritis, as well as previous trauma sustained with the Air Force in 1970. 

The Board acknowledges the negative VA opinions of record but finds that the medical evidence shows that the Veteran's left knee and low back disabilities are caused by his service-connected right knee and leg disability.  

The Board further interprets the June 2024 VA opinion to support the finding that the Veteran's left knee and leg disability was caused by his right knee and leg disability. 

The Board has considered and weighed the evidence of record.  The competent and credible evidence is at least approximately balanced in favor of the Veteran, and benefit of the doubt doctrine applies.  38 U.S.C. § 5107 (b); see Lynch, 21 F.4th 776.  

The Veteran's left knee and leg disability and low back disability are caused by his service-connected right knee and leg disability.  As such, the last prong of secondary service-connection is met. 

As such, after resolving all reasonable doubt in the Veteran's favor, the Board finds that secondary service connection for a left knee and leg disability and a low back disability, caused by his service-connected right knee and leg disability, is warranted.   38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.  

 

 

STEVEN D. REISS

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	B. Mountjoy, 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.