KNEE IMPAIRMENT OF

Summary

The Veteran, a Veteran who served from October 1967 to May 1970, including service in Vietnam, appealed the denial of service connection for left knee and lumbar spine disabilities, claimed as secondary to his service-connected right knee degenerative arthritis. The Veteran asserted that his altered gait and posture due to decades of right knee pain caused these secondary conditions. The Board reviewed the evidence, including VA examinations and a private medical opinion. The VA examinations were found insufficient due to conclusory findings and inadequate rationale regarding the altered gait theory. In contrast, a private medical opinion from February 2024 provided a detailed rationale, citing medical literature, to support the Veteran's theory. This opinion concluded that the left knee disability resulted from an altered gait due to the long-standing right knee condition, and the lumbar spine disability was a consequence of the altered biomechanics and increased stress on the spine. The Board found this private opinion more persuasive, significantly outweighing the evidence against service connection. Consequently, the Board granted service connection for both the left knee and lumbar spine disabilities as secondary to the service-connected right knee degenerative arthritis.

Rationale

Private medical opinion found left knee disability resulted from altered gait due to long-standing right knee condition.; Private opinion cited medical literature supporting the link.; VA examinations were insufficient due to conclusory findings and inadequate rationale.

Full Decision Text

Citation Nr: A24014608
Decision Date: 03/26/24	Archive Date: 03/26/24

DOCKET NO. 210628-168588
DATE: March 26, 2024

ORDER

Service connection for left knee disability as proximately due to right knee degenerative arthritis is granted.

Service connection for lumbar spine disability as proximately due to right leg degenerative arthritis is granted.

FINDINGS OF FACT

1. The Veteran's left knee disability is shown to have been caused by his service-connected right knee degenerative arthritis.

2. The Veteran's lumbar spine disability is shown to have been caused by his service-connected right knee degenerative arthritis.

CONCLUSIONS OF LAW

1. The criteria for service connection for left knee disability as secondary to right knee degenerative arthritis have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for lumbar spine disability as secondary to right knee degenerative arthritis have 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 duty military service from October 1967 to May 1970, to include service in the Republic of Vietnam.

This matter comes before the Board on appeal of a rating decision issued in March 2021 which denied service connection for left knee disability and low back disability secondary to right knee degenerative arthritis. This matter falls within the Appeals Management Act (AMA) system of adjudication. In the June 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board hearing was held in November 2023. The AMA does not require that the same Veterans Law Judge (VLJ) who presided over a hearing on an appeal be the one to issue the decision.

Therefore, the Board may only consider the evidence of record at the time of the March 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran or his attorney at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision. 

Service connection for left leg disability 

Service connection for lumbar spine disability 

The Veteran seeks service connection for a left knee disability and a lumbar spine disability, both of which he asserts were caused by his service-connected right knee degenerative arthritis. He specifically asserts that his gait and posture adaptations to accommodate right knee pain over several decades caused these disabilities. 

Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement.  Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  All three elements must be established by competent and credible evidence in order that service connection may be granted. Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. 

The evidence shows diagnoses of left knee degenerative arthritis and degenerative arthritis of the spine with spinal stenosis. The Veteran was afforded VA examinations to address the question of whether these disabilities were caused by his service-connected right knee degenerative arthritis.
, 381 F.3d 1163, 1167 (Fed. Cir. 2004).  All three elements must be established by competent and credible evidence in order that service connection may be granted. Service connection is also provided for a disability which is proximately due to, the result of, or aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995); 38 C.F.R. § 3.310. 

The evidence shows diagnoses of left knee degenerative arthritis and degenerative arthritis of the spine with spinal stenosis. The Veteran was afforded VA examinations to address the question of whether these disabilities were caused by his service-connected right knee degenerative arthritis. A VA examination in October 2019 yielded the opinion that the Veteran's low back disability was not attributable to his right knee disability because there was no medical literature to support such a relationship. The VA examination and opinion on the left knee from March 2021 stated that arthritis in one joint would not have "spread" to another joint although it was not uncommon for two joints to share properties. Neither of these opinions addressed the theory of altered gait or postural impact and both have inadequate rationale which render them insufficient for adjudicative purposes. 

At the Board hearing in November 2023, the Veteran and his attorney presented arguments regarding the altered gait and posture theory.  They asserted that the Veteran favored his left knee because of his right knee pain, resulting in a limp; the more his right leg was used, the more pain he experienced.  His doctor had told him that his right knee disability caused him to walk differently which in turn was causing his back pain. The Veteran testified that he didn't fully understand the relationship because he was not a doctor, but he had noticed increased pain in his back and left knee as a result of overcompensating for this right knee disability.

In February 2024, the Veteran submitted a private medical opinion regarding the relationship between his right knee disability and his left knee and low back disabilities. The provider reviewed the entire claims record with specific attention to the medical documentation and discussed the evidence in connection with specific medical research. She provided the opinion that the Veteran's left knee disability was the result of an altered gait due to the right knee disability which began in service in Vietnam. She noted that for more than 50 years the Veteran had been walking on a painful right knee which medical literature showed had a likelihood to cause him to put more weight on his left knee to reduce pain and compensate for a feeling of instability, particularly when going up or down stairs. The change in biomechanics and muscle control has been documented to be related to an increased risk of injury to the opposite knee.  She also provided the opinion that the Veteran's low back disability was the result of his right knee disability because of a chain reaction. Specifically, the right knee constituted a weak link in the chain of body mechanics due to altered alignment, causing problems up and down the body including in the hips and spine because of increased stress on the muscles and joints. She provided a citation to medical research supporting this opinion. 

(Continued on the next page)

?

The Board has reviewed the evidence of record, with specific attention to the documents discussed above. The Board finds that the evidence in favor of service connection on a secondary basis for left knee disability and low back disability significantly outweighs the evidence against such a relationship. The Board notes that the VA examinations and opinions are conclusory and lack any true rationale. In contrast, the private medical opinion includes a discussion of the other medical evidence, citations of medical research literature, and consideration of the impact of a right knee disability which had been present for more than 50 years. It is more persuasive, and the claims of service connection are granted.

 

 

Eric S. Leboff

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Handy, Cheryl E.

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. 


.R. § 20.1303.