DEGENERATIVE ARTHRITIS OF THE SPINE (SPONDYLOSIS)

Summary

The veteran, who served in the U.S. Army from December 1973 to May 1974, appeals the denial of service connection for a lumbar spine disability. The Board found that while the veteran has a current diagnosis of degenerative arthritis of the spine, the evidence persuasively weighs against a finding that it began during active service or is otherwise related to an in-service injury. The veteran reported a fall from a top bunk in 1973 causing his back pain, but service treatment records did not document this fall or any related complaints or diagnoses. The Board noted that the absence of documentation for such a severe injury, especially when the veteran sought treatment for less debilitating heel pain, suggests the injury did not occur. The Board also considered the veteran's claim that his lumbar spine disability is secondary to his service-connected pes planus. However, medical opinions indicated no literature supports a link between foot callosities or pain and back pain without significant gait abnormalities or leg length discrepancies, which were not noted in the veteran's service records or examinations. Therefore, service connection for the lumbar spine disability, both directly and secondarily, was denied.

Rationale

Service treatment records negative for lumbar spine complaints or injury.; Veteran's report of severe back injury inconsistent with lack of treatment.; Absence of documentation for severe injury suggests it did not occur.

Full Decision Text

Citation Nr: A25039041
Decision Date: 04/29/25	Archive Date: 04/29/25

DOCKET NO. 210922-188253
DATE: April 29, 2025

ORDER

Service connection for a lumbar spine disability is denied.

FINDING OF FACT

The Veteran's lumbar spine disability is not secondary to service-connected pes planus and is not otherwise related to an in-service injury or disease.

CONCLUSION OF LAW

The criteria for service connection for a lumbar spine disability have not been met.  38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, d 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran had active service in the U.S. Army from December 1973 to May 1974.

An initial rating decision was issued in June 2019; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies.  The Board remanded the claim in October 2020.  The agency of original jurisdiction (AOJ) then issued a November 2020 supplemental rating decision.

In his September 22, 2021, VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.  Therefore, the Board may only consider the evidence of record at the time of the November 2020 supplemental rating decision on appeal, as well as any evidence submitted by the Veteran or his representative with, or within 90 days from receipt of, the VA Form 10182.  38 C.F.R. § 20.303.  If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision.  38 C.F.R. §§ 20.300, 20.303, 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 claim, 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

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service.  38 U.S.C. §§ 1110, 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).

The AOJ favorably found that the Veteran has a current diagnosis of degenerative arthritis of the spine.  However, the evidence of record persuasively weighs against finding that it began during active service, or is otherwise related to an in-service injury, event, or disease. 

During a June 2019 VA examination, the Veteran reported that his back pain had its onset in 1973 when he fell from a top bunk on to a concrete floor.  He stated that he was not able to get up off the ground for 30 minutes, and that he experienced gradually worsening back problems since then.  However, service treatment records do not document any such fall or any other complaints, treatment, or diagnoses of a lumbar spine disability.

These records do document complaints of heel pain and foot callosities.  Therefore, it appears the Veteran was actively reporting health concerns without mention of any back pain.  This strongly suggests no such pain or injury was present.  See AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely-held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present).

The Board may draw inferences against a claimant from a lack of documentation if it lays a proper foundation.  Horn v. Shinseki,
 lumbar spine disability.

These records do document complaints of heel pain and foot callosities.  Therefore, it appears the Veteran was actively reporting health concerns without mention of any back pain.  This strongly suggests no such pain or injury was present.  See AZ v. Shinseki, 731 F.3d 1303, 1318 (Fed. Cir. 2013) (recognizing the widely-held view that the absence of an entry in a record may be considered evidence that the fact did not occur if it appears that the fact would have been recorded if present).

The Board may draw inferences against a claimant from a lack of documentation if it lays a proper foundation.  Horn v. Shinseki, 25 Vet. App. 231, 239 n.7 (2012); Fountain v. McDonald, 27 Vet. App. 258, 272 (2015).  If that inquiry concerns a lack of medical documentation, the Board must discuss whether the condition was of such severity that it would have been reasonable to expect the appellant to seek treatment.  In this case, given that the Veteran reported being unable to get up off the ground for 30 minutes after his alleged fall and that he experienced worsening pain since then, it is reasonable to expect that he would have sought treatment, especially given that he was seen for heel pain and callosities which, by every indication, were not as debilitating as the alleged back injury.

For these reasons, while the Veteran believes his lumbar spine disability is related to a fall in service, the Board reiterates that the evidence of record persuasively weighs against findings that any such fall occurred.

Service connection may also be granted on a secondary basis for a disability that is due to or aggravated by a service-connected disease or injury.  Establishing service connection on a secondary basis requires evidence sufficient to show that (1) a current disability exists and (2) the current disability was either (a) caused by or (2) aggravated by a service-connected disability.  Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc); see also Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023) (invalidating the requirement of "proximate cause" and instead holding "but for" causation or aggravation is enough to show entitlement to secondary service connection).

The Veteran contends that his current lumbar spine disability is secondary to his service-connected bilateral pes planus.  However, the evidence of record persuasively weighs against finding this to be the case.  A June 2013 VA opinion stated that there was nothing in the medical literature to support a finding that foot callosities or pain would cause or aggravate back pain in the absence of any leg length discrepancy or clinical gait abnormality.  A November 2020 VA examiner similarly found that there was no evidence in orthopedic literature to suggest that an injury to one joint would have any significant impact on another, unless the injury resulted in leg length discrepancy of more than 5 centimeters, or the individual had a Trendelenburg gait.  For reference, this is a gait marked by listing of the trunk towards the affected side at each step.  See Dorland's Illustrated Medical Dictionary 765 (31st ed. 2007).

Notably, during a June 2018 VA examination for his pes planus, the Veteran reported having a limp caused by foot pain.  While the Board acknowledges his statement, the VA examiner did not note any instability of station or disturbance of locomotion associated with pes planus.  In addition, the Veteran's VA treatment records, including from December 2018 and June 2020, specifically noted an intact or normal gait.  The Veteran also denied the presence of any gait instability in June 2020.  His records are otherwise negative for any indications of an impaired gait.

There is no competent medical opinion to refute these conclusions or otherwise link the Veteran's lumbar spine disability to his service-connected pes planus.  To the extent that the Veteran himself has asserted such a connection, he has not shown the necessary medical knowledge or expertise to provide a competent medical opinion in this case.  The issue is medically complex, as it requires knowledge of pathology and anatomical relationships.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). 

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For these reasons, service connection for a lumbar spine disability, to include as secondary to service-connected pes planus, is not warranted.

 

 

JOHN Z. JONES

Veterans Law Judge

Board of
 that the Veteran himself has asserted such a connection, he has not shown the necessary medical knowledge or expertise to provide a competent medical opinion in this case.  The issue is medically complex, as it requires knowledge of pathology and anatomical relationships.  Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). 

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For these reasons, service connection for a lumbar spine disability, to include as secondary to service-connected pes planus, is not warranted.

 

 

JOHN Z. JONES

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Patel, Shamil

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.