OSTEOARTHRITIS

Summary

The Veteran served from March 1987 to August 1987. The Veteran appealed the denial of service connection for right knee osteoarthritis of the medial patellofemoral compartment, claimed as secondary to his service-connected left knee disability. The Veteran also appealed the denial of service connection for atherosclerotic heart disease, claimed as secondary to his left knee disability and potentially due to toxic exposures. For the right knee osteoarthritis, the Veteran submitted a private medical opinion from a Physician's Assistant who opined that the condition was linked to the service-connected left knee post-surgery, citing altered gait and biomechanics supported by medical literature. The Board found this opinion probative and well-reasoned, granting service connection for the right knee osteoarthritis as secondary to the left knee disability. The claim for atherosclerotic heart disease was remanded due to a duty to assist error. The VA examiner's prior opinion was flawed as it addressed direct service connection instead of secondary connection and did not adequately consider the Veteran's obesity or the impact of his left knee disability on his physical activity. Furthermore, the Board noted the Veteran's exposure to asbestos and contaminated water at Camp Lejeune, requiring a new VA medical opinion to assess the nexus between his heart disease and these toxic exposures, as well as the secondary connection to his left knee disability and obesity. The remand also requires consideration of whether obesity was caused or aggravated by the left knee disability and if that obesity, in turn, caused or aggravated the heart disease.

Rationale

Private PA opinion found probative and well-reasoned.; Opinion linked right knee osteoarthritis to service-connected left knee disability.; Medical literature cited to support nexus.

Full Decision Text

Citation Nr: A26008890
Decision Date: 01/30/26	Archive Date: 01/30/26

DOCKET NO. 250701-559633
DATE: January 30, 2026

ORDER

Entitlement to service connection for right knee osteoarthritis of the medial patellofemoral compartment, as secondary to service-connected left knee total arthroplasty (left knee disability), is granted.

REMANDED

Entitlement to service connection for atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, to include as secondary to a service-connected left knee disability, is remanded.

FINDING OF FACT

The Veteran's right knee osteoarthritis of the medial patellofemoral compartment was caused by his service-connected left knee disability.

CONCLUSION OF LAW

The criteria for entitlement to service connection for right knee osteoarthritis of the medial patellofemoral compartment as secondary to a service-connected left knee disability have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDING AND CONCLUSION

The Veteran served on active duty from March 1987 to August 1987. 

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an August 2024 Appeals Modernization Act (AMA) rating decision by the Agency of Original Jurisdiction (AOJ) that considered the evidence of record on that date.  In July 2025, the Veteran submitted a VA Form 10182 electing Evidence Submission Reviewed by a Veterans Law Judge as the review option.

Based on the Veteran's election, the Board may only consider the evidence of record at the time of the August 2024 rating decision, 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.

Any additional evidence associated with the claims file during a period of time when additional evidence was not allowed has not been considered. If the Veteran would like VA to consider any evidence that was added to the claims file 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.

However, because the Board is remanding the claim of entitlement to service connection for atherosclerotic heart disease of native coronary artery with unspecified angina pectoris, any evidence the Board could not consider will be considered by the AOJ in the adjudication of the claim. 38 C.F.R. § 3.103(c)(2)(ii).

Entitlement to service connection for right knee osteoarthritis of the medial patellofemoral compartment. 

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 

Service connection may also be granted on a secondary basis for a disability which is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310.  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) proximately caused by; or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc).

A claimant is entitled to the benefit of the doubt when there is an approximate balance of positive and negative evidence on any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. If the positive and negative evidence is in approximate balance-which includes but is not limited to equipoise-the claimant receives the benefit of the doubt. Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021). If the evidence persuasively favors one side or the other, there is not an approximate balance, and therefore the benefit-of-the-doubt-rule does not apply. Id. at 781-82.

The Veteran asserts that his right knee disability is secondary to his service-connected left knee disability. In particular, he
 any issue material to the claim. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. If the positive and negative evidence is in approximate balance-which includes but is not limited to equipoise-the claimant receives the benefit of the doubt. Lynch v. McDonough, 21 F.4th 776, 781 (Fed. Cir. 2021). If the evidence persuasively favors one side or the other, there is not an approximate balance, and therefore the benefit-of-the-doubt-rule does not apply. Id. at 781-82.

The Veteran asserts that his right knee disability is secondary to his service-connected left knee disability. In particular, he asserts that his service-connected left knee disability has caused an altered gait and biomechanics, resulting in his right knee disability. The Veteran has several current diagnoses of the right knee, to include mild osteoarthritis of the medial patellofemoral compartment, meniscal tear, and degenerative arthritis other than posttraumatic. See September 2022, November 2023 VA Examinations. Accordingly, he has a current disability, and the first element of service connection is satisfied.

The Veteran is service connected for left knee total arthoplasty. Therefore, the lone question for the Board to resolve is whether the Veteran's right knee disability is caused or aggravated by his service-connected left knee disability.

The Veteran stated that he has right knee pain resulting from compensating from his left knee replacement. See September 2022 VA Examination. He submitted a medical opinion written by a private Physician's Assistant (PA) in June 2025, who opined that the Veteran's right knee osteoarthritis is linked to his service-connected left knee post ACL reconstruction, arthroscopy, and total knee arthroplasty. The private PA explained that the Veteran reported a long history of left knee instability, surgeries, and rehabilitation which has changed his balance and weight distribution. The private PA stated that medical literature demonstrates how disruption in the kinetic chain factors into the overall alignment and causes chronic issues. The private PA recited numerous medical studies in support of his opinion. 

The Board finds the June 2025 private PA's opinion probative. In this regard, the private PA offered a well-reasoned and sufficient explanation for his opinion. 

The Board notes that negative medical opinions exist in the form of the September 2022 and November 2023 VA medical opinions. However, the Board finds the private PA's June 2025 opinion more probative. In this regard, the private PA completed an orthopedic fellowship program and has a Doctorate in Science with emphasis in clinical orthopedics. Furthermore, the private PA provided a well-reasoned rationale for his positive opinion, supported by numerous medical articles which the PA provided.  

Given the probative June 2025 private medical opinion finding a nexus, the Board finds that the Veteran's right knee osteoarthritis of the medial patellofemoral compartment was caused by his service-connected left knee disability. Accordingly, entitlement to service connection on a secondary basis is granted.

REASONS FOR REMAND

Entitlement to service connection for atherosclerotic heart disease of native coronary artery with unspecified angina pectoris. 

Under the AMA, if a duty to assist error occurred prior to the AOJ's decision on appeal, the appeal must be remanded to the AOJ for correction of the error. 38 C.F.R. § 20.802(a).

During the appeal, Congress passed, and the President signed, the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act).  Under the PACT, certain development is necessary when a Veteran participates in toxic exposure risk activities (TERAs).  VA is required to provide a disability examination and medical nexus opinion when a veteran submits a compensation claim and has evidence of a disability and participation in TERAs, but the evidence is not sufficient to establish service connection for the disability.  See 38 U.S.C. § 1168(a) (see PACT Act, Sec. 303).  

The Veteran seeks service connection for atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (heart disability), which was denied in the decision on appeal based, in part, on the opinion of a VA examiner in November 2023 that it is less likely than not that his heart disability was related to his in-service TERA, to include exposure to diesel, fuel, gunpowder, and smoke.  

The Board notes, however, that December 2025 TERA Memoranda reflect that the Veteran was also exposed to asbestos and contaminated water at Camp Lejeune during active duty. Accordingly, a TERA medical opinion considering whether the Veteran's heart disability
see PACT Act, Sec. 303).  

The Veteran seeks service connection for atherosclerotic heart disease of native coronary artery with unspecified angina pectoris (heart disability), which was denied in the decision on appeal based, in part, on the opinion of a VA examiner in November 2023 that it is less likely than not that his heart disability was related to his in-service TERA, to include exposure to diesel, fuel, gunpowder, and smoke.  

The Board notes, however, that December 2025 TERA Memoranda reflect that the Veteran was also exposed to asbestos and contaminated water at Camp Lejeune during active duty. Accordingly, a TERA medical opinion considering whether the Veteran's heart disability is related these toxic exposures must be obtained on remand.  See Green v. McDonough, 37 Vet. App. 127 (2024) ("The Board also has the discretion to 'remand for correction of any other error by the [AOJ] in satisfying a regulatory or statutory duty, if correction of the error would have a reasonable possibility of aiding in substantiating the appellant's claim.' 38 C.F.R. § 20.802(a)").

Further, the Veteran asserts that his heart disability is related to his service-connected left knee disability. In particular, he asserts that his left knee pain has severely impacted his ability to run, hike, or walk without pain, resulting in obesity, and that medical literature links cardiovascular health with regular physical activity. See April 2022, May 2022 Lay Witness Statement. 

The United States Court of Appeals for Veterans Claims (Court) has held that obesity may serve as an "intermediate step" between a service-connected disability and a current disability that may be service connected on a secondary basis under 38 C.F.R. § 3.310(a). Walsh v. Wilkie, 32 Vet. App. 300 (2020); see also VAOGCPREC 1-2017.  No medical opinion has been obtained to determine whether obesity served as an intermediate step between the Veteran's service-connected left knee disability and his heart disability.  Further, the November 2023 VA examiner's opinion that the Veteran's heart disease was not due to his service-connected left knee disability was flawed as the rationale provided by the examiner addressed direct service connection rather than secondary service connection.  Specifically, the examiner reasoned that the Veteran's heart disease was not due to his left knee disability because his service treatment records did not show coronary artery disease and he only served on active duty for approximately five months.

The AOJ's failure to obtain an adequate VA medical opinion constitutes a pre-decisional duty to assist error; therefore, the Veteran's claim must be remanded. 38 C.F.R. § 20.802(a).

The matters are REMANDED for the following action:

Obtain a VA medical opinion from an appropriately qualified examiner regarding the Veteran's heart disease.  The examiner must review the claims file.  If the examiner determines that an additional examination is necessary, then an appropriate examination must be scheduled.

After review of the claims file, the examiner must provide opinions on the following:

(a) Whether it is at least as likely as not (i.e., the likelihood is at least in approximate balance or nearly equal, if not greater) that the Veteran's heart disease is related to his in-service toxic exposures, including asbestos, contaminated water at Camp Lejeune, diesel fuel, and/or gunpowder smoke.  In formulating this opinion, the examiner should consider the total potential exposure through all applicable deployments and the synergistic, combined effect of all toxic exposure risk activities (TERAs) involving the Veteran.

(b) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's heart disease was (i) caused (in whole or in part) by, or is/was (ii) aggravated by decreased physical activity associated with his left knee disability.

"	In formulating this opinion, the examiner should consider the Veteran's assertion that he was unable to run, hike, or walk due to left knee pain which decreased his ability to maintain cardiovascular health, as well as the literature he cited concerning the relationship between physical activity, physical fitness, and cardiovascular health.  See Lay/Witness Statement, dated April 25, 2022.   

"	The examiner should also review and consider the June 2025 medical opinion by the physician's assistant, A.B., MPAS, DSc, PA-C.

(c) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's obesity was (i) caused (in whole or in part) by, or is/was (ii) aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless
 left knee pain which decreased his ability to maintain cardiovascular health, as well as the literature he cited concerning the relationship between physical activity, physical fitness, and cardiovascular health.  See Lay/Witness Statement, dated April 25, 2022.   

"	The examiner should also review and consider the June 2025 medical opinion by the physician's assistant, A.B., MPAS, DSc, PA-C.

(c) Whether it is at least as likely as not (likelihood is at least approximately balanced or nearly equal, if not higher) that the Veteran's obesity was (i) caused (in whole or in part) by, or is/was (ii) aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless of its permanence) by his service-connected knee disability, in particular by any physical limitations associated with his knee disability.

(d) If the Veteran's obesity is found to have been caused or aggravated by his service-connected knee disability, whether the Veteran's heart disability was at least as likely as not (i.e., the likelihood is at least in approximate balance or nearly equal, if not greater) (i) caused (in whole or in part) by, or is/was (ii) aggravated (any incremental increase in disability or any additional impairment of earning capacity regardless of its permanence) by his obesity.

(e) Whether it is least as likely as not (i.e., the likelihood is at least in approximate balance or nearly equal, if not greater) the Veteran's heart disability would not have occurred but for the obesity caused by his service-connected disability.

NOTE: The examiner is advised that a "permanent worsening" is not required to establish aggravation. Aggravation may include temporary worsening, or flare-ups, of a disability.

Concerning secondary service connection, the examiner must provide clear and separate opinions as to both causation and aggravation.   

The examiner must provide all findings, along with a complete rationale for his or her opinion(s) in the examination report. If the examiner cannot provide an opinion without resort to speculation, he or she should provide an explanation as to why this is so and identify what, if any, additional evidence would permit such an opinion to be made.

 

 

P.M. DILORENZO

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Mohammad, Tahmina

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.