LUMBOSACRAL STRAIN

Summary

The Veteran, who served from April 2002 to February 2005, appeals the denial of service connection for a low back condition, radiculopathy of the left lower extremity, and radiculopathy of the right lower extremity. The Veteran claims these conditions are secondary to his service-connected left knee degenerative joint disease, left knee ACL tear with chondromalacia and meniscal repair, right knee strain, and lumbosacral strain. The Board found that the Veteran has a current diagnosis of lumbosacral strain and is service-connected for right knee strain and left knee degenerative joint disease. The primary issue was establishing a nexus between these service-connected knee conditions and the current low back condition. The VA examiner opined it was less likely than not that the low back condition was proximately due to the knee conditions, citing a lack of data showing a causal relationship and failing to provide an aggravation opinion. However, a private medical opinion from Dr. S.E. found it more likely than not that the degenerative joint disease of the left knee and chronic strain of the right knee were causative factors in the Veteran's chronic lumbosacral strain, referencing medical literature on spinal-knee biomechanics. The Board found the private opinion more probative and, resolving reasonable doubt in the Veteran's favor due to the approximate balance of evidence, granted service connection for the low back condition. The Board also found the VA examiner's opinion regarding radiculopathy secondary to the low back condition to be sufficiently supported and, again resolving reasonable doubt, granted service connection for radiculopathy of both lower extremities secondary to the now-service-connected low back condition.

Rationale

Current diagnosis of lumbosacral strain.; Service-connected left knee degenerative joint disease and right knee chronic strain.; Conflicting medical opinions on nexus; VA examiner found less likely than not, private examiner found more likely than not and provided sufficient reasoning.; Board found private opinion more probative and applied benefit of the doubt due to approximate balance of evidence.

Full Decision Text

Citation Nr: A26039375
Decision Date: 04/28/26	Archive Date: 04/28/26

DOCKET NO. 250611-552618
DATE: April 28, 2026

ORDER

Entitlement to service connection for a low back condition is granted.

Entitlement to service connection for radiculopathy of the left lower extremity is granted.

Entitlement to service connection for radiculopathy of the right lower extremity is granted.

FINDINGS OF FACT

1. Resolving reasonable doubt in favor of the Veteran, the Veteran's lumbosacral strain is due to his service-connected degenerative joint disease of the left knee and chronic strain of the right knee.

2. Resolving reasonable doubt in favor of the Veteran, the Veteran's radiculopathy of the left lower extremity is due to his now service-connected low back condition.

3. Resolving reasonable doubt in favor of the Veteran, the Veteran's radiculopathy of the right lower extremity is due to his now service-connected low back condition.

CONCLUSIONS OF LAW

1. The criteria for service connection for a low back condition are met.  38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

2. The criteria for service connection for radiculopathy of the left lower extremity as secondary to the Veteran's now service-connected lumbosacral strain have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria for service connection for radiculopathy of the right lower extremity as secondary to the Veteran's now service-connected lumbosacral strain have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from April 2002 to February 2005. 

These matters come before the Board of Veterans' Appeals (Board) from an April 2025 rating decision by a Department of Veterans Affairs (VA) Regional Office (RO).

In the June 2025 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 April 2025 agency of original jurisdiction (AOJ) 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 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

Service connection may be established for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection requires evidence showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (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.  38 C.F.R. § 3.310(a)-(b).  Secondary causation exists when, but for the service
 showing: (1) a current disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a nexus between the current disability and the disease or injury incurred or aggravated in service. See Shedden v. Principi, 381 F.3d 1163, 1167 (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.  38 C.F.R. § 3.310(a)-(b).  Secondary causation exists when, but for the service-connected disability, the non-service-connected was caused by a service-connected disability either in a direct, etiological way or via multiple steps in a causal chain. See Spicer v. McDonough, 61 F.4th 1360, 1365 (Fed. Cir. 2023) (citations omitted).  Secondary aggravation exists when the nonservice-connected disability not caused by a service-connected disability would be less severe were it not for a service-connected disability.  Id. at 1364.  

In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994); Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). Competency of evidence differs from weight and credibility. Competency is a legal concept determining whether testimony may be heard and considered by the trier of fact, while credibility is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997); Layno v. Brown, 6 Vet. App. 465, 469 (1994); see also Cartright v. Derwinski, 2 Vet. App. 24, 25 (1991) ("although interest may affect the credibility of testimony, it does not affect competency to testify").

For VA purposes, when there is an approximate balance in the evidence regarding the merits of an issue material to the determination of a matter, the benefit of the doubt in resolving each such issue is given to the claimant. 38 U.S.C. §5107 (b); 38 C.F.R. § 3.102. The U.S. Court of Appeals for Veterans Claims (Court) held that a claimant is only required to demonstrate that there is an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski,1 Vet. App. 49, 53 (1990). The Court further pointed out that, "to deny a claim on its merits, the evidence must preponderate against the claim." See Alemany v. Brown, 9 Vet. App. 518, 519 (1996).

Under 38 U.S.C. § 7104, Board decisions must be based on the entire record, with consideration of all the evidence. The law requires only that the Board address its reasons for rejecting evidence favorable to the Veteran. See Timberlake v. Gober, 14 Vet. App. 122, 128-29 (2000). The Board must review the entire record but does not have to discuss each piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1381 (Fed. Cir. 2000). The analysis below focuses on the most salient and relevant evidence within the period on appeal and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, supra.

1. Entitlement to service connection for a low back condition is granted.

The Veteran asserts that his low back condition is due to his service-connected instability/subluxation of the left knee, anterior cruciate ligament tear of the left knee with degenerative joint disease and chondromalacia and meniscal repair and right knee strain. 

As an initial matter, the RO has made the following favorable findings: 

The Veteran has been diagnosed with a disability, lumbosacral strain. The claimed primary disability, anterior cruciate ligament tear, left knee with degenerative joint disease and chondromalacia and meniscal repair, is service connected. The Veteran has been diagnosed with a disability of radiculopathy of the
.

1. Entitlement to service connection for a low back condition is granted.

The Veteran asserts that his low back condition is due to his service-connected instability/subluxation of the left knee, anterior cruciate ligament tear of the left knee with degenerative joint disease and chondromalacia and meniscal repair and right knee strain. 

As an initial matter, the RO has made the following favorable findings: 

The Veteran has been diagnosed with a disability, lumbosacral strain. The claimed primary disability, anterior cruciate ligament tear, left knee with degenerative joint disease and chondromalacia and meniscal repair, is service connected. The Veteran has been diagnosed with a disability of radiculopathy of the left lower extremity and a disability of radiculopathy of the right lower extremity. The claimed issues, radiculopathy of the right lower extremity and left lower extremity, are secondary to the primary disability, lumbosacral strain. 

Additionally, the AOJ has awarded service connection for right knee strain, associated with the Veteran's left knee condition.

There being no clear and unmistakable error, the Board is bound by these favorable findings. 38 C.F.R. § 3.104(c).

First, the Veteran has a current diagnosis of lumbosacral strain. See March 2025 Back (Thoracolumbar Spine) Disability Benefits Questionnaire (DBQ).  

Next, the Veteran is service connected for right knee strain and disability anterior cruciate ligament tear, left knee with degenerative joint disease and chondromalacia and meniscal repair. See April 2025 Rating Decision Codesheet. 

The remaining inquiry is whether a causal relationship or nexus exists between the Veteran's lumbosacral strain is due to or has been aggravated by these service-connected left knee and right knee conditions. 

After a review of all the lay and medical evidence, and resolving reasonable doubt in favor of the Veteran, the Board finds that the evidence establishes that the Veteran's current low back condition is due to the Veteran's service-connected degenerative joint disease of the left knee and chronic strain of the right knee. 

Here, there is both positive and negative medical evidence of record regarding the Veteran's secondary service connection claim for a low back condition. 

In a March 2025 VA medical opinion, the VA examiner opined that it was less likely than not that the Veteran's low back condition was proximately due to or the result of instability/subluxation of the knee or anterior cruciate ligament tear of the knee with degenerative joint disease and chondromalacia and meniscal repair. See March 2025 VA Medical Opinion. The VA examiner provided the rationale that "these conditions have been shown to aggravate or worsen low back pain conditions such as lumbosacral strain, but there has been no significant data showing that instability or subluxation of the knee or anterior cruciate ligament tears can cause low back conditions or lumbosacral strain." Id. The Board notes that the March 2025 VA opinion included hyperlinks to content not otherwise part of the appeal before the Board; however, that content was not accessed nor considered as part of the record before the Board. See Bowey v. West, 11 Vet. App. 106, 108-09 (1998) (holding that the mere reference to non-VA documents is insufficient to incorporate them into the record). For the VA examiner's opinion to adequately inform VA as to the nature of the relationship between the Veteran's left knee disabilities and low back condition, it must be explained why the conditions are not related. This requires a discussion regarding the relationship between the Veteran's specific cases of a low back condition and his service-connected left knee disabilities, in addition to the established medical relationship between the two. See Bailey v. O'Rourke, 30 Vet. App. 54, 60 (2018) (criticizing a medical conclusion that was based solely on general medical literature and unspecific to the claimant's individual circumstances). Although the VA examiner referenced medical literature and the absence of significant data showing a causal relationship between instability/subluxation of the knee or anterior cruciate ligament tear of the knee with degenerative joint disease and chondromalacia and meniscal repair, the Board finds that the rationale's reliance on the absence of data to support a causal relationship without further explanation to be insufficient.

Further, while the VA examiner alludes to such left knee conditions having been shown to aggravate or worsen low back pain conditions, such as lumbosacral strain, the VA examiner has not provided an opinion as to whether or not the Veteran's lumbsacral strain was worsened or aggravated by the Veteran's service-connected left knee disabilities. Thus, to the extent the March 2025 VA medical opinion
 significant data showing a causal relationship between instability/subluxation of the knee or anterior cruciate ligament tear of the knee with degenerative joint disease and chondromalacia and meniscal repair, the Board finds that the rationale's reliance on the absence of data to support a causal relationship without further explanation to be insufficient.

Further, while the VA examiner alludes to such left knee conditions having been shown to aggravate or worsen low back pain conditions, such as lumbosacral strain, the VA examiner has not provided an opinion as to whether or not the Veteran's lumbsacral strain was worsened or aggravated by the Veteran's service-connected left knee disabilities. Thus, to the extent the March 2025 VA medical opinion does not include an aggravation opinion, it is inadequate. See El-Amin v. Shinseki, 26 Vet. App. 136, 140-41 (2013) (stating that a secondary service connection medical opinion was inadequate because it did not discuss aggravation). 

In light of these insufficiencies, the Board assigns some probative weight to the March 2025 VA medical opinion regarding the Veteran's low back condition as secondary to his service-connected left knee disabilities.

During the applicable evidentiary window, the Veteran submitted a private medical opinion. In the June 2025 private medical opinion, Dr. S.E. opined that the Veteran's service-connected degenerative joint disease of the left knee and chronic strain of the right knee were more likely than not causative factors in the development of his chronic lumbosacral strain. See June 2025 Private Medical Opinion. The private physician provided summaries of cited medical literature which addressed the causative relationship between the knees and spine through alterations in balance and anatomical alignment. See June 2025 Private Medical Opinion. The rationale applied the findings of the referenced medical literature to the Veteran's pertinent medical history, including the Veteran's documented development of a gait abnormality and explaining the failure of muscular compensation surrounding the affected joints resulting in the straining of the Veteran's spine. Id. The Board finds this opinion provides sufficient reasoning to support its conclusion and affords it great probative weight.

Based on the discussion above, the Board finds that the evidence is in nearly approximate balance, and the Veteran is afforded the benefit of the doubt. See Lynch v. McDonough, 21 F. 4th 776 (Fed, Cir. 2021) (holding that exact equipoise is not required for the benefit of the doubt to be applied, but rather the Veteran is entitled to the benefit of the doubt when the evidence is in approximate balance or "nearly equal"). 

Accordingly, entitlement to service connection for a low back condition secondary to the Veteran's service-connected degenerative joint disease of the left knee and chronic strain of the right knee is granted.

2. Entitlement to service connection for radiculopathy of the left lower extremity is granted.

3. Entitlement to service connection for radiculopathy of the right lower extremity is granted.

The Veteran contends that his radiculopathy of the left lower extremity and radiculopathy of his right lower extremity are due to his low back condition.

As previously established, the AOJ has favorably found that the Veteran has the current disabilities of radiculopathy of the left and right lower extremities, and these disabilities are secondary to the Veteran's lumbosacral strain. Specifically, in the March 2025 VA medical opinion regarding radiculopathy of the Veteran's right and left lower extremities, the VA examiner opined that it was at least as likely as not that the Veteran's radiculopathy of the left and right lower extremities are proximately due to or the result of the Veteran's low back pain. See March 2025 Medical Opinion. The rationale provided explained that the Veteran's low back pain can be secondary to a herniated or bulging disc in the lumbar spine, which can compress nearby nerve roots, causing radiculopathy, spinal stenosis, which is narrowing of the spinal canal and can compress the nerve roots leading to radicular pain, and secondary to degenerative disc disease, which can cause radicular pain secondary to reduced space between the vertebrae putting pressure on the nerve. Id. The VA examiner opined further that instability and subluxation could aggravate radicular pain due to a shift in biomechanics but would not be a cause of radiculopathy. Id. The Board notes that the rationale discusses conditions such as herniated or bulging discs, spinal stenosis, and degenerative disc disease, which were not identified as current conditions in the associated March 2025 Back Conditions DBQ. Resolving all reasonable doubt in favor of the Veteran, the Board finds the VA examiner's opinion is sufficiently supported by their professional expertise, consideration
 radicular pain, and secondary to degenerative disc disease, which can cause radicular pain secondary to reduced space between the vertebrae putting pressure on the nerve. Id. The VA examiner opined further that instability and subluxation could aggravate radicular pain due to a shift in biomechanics but would not be a cause of radiculopathy. Id. The Board notes that the rationale discusses conditions such as herniated or bulging discs, spinal stenosis, and degenerative disc disease, which were not identified as current conditions in the associated March 2025 Back Conditions DBQ. Resolving all reasonable doubt in favor of the Veteran, the Board finds the VA examiner's opinion is sufficiently supported by their professional expertise, consideration of the Veteran's lay statements, and findings during the VA examination. Therefore, as the medical evidence supporting a nexus is in approximate balance, the Veteran is afforded the benefit of the doubt. See Lynch, supra.

As the Veteran is now service-connected for a low back condition, service connection for the Veteran's left and right lower extremities as secondary to his now service-connected lumbsacral strain is warranted.

As a final matter, the Board wishes to underline that the Veteran's appeal for the issues of secondary service connection for a low back condition, radiculopathy of the left lower extremity and radiculopathy of the right lower extremity is being granted under the causation prong of 38 C.F.R. § 3.310 and Allen. As such, the award downstream from the Veteran's allowance shall not be subject to a rating offset upon implementation.

 

 

Cynthia M. Bruce

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	M.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.