DEGENERATIVE ARTHRITIS OF THE SPINE (SPONDYLOSIS)

J. CONNOLLY · 2022 · Case ID: 22016954

GRANTED

Summary

The veteran, who served in the Navy from February 1990 to March 2000, appeals the denial of service connection for back, left shoulder, and left knee disabilities. The veteran claims these conditions are secondary to service-connected right knee and right shoulder disabilities. The Board reviewed multiple VA examinations and a private medical opinion. For the back disability, the Board found direct service connection was not established, citing a lack of service treatment record evidence for injury and a lack of medical literature supporting a link between the right knee condition and the current back issues. However, a private medical opinion provided a reasoned analysis linking the back condition to biomechanical changes from the service-connected right knee disability. The Board found the evidence in equipoise, applying the benefit of the doubt to grant secondary service connection for the back disability. For the left shoulder disability, the Board found direct service connection was not established, noting the lack of service treatment records for the left shoulder and the VA examiner's opinion that it was not related to the service-connected right shoulder. However, a private medical opinion linked the left shoulder condition to overuse and compensatory strategies due to the right shoulder disability. Again, finding the evidence in equipoise, the Board applied the benefit of the doubt to grant secondary service connection for the left shoulder disability. For the left knee disability, the Board found direct service connection was not established, citing lack of service treatment records and a negative VA opinion. However, a private medical opinion linked the left knee condition to biomechanical changes and compensatory strategies from the service-connected right knee disability. The Board found the evidence in equipoise and applied the benefit of the doubt to grant secondary service connection for the left knee disability.

Rationale

Private opinion linked back condition to service-connected right knee disability.; Evidence found in equipoise.; Benefit of the doubt applied.

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

17-25 890

Full Decision Text

Citation Nr: 22016954
Decision Date: 03/23/22 Archive Date: 03/23/22

DOCKET NO. 17-25 890
DATE: March 23, 2022

ORDER

Service connection for a back disability as secondary to service-connected right knee disability is granted.

Service connection for a left shoulder disability as secondary to service-connected right shoulder disability is granted.

Service connection for a left knee disability as secondary to service-connected right knee disability is granted.

FINDINGS OF FACT

1. The Veteran's current back disabilities are lumbar spine arthritis and degenerative disc disease which were not manifest in service or within 1 year afterwards, and are not otherwise attributable to service.

2. The Veteran's current back disabilities, lumbar spine arthritis and degenerative disc disease, are caused by his service connected right knee disability.

3. The Veteran's current left shoulder disabilities are arthritis and impingement syndrome which were not manifest in service or within 1 year afterwards, and are not attributable to service.

4. The Veteran's current left shoulder disabilities, arthritis and impingement syndrome, are caused by his service connected right shoulder disability.

5. The Veteran's current left knee disabilities are arthritis and patellofemoral pain syndrome which were not manifest in service or within 1 year afterwards, and are not attributable to service.

6. The Veteran's current left knee disabilities, arthritis and patellofemoral pain syndrome, are caused by his service connected right knee disability

CONCLUSIONS OF LAW

1. The criteria for direct and presumptive service connection for a back disability, lumbar spine arthritis and degenerative disc disease, have not been met. 38 U.S.C. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.303, 3.307, 3.309.

2. The criteria for service connection for back disabilities, lumbar spine arthritis and degenerative disc disease, as secondary to service-connected right knee disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

3. The criteria for direct and presumptive service connection for a left shoulder disability, arthritis and impingement syndrome, have not been met. 38 U.S.C. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.303, 3.307, 3.309.

4. The criteria for service connection for left shoulder disabilities, arthritis and impingement syndrome, as secondary to service-connected right shoulder disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

5. The criteria for direct and presumptive service connection for a left knee disability, arthritis and patellofemoral pain syndrome, have not been met. 38 U.S.C. §§ 1101, 1110, 1112; 38 C.F.R. §§ 3.303, 3.307, 3.309.

6. The criteria for service connection for left knee disabilities, arthritis and patellofemoral pain syndrome, as secondary to service-connected right knee disability are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from February 1990 to March 2000. He appeals from February 2015 rating decisions based on claims filed in October 2014. His appeals were remanded by the Board of Veterans' Appeals (Board) in February 2019 and August 2021 and are now ready for appellate review.

SERVICE CONNECTION

Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1153; 38 C.F.R. §§ 3.303, 3.304, 3.306.

In addition, arthritis will be presumed to have been incurred in or aggravated by service if it had become manifest to a degree of 10 percent or more within one year of a veteran's separation from service. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With chronic diseases shows as such in service or within the presumptive period so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. This rule does not mean that any manifestation of joint pain, any abnormality of heart action or heart sounds, any urinary findings of casts, or any cough, in service will permit service connection of arthritis, disease of the heart, nephritis, or pulmonary disease, first shown as a clear cut clinical entity, at some later date. Continuity of symptomatology is required only where the condition noted during service or the presumptive period is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after service is required to support the claim. 38 C.F.R. § 3.303(b). This regulation pertains to "chronic diseases" enumerated in 38 C.F.R. § 3.309(a) (listing named chronic diseases). Walker v. Shinseki, 708 F.3d 1331, 1336-37 (Fed. Cir. 2013).

The United States Court of Appeals for the Federal Circuit (Federal Circuit) noted that the requirement of showing a continuity of symptomatology after service is a "second route by which a veteran can establish service connection for a chronic disease" under subsection 3.303(b). Walker, supra. Showing a continuity of symptoms after service itself "establishes the link, or nexus" to service and also "confirm[s] the existence of the chronic disease while in service or [during the] presumptive period." Id. (holding that section 3.303(b) provides an "alternative path to satisfaction of the standard three-element test for entitlement to disability compensation").

Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004).

Service connection may be granted, on a secondary basis, for a disability which is proximately due to, or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a non-service connected disease or injury that is proximately due to or the result of a service connected disease or injury, and not due to the natural progress of the nonservice connected disease, will be service connected. Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the non-service connected disease or injury is said to have been aggravated by the service-connected disease or injury. 38 C.F.R. § 3.310.

Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.

1. Service connection for a back disability

The Veteran appeals for service connection for a back disability. The evidence shows that the Veteran currently has lumbar spine degenerative arthritis and degenerative disc disease.

An August 1996 service treatment record shows that the Veteran reported having back pain on lifting heavy tools, equipment, and materials from 1990 to 1992.

On VA general medical examination in June 2000, the Veteran reported other orthoped
38 C.F.R. § 3.310.

Reasonable doubt concerning any matter material to the determination is resolved in the Veteran's favor. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102.

1. Service connection for a back disability

The Veteran appeals for service connection for a back disability. The evidence shows that the Veteran currently has lumbar spine degenerative arthritis and degenerative disc disease.

An August 1996 service treatment record shows that the Veteran reported having back pain on lifting heavy tools, equipment, and materials from 1990 to 1992.

On VA general medical examination in June 2000, the Veteran reported other orthopedic problems, but not current back problems, and his posture and gait were normal, with no back problems found.

In April 2015, a VA examiner indicated that the Veteran fell 4 feet during the military and has had low back pain since that time. However, this examiner did not address current diagnoses, so the opinion is of diminished probative value.

In June 2015, the Veteran was afforded a VA examination. The diagnosis was degenerative arthritis of the spine. The Veteran reported that he performed heavy labor in the military. He fell 4 feet down in the engine room in early 1990 per his history when he injured his right knee (which is service-connected). He injured his right knee surgery the short fall. He did not feel pain in the hip or back after the injury at the time. Later on, he noticed he some small mild pain in the hip and back region if he ran and he felt it was regular muscular pain at times and thus never thought to report an injury. He thinks somehow, he may have compensated by using his left leg and back over the years because of the right knee injury which he believes may have caused his pain in the back and the left knee now and hip now. He believes the forces have been increased on the other joints now because of injury to the right knee. His pain he feels is in the low back. The Veteran had a right shoulder injury in 1995 per his history today that was in the service. He also states today that his left shoulder was not injured in the service but started to become symptomatic around 2008. He works 40 hours a week doing mostly office work. The examiner indicated that the Veteran's contention that other ipsilateral joints and contralateral joints to the service-connected right knee was reviewed. The contention that the low back is secondarily connected to the service-connected right knee is unsupported and medically unjustified. There is absolutely no data in orthopedic literature or in the medical literature that supports the notion that this joint listed would have incurred secondary damage due to patellofemoral syndrome and degenerative joint disease in the right knee. This is purely speculative and unfounded and unsupported by medical science. The medical records indicate the veteran has some mild spondylosis and degenerative disc disease at L4-5 on recent lumbar films in 2014. The right knee injury may have even had some protective role against damage to the back as it would likely have decreased the Veteran's ability to do high impact activity which often increases the chance of subsequent trauma or degeneration. However, the literature does not support either a protective or negative role of the right knee injury in this case on other joints in the body. The service treatment records do not support injury that is service-connected and thus it is less than 50 percent likely that the Veteran's back is secondarily connected to the service-connected right knee condition. The examiner indicated that it is purely speculative if "heavy lifting" may increase the risk of injury at times and in certain predisposed individuals. However, the Veteran did not have an injury found due to lifting in service to his spine. In addition, the knee would not affect the spine. These are separate anatomically isolated regions. In this case, no evidence exists for an aggravation of the lumbar spine due to his service-related right shoulder and/or right knee conditions. His lumbar spine conditions can be explained due to the lag time since he has been in service and generalized aging which has occurred over the years which predisposed or increases his risk of these non-service-related orthopedic conditions.

In April 2017, a medical opinion was received from Dr. G.G.U. She noted that the Veteran was service-connected for right knee disability and the Veteran is claiming that, due to his right knee disabilities, he has developed an antalgic gait and/or has transferred his center of gravity toward the opposite side of the body, resulting in and/or aggravating his lumbar spine condition. It was noted that the Veteran had degenerative arthritis of the spine and that a VA examination noted the Veteran's symptomatology includes "abnormal and painful range of motion" and "guarding or muscle spasm of the thoracolumbar spine." She indicated that current medical literature (with citations) has linked low back pain to biomechanical changes and alterations in knee joint kinematics related to compensatory strategies, antalgic gait patterns, abnormal dynamic forces in the low back/pelvis/lower extremity joints, and the transfer of weight away from the normal center of gravity due to knee pain/painful motion while ambulating related to inner joint pathology. According to the University of Washington's Department of Orthopedics and Sports Medicine, "Lower back pain can become more intense when osteoarthritis affects the hips or the knees." The biomechanical relationships between the knees, hips, and spine are still being studied, though it is clear that when one of these major joints is damaged, the others are adversely affected. Another study found that patients who suffered from knee osteoarthritis had a significant association with increased low back pain. These results were corroborated by another study (all cited) which found back pain was present in 54.6 percent of patients with osteoarthritis of the knee. A study in the Journal of Orthopedic Medicine found that "A correlation between sacral inclination and Patellar Femoral (PF) joint pain is defined, and its prevalence in the elderly is reported." It was found that this phenomenon is caused by changing of lumbar alignment and have coined this new pathological concept the "Knee-Spine Syndrome." Multiple studies within the medical literature document that alterations in joint kinematics affect other major joints, including the lumbar spine facet joints and discs, and, over time, can accelerate wear on these joints by means of compensation and altered biomechanics. Therefore, she concluded that it is more than reasonable to conclude that this Veteran's right knee condition to include patellofemoral disease and degenerative joint disease caused him painful motion, as substantiated and documented in his medical records, which lead to a center of gravity shift and an antalgic gait pattern, and caused his lumbar spine condition to include degenerative arthritis. Therefore, based upon the Veteran's current diagnosis of lumbar spine condition to include degenerative arthritis, preceding history and current symptomatology of his service-connected right knee patellofemoral disease and degenerative joint disease, radiologic studies of the knee and lumbar spine, and current medical literature in support of the nexus, the Veteran's low back condition is least as likely as not secondary to, related to, and/or aggravated by Kinematic and Biochemical Changes from his service-connected right knee conditions.

Thereafter, in April 2017, another VA opinion was provided. The examiner opined that the lumbar spine degenerative arthritis was not aggravated by his service-related conditions including the right knee and right shoulder. The low back disability was neither caused in or aggravated by his service-related right shoulder or right knee problems. The examiner opined that there is no reasonable medical basis that lower back pain was due to the military because the Veteran did a lot of "heavy lifting". This is purely speculative without medical basis or merit based on the literature which has never shown or proven "heavy lifting" leads to arthritis. Certainly, heavy lifting may increase the risk of injury at times and in certain predisposed individuals. However, the Veteran did not have an injury found due to lifting in service to his spine. The examiner indicated that in this case, no evidence exists for an aggravation of the lumbar spine due to his service-related right shoulder and/or right knee conditions. His left-sided joint conditions and lumbar spine conditions can be explained due to the lag time since he has been in service and generalized aging which has occurred over the years which predisposed or increases his risk of these not service-related orthopedic conditions.

In October 2019, the Veteran was afforded a VA examination. It was noted that the Veteran served in the Navy from February 1990 until March 2000 as a mechanic. He was stationed in Panama Canal for 5 years. His verbal history indicates an injury in 1990 when he fell about 4 feet down an engine room ladder and injured his right knee. Later he began to have symptoms in his lower back. The examiner indicated that there is no service treatment record documentation of injury or treatment during his Navy service. The examiner opined that the condition claimed was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event or illness. The rationale was that there is no service treatment record documentation of back injury or treatment found in his medical record. Further, medical literature does not support aggravation or causation of back pain or arthritis due to any lower extremity injury or gait abnormality. The examiner indicated that the examiner did not believe there is any reasonable doubt about this lack of association. Most medical literature does not support this causal association and the studies provided are not double blinded or controlled appropriately. The examiner noted that back pain and arthritis may be highly prevalent in people with knee arthritis especially in older age, but this is not a causal association.

The Board remanded this case in August 2021. It was noted that The Board notes that the Veteran was provided prior VA examinations and the Veteran submitted medical opinions in support of his claim. The Board noted that the VA examinations did not address the August 1996 medical questionnaire wherein the Veteran reported back pain and shoulder pain after lifting heavy tools, equipment and materials and while playing tennis and ping pong. Additionally, the VA examinations did not address a January1999 onset of left flank pain and costovertebral tenderness diagnosed as ureteral lithiasis. Further, the VA examinations did not address whether the Veteran's claimed back disability was aggravated by service-connected right knee patellofemoral disease and/or did not provide a rationale. So, another opinion was requested.

A VA examiner rendered a medical opinion in November 2021. The examiner opined that the Veteran's current back disability is less likely than not incurred in or caused by service, manifest within 1 year after service, or noted in service with continuity of the same symptoms since service, including due to heavy lifting and left flank pain in service. The examiner reviewed the record and found that the Veteran's complaints from in service were most consistent with a muscular strain. The examiner further indicated that the medical literature and expert opinion do not support that a muscular strain is a risk factor for lumbar degenerative disc disease. Moreover, the Veteran did not complain of back pain during his post-discharge VA examination in June 2000. The examiner indicated that the preponderance of the evidence suggests that the Veteran's in service back pain episodes were acute and transitory, resolving without residual disability and not predisposing him to lumbar degenerative disc disease. The VA examiner in November 2021 explained that the service records do not document objective findings consistent with a high energy injury to the soft tissue or osseous structures of the Veteran's lumbar spine, such as fracture, disc derangement, spinal ligament tear, or dislocation. The examiner indicated that in the absence of such findings, a posttraumatic or chronic process is less likely than not. Also, the service treatment records do not document repetitive microtrauma which would be required to initiate and sustain a posttraumatic or chronic inflammatory process, and the Veteran's radiographs do not reveal advanced, asymmetric degenerative changes and therefore are not consistent with a posttraumatic process. Finally, there is no evidence of consistent treatment in the near or midterm after discharge, and a record from Dr. F. in September 2014 shows that the Veteran reported low back pain after an injury in 1993 where the Veteran fell only 4 feet onto his knee.

The VA examiner in November 2021 also opined that the Veteran's current lumbar spine disability is less likely than not caused or aggravated by his service connected right knee disability. The examiner indicated that empiric evidence in the medical literature does not support a causative or aggravation type relationship between right knee pathology and lumbar degenerative disc disease. He indicated that while some authors might argue that a theoretical relationship exists, this has not been corroborated by hard science. Moreover, for a theoretical relationship
near or midterm after discharge, and a record from Dr. F. in September 2014 shows that the Veteran reported low back pain after an injury in 1993 where the Veteran fell only 4 feet onto his knee.

The VA examiner in November 2021 also opined that the Veteran's current lumbar spine disability is less likely than not caused or aggravated by his service connected right knee disability. The examiner indicated that empiric evidence in the medical literature does not support a causative or aggravation type relationship between right knee pathology and lumbar degenerative disc disease. He indicated that while some authors might argue that a theoretical relationship exists, this has not been corroborated by hard science. Moreover, for a theoretical relationship to be considered, a severe dysfunction of the Veteran's right knee must be present, such as severe dysfunction of strength, stability, range of motion, and/or alignment. The examiner indicated that based on previous VA examinations, the Veteran has mild to moderate right knee dysfunction that still allows usage of his right knee in a functional manner.

In determining the probative value to be assigned to a medical opinion, the Board must consider three factors: whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case; whether the medical expert provided a fully articulated opinion; and whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the s file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions.").

In this case, the most recent VA examiner in 2021 was aware of the Veteran's medical history, provided a fully articulated opinion, and also furnished a reasoned analysis. The Board therefore attaches significant probative value to this opinion, and the most probative value in this case as to direct service connection, as it is well reasoned, detailed, consistent with other evidence of record, and included an access to the accurate background of the Veteran. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (Factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion). The Board finds that the opinion that current back disability is not etiologically related to service and arthritis was not manifest in the initial post-service year is supported by the record. Although the April 2015 opinion indicated a causal relationship to an inservice fall, that opinion, as noted, was incomplete as compared to the detailed 2021 opinion. Further, although the Veteran is competent to report back symptoms, his statements are less probative than the medical opinion regarding whether his current back disability is attributable to service. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative).

However, with regard to secondary service connection, the Board finds that the evidence is in equipoise. Although VA opinions indicated that medical principles and literature do not support a causal connection between the Veteran's low back disability and his service-connected disabilities, the April 2017 private opinion indicates otherwise with the supportive findings and citations. The evidence in this case is so evenly balanced so as to allow application of the benefit-of- the-doubt rule as required by law and VA regulations. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, secondary service connection for low back disability is warranted.

2. Service connection for a left shoulder disability

The Veteran appeals for service connection for a left shoulder disability. The evidence including July 2014 VA medical records and an October 2019 VA examination report shows that the Veteran currently has left shoulder acromioclavicular joint osteoarthritis and rotator cuff impingement syndrome.

An August 1996 service treatment record shows that the Veteran reported having shoulder pain on lifting heavy tools, equipment, and materials from 1990 to 1992, and due to tremendous arm rotating speed while playing tennis and ping-pong. However, on VA general medical examination in June 2000, the Veteran
. Accordingly, secondary service connection for low back disability is warranted.

2. Service connection for a left shoulder disability

An August 1996 service treatment record shows that the Veteran reported having shoulder pain on lifting heavy tools, equipment, and materials from 1990 to 1992, and due to tremendous arm rotating speed while playing tennis and ping-pong. However, on VA general medical examination in June 2000, the Veteran reported other orthopedic problems, but no current left shoulder problems, his posture was normal, and he had excellent and complete motion of his left shoulder. There were no left shoulder problems claimed or found.

In January 2015, the Veteran was afforded a VA examination. The examiner opined that left shoulder disability was not related to right shoulder disability, but a rationale was not provided.

However, a subsequent April 2015 VA opinion indicated that the left shoulder disability was related to the right shoulder disability based on his overcompensation and use of the shoulder.

In June 2015, the Veteran was afforded a VA examination. The Veteran reported that he had a right shoulder injury in 1995 per his history today that was in the service. He also states today that his left shoulder was not injured in the service, but started to become symptomatic around 2008. The examiner noted the Veteran's contention that other ipsilateral joints and contralateral joints to the service-connected right knee disability was reviewed. The examiner indicated that there was no support in medical literature that the left shoulder would be secondary to the right knee.

In April 2017, the above-cited private opinion also addressed the left shoulder. The provider stated that due to the severity of his right shoulder pathology and associated pain, the Veteran has developed an overuse syndrome that has led to the over usage of his left shoulder due to compensatory strategies and diminished range of motion of the right shoulder. Subsequently, this has hastened the development and progression of the Veteran's left shoulder strain and impingement syndrome. Per the medical literature, it is established that patients who experience immobilization of an injured shoulder, either as part of their treatment plan or due to the patient guarding the injury due to pain or impaired range of motion can result in and cause permanent harm. In the case of this veteran, the guarding and diminished range of motion of the injured right shoulder with rotator cuff tear and acromioclavicular osteoarthritis resulted in abduction capabilities below the shoulder height and made it necessary to over utilize the left arm, including the shoulder joint, to perform daily tasks. In one study, it was documented in their study that amputation of the upper extremity resulted in an overuse syndrome of both the affected arm and the contralateral arm, despite usage of a prosthetic device. This study and other studies within the medical literature substantiate that even though this Veteran does not have an amputation of the upper extremity, he has significantly diminished usage of the right upper extremity due to pain, painful motion, and severely limited range of motion, resulting in over usage of his left upper extremity shoulder joint anatomical structures. According to a medical study, overused and fatigued muscles are at a greater risk for injuries. Injuries and other shoulder conditions often occur due to inappropriate increased over-usage related to biomechanical muscular compensation. In this Veteran's case, he over-used his left shoulder joint in order to compensate for the pain, painful motion, and limited range of motion at the shoulder height of his right shoulder. These efforts resulted in an over-use type syndrome and abnormal joint arthrokinematics. These abnormal processes resulted in a strain of the muscles of the right shoulder joint. It was opined that it is at least as likely as not that the Veteran's current left shoulder condition to include strain and impingement syndrome is secondary to, related to, and/or aggravated by Kinematic and Biomechankal Changes from his service-connected right shoulder rotator cuff tear with acromioclavicular osteoarthritis condition."

In April 2017, the Veteran was examined again. The examiner indicated that the left shoulder strain/impingement was not aggravated by his service-related conditions including the right knee and right shoulder. The examiner stated that the left shoulder impingement was neither caused in or aggravated by his service-related right shoulder or right knee problems. The examiner did not support that the left shoulder is due to "overcompensation." However, rotator cuff impingement is often bilateral in nature and occurs very commonly during life especially as we age. Stating the theory of "overcompensation" is not considered reasonable medical evidence for aggravation. In fact, an opposite theory to "overcompensation" is reduced overhead activity secondary to his painful ipsilateral shoulder. In other words, often when one joint becomes inflamed or painful, the overall joint related activity in that joint and the opposite joint tend to decrease in many patients as they tend to avoid the inciting or painful activity such as avoid overhead motion in general. Thus, one can argue that because the Veteran has pain in the opposite shoulder, this could reduce his overall activity that leads to pain in the opposite joint. In any case, both arguments are purely speculative in nature, as the orthopedic literature nor reasonable clinical practice supports either a protective effect or deleterious effect from cuff tendinopathy and/or shoulder strain in one shoulder effecting the opposite shoulder on a permanent or aggravating basis. In addition, the examiner indicated that the right knee disability did not aggravate his left shoulder. His left sided joint condition can be explained due to the lag time since he has been in service and generalized aging which has occurred over the years which predisposed or increases his risk of these not service-related orthopedic conditions.

In October 2019, another VA opinion was provided. The examiner opined that it is less likely than not the left shoulder is related to the right shoulder as his symptoms in the left shoulder did not occur until 2008. It is not likely due to a repetitive trauma injury to the left shoulder not associated with the right shoulder. Medical literature does not support a causal association between shoulder pain on one side and eventual development of contralateral shoulder pain. Likewise, there is no medical literature associating aggravation of shoulder pain due to contralateral shoulder pain. Medical literature can be confusing and analysis of the data is of paramount importance. Studies at are not correctly controlled can lead to improper and inaccurate conclusions. Double-blind studies are the goal standard for documenting causation. The shoulder is not a weightbearing joint and therefore abnormality in one shoulder has minimal impact on the contralateral shoulder.

As previously noted, in August 2021, the Board remanded this case due to incomplete opinions by prior VA examination reported.

In November 2021, a VA examiner then opined that the Veteran's current left shoulder disability is less likely than not is related to service. The examiner indicated that in service shoulder complaints were most consistent with a muscular strain, and that such is not a risk factor for the Veteran's current chronic left shoulder impingement. Additionally, the examiner noted that the Veteran did not complain of left shoulder pain during his post-discharge VA examination in June 2000, and that a normal left shoulder was documented. The examiner felt that the preponderance of the evidence suggests that any episodes of left shoulder pain in service were acute and transitory, resolving without evidence of residual disability and not predisposing the Veteran to chronic left shoulder disability. The service treatment records document right shoulder trouble, including from playing tennis, but not left shoulder trouble.

The VA examiner in November 2021 also opined that the Veteran's current left shoulder disability is less likely than not caused or aggravated by his service connected right shoulder disability. The examiner indicated that empiric evidence in the medical literature does not support a causative or aggravation type relationship between right shoulder pathology and overuse/overload/left shoulder impingement. He indicated that while some authors might argue that a theoretical relationship exists, this has not been corroborated by hard science. Moreover, for a theoretical relationship to be considered, a severe dysfunction of the Veteran's right shoulder must be present, such as severe dysfunction of strength, stability, range of motion, and/or alignment. The examiner indicated that based on previous VA examinations, the Veteran has mild to moderate right shoulder dysfunction that still allows usage of his right shoulder in a functional manner.

However, with regard to secondary service connection, the Board finds that the evidence is in equipoise. Although VA opinions indicated that medical principles and literature do not support a causal connection between the Veteran's left shoulder disability and his service-connected disabilities, the April 2017 private opinion indicates otherwise with the supportive findings and citations. The evidence in this case is so evenly balanced so as to allow application of the benefit-of- the-doubt rule as required by law and VA regulations. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, secondary service connection for left shoulder disability is warranted.

Service connection for a left knee disability

The Veteran appeals for service connection for a left knee disability. The evidence including a July 2014 VA medical record and an October 2019 VA examination report shows that the Veteran currently has left knee osteoarthritis and patellofemoral pain syndrome, diagnosed no earlier than in or about July 2014.

Service treatment records contain no indication of any left knee problems. And when the Veteran fell on his right knee in service in April 1995, X rays of his knees were obtained and the X rays showed no left knee abnormalities. On VA general medical examination in June 2000, the Veteran reported other orthopedic problems including right knee problems, but no current left knee problems. Also, his posture was normal, and he had excellent and complete motion of his left knee. There were no left knee problems found.

In January 2015, the Veteran was afforded a VA examination. The examiner opined that left shoulder disability was not related to right shoulder disability, but a rationale was not provided.

However, a subsequent April 2015 VA opinion indicated that his left knee disability is the result of overcompensation due to his right knee disability.

The June 2015 examiner also provided an opinion. The examiner indicated that the Veteran's contention that other ipsilateral joints and contralateral joints to the service-connected right knee was reviewed. The contention that the left knee was secondarily connected to the service-connected right knee is unsupported and medically unjustified. The examiner indicated that there was no data in orthopedic literature or in the medical literature that supports the notion that this joints would have incurred secondary damage due to patellofemoral syndrome and degenerative joint disease in the right knee. This is purely speculative and unfounded and unsupported by medical science. The medical records indicate the Veteran has some mild spondylosis and degenerative disc disease at L4-5 on recent lumbar films in 2014. The service treatment records do not support injury that is service connected and thus it is less than 50 percent likely that the Veteran's left knee is secondarily connected to the service-connected right knee condition.

The April 2017 opinion also addressed the left knee. The Veteran has a current diagnosis of a left knee condition to include joint osteoarthritis and patellofemoral pain syndrome. Additionally, his medical records are positive for a history of a right knee condition and he is currently service-connected for his right knee condition to include patellofemoral disease and degenerative joint disease. It is noted throughout the Veteran's medical records that he suffers from chronic right knee strain and pain that dates back to 1994, during his active duty in the Navy. Due to the severity of his right knee pathology and associated pain, the Veteran has developed an antalgic gait pattern with limping and/or a shift in his center of gravity that the medical literature associates with secondary biomechanical changes that cause abnormal kinetics to occur within both of the lower extremity joints, and per the below medical literature, hastened the development and progression of his left knee condition to include joint osteoarthritis and patellofemoral pain syndrome. In a cited medical study, the pathophysiology of osteoarthritis: a mechanical perspective on the knee joint, that "The initiation and progression of knee OA is influenced by many factors, including kinematics. In response to loading during weight-bearing activity, cartilage in healthy knees demonstrates spatial adaptations in morphology and mechanical properties. These adaptations allow certain regions of the cartilage to respond to loading; other regions are less suited to accommodate loading. Alterations in normal knee kinematics shift loading from cartilage regions adapted for loading to regions less well suited for loading, which leads to the initiation and progression of degenerative processes consistent with knee osteoarthritis. Kinematic variables that are associated with the development, progression, and severity of knee osteoarthritis are the adduction moment and tibiofemoral rotation." Another study documented more specific abnormal kinematic changes associated with knee arthritis in the study titled, Biomechanical changes at the hip, knee, and ankle joints during gait are associated with knee osteoarthritis severity that abnormal mechanical gait changes occur as a result of knee osteoarthritis. These changes include: "increased mid-stance knee adduction moments, decreased peak knee flexion moments, decreased peak hip adduction moments, and decreased peak hip extension moments. Additional changes were found only in the severe knee osteoarthritis group that included multiple kinematic and kinetic differences at the hip, knee, and ankle joints. Gait differences that progressed with osteoarthritis severity included decreased stance phase knee flexion angles, decreased early stance knee extension moments, decreased peak stance phase hip internal rotation moments, and decreased peak ankle dorsiflexion moments." As a result of these biomechanical gait changes, a study concluded secondary gait changes in patients with medial compartment knee osteoarthritis: increased load at the ankle, knee, and hip during walking, that "The secondary gait changes observed among patients with knee osteoarthritis reflect a potential strategy to shift the body's weight more rapidly from the contralateral limb to the support limb, which appears to be successful in reducing the load at the knee in only patients with less severe knee osteoarthritis. The increased loading rate in the lower extremity joints may lead to a faster progression of existing osteoarthritis and to the onset of osteoarthritis at joints adjacent to the knee. The provider indicated that the cited medical literature states that compensation eventually alters the previously unaffected knee at the structural level (bone). If the bone is degraded from chronic wear and tear due to compensation, it is evident that the surrounding muscles must also experience an increased workload and altered mechanics, which would predispose them to arthritis. Thus, in summation, this Veteran has joint osteoarthritis and patellofemoral pain syndrome of his left knee with an antalgic gait pattern with limping due to more than 20 years of progressive severity of his right knee condition, which has resulted in secondary biomechanical gait changes that have included a compensatory strategy to shift weight from the right knee to the left knee to help reduce the weight load and pain. These biomechanical kinematic changes resulted in abnormal and excessive "wear and tear" on both the right and left knees and hastened the development and progression of his bilateral knee conditions. Therefore, per the Veteran's current diagnosis of left knee condition to include joint osteoarthritis and patellofemoral pain syndrome, service-connected right knee condition to include patellofemoral disease and degenerative joint disease with significant pain causing a weight shift to the left leg, service treatment records, radiologic studies, and current medical literature in support of the nexus, the Veteran's left knee as being at least as likely as not secondary to ,related to, and/or aggravated by compensating walking strategies
to help reduce the weight load and pain. These biomechanical kinematic changes resulted in abnormal and excessive "wear and tear" on both the right and left knees and hastened the development and progression of his bilateral knee conditions. Therefore, per the Veteran's current diagnosis of left knee condition to include joint osteoarthritis and patellofemoral pain syndrome, service-connected right knee condition to include patellofemoral disease and degenerative joint disease with significant pain causing a weight shift to the left leg, service treatment records, radiologic studies, and current medical literature in support of the nexus, the Veteran's left knee as being at least as likely as not secondary to ,related to, and/or aggravated by compensating walking strategies for his service-connected right knee disability.

The April 2017 and June 2019 VA examiners also provided negative opinions with regard to the left knee.

The Veteran reported during treatment in June 2018 that he developed left knee trouble at about the same time as he developed right shoulder trouble in service. However, this is not supported but is instead contradicted by the June 2000 VA examination report, and his current left knee disabilities are not shown until years post-service.

As indicated above, due to incomplete VA opinions, the Board remanded this case for a VA opinion which was provided in November 2021. That examiner opined that the Veteran's current left knee osteoarthritis less likely than not began in service, manifested within 1 year after discharge, or was noted during service with continuity of the same symptoms since service. The VA examiner indicated that the record does not document objective findings consistent with a high energy injury to the soft tissues or osseous structures of the Veteran's left knee, such as a fracture, internal derangement, tendon/ligament tear, or dislocation. In the absence of such findings, a posttraumatic or chronic inflammatory process (such as arthritis) is less likely than not. Moreover, the service department records do not document repetitive microtrauma which would be required to initiate and sustain a posttraumatic or chronic inflammatory process. Additionally, the VA examiner in November 2021 noted that the Veteran did not complain of left knee pain during his post-discharge VA examination in June 2000, and a normal left knee was documented at that time.

With regard to secondary service connection, the Board finds that the evidence is in equipoise. Although VA opinions indicated that medical principles and literature do not support a causal connection between the Veteran's left knee disability and his service-connected disabilities, the April 2017 private opinion indicates otherwise with the supportive findings and citations. The evidence in this case is so evenly balanced so as to allow application of the benefit-of- the-doubt rule as required by law and VA regulations. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, secondary service connection for left knee disability is warranted.

J. CONNOLLY

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board C. Lawson

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.

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