SHOULDER IMPAIRMENT OF

J. ABRAMS · 2026 · Case ID: A26030203

MIXED

Summary

The veteran, who served from July 1973 to June 1977, appeals the denial and remand of claims for service connection for various musculoskeletal conditions, including left and right shoulder disabilities, cervical spine disability, left and right elbow disabilities, bilateral hip disabilities, and left knee disability. All of these conditions were claimed as secondary to a service-connected right knee disability. The veteran's contentions, supported by lay statements and medical literature, suggest that the right knee disability, exacerbated by altered gait and the use of a cane, led to secondary issues in the shoulders, cervical spine, elbows, hips, and left knee. The Board found that the initial VA examinations were inadequate because they failed to adequately address the secondary nature of the claims, particularly the aggravation prong of secondary service connection, and in some instances, relied impermissibly on a lack of in-service treatment or diagnosis. The Board remanded these claims for new VA examinations and opinions to properly assess causation and aggravation, emphasizing the need for examiners to consider all evidence, including lay contentions and medical literature, and to avoid relying solely on the absence of in-service treatment records. The Board also noted the importance of addressing the veteran's gait abnormalities and the potential impact on other joints.

Rationale

Remanded due to duty to assist error; Inadequate VA examinations; Failure to address secondary causation/aggravation

Special Benefit

NO SPECIAL BENEFIT

Docket No.

241122-499484

Full Decision Text

Citation Nr: A26030203
Decision Date: 04/02/26 Archive Date: 04/02/26

DOCKET NO. 241122-499484
DATE: April 2, 2026

REMANDED

Entitlement to service connection for a left shoulder disability, to include as due to the service-connected right knee disability, is remanded.

Entitlement to service connection for a right shoulder disability, to include as due to the service-connected right knee disability, is remanded.

Entitlement to service connection for a cervical spine disability, to include as due to the service-connected right knee disability, is remanded.

Entitlement to service connection for a left elbow disability, to include as due to the service-connected right knee disability, is denied.

Entitlement to service connection for a right elbow disability, to include as due to the service-connected right knee disability, is denied.

Entitlement to service connection for a left hip disability, to include as due to the service-connected right knee disability, is remanded.

Entitlement to service connection for a right hip disability, to include as due to the service-connected right knee disability, is remanded.

Entitlement to service connection for a left knee disability, to include as due to the service-connected right knee disability, is remanded.

REASONS FOR REMAND

The Veteran served on active duty from July 1973 to June 1977. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2024 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO).

The Veteran selected the Direct Review docket without a Board hearing in the Appeals Modernization Act (AMA) review system by submitting a VA Form 10182 (Decision Review Request: Board (Notice of Disagreement)) in November 2024. Based upon the selection of the Direct Review option, the Board may consider the evidence of record as of May 7, 2024 - the date of the rating decision, which prompted the Veteran's selection in June 2024 of the higher-level review lane. See 38 C.F.R. §§ 3.2601(f), 20.303. ("The evidentiary record in a higher-level review is limited to the evidence of record as of the date the agency of original jurisdiction (AOJ) issued notice of the prior decision under review and the higher-level adjudicator may not consider additional evidence.").

If the Veteran submitted evidence that was added to the record after May 7, 2024, the Board did not consider it. If the Veteran wishes to have VA consider any evidence that was not considered, a supplemental claim should be submitted identifying such evidence. See 38 C.F.R. § 3.2501.

Finally, during the September 2024 rating decision, the agency of original jurisdiction (AOJ) determined the Veteran had been diagnosed with left shoulder impingement, cervical herniated disc, bilateral hip osteoarthritis, and left knee total knee arthroplasty and laparoscopic debridement with degenerative arthritis, and bilateral lower extremity varus deformity. Additionally, the AOJ determined that the primary disability of right knee disability was service connected. The Board is bound by the above favorable findings, absent clear and unmistakable evidence and sees no reason to disturb them. 38 C.F.R. §§ 3.104(c).

REASONS FOR REMAND

1. Service connection for a left shoulder disability is remanded.

2. Service connection for a right shoulder disability is remanded.

3. Service connection for a cervical spine disability is remanded.

4. Service connection for a left elbow disability is remanded.

5. Service connection for a right elbow disability is remanded.

VA is obliged to provide an examination or obtain a medical opinion in a claim of service connection when the record contains competent lay or medical evidence of (1) a current diagnosed disability or persistent or recurrent symptoms of disability; (2) evidence establishing that the veteran suffered an event, injury or disease in-service; and (3) an indication that the claimed disability or symptoms may be associated with the established event, injury, or disease in-service or with another service-connected disability; and (4) insufficient competent medical evidence for VA to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006); see
A; 38 C.F.R. § 3.159.

The Veteran contends service connection for cervical spine and bilateral shoulder and elbow pain, to include as due to the Veteran's service-connected right knee disability. See 12/16/2022 VA 21-526EZ. Specifically, the Veteran's authorized attorney representative argued that the Veteran uses "a cane at times, which could further impact the Veteran's shoulders [neck and elbows] due to his altered gait and weight distribution." See 3/8/2024 VA Form 20-0995, at page 7. Additionally, the Veteran's representative argued that medical literature supports an association between pelvic posture and neck reposition. Id.

In support, the Veteran submitted a medical article, which suggests a relationship between posture and neck. See 3/8/2024 Correspondence, at page 10.

It does not appear the Veteran is contending that these disabilities are directly related to service; instead, he has limited the theory of entitlement to secondary service connection.

As mentioned above, the AOJ determined that the Veteran was diagnosed with left shoulder impingement and cervical herniated disc. Further, post service treatment records showed that the Veteran complained of bilateral shoulder pain and diagnostic imaging showed moderate acromioclavicular arthropathy. See 2/27/2023 Medical Treatment Record - Non-Government Facility, at page 11; see also 4/12/2023 Medical Treatment Record - Non-Government Facility, at pages 24 and 34.

The AOJ did not obtain VA examinations and/or opinions regarding whether the Veteran's cervical spine and bilateral shoulder and elbow disabilities are related to service, to include as due to the service-connected right knee disability. As mentioned above, the Veteran contends he experiences symptoms of cervical spine and bilateral shoulder pain, to include as due to the Veteran's service-connected right knee disability, and submitted documentation, which supports the contention. In addition, the record showed that the Veteran was diagnosed with cervical herniated disc, bilateral shoulder pain, left shoulder impingement, and right shoulder moderate acromioclavicular arthropathy. Also, the October 2015 and the April 2024 VA knee examination reports showed that the Veteran used a cane to ambulate. Considering the above-mentioned complaints and diagnoses, the Board finds that the low threshold to afford a VA medical examination and opinion was met.

Regarding the bilateral elbow disability, the AOJ did not obtain a VA examination to establish whether the Veteran has a current diagnosed disability or in the alternative, symptoms including pain, which reach to the level of functional impairment of earning capacity. As mentioned above, the Veteran contends he experiences symptoms of bilateral elbow pain, to include as due to the Veteran's service-connected right knee disability. However, based on the evidence of record, to include the Veteran's lay contentions of bilateral elbow pain, the Board finds that VA examinations are required to make a decision regarding nature and etiology of the Veteran's cervical spine and bilateral shoulder and elbow disabilities.

Additionally, and generally, concerning the Veteran's contentions of bilateral elbow pain, in the absence of proof of a present disability, there can be no valid claim of service connection. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The current disability requirement for a service connection claim is generally satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 318, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that the Veteran satisfies the current disability requirement when a disability exists at the time the claim is filed or during its pendency, even if it resolved itself prior to adjudication). The Court of Appeals for the Federal Circuit found that pain alone can constitute a "disability" under § 1110, if such pain causes functional impairment of earning capacity. Saunders,
a service connection claim is generally satisfied if the claimant has a disability at the time the claim is filed or during the pendency of that claim. See McClain v. Nicholson, 21 Vet. App. 318, 321 (2007); see also Romanowsky v. Shinseki, 26 Vet. App. 289 (2013) (holding that the Veteran satisfies the current disability requirement when a disability exists at the time the claim is filed or during its pendency, even if it resolved itself prior to adjudication). The Court of Appeals for the Federal Circuit found that pain alone can constitute a "disability" under § 1110, if such pain causes functional impairment of earning capacity. Saunders, 886 F.3d 1367-68. In light of Saunders, the Board finds that the Veteran's reports of bilateral elbow pain may indicate chronic pain and/or a persistent disability.

As such, on remand, the AOJ should obtain in-person VA examinations regarding the claims for service connection for cervical spine and bilateral shoulder and elbow disabilities to establish whether the Veteran's disabilities are related to service, to include as due to the service-connected right knee disability, and correct this pre-decisional duty to assist error. 38 C.F.R. § 20.802(a).

6. Service connection for a left hip disability is remanded.

7. Service connection for a left hip disability is remanded.

The Veteran contends service connection for a bilateral hip disability. Specifically, the Veteran contends that his bilateral shoulder disability is due to the Veteran's service-connected right knee disability. See 12/16/2022 VA 21-526EZ. Additionally, the Veteran's authorized attorney representative argued that the Veteran's right knee disability can affect the hip joints, as these joints "operate as a kinetic/kinematic chain while walking." In this regard, the Veteran's representative argued that medical literature supports an association between knee disabilities and the effects of the knee on hip gait mechanics. Further, the Veteran's representative argued that due to the service-connected right knee disability, the Veteran favored one leg, which could have potentially affected the Veteran's gait and could lead to the bilateral hip disability. See 3/8/2024 VA Form 20-0995, at page 7.

In support, the Veteran's representative submitted a medical article regarding the relationship between knee osteoarthritis and hips. See 3/8/2024 Correspondence, at pages 3-8.

During the April 2024 VA examination, the Veteran was diagnosed with bilateral hip osteoarthritis. At the conclusion of the examination, the examiner rendered a negative secondary nexus opinion. As rationale, the examiner stated that the bilateral hip and right knee disabilities are not medically related, are separate entities entirely, and are unrelated to each other. See 4/17/2024 C&P Examination. However, the Board finds this opinion inadequate to decide the claim. The examiner did not address the Veteran's and his authorized representative's arguments or the submitted medical article, which suggest a relationship between knee osteoarthritis and hip joints. Additionally, the Board notes that the examiner did not address the aggravation prong required for secondary service connection. A finding of "not due to," "not caused by," or "not related to" a service-connected disability is insufficient to address the question of aggravation under 38 C.F.R. § 3.310. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013) (holding that a medical opinion is inadequate when it fails to adequately address the question of aggravation).

As such, on remand, the AOJ must obtain a VA addendum medical opinion that addresses the entire claims file and determines whether the Veteran's bilateral hip disability is related to service, to include as due to the service-connected right knee disability, before adjudication on the merits and correct this pre-decisional duty to assist error. 38 C.F.R. § 20.802(a).

8. Service connection for a left knee disability is remanded.

In this matter, a remand is necessary to correct a duty to assist error that occurred prior to the May 2024 rating decision on appeal. After review of the record, a remand is required in this case to ensure that VA's responsibilities under the duty to assist are followed and that the Veteran is afforded
the AOJ must obtain a VA addendum medical opinion that addresses the entire claims file and determines whether the Veteran's bilateral hip disability is related to service, to include as due to the service-connected right knee disability, before adjudication on the merits and correct this pre-decisional duty to assist error. 38 C.F.R. § 20.802(a).

8. Service connection for a left knee disability is remanded.

The Veteran contends service connection for a left knee disability. Specifically, the Veteran contends that his bilateral shoulder disability is due to the Veteran's service-connected right knee disability. See 12/16/2022 VA 21-526EZ. In this regard, the Veteran reported that his left knee disability is due to the altered gait caused by over-compensating for the right knee discomfort. Additionally, the Veteran reported that when he experienced a right knee flare-up, he would shift his weight to his left knee and walk with a limp. See 3/8/2024 VA Form 21-10210; see also 3/8/2024 Correspondence, at page 1.

As mentioned above, the AOJ determined that the Veteran was diagnosed with left knee total knee arthroplasty and laparoscopic debridement with degenerative arthritis, and bilateral lower extremity varus deformity.

Private treatment records from September 2015 showed that the Veteran complained that his gait has been altered from trying to compensate due to discomfort and the objective examination showed that he had an obvious altered gait secondary to discomfort. Additionally, an objective examination from February 2016 showed that the Veteran had a slightly antalgic gait and "somewhat of a varus alignment of the left knee on standing compared to the right, which appears more neutral. See 11/17/2016 Medical Treatment Record - Non-Government Facility, at pages 4 and 23.

During the October 2015 VA examination, the Veteran was diagnosed with bilateral knee degenerative arthritis. See 10/29/2015 C&P Examination. Further, in November 2015, the AOJ obtained a VA addendum medical opinion. The examiner rendered a negative nexus opinion. As rationale, the examiner stated that service records did not show treatment for the left knee and that his left knee problems began many years after military service. Moreover, the examiner stated that ageing, wear and tear, and employment and lifestyle choices after leaving military service were the most likely cause of the Veteran's left knee disability. See 11/10/2015 C&P Examination. However, the Board finds this examination inadequate to decide the claim. The examiner impermissibly relied on a lack of in-service treatment or diagnosis. In addition, the examiner did not address the Veteran's contentions that his left knee disability is due to the service-connected right knee disability. Also, the examiner did not address the positive private opinion from T.G., FNP-C (discussed below).

Another VA examination was conducted in July 2019. During the examination, the Veteran reported that he did not injure his left knee during his reported in-service parachute jump incident. The examiner stated that the Veteran had a pronounced genu varum and had a bow-legged gait, in-toed markedly, and walked pigeon toed from childhood. Additionally, the Veteran walked on the outside of his shoes and supinated his ankles. The examiner further stated that "[n]one of these seem to be residuals to his injury or subsequent knee replacement, however, together they would have added considerable stress to his knee joints because of his abnormal gait." At the conclusion of the examination, the examiner rendered a negative nexus opinion. As rationale, the examiner stated that the Veteran's left knee needed a total knee replacement because due to advanced degenerative arthritis, over a year after his right knee replacement. The examiner also stated that the Veteran reported that his left knee was not injured in the in-service parachute jump incident. See 7/11/2019 C&P Examination. However, the Board finds this examination inadequate to decide the claim. The examiner impermissibly relied on a lack of in-service treatment or diagnosis. Additionally, the examiner did not address the Veteran's contentions that his left knee disability is due to the service-connected right knee disability. Further, the examiner did not address the positive private opinion from T.G., FNP-C (discussed below).

The most recent VA examination was conducted in April 2024.
knee needed a total knee replacement because due to advanced degenerative arthritis, over a year after his right knee replacement. The examiner also stated that the Veteran reported that his left knee was not injured in the in-service parachute jump incident. See 7/11/2019 C&P Examination. However, the Board finds this examination inadequate to decide the claim. The examiner impermissibly relied on a lack of in-service treatment or diagnosis. Additionally, the examiner did not address the Veteran's contentions that his left knee disability is due to the service-connected right knee disability. Further, the examiner did not address the positive private opinion from T.G., FNP-C (discussed below).

The most recent VA examination was conducted in April 2024. At the conclusion of the examination, the examiner rendered a negative secondary nexus opinion. As rationale, the examiner stated that the left knee disability is a separate entity entirely from the right knee disability and unrelated to it. Moreover, the examiner stated that private lay statements and the private medical opinion (discussed below) stated that an altered gait pattern caused the left knee disability. However, the examiner stated that objective evidence showed that the Veteran's altered gait pattern began with the congenital condition of varus deformity, which altered his gait and mechanics, and chronically placed more friction on medial knee joint. In addition, the examiner stated that there is a lack of objective medical evidence of a chronically altered gait pattern due to the right knee and that the reports are only subjective lay statements. Also, the examiner stated that although the Veteran may have intermittent altered gait pattern from right knee pain, the pattern of degeneration noted in the June 1986 right knee operative report and 2010 diagnostic imaging of the left knee clearly showed a medial pattern of degeneration of chondral surfaces and medial joint markedly advanced when compared to lateral. The examiner concluded that the Veteran's congenital varus leg deformity to both legs significantly impacted his knees above and beyond the in-service trauma to right knee. See 4/17/2024 C&P Examination.

However, the Board finds this examination inadequate to decide the claim. The examiner's rationale was convoluted and contradictory. In this regard, the examiner stated that there is a lack of objective medical evidence of a chronically altered gait pattern due to the right knee disability. However, in the next sentence, the examiner stated that although the Veteran may have intermittent altered gait pattern from right knee pain. Additionally, the examiner's rationale was conclusory and devoid of medical analysis. In this regard, the examiner stated that the Veteran's altered gait pattern began with the congenital condition of varus deformity and that his congenital varus leg deformity to both legs significantly impacted his knees above and beyond the in-service trauma to right knee. However, the examiner did not explain how this conclusion was reached. Finally, the examiner discussed secondary causation; however, the examiner did not provide an opinion as to aggravation of the Veteran's claimed left knee disability by the service-connected right knee disability. The U.S. Court of Appeals for Veterans Claims has indicated that findings of "not due to," "not caused by," and "not related to" a service-connected disability are insufficient to address the question of aggravation under 38 C.F.R. § 3.310(b). El-Amin, 26 Vet. App. 140.

Furthermore, in March 2024, the Veteran submitted a February 2024 private positive opinion from T.G., FNP-C. The examiner opined that it is more likely than not that the Veteran's left knee disability is due to the service-connected right knee disability. As rationale, the examiner stated that the Veteran's right knee disability ultimately contributed to his left knee disability due to a poor posture in walking. In this regard, the examiner stated that having a poor gait to compensate for pain wears down the weight-bearing joints faster than would occur without pain. In addition, the examiner stated that the gait change occurs to reduce pain when ambulating. The examiner further stated that chronic antalgic gait weakens the muscles and joints, ultimately causing altered stressors, tearing, and arthritis in the weight-bearing joints. See 3/8/2024 Medical Treatment Record - Non-Government Facility.

However, the Board finds this opinion inadequate and, as such, not enough to put this matter into approximate balance. The examiner did not address the medical records, to include the July 2019 VA examiner's findings, which suggested that the Veteran's genu varum, bow-legged gait, in-toed, and pigeon toed walk from childhood could have caused the Veteran's abnormal gait due to considerable added stress to his knee joints. This factor erodes the weight of the opinion. See Nieves-Rodriguez, 22 Vet. App. 304 (holding that a medical
ors, tearing, and arthritis in the weight-bearing joints. See 3/8/2024 Medical Treatment Record - Non-Government Facility.

However, the Board finds this opinion inadequate and, as such, not enough to put this matter into approximate balance. The examiner did not address the medical records, to include the July 2019 VA examiner's findings, which suggested that the Veteran's genu varum, bow-legged gait, in-toed, and pigeon toed walk from childhood could have caused the Veteran's abnormal gait due to considerable added stress to his knee joints. This factor erodes the weight of the opinion. See Nieves-Rodriguez, 22 Vet. App. 304 (holding that a medical opinion obtains probative weight from "factually accurate, fully articulated, sound reasoning for the conclusion"); see also Reonal, 5 Vet. App. 461 ("An opinion based upon an inaccurate factual premise has no probative value.").

As such, on remand, the AOJ must obtain a VA addendum medical opinion that addresses the entire claims file and determines whether the Veteran's left knee disability is related to service, to include as due to the service-connected right knee disability, before adjudication on the merits and correct this pre-decisional duty to assist error. 38 C.F.R. § 20.802(a).

These matters are REMANDED for the following actions:

1. Schedule the Veteran for a VA examination with an appropriate examiner regarding the Veteran's bilateral shoulder disability. A copy of the clams file, to include this Remand, is to be reviewed to become familiar with the Veteran's pertinent medical history. If the VA examiner determines that a physical examination of the Veteran is necessary to provide a reliable opinion as to causation and aggravation, such examination should be scheduled; however, the Veteran should not be required to report for a physical examination as a matter of course, if it is not found to be necessary.

After review of the claims file, the examiner must address:

(a.) 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 bilateral shoulder disability was CAUSED by the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

(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 bilateral shoulder disability was AGGRAVATED (any incremental increase in severity) due to the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

The opinion must address aggravation. Under Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023), when addressing aggravation of non-service-connected disabilities, it is enough to show that "but for" the Veteran's service-connected right knee disability, any incremental-increase in severity of the Veteran's bilateral shoulder disability would not have occurred.

If the examiner finds that the service-connected right knee disability aggravates the bilateral shoulder disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the bilateral shoulder disability prior to aggravation. If the examiner is unable to establish a baseline for the bilateral shoulder disability prior to the aggravation, he or she should state such and explain why a baseline cannot be determined.

If the examiner is unable to provide an opinion without resorting to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered.

**The examiner must provide specific evidence of record to support his/her conclusions, such as references from this Veteran's relevant medical history and/or medical literature. THE EXAMINER CANNOT RELY SOLELY ON THE ABSENCE OF DOCUMENTED TREATMENT.

Additionally, the Veteran's authorized attorney representative argued that the Veteran uses "a cane at times, which could further impact the Veteran's shoulders [...] due to his altered gait and weight distribution." See 3/8/2024 VA Form 20-0995.

The examiner is reminded that the competent and probative evidence only needs to be in approximate balance (or nearly equal).**

A comprehensive rationale for all opinions is to be provided and must not be based on the lack of an in-service record of the claimed disability. All pertinent evidence, including both lay and medical, should be considered. If medical literature is referenced, please provide a copy of it or a full citation that allows general access. If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training).

2. Schedule the Veteran for a VA examination with an appropriate examiner regarding the Veteran's cervical spine disability. A copy of the clams file, to include this Remand, is to be reviewed to become familiar with the Veteran's pertinent medical history. If the VA examiner determines that a physical examination of the Veteran is necessary to provide a reliable opinion as to causation and aggravation, such examination should be scheduled; however, the Veteran should not be required to report for a physical examination as a matter of course, if it is not found to be necessary.

After review of the claims file, the examiner must address:

(a.) 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 cervical spine disability was CAUSED by the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

(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 cervical spine disability was AGGRAVATED (any incremental increase in severity) due to the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

If the examiner finds that the service-connected right knee disability aggravates the cervical spine disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the cervical spine disability prior to aggravation. If the examiner is unable to establish a baseline for the cervical spine disability prior to the aggravation, he or she should state such and explain why a baseline cannot be determined.

In rendering this opinion, the examiner must address the Veteran's contentions that his cervical spine and bilateral shoulder disabilities are due to the Veteran's service-connected right knee disability. See 12/16/2022 VA 21-526EZ.

Additionally, the examiner must address the Veteran's authorized attorney representative's arguments that the Veteran used a cane for ambulation, which could further impact the Veteran's neck due to his altered gait and weight distribution. Moreover, the Veteran's representative argued that medical literature supports an association between pelvic posture and neck reposition. See 3/8/2024 VA Form 20-0995, at page 7.

In addition, the examiner must address the medical article submitted by the Veteran, which suggests a relationship between posture and neck. See 3/8/2024 Correspondence, at page 10.

The examiner is reminded that the competent and probative evidence only needs to be in approximate balance (or nearly equal).**

In addition, the examiner must address the medical article submitted by the Veteran, which suggests a relationship between posture and neck. See 3/8/2024 Correspondence, at page 10.

The examiner is reminded that the competent and probative evidence only needs to be in approximate balance (or nearly equal).**

3. Schedule the Veteran for a VA examination with an appropriate examiner regarding the Veteran's bilateral elbow disability. A copy of the clams file, to include this Remand, is to be reviewed to become familiar with the Veteran's pertinent medical history. If the VA examiner determines that a physical examination of the Veteran is necessary to provide a reliable opinion as to causation and aggravation, such examination should be scheduled; however, the Veteran should not be required to report for a physical examination as a matter of course, if it is not found to be necessary.

After review of the claims file, the examiner must address:

(a.) 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 bilateral elbow disability was CAUSED by the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

(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 bilateral elbow disability was AGGRAVATED (any incremental increase in severity) due to the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

(c.) The opinion must address aggravation. Under Spicer v. McDonough, 61 F.4th 1360 (Fed. Cir. 2023), when addressing aggravation of non-service-connected disabilities, it is enough to show that "but for" the Veteran's service-connected right knee disability, any incremental-increase in severity of the Veteran's bilateral elbow disability would not have occurred.

If the examiner finds that the service-connected right knee disability aggravates the bilateral elbow disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the bilateral elbow disability prior to aggravation. If the examiner is unable to establish a baseline for the bilateral elbow disability prior to the aggravation, he or she should state such and explain why a baseline cannot be determined.

In rendering this opinion, the examiner must address the Veteran's contentions that his bilateral elbow disability is due to the Veteran's service-connected right knee disability. See 12/16/2022 VA 21-526EZ.

Additionally, the Veteran's authorized attorney representative argued that the Veteran uses "a cane at times, which could further impact the Veteran's [elbows] due to his altered gait and weight distribution." See 3/8/2024 VA Form 20-0995.

The examiner is reminded that the competent and probative evidence only needs to be in approximate balance (or nearly equal).**

4. Forward the claims file to an appropriate examiner regarding the Veteran's bilateral hip disability. A copy of the clams file, to include this Remand, is to be reviewed to become familiar with the Veteran's pertinent medical history. If the VA examiner determines that a physical examination of the Veteran is necessary to provide a reliable opinion as to causation and aggravation, such examination should be scheduled; however, the Veteran should not be required to report for a physical examination as a matter of course, if it is not found to be necessary.

After review of the claims file, the examiner must address:

(a.) 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 bilateral hip disability was CAUSED by the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

(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 bilateral hip disability was AGGRAVATED (any incremental increase in severity) due to the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

If the examiner finds that the service-connected right knee disability aggravates the bilateral hip disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the bilateral hip disability prior to aggravation. If the examiner is unable to establish a baseline for the bilateral hip disability prior to the aggravation, he or she should state such and explain why a baseline cannot be determined.

In rendering this opinion, the examiner must address the Veteran's contentions that his bilateral shoulder disability is due to the Veteran's service-connected right knee disability. See 12/16/2022 VA 21-526EZ. Additionally, the Veteran's authorized attorney representative argued that the Veteran's right knee disability can affect the hip joints, as these joints "operate as a kinetic/kinematic chain while walking." In this regard, the Veteran's representative argued that medical literature supports an association between knee disabilities and the effects of the knee on hip gait mechanics. Further, the Veteran's representative argued that due to the service-connected right knee disability, the Veteran favored one leg, which could have potentially affected the Veteran's gait and could lead to the bilateral hip disability. See 3/8/2024 VA Form 20-0995.

Moreover, the examiner must explicitly address the medical article submitted by the Veteran regarding the relationship between knee osteoarthritis and hips. See 3/8/2024 Correspondence, at pages 3-8.

The examiner is reminded that the competent and probative evidence only needs to be in approximate balance (or nearly equal).**

Moreover, the examiner must explicitly address the medical article submitted by the Veteran regarding the relationship between knee osteoarthritis and hips. See 3/8/2024 Correspondence, at pages 3-8.

The examiner is reminded that the competent and probative evidence only needs to be in approximate balance (or nearly equal).**

5. Forward the claims file to an appropriate examiner regarding the Veteran's left knee disability. A copy of the clams file, to include this Remand, is to be reviewed to become familiar with the Veteran's pertinent medical history. If the VA examiner determines that a physical examination of the Veteran is necessary to provide a reliable opinion as to causation and aggravation, such examination should be scheduled; however, the Veteran should not be required to report for a physical examination as a matter of course, if it is not found to be necessary.

After review of the claims file, the examiner must address:

(a.) 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 left knee disability was CAUSED by the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

(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 left knee disability was AGGRAVATED (any incremental increase in severity) due to the Veteran's service-connected right knee disability, to include the treatment prescribed for the service-connected right knee disability.

If the examiner finds that the service-connected right knee disability aggravates the left knee disability, the examiner is asked to state whether there is medical evidence created prior to the aggravation or at any time between the time of aggravation and the current level of disability that shows a baseline for the left knee disability prior to aggravation. If the examiner is unable to establish a baseline for the left knee disability prior to the aggravation, he or she should state such and explain why a baseline cannot be determined.

In rendering this opinion, the examiner must address the Veteran's contentions that his left knee disability is due to the altered gait caused by over-compensating for right knee discomfort. Additionally, the Veteran reported that when he experienced a right knee flare-up, he would favor his left knee, walk with a limp, and shift his weight to his left knee. See 3/8/2024 VA Form 21-10210; see also 3/8/2024 Correspondence, at page 1.

Further, the examiner must address the private treatment records from September 2015 showed that the Veteran complained that his gait has been altered from trying to compensate due to discomfort and the objective examination showed that he had an obvious altered gait secondary to discomfort. Moreover, an objective examination from February 2016 showed that the Veteran had a slightly antalgic gait and "somewhat of a varus alignment of the left knee on standing compared to the right, which appears more neutral. See 11/17/2016 Medical Treatment Record - Non-Government Facility, at pages 4 and 23.

In addition, the examiner must clarify the April 2024 VA examiner's seemingly contradictory statement that there is a lack of objective medical evidence of a chronically altered gait pattern due to the right knee
2015 showed that the Veteran complained that his gait has been altered from trying to compensate due to discomfort and the objective examination showed that he had an obvious altered gait secondary to discomfort. Moreover, an objective examination from February 2016 showed that the Veteran had a slightly antalgic gait and "somewhat of a varus alignment of the left knee on standing compared to the right, which appears more neutral. See 11/17/2016 Medical Treatment Record - Non-Government Facility, at pages 4 and 23.

In addition, the examiner must clarify the April 2024 VA examiner's seemingly contradictory statement that there is a lack of objective medical evidence of a chronically altered gait pattern due to the right knee disability. However, in the next sentence, the examiner stated that the Veteran may have intermittent altered gait pattern from right knee pain.

Also, the examiner must address the April 2024 VA examiner's conclusory statement that the Veteran's altered gait pattern began with the congenital condition of varus deformity and that his congenital varus leg deformity to both legs significantly impacted his knees above and beyond the in-service trauma to right knee, and explain how that conclusion was reached.

The examiner is reminded that the competent and probative evidence only needs to be in approximate balance (or nearly equal).**

(Continued on next page)

If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training).

J. Abrams

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board J.F.

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.

Analyze in VA Law Explorer