SHOULDER IMPAIRMENT OF

Summary

The Veteran served from January 1989 to December 1991, January 1997 to August 1997, and January 2003 to August 2004. The Veteran appeals decisions regarding service connection for several conditions, including left shoulder strain, left knee strain, lumbar spine condition, right knee condition, posttraumatic stress disorder (PTSD), and obstructive sleep apnea. The Veteran claimed the lumbar spine and right knee conditions were secondary to the left knee condition, and the sleep apnea was secondary to service-connected disabilities with obesity as an intermediary step. The Board reviewed evidence including service treatment records, VA examinations, and private medical opinions. For the left shoulder and knee conditions, the Board found private medical opinions more probative than VA opinions, granting service connection for both. For the lumbar spine and right knee conditions, the Board found evidence supported a secondary service connection due to aggravation or causation from the service-connected left knee condition, resolving doubt in the Veteran's favor. Service connection for PTSD was granted based on a positive VA nexus opinion linking symptoms to in-service hostile incidents and fatalities. For sleep apnea, the Board found the private medical opinion more probative than the VA opinion, which failed to adequately address the secondary service connection via obesity as an intermediary step. The Board granted service connection for sleep apnea secondary to service-connected disabilities, resolving doubt in the Veteran's favor.

Rationale

Private medical opinion found left shoulder condition related to service; VA opinion found left shoulder condition not related to service; Board found private opinion more probative than VA opinion

Full Decision Text

Citation Nr: A26038269
Decision Date: 04/23/26	Archive Date: 04/23/26

DOCKET NO. 250801-567816
DATE: April 23, 2026

ORDER

Entitlement to service connection for left shoulder condition is granted.

Entitlement to service connection for left knee condition is granted.

Entitlement to service connection for a lumbar spine condition, as secondary to a left knee condition, is granted.

Entitlement to service connection for right knee condition, as secondary to left knee condition, is granted.

Entitlement to service connection for posttraumatic stress disorder is granted.

Entitlement to service connection for obstructive sleep apnea, as secondary to service-connected disabilities with obesity as an intermediary step, is granted.

FINDINGS OF FACT

1. Left shoulder condition is related to service.

2. Left knee condition is related to service.

3. Lumbar spine condition is caused and/or aggravated by left knee condition.

4. Right knee condition is caused and/or aggravated by left knee condition.

5. Posttraumatic stress disorder is related to service.

6. The evidence persuasively supports that the Veteran's sleep apnea is etiologically related to his obesity, which is caused by his service-connected disabilities.

CONCLUSIONS OF LAW

1. The criteria for service connection for left shoulder condition have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303.

2. The criteria for service connection for left knee condition have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303.

3. The criteria for service connection for a lumbar spine condition, as secondary to a left knee condition, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. The criteria for service connection for right knee condition, as secondary to left knee condition, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

5. The criteria for service connection for posttraumatic stress disorder have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303.

6. The criteria for service connection for obstructive sleep apnea, as secondary to service-connected disabilities with obesity as an intermediary step, have been met. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from January 1989 to December 1991, from January 1997 to August 1997, and from January 2003 to August 2004. 

The rating decisions on appeal were issued in October 2023, August 2024, and March 2025 and constitute initial decisions; therefore, the modernized review system, also known as the Appeals Modernization Act (AMA), applies. 

In the August 2025 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Evidence Submission docket.

Therefore, regarding sleep apnea, the Board may only consider the evidence of record at the time of the March 2025 AOJ decision on appeal, as well as any evidence submitted by the Veteran or representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision on appeal and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. 

Regarding the other issues, in October 2024, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of an October 2023 and August 2024 decisions. In February 2025, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior October 2023 and August 2024 decisions.
 (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. 

Regarding the other issues, in October 2024, the Veteran submitted a VA Form 20-0996, Decision Review Request: Higher-Level Review (HLR), and requested review of an October 2023 and August 2024 decisions. In February 2025, the agency of original jurisdiction (AOJ) issued the HLR decision on appeal, which considered the evidence of record at the time of the prior October 2023 and August 2024 decisions. Therefore, the Board of Veterans' Appeals (Board) may only consider the evidence of record at the time of the October 2023 and August 2024 decisions and any evidence submitted by the Veteran or representative with, or within 90 days from receipt of, the VA Form 10182. 38 C.F.R. § 20.303. If evidence was submitted either (1) during the period after the AOJ issued the decision, which was subsequently subject to higher-level review and prior to the date the Board received the VA Form 10182, or (2) more than 90 days following the date the Board received the VA Form 10182, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.303, 20.801. 

Service Connection

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).

Service connection may be established on a secondary basis for a disability resulting from a service-connected disease or injury. 38 U.S.C. §§ 1110, 1131. Establishing service connection on a secondary basis requires sufficient evidence to show that a current disability exists and that the current disability results from the service-connected disability. 38 U.S.C. §§ 1110, 1131; Spicer v. McDonough, 61 F.4th 1360, 1364 (Fed. Cir. 2023) (holding that section 1110 "requires compensation when a service-connected disease or injury is a but-for cause of a present-day disability"); Allen v. Brown, 7 Vet. App. 439 (1995).

1. Entitlement to service connection for left shoulder condition.

2. Entitlement to service connection for left knee condition.

The Veteran contends he has a left shoulder and left knee condition due to service. 

The Veteran is diagnosed with left shoulder strain and left knee strain. On the January 2007 discharge Report of Medical History (RMH), the Veteran reported painful shoulder and knee trouble. He had an in-service running profile due to knee problems. 

As to a nexus, a September 2023 VA examiner found that the Veteran's left knee condition was related to left knee pain in service due to the pain being chronic. An August 2025 private medical opinion also found the left knee was related to service due to in-service injuries and repetitive strain mechanisms. 

An October 2023 VA medical opinion provided a negative nexus. The examiner opined that the Veteran's left shoulder was not related to service due to a lack of chronicity during and after service. An August 2025 private medical opinion found the left shoulder was related to service due to in-service injuries and repetitive strain mechanisms.

The Board finds the private medical opinion is more probative because the VA examiner did not discuss the Veteran's contention that he has experienced left shoulder pain since service. 

As such, the Board finds service connection is warranted for left knee condition and left shoulder condition. 

3. Entitlement to service connection for a lumbar spine condition, as secondary to a left knee condition.

4. Entitlement to service connection for right knee condition, as secondary to left knee condition.

The Veteran contends he has a lumber spine condition that is related to service. He stated overcompensation for the left knee injury caused back pain and right knee pain.

The Veteran is diagnosed with lumbosacral strain and right knee strain, and he is now service connected for left knee condition. The September 2023 VA medical opinion provided a positive nexus opinion. The
 Veteran's contention that he has experienced left shoulder pain since service. 

As such, the Board finds service connection is warranted for left knee condition and left shoulder condition. 

3. Entitlement to service connection for a lumbar spine condition, as secondary to a left knee condition.

4. Entitlement to service connection for right knee condition, as secondary to left knee condition.

The Veteran contends he has a lumber spine condition that is related to service. He stated overcompensation for the left knee injury caused back pain and right knee pain.

The Veteran is diagnosed with lumbosacral strain and right knee strain, and he is now service connected for left knee condition. The September 2023 VA medical opinion provided a positive nexus opinion. The examiner opined that patients experiencing knee pain tend to use different pressure points in the lower back and opposite knee. The August 2025 private medical opinion also provided a positive nexus for both conditions. 

Given the evidence of record, the Board finds the evidence supports that the Veteran's lumbar spine condition and right knee condition are proximately due to or aggravated by his service-connected left knee condition. Therefore, reasonable doubt must be resolved in favor of the Veteran.

5. Entitlement to service connection for posttraumatic stress disorder.

The Veteran contends he has posttraumatic stress disorder that is due to service. He stated he experienced many hostile incidents and scenes where people lost their lives in service. 

The Veteran is diagnosed with posttraumatic stress disorder. 

The April 2021 VA examiner provided a positive nexus. The examiner opined that the Veteran's mental health symptoms are in response to fatalities and hostile incident while stationed in Germany. The August 2025 private medical opinion also provided a positive nexus. 

Given the evidence of record, the Board finds the evidence supports that the Veteran's posttraumatic stress disorder is related to service. Therefore, reasonable doubt must be resolved in favor of the Veteran.

6. Entitlement to service connection for obstructive sleep apnea, as secondary to service-connected disabilities with obesity as an intermediary step. 

Initially, the Board notes the Veteran has a diagnosis of obstructive sleep apnea. The Veteran is service connected for hypertension, bilateral knee condition, posttraumatic stress disorder, left shoulder condition, and a lumbar spine condition. Therefore, the first two requirements of a secondary service connection claim are met. All that remains to be resolved is whether the medical evidence of record establishes a link between the Veteran's service-connected disabilities and his sleep apnea.

In Walsh v. Wilkie, the Court of Appeals for Veterans Claims (Court) held that the Board needs to consider the obesity-intermediate step theorem predicated on aggravation where appropriate. Thus, the Court held that proper interpretation of G.C. Prec. Op. 1-2017 requires consideration of both proximate causation and aggravation in its analytical framework: (1) whether the service-connected disability (caused the veteran to become obese/aggravated the veteran's obesity); (2) if so, whether the (obesity/aggravation of obesity) as a result of the service-connected disability was a substantial factor in causing the current disability; and (3) whether the current disability would not have occurred but for (obesity caused/obesity aggravated) by the service-connected disability. If these questions are answered in the affirmative, then the current disability may be service connected on a secondary basis. Walsh v. Wilkie, 32 Vet. App. 300 (2020).

There is evidence for and against a nexus.

A March 2025 VA medical opinion provided a negative nexus for sleep apnea's association with toxic exposures. The examiner opined that medical literature did not support a causal relationship between the toxins the Veteran was exposed to during service and sleep apnea. The examiner noted obesity was a more likely alternative risk factor.  

The Veteran submitted an August 2025 private medical opinion. The examiner opined that the Veteran's obesity was at least as likely as not caused by reduced mobility and weight gain from chronic musculoskeletal injuries. 

The Board finds the private opinion to be more probative because the VA opinion did not properly discuss whether the Veteran's service-connected disabilities caused/aggravated sleep apnea with obesity as an intermediary step. 

Given the evidence discussed above, the Board finds that the evidence of record supports that the Veteran's sleep apnea is proximately due to, or aggravated by, his service-connected disabilities, with obesity as an intermediary step. Therefore, reasonable doubt must be resolved in favor of the Veteran. As such, the third prong of secondary service connection is met. See Wallin v. West, 11 Vet. App. 509, 512. Accordingly, service connection for the Veteran's sleep apnea is granted secondary to his service-connected disabilities. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R
's service-connected disabilities caused/aggravated sleep apnea with obesity as an intermediary step. 

Given the evidence discussed above, the Board finds that the evidence of record supports that the Veteran's sleep apnea is proximately due to, or aggravated by, his service-connected disabilities, with obesity as an intermediary step. Therefore, reasonable doubt must be resolved in favor of the Veteran. As such, the third prong of secondary service connection is met. See Wallin v. West, 11 Vet. App. 509, 512. Accordingly, service connection for the Veteran's sleep apnea is granted secondary to his service-connected disabilities. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.310.

 

 

Ann K. Minami

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	P. McDaniels, Counsel

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.