KNEE IMPAIRMENT OF

Summary

The Veteran, an Army veteran who served from November 1976 to May 1978, appeals a May 2025 rating decision. The appeal concerns entitlement to service connection for a left knee disability claimed as secondary to a service-connected left foot neuroma. The Board reviewed the evidence of record as of the May 2025 decision. The primary issue is whether the Veteran's left knee condition is due to or aggravated by his service-connected left foot neuroma. The Board considered a January 2025 private medical opinion which found the left knee disability was at least as likely as not due to or aggravated by the service-connected neuroma, citing compensatory walking patterns and altered gait. The Board afforded this opinion probative value. A February 2025 VA medical opinion found the left knee disability less likely than not proximately due to the service-connected neuroma, but this opinion was deemed inadequate because it used the "proximate cause" standard instead of the "but-for causation" standard required by Spicer v. McDonough. The Board found the evidence in approximate balance. Resolving reasonable doubt in the Veteran's favor, the Board granted service connection for the left knee disability as secondary to the left foot neuroma.

Rationale

Private medical opinion found condition at least as likely as not due to or aggravated by service-connected neuroma.; VA medical opinion inadequate due to use of "proximate cause" standard.; Evidence in approximate balance; benefit of doubt applied in Veteran's favor.

Full Decision Text

Citation Nr: A26039958
Decision Date: 04/29/26	Archive Date: 04/29/26

DOCKET NO. 260205-638801
DATE: April 29, 2026

ORDER 

Entitlement to service connection for a left knee disability secondary to service-connected left foot neuroma is granted. 

FINDING OF FACT 

The Veteran's left knee disability is at least as likely as not due to or aggravated by his service-connected left foot neuroma.

CONCLUSION OF LAW 

The criteria for service connection for left knee disability as secondary to service-connected left foot neuroma are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 

REASONS AND BASES FOR FINDING AND CONCLUSION 

The Veteran served on active duty in the United States Army from November 1976 to May 1978. 

This matter comes before the Board on appeal of a May 2025 rating decision. In the February 2026 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Direct Review docket. Therefore, the Board may only consider the evidence of record at the time of the May 2025 agency of original jurisdiction (AOJ) decision on appeal. 38 C.F.R. § 20.301. Any evidence submitted after the AOJ decision on appeal cannot be considered by the Board. 38 C.F.R. §§ 20.300, 20.301, 20.801. 

Entitlement to service connection for a left knee disability secondary to service-connected left foot neuroma is granted. 

"Secondary service connection will be granted if a disability is... due to or the result of a service-connected disease or injury or aggravated by a service-connected disease or injury." 38 C.F.R. § 3.310; Spicer v. McDonough, 61 F.4th 1360, 1363 (Fed. Cir. 2023) (secondary service connection requires "but-for causation," which is "broader than proximate causation"). 

In Spicer, the Federal Circuit held that under the causation standard of 38 U.S.C. § 1110, secondary service connection is warranted where a nonservice-connected disability would have been less severe "but-for" a service-connected disability, either because there is an etiological link (to include worsening of functionality) between the two, or because the service-connected disability resulted in the inability to treat the nonservice-connected disability. The Federal Circuit specifically found that requiring "proximate cause" in secondary service connection appeals is a stricter standard than the "but-for cause" standard in 38 U.S.C. § 1110 and, therefore, is unlawful. 

Here, in the May 2025 rating decision, the AOJ favorably found the Veteran has a current diagnosis for left knee total arthroplasty. The Board is bound by this favorable finding of fact as the record does not contain clear and unmistakable error to rebut it. See 38 C.F.R. § 20.801(a). 

In January 2025, VA received a private medical opinion. The private medical provider endorsed a diagnosis of chronic left knee condition and opined it was at least as likely as not that the Veteran's left knee disability was due to or aggravated by his service-connected left foot neuroma. The private medical provider reasoned that that Veteran's service-connected left foot neuroma "led to compensatory walking patterns and altered gait, subsequently resulting in biomechanical and kinematic changes [which] contributed to the development of [a] chronic left knee condition." The private medical provider used reliable?principles and methods of observation, fact-gathering, and analysis to continue a diagnosis of a chronic left knee disability and?determine?the Veteran's left knee disability was due to or aggravated by his service-connected left foot neuroma.?As such, the Board affords this opinion probative value. 

In February 2025, VA received a VA medical opinion. The VA medical provider opined the Veteran's left knee disability was less likely than not "proximately due to or the result of" his service-connected left foot neuroma. However, because the opinion used the "proximate cause" standard, it is therefore inadequate. As such, the evidence of record is at least in approximate balance as to whether the Veteran's left knee disability was due to or aggravated by his service-connected left foot neuroma.  

Accordingly, resolving reasonable doubt in the Veteran's favor, the Board finds that entitlement to service connection for a left knee disability as secondary to his service-connected left foot neuroma is warranted. 38 U.S.C. § 5107(b);
5, VA received a VA medical opinion. The VA medical provider opined the Veteran's left knee disability was less likely than not "proximately due to or the result of" his service-connected left foot neuroma. However, because the opinion used the "proximate cause" standard, it is therefore inadequate. As such, the evidence of record is at least in approximate balance as to whether the Veteran's left knee disability was due to or aggravated by his service-connected left foot neuroma.  

Accordingly, resolving reasonable doubt in the Veteran's favor, the Board finds that entitlement to service connection for a left knee disability as secondary to his service-connected left foot neuroma is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. §§ 4.3, 4.7; see Lynch v. McDonough, 21 F.4th 776 (Fed. Cir. 2021) (holding "if the positive and negative evidence is in approximate balance..., the claimant receives the benefit of the doubt."). The appeal is therefore granted.  

  

 

ANTHONY C. SCIRÉ, JR

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Mills, D.

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.