KNEE STRAIN

J.P. NORMAN · 2026 · Case ID: A26040386

MIXED

Summary

The veteran, who served in the U.S. Navy from May 2014 to May 2019, appeals the denial of increased ratings for bilateral lower extremity radiculopathy. The veteran also sought service connection for left knee strain secondary to a service-connected left ankle condition and for migraine headaches secondary to a service-connected cervical spine condition. The Board granted service connection for both the left knee condition and the migraine headaches. For the left knee condition, the Board found the evidence in equipoise, resolving doubt in the veteran's favor based on a private ARNP's opinion that linked the knee condition to altered gait from the service-connected ankle condition. The Board found the VA examiner's opinion inadequate for failing to address aggravation. For the migraine headaches, the Board also found the evidence in equipoise, resolving doubt in the veteran's favor based on a private ARNP's opinion linking the headaches to cervical spine pain affecting nerves. The VA examiner's opinion was again found inadequate for failing to address aggravation. The Board remanded the claims for increased ratings for bilateral lower extremity radiculopathy due to an inadequate VA examination, requiring a new examination to determine the severity of the conditions.

Rationale

Private ARNP opinion found more probative than VA examiner's opinion; VA examiner's opinion inadequate for failing to address aggravation; Evidence in equipoise, doubt resolved in veteran's favor

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

251016-599908

Full Decision Text

Citation Nr: A26040386
Decision Date: 04/29/26 Archive Date: 04/29/26

DOCKET NO. 251016-599908
DATE: April 29, 2026

ORDER

Entitlement to service connection for left knee strain with patellofemoral pain syndrome (claimed as left knee condition) as secondary to a service-connected left ankle condition is granted.

Entitlement to service connection for migraine headaches as secondary to a service-connected cervical spine condition is granted.

REMANDED

Entitlement to an initial rating in excess of 10 percent disabling for service-connected radiculopathy, left lower extremity (sciatic) is remanded.

Entitlement to an initial rating in excess of 10 percent disabling for service-connected radiculopathy, right lower extremity (sciatic) is remanded.

FINDINGS OF FACT

1. The evidence is at least in equipoise as to whether the Veteran's left knee strain with patellofemoral pain syndrome (claimed as left knee condition) is causally related to his service-connected left ankle condition.

2. The evidence is at least in equipoise as to whether the Veteran's migraine headaches condition is causally related to his service-connected neck condition.

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for left knee strain with patellofemoral pain syndrome (claimed as left knee condition), on a secondary basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for entitlement to service connection for migraine headaches, on a secondary basis, have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Navy from May 2014 to May 2019.

This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2025 rating decision.

In the October 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 April 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.

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claim, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

However, because the Board is remanding the claims of entitlement to increased ratings for bilateral lower extremity radiculopathy, any evidence the Board could not consider will be considered by the AOJ in the adjudication of those claims. 38 C.F.R. § 3.103(c)(2)(ii).

Service Connection

Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred in, or if preexisting service, was aggravated therein. 38 C.F.R. § 3.303(a). Service connection may 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).

Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet
Service connection may 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).

To establish service connection for a disability there must be competent evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship or nexus between the present disability and the disease or injury incurred or aggravated during service. Horn v. Shinseki, 25 Vet. App. 231, 236 (2010); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Gutierrez v. Principi, 19 Vet. App. 1, 5 (2004) (citing Hickson v. West, 12 Vet. App. 247, 253 (1999)).

Ultimately, the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for the evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value.

VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with a claimant prevailing in either event. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The claimant is entitled to the benefit of the doubt when there is an "approximate" (meaning nearly equal) balance of positive and negative evidence regarding any material determination. See Lynch v. McDonough, 999 F.3d 1391 (2021); Ortiz v. Principi, 274 F.3d 1361 (Fed. Cir. 2001).

1. Entitlement to service connection for left knee strain with patellofemoral pain syndrome (claimed as left knee condition) as secondary to a service-connected left ankle condition is granted.

The Veteran contends that his left knee condition is related to service. Specifically, he contends that the condition is secondary to his service-connected left ankle disability. He contends that he has been dealing with knee problems that stem from ongoing ankle pain; that the discomfort in his ankle has altered his gait, causing him to walk with a limp and impacting his posture, making him lead to one side; and that this has placed additional strain on his knee over time, leading ot increased pain and stiffness and making it difficult to perform everyday activities. See November 2024 VA Form 21-4138.

In connection with his claim, the Veteran was afforded a VA Knee Conditions examination in December 2024. Based on an in-person examination and review of the Veteran's VA e-folder, the examiner reported a diagnosis of left knee strain and patellofemoral pain syndrome. The examiner noted the Veteran's report of onset in 2016 and that from working construction and going up and down steps carrying heavy things his knees started to hurt; and that when he walks a lot or runs, he feels pain around the knee, mostly in front. As a result of the examination, however, the VA examiner opined that the claimed condition is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the Veteran's service-connected condition. By way of rationale, the examiner explained that, even though an ankle condition/pain can affect the knee and cause
-folder, the examiner reported a diagnosis of left knee strain and patellofemoral pain syndrome. The examiner noted the Veteran's report of onset in 2016 and that from working construction and going up and down steps carrying heavy things his knees started to hurt; and that when he walks a lot or runs, he feels pain around the knee, mostly in front. As a result of the examination, however, the VA examiner opined that the claimed condition is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the Veteran's service-connected condition. By way of rationale, the examiner explained that, even though an ankle condition/pain can affect the knee and cause knee strain/pain by altering the gait and the weight distribution to the knee, in the case of this Veteran, this could not happen as his knee strain/pain occurred (2016) about one year before his left ankle sprain (2017) so it is less likely than not that the Veteran's left ankle sprain caused his left knee strain. See March 2025 VA examination report.

Whenever VA undertakes to either provide an examination or to obtain an opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Here, although the examiner opined as to causation, they did not address the aggravation prong of secondary service connection. See El Amin v. Shinseki, 26 Vet. App. 136 (2013). As such, the December 2024 VA opinion is inadequate.

In support of his claim, the Veteran submitted a private opinion written by M R.-P., ARNP, FNP-C, PMHNP-BC, in November 2024. The provider stated that the opinion was formed in conjunction with Registered Nurse J.S., who personally evaluated the Veteran, and that they had reviewed documentation from the encounter. The provider noted that the nurse discussed the medical history, onset of left knee symptoms, progression, and current symptoms; and that the documentation shows that the left knee symptoms began chronologically after the onset of his service-connected lower extremity condition, and the findings are consistent with a chronic left knee condition. The provider opined that, based on their knowledge, training, and clinical experience, the documentation from the encounter, and the body of medical literature explaining the pathophysiological processes involved, it is more likely than not that the Veteran's service-connected lower extremity condition led to compensatory walking patterns and altered gait, subsequently resulting in biomechanical and kinematic changes that contributed to the development of his chronic left knee condition. The provider explained the science behind the connection between lower extremity conditions characterized by chronic pain and limited mobility and knee conditions and cited to medical literature in support of the opinion. See November 2024 private treatment records.

After careful review and consideration, the Board affords the November 2024 private opinion great probative weight. The provider's rationale is logical, well-reasoned, thorough, and relied upon consideration of the entire record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion).

For the reasons discussed above, and resolving any doubt in the Veteran's favor, the Board finds that the evidence of record is sufficient to decide the Veteran's service connection claim, as it is at least evenly balanced as to whether the Veteran's patellofemoral pain syndrome (claimed as left knee condition) is secondary to his service-connected left ankle disability. As the reasonable doubt created by this relative equipoise must be resolved in favor of the Veteran, entitlement to service connection for patellofemoral pain syndrome (claimed as left knee condition) is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 3.303, 3.310. The claim is hereby GRANTED.

2. Entitlement to service connection for migraine headaches as secondary to a service-connected cervical spine condition is granted.

The Veteran contends that his migraine headaches are related to service. Specifically, he contends that the condition is secondary to his service-connected cervical spine disability. He contends that the condition causes him to experience pain, limited movement, and tightness, and that he has been experiencing frequent headaches which he believes are the result of his chronic neck pain. He contends that the tension and discomfort in his neck often radiate up to his head, resulting in persistent headaches that make it difficult for him to concentrate and perform daily tasks. See November 2024 VA Form
, 3.310. The claim is hereby GRANTED.

2. Entitlement to service connection for migraine headaches as secondary to a service-connected cervical spine condition is granted.

Initially, the Board notes that in the April 2025 rating decision, the AOJ found that the claimed primary disability is service connected, as the Veteran is service connected for left ankle, lateral collateral ligament; and that the Veteran has been diagnosed with a disability, as VA contract examination indicates a diagnosis of migraine headaches. The Board is bound by these favorable findings. The Board notes that the favorable finding regarding service connection for left ankle appears to be a typographical error; however, the Board notes that the Veteran is also service connected for the claimed primary disability of cervical strain.

In connection with his claim, the Veteran was afforded a VA Headaches examination in December 2024. Based on an in-person examination and review of the Veteran's VA e-folder, the examiner reported a diagnosis of migraine including migraine variants. The examiner noted the Veteran's report of onset in 2016. As a result of the examination, however, the VA examiner opined that the claimed condition is less likely than not (likelihood is less than approximately balanced or nearly equal) proximately due to or the result of the Veteran's service-connected condition. By way of rationale, the examiner explained that the Veteran is diagnosed with migraine headache which are secondary to specific chemical imbalances in the brain, actually as of lately these imbalances are visible in the MRI of the brain, and there is no scientific evidence found that cervical strain can specifically cause migraine headaches, so the Veteran's migraine headaches are less likely than not secondary to his cervical strain. See December 2024 VA examination report.

In support of his claim, the Veteran submitted a private opinion written by M R.-P., ARNP, FNP-C, PMHNP-BC, in November 2024. The provider stated that the opinion was formed in conjunction with Registered Nurse J.S., who personally evaluated the Veteran, and that they had reviewed documentation from the encounter. The provider noted that the nurse discussed the medical history, onset of headaches, progression, and current symptoms; and that the documentation shows that the headaches began chronologically after the onset of cervical spine symptoms, and the findings are consistent with a chronic headache condition. The provider opined that, based on their knowledge, training, and clinical experience, the documentation from the encounter, and the body of medical literature explaining the pathophysiological processes involved, it is more likely than not that the Veteran's cervical spine pain affected nerves that share a pain nucleus with the trigeminal nerve, which led to the Veteran's chronic headache condition. The provider explained the science behind the connection between cervical spine disorders and headaches and cited to medical literature in support of the opinion. See November 2024 private treatment records.

For the reasons discussed above, and resolving any doubt in the Veteran's favor, the Board finds that the evidence of record is sufficient to decide the Veteran's service connection claim, as it is at least evenly balanced as to whether the Veteran's migraine headaches are secondary to his service-connected cervical spine disability. As the reasonable doubt created by this relative equipoise must be resolved in favor of the Veteran,
is logical, well-reasoned, thorough, and relied upon consideration of the entire record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion).

For the reasons discussed above, and resolving any doubt in the Veteran's favor, the Board finds that the evidence of record is sufficient to decide the Veteran's service connection claim, as it is at least evenly balanced as to whether the Veteran's migraine headaches are secondary to his service-connected cervical spine disability. As the reasonable doubt created by this relative equipoise must be resolved in favor of the Veteran, entitlement to service connection for migraine headaches is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102, 3.303, 3.310. The claim is hereby GRANTED.

REASONS FOR REMAND

Under the AMA, remands are limited to correction of (1) duty to assist errors occurring prior to the date of the AOJ decision on appeal and (2) AOJ errors in satisfying a regulatory or statutory duty if correction of such error would have a reasonable possibility of aiding in substantiating the appellant's claim. 38 C.F.R. § 20.802(a).

Although the Board sincerely regrets further delay, for the reasons discussed below, the Board finds that remand is required to correct a duty to assist error that occurred prior to the issuance of the rating decision on appeal. Specifically, remand is required in order to obtain an adequate VA examination with respect to the issue of increased ratings for the Veteran's service-connected left and right lower extremity radiculopathy.

1. Entitlement to an initial rating in excess of 10 percent disabling for service-connected radiculopathy, left lower extremity (sciatic) is remanded.

2. Entitlement to an initial rating in excess of 10 percent disabling for service-connected radiculopathy, right lower extremity (sciatic) is remanded.

The Veteran contends that the severity of his service-connected radiculopathy of his left and right lower extremities warrants a higher rating than is currently assigned.

By way of background, the Veteran filed his claim for back strain along with left and right lower extremity nerve conditions in November 2024. The Veteran was afforded a VA Back Conditions examination in December 2024; based on an in-person examination and review of the Veteran's VA e-folder, the VA examiner diagnosed bilateral lower extremity radiculopathy of the sciatic nerve. Service connection was subsequently granted in the April 2025 rating decision, and an initial evaluation of 10 percent was assigned for radiculopathy of both the left and right lower extremity.

Although the Veteran underwent limited radiculopathy testing as part of his December 2024 VA Back Conditions examination, he has not been afforded a VA examination concerning his peripheral nerves in particular. The December 2024 VA Back examination report and the information available in the VA treatment records associated with the claims file are insufficient/inadequate for rating the Veteran's disabilities under the applicable Diagnostic Codes.

Based on the foregoing, the Board finds that the failure to obtain an adequate VA examination is a pre-decisional duty to assist error. Accordingly, remand is required to obtain an adequate VA examination.

The matters are REMANDED for the following action(s):

Schedule the Veteran for an examination by an appropriate clinician to determine the severity of his service-connected left and right lower extremity radiculopathy. The examiner should provide a full description of the disability and report all signs and symptoms necessary for evaluating the Veteran's disability under the rating criteria.

J.P. Norman

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board L. Fulmer

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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