Citation Nr: 1439540 Decision Date: 09/05/14 Archive Date: 09/09/14 DOCKET NO. 11-15 558 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a left knee disability, to include as secondary to service-connected right knee disability. 2. Entitlement to service connection for a low back disability, to include as secondary to service-connected right knee disability. REPRESENTATION Veteran represented by: Georgia Department of Veterans Services WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD Jack S. Komperda, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1974 to July 1978. This matter comes before the Board of Veterans' Appeals (Board) on appeal from rating decisions of the Department of Veterans Affairs (VA) Atlanta Regional Office (RO) in Decatur, Georgia. In April 2014, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. The transcript of the hearing is of record. In addition to the paper claims file, the Board has reviewed the record maintained in the Virtual VA and Veterans Benefits Management System (VBMS) electronic claims files associated with the Veteran's claim. FINDINGS OF FACT 1. Affording the Veteran the benefit of the doubt, his currently diagnosed osteoarthritis of the left knee, status post bilateral total knee replacement, is due to his service-connected right knee disability. 2. Affording the Veteran the benefit of the doubt, his currently diagnosed lumbar strain with degenerative disc disease of the lumbar spine, is due to his service-connected right knee disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a left knee disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2013). 2. The criteria for entitlement to service connection for a low back disability have been met. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA has duties to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. However, as the Board is granting the benefits sought in their entirety, there is no further need to discuss VA's efforts to comply with the duties to notify and assist. The Veteran seeks service connection for left knee and low back disabilities, claiming that both conditions developed as a result of his service-connected right knee disability. Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also 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 or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). When the evidence "is in relative equipoise," the law dictates that the veteran prevails. Gilbert v. Derwinski, 1 Vet. App. 49, 55-56 (1990). Left knee In September 2006, the Veteran underwent a VA examination for his knees. The examiner noted that the Veteran's gait and posture were both abnormal, and that the Veteran leaned to his left. Range-of-motion testing of the Veteran's left knee did not reveal any pain on motion or limitations in either flexion or extension. The Veteran was diagnosed with traumatic arthritis of the right knee with instability. However, the Veteran was not diagnosed with a left knee disability. In June 2007, the Veteran underwent a VA examination where he complained of crushing, localized pain in his left knee. X-rays showed the Veteran had degenerative arthritic changes of the left knee, and range-of-motion testing revealed he had pain on movement. The Veteran was diagnosed with degenerative joint disease of the left knee joint. The examiner opined that "[i]t is equally likely (50%) that the veteran's [left] knee problem is secondary to the service connected [right] knee condition." In support of this conclusion, the examiner noted that "favoring one knee can put undue stress on the other knee." An April 2009 letter from a VA nurse practitioner notes that the Veteran was under the care of the Atlanta Medical Center primary care clinic for his back, hips and knees. The letter notes the Veteran had right knee replacement in 2006 and "has had an exacerbation of his chronic low back pain as well as pain in both hips and [left] knee." The VA nurse practitioner states that it is likely the conditions in the Veteran's hips, low back and left knee are "related to and exacerbated by his long history of [right] knee pain and persistent swelling and numbness since his knee replacement surgery." In December 2009, the Veteran was given another VA examination for his knees. Range-of-motion testing revealed that the Veteran's left knee was limited to 90 degrees in flexion. However, the examiner did not provide a diagnosis for the Veteran's left knee or provide an opinion on what, if any, relationship the Veteran's left knee condition had to his service-connected right knee disability. In a May 2010 opinion, a VA examiner noted that the Veteran underwent a total replacement of the left knee in April 2010. Further, the VA examiner noted that over the last five years, the Veteran began to lose range of motion to his left knee, ultimately leading to his total knee replacement. The examiner stated that it was too early to ascertain whether there is a relationship between the Veteran's right and left knee conditions. The examiner noted that the Veteran was 65 years old and the "type of involvement of the left knee is not unusual and would not need a precipitating or aggravating condition." However, the examiner stated that at the time, there was not enough information in the claims file to "come to a firm conclusion." The examiner stated that the clinical involvement of the right knee, as well as the back and hip pathology would be useful information in coming to a firm conclusion. The examiner stated that the Veteran would need to be seen approximately six to 12 months following his left knee replacement. In February 2011, the Veteran's claims file was again sent to a VA examiner for an opinion on whether there was a relationship between the Veteran's left and right knee disabilities. The VA examiner noted the Veteran's diagnosis of osteoarthritis of bilateral knees, status post bilateral total knee replacement. After a review of the Veteran's claims file, the VA examiner opined that it was less likely as not (less than 50/50 probability) the Veteran's left knee disability was either causally related to or aggravated beyond the natural progression by his service-connected right knee disability. In support of this conclusion, the examiner noted that radiographic evidence of additional joint degeneration subsequent to the Veteran's total knee replacements is "nil." Further, the examiner stated that purported development of contralateral knee arthritis arising from an ipsilateral total knee replacement appears speculative and without scientific citation. Upon careful review of the record, the Board finds that the evidence in this case to be in relative equipoise. The medical evidence and opinions provide contrasting, yet well-reasoned viewpoints, and the reports are adequate for adjudication. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Reasonable doubt created by the approximate balance of evidence must be resolved in favor of the Veteran. Affording the Veteran the benefit of the doubt, the Board finds the evidence is at least in equipoise as to whether the Veteran's osteoarthritis of the left knee, status post bilateral knee replacements, is secondary to his service-connected right knee disability. Consequently, service connection is granted on a secondary basis. 38 U.S.C.A. § 5107(b). Lumbar spine In June 2007, the Veteran underwent a VA examination where he complained of stiffness and weakness in his lower back and constant pain that has existed for five years. X-rays showed the Veteran had degenerative arthritis and joint narrowing of the lumbar spine at L4-5 and L5-S1. Range-of-motion testing revealed the Veteran had pain on movement when extending his thoracolumbar spine. The Veteran was diagnosed with degenerative arthritis of the lumbar spine. The examiner opined that "[i]t is equally likely (50%) that the veteran's low back condition is secondary to the service connected [right] knee condition." In support of this conclusion, the examiner noted that "favoring one side of the body can alter biomechanics and cause back problems." As noted above, the April 2009 letter from a VA nurse practitioner noted that the Veteran had an exacerbation of low back pain that the nurse practitioner stated was likely due to the Veteran's right knee disability, particularly his long history of right knee pain and swelling. In a May 2010 opinion, a VA examiner noted that a review of the Veteran's record revealed one instance of low back pain in July 1991 that apparently resolved, and VA treatment records noted the Veteran's low back pain but provided no details. Therefore, the VA examiner stated that there was not enough information for him to make a comment regarding the low back pain as associated with the Veteran's right knee. The examiner stated that the Veteran would need to be seen approximately six to 12 months following his left knee replacement. The Veteran underwent a total replacement of the left knee in April 2010. Further, the VA examiner noted that over the last five years, the Veteran began to lose range of motion to his left knee, ultimately leading to his total knee replacement. The examiner stated that it was too early to ascertain whether there is a relationship between the Veteran's right and left knee conditions. The examiner noted that the Veteran was 65 years old and the "type of involvement of the left knee is not unusual and would not need a precipitating or aggravating condition." However, the examiner stated that at the time, there was not enough information in the claims file to "come to a firm conclusion." The examiner stated that the clinical involvement of the right knee, as well as the back and hip pathology would be useful information in coming to a firm conclusion. In February 2011, the Veteran's claims file was again sent to a VA examiner for an opinion on whether there was a relationship between the Veteran's low back and right knee conditions. The VA examiner noted the Veteran's diagnosis of lumbar strain with radiographic evidence of degenerative disc disease. After a review of the Veteran's claims file, the VA examiner opined that it was less likely as not (less than 50/50 probability) the Veteran's back condition was either causally related to or aggravated beyond the natural progression by his service-connected right knee disability. In support of this conclusion, the examiner noted that radiographic evidence of for additional joint degeneration subsequent to the Veteran's total knee replacements is "nil." Further, the examiner stated that purported development of lumbar spine degenerative disc disease arising from an ipsilateral total knee replacement appears speculative and without scientific citation. Upon careful review of the record, the Board finds that the evidence in this case to be in relative equipoise. The medical evidence and opinions provide contrasting, yet well-reasoned viewpoints, and the reports are adequate for adjudication. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Reasonable doubt created by the approximate balance of evidence must be resolved in favor of the Veteran. Affording the Veteran the benefit of the doubt, the Board finds the evidence is at least in equipoise as to whether the Veteran's degenerative disc disease of the lumbar spine is secondary to his service-connected right knee disability. Consequently, service connection is granted on a secondary basis. 38 U.S.C.A. § 5107(b). ORDER Entitlement to service connection for a left knee disability is granted. Entitlement to service connection for a low back disability is granted. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs