Secondary Conditions to Back Pain

The low back sits upstream of a lot of other problems. A disc that presses on a nerve root sends symptoms down the leg, a painful back changes how you walk and sleep, and back pain medications have effects of their own. Under 38 CFR § 3.310, a condition caused or worsened by your service-connected back condition is service connected too, and it is rated under its own diagnostic code. This page covers what you can claim, the research behind each link, which claims to file first, and how the ratings combine.

What can you claim secondary to a back condition?

Any condition a doctor can tie to your back, with reasoning, can be claimed. In the Board's 2021 to 2026 decisions the most common were these.

• Nerve conditions of the legs, including radiculopathy, sciatica and leg neuropathy.
• The knee and the hip. See knee, hip and hip secondary to back.
• The neck. See cervical spine.
• Sleep apnea. See sleep apnea secondary to back.
• Nerve conditions of the arms and the shoulder.
• Mental health conditions, such as depression and anxiety, which the Board often writes as an acquired psychiatric disorder.
• The feet and ankles, such as flat feet, plantar fasciitis and the ankle.
• Erectile dysfunction and bladder problems.
• Migraines and high blood pressure.

The Board section further down lists every condition claimed secondary to the back with enough rulings to show, with its count and grant rate. The back can also be the claimed condition: see back secondary to knee and back secondary to flat feet.

How secondary service connection works for a back condition

VA grants a secondary claim in two ways under 38 CFR § 3.310.

• Caused by. Your service-connected back condition caused the condition, at least as likely as not.
• Aggravated by. The condition is worse because of your back, meaning it would be less severe but for the back condition (M21-1 V.ii.2.D). VA rates only the part above the condition's baseline before the aggravation.

The text of § 3.310(b) still tells VA to subtract "natural progress," but VA's current claims manual (M21-1 V.ii.2.D, revised after Spicer v. McDonough) no longer applies that part, and the worsening does not have to be permanent. VA still needs a baseline shown by medical evidence, and it rates the difference between that baseline and the current level.

The file needs three things: a service-connected back, a current diagnosis of the secondary condition, and a medical opinion linking the two with reasoning. The opinion should explain why the condition comes from the back rather than only from age, work, weight or a separate injury. An opinion that answers only the "caused by" question and skips aggravation is inadequate (El-Amin v. Shinseki, 26 Vet. App. 136 (2013)).

Some chains run through weight. VA does not treat obesity as a disability on its own, but VA's General Counsel (VAOPGCPREC 1-2017) allows it to be a middle step when the back condition, or the inactivity or medication it causes, led to weight gain, the weight gain was a substantial factor in causing the claimed condition, and the condition would not have happened without it. The Court of Appeals for Veterans Claims built on that framework in Walsh v. Wilkie, 32 Vet. App. 300 (2020).

The most common secondary conditions to a back condition

Radiculopathy, sciatica and other leg nerve conditions

This link has the clearest medicine behind it. A review of disc herniation research (Cosamalón-Gan and colleagues, Neurocirugia, 2021) explains that sciatic pain is not only pressure on the nerve root: the herniated disc tissue releases inflammatory chemicals, including interleukin-1, interleukin-6, interleukin-8 and tumor necrosis factor, that irritate the root as well.

Note (1) of the spine formula in 38 CFR § 4.71a tells VA to rate associated objective neurologic abnormalities separately. The sciatic nerve is rated under Diagnostic Code 8520: 10 percent for mild incomplete paralysis, 20 for moderate, 40 for moderately severe, 60 for severe with marked muscular atrophy, and 80 for complete paralysis. Each leg is rated on its own. When the involvement is wholly sensory, the schedule limits the rating to the mild or, at most, the moderate level (38 CFR § 4.124a).

Radiculopathy, sciatica and "nerve conditions of the legs" usually describe the same problem, so VA rates the affected nerve once per leg, not once per label (38 CFR § 4.14). If your records say "neuropathy," the opinion should state whether the problem starts at a lumbar nerve root, because that is the link a back claim needs. Nerve conduction studies, an MRI showing nerve root compression, and exam findings on reflexes, strength and sensation carry these claims. Arm nerves are grouped by cervical roots in the schedule (Diagnostic Code 8510 covers the fifth and sixth cervicals), so an arm nerve claim usually needs a service-connected neck in the chain.

The hip and the knee

In a cohort of 983 adults aged 55 and older with hip or knee arthritis (Stupar and colleagues, Journal of Manipulative and Physiological Therapeutics, 2010), low back pain at the start predicted more arthritis pain and disability at follow-up in people with hip arthritis, but not in people with knee arthritis. That fits an aggravation argument for the hip better than for the knee. A review of gait studies (Smith and colleagues, Journal of Sport and Health Science, 2022) found that people with persistent low back pain walk slower and with shorter strides, though it found no difference in how far the hips and pelvis move. Hip arthritis and lumbar stenosis can also appear together and be hard to tell apart (Devin and colleagues, Journal of the American Academy of Orthopaedic Surgeons, 2012), so the opinion has to name which one is producing your pain.

The neck

VA rates the neck and the low back separately (Note (6) of the spine formula). I found no study showing that a low back condition causes a neck condition, so this claim rests on the examiner's reasoning about posture; a direct claim is stronger when service records support it.

Sleep apnea

Two paths are argued: pain medication and weight. A meta-analysis of 803 people with obstructive sleep apnea (Filiatrault and colleagues, Journal of Clinical Sleep Medicine, 2016) found long-term opioid use had a small effect on the overall apnea index and a medium effect on central apnea. A later meta-analysis of 3,791 patients (Mubashir and colleagues, Journal of Clinical Sleep Medicine, 2020) found sleep-disordered breathing not significantly more common in opioid users with chronic pain than in comparison groups, though central apnea was common among them. On weight, a population cohort (Peppard and colleagues, JAMA, 2000) found a 10 percent weight gain predicted about a 32 percent rise in the apnea-hypopnea index. Sleep apnea that requires a CPAP rates 50 percent under Diagnostic Code 6847.

Depression and anxiety

A review of 83 studies (Fishbain and colleagues, Clinical Journal of Pain, 1997) found more support for depression following chronic pain than preceding it, while warning that depression is hard to measure in people with pain. A 2025 meta-analysis of 347,468 adults with chronic pain (Aaron and colleagues, JAMA Network Open) found clinical symptoms of depression in 39.3 percent and of anxiety in 40.2 percent. All of your mental health diagnoses share one rating under the mental disorders formula, so depression and anxiety together add one rating, not two.

Erectile dysfunction and bladder problems

Note (1) of the spine formula names bowel and bladder impairment among the neurologic abnormalities to rate separately. A review of lumbar spinal stenosis (Gandhi and colleagues, International Journal of Neuroscience, 2018) lists bladder dysfunction, urinary symptoms and erectile dysfunction among its effects. Long-term opioid treatment can lower testosterone, with reduced libido and erectile dysfunction among the symptoms (Smith and Elliott, Pain Physician, 2012). Erectile dysfunction rates 0 percent under Diagnostic Code 7522, and the code's footnote tells VA to review special monthly compensation (SMC-K) under 38 CFR § 3.350.

Feet, ankles, the shoulder, blood pressure and migraines

Foot, ankle and shoulder claims argue that a painful back changes your gait, or that leaning on a cane loads the shoulder. I found no study that followed these problems developing from a back condition, so the opinion has to carry them with your gait findings, any cane or brace, and the timeline. For blood pressure, a meta-analysis of 50 randomized trials (Johnson and colleagues, Annals of Internal Medicine, 1994) found anti-inflammatory pain relievers (NSAIDs) raised average lying-down blood pressure by 5.0 mm Hg and blunted blood pressure medicine. I found no study tying a back condition to migraines; that claim rests on a theory, such as lost sleep from pain, that the opinion must explain.

Which secondary claims to file first

Three questions sort the claims worth filing.

1. Is there a current diagnosis? No diagnosis, no claim. Leg nerve claims need exam findings or nerve testing; sleep apnea needs a sleep study.
2. Can it be rated on its own? Leg nerve conditions, the hip, sleep apnea and bladder problems have their own ratings. A second mental health diagnosis does not add a second rating, and erectile dysfunction rates 0 percent apart from SMC-K.
3. Will a doctor explain the link? The medical opinion decides most of these claims. If no clinician will put the reasoning in writing, start there.

For most veterans the leg nerve claims come first: the medicine is clearest, the evidence is objective, and each leg is rated. Raven Nexus organizes your records and the relevant research into a draft your doctor can review, and C&P exam prep helps you describe nerve symptoms and flare-ups accurately.

How secondary ratings combine with a back rating

VA combines ratings under 38 CFR § 4.25, largest first, and each smaller rating takes its share of what remains. Paired leg ratings get a step first: under 38 CFR § 4.26, VA combines the right and left leg ratings, adds 10 percent of that value, and treats the result as one rating.

Take a back at 40 percent with moderate radiculopathy at 20 percent in each leg. The two legs combine to 36, and the bilateral factor adds 3.6, which gives about 40. That 40 and the back's 40 combine to 64, which VA rounds to 60 percent. Now add sleep apnea at 50 percent. VA starts with the largest: 50, then the leg rating of 40 brings it to 70, then the back's 40 brings it to 82. Add depression at 30 percent and the combined value is about 87, which VA rounds to 90 percent.

Secondary conditions also count toward TDIU. For its percentage test, 38 CFR § 4.16(a) treats disabilities of one or both legs, including the bilateral factor, and disabilities resulting from a common etiology as one disability.

Questions veterans ask about secondary conditions to back pain

What conditions are secondary to back pain?

The most common in Board decisions are nerve conditions of the legs (radiculopathy and sciatica), the knee, the hip, the neck and sleep apnea. Any condition a doctor can tie to your back with reasoning can be claimed.

Is radiculopathy rated separately from my back?

Yes. Note (1) of the spine formula tells VA to rate nerve abnormalities separately, and each affected leg gets its own rating under Diagnostic Code 8520.

Can sleep apnea be secondary to back pain?

It can, usually through long-term opioid use or weight gain caused by the back condition. The research on opioids is mixed, so the opinion has to explain the path in your own history.

Can hip pain be secondary to a back condition?

Yes, if a doctor explains how the back caused or worsened the hip. One cohort found low back pain predicted worse hip arthritis pain and disability later, which supports an aggravation argument.

Sources

• 38 CFR § 3.310, secondary service connection; M21-1 V.ii.2.D, aggravation of a nonservice-connected disability by a service-connected one; Spicer v. McDonough (Federal Circuit).
• 38 CFR § 4.71a, General Rating Formula for Diseases and Injuries of the Spine, Notes (1) and (6); 38 CFR § 4.124a, Diagnostic Codes 8510 and 8520; 38 CFR § 4.97, Diagnostic Code 6847; 38 CFR § 4.115b, Diagnostic Code 7522; 38 CFR § 3.350(a).
• 38 CFR § 4.14, avoiding pyramiding; 38 CFR § 4.25, combined ratings; 38 CFR § 4.26, bilateral factor; 38 CFR § 4.16, TDIU.
• VA General Counsel Precedent Opinion 1-2017 (VAOPGCPREC 1-2017), obesity as an intermediate step; Walsh v. Wilkie, 32 Vet. App. 300 (2020).
• El-Amin v. Shinseki, 26 Vet. App. 136 (2013), an opinion must address aggravation.
• Cosamalón-Gan I, Cosamalón-Gan T, Mattos-Piaggio G, et al. Inflammation in the intervertebral disc herniation. Neurocirugia. 2021;32(1):21-35. PMID 32169419.
• Stupar M, Côté P, French MR, et al. The association between low back pain and osteoarthritis of the hip and knee: a population-based cohort study. Journal of Manipulative and Physiological Therapeutics. 2010;33(5):349-354. PMID 20605553.
• Smith JA, Stabbert H, Bagwell JJ, et al. Do people with low back pain walk differently? A systematic review and meta-analysis. Journal of Sport and Health Science. 2022;11(4):450-465. PMID 35151908.
• Devin CJ, McCullough KA, Morris BJ, et al. Hip-spine syndrome. Journal of the American Academy of Orthopaedic Surgeons. 2012;20(7):434-442. PMID 22751162.
• Filiatrault ML, Chauny JM, Daoust R, et al. Medium Increased Risk for Central Sleep Apnea but Not Obstructive Sleep Apnea in Long-Term Opioid Users: A Systematic Review and Meta-Analysis. Journal of Clinical Sleep Medicine. 2016;12(4):617-625. PMID 26943709.
• Mubashir T, Nagappa M, Esfahanian N, et al. Prevalence of sleep-disordered breathing in opioid users with chronic pain: a systematic review and meta-analysis. Journal of Clinical Sleep Medicine. 2020;16(6):961-969. PMID 32105208.
• Peppard PE, Young T, Palta M, et al. Longitudinal study of moderate weight change and sleep-disordered breathing. JAMA. 2000;284(23):3015-3021. PMID 11122588.
• Fishbain DA, Cutler R, Rosomoff HL, et al. Chronic pain-associated depression: antecedent or consequence of chronic pain? A review. Clinical Journal of Pain. 1997;13(2):116-137. PMID 9186019.
• Aaron RV, Ravyts SG, Carnahan ND, et al. Prevalence of Depression and Anxiety Among Adults With Chronic Pain: A Systematic Review and Meta-Analysis. JAMA Network Open. 2025;8(3):e250268. PMID 40053352.
• Gandhi J, Shah J, Joshi G, et al. Neuro-urological sequelae of lumbar spinal stenosis. International Journal of Neuroscience. 2018;128(6):554-562. PMID 29098915.
• Smith HS, Elliott JA. Opioid-induced androgen deficiency (OPIAD). Pain Physician. 2012;15(3 Suppl):ES145-ES156. PMID 22786453.
• Johnson AG, Nguyen TV, Day RO. Do nonsteroidal anti-inflammatory drugs affect blood pressure? A meta-analysis. Annals of Internal Medicine. 1994;121(4):289-300. PMID 8037411.
• Board figures on this page: Claim Raven's read of every Board decision from 2021 to 2026 that it holds.