How the conditions may be related
Glucocorticoid-induced osteoporosis (GIOP) is the most common form of secondary osteoporosis and a direct consequence of long-term corticosteroid therapy. Mechanisms: glucocorticoids suppress osteoblast differentiation and proliferation (reducing bone formation) while promoting osteoclast lifespan (increasing bone resorption); suppress intestinal calcium absorption and increase renal calcium excretion (producing secondary hyperparathyroidism); directly suppress gonadal hormone production (reducing protective estrogen and testosterone); and promote skeletal muscle wasting, increasing fall risk. Vertebral fracture risk increases 2.6-fold within 3 months of corticosteroid initiation at doses ≥5 mg/day prednisone equivalent. Avascular necrosis (osteonecrosis) of the femoral head is a devastating direct complication of corticosteroid use, occurring in 3–30% of long-term steroid users through fat embolism to the femoral head microvasculature and direct adipocyte hypertrophy causing intraosseous pressure necrosis.
“Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected.”
A disability may qualify for secondary service connection when evidence shows that an existing service-connected condition caused it or increased its severity beyond natural progression. These are the causation and aggravation paths in 38 CFR § 3.310. Having both conditions does not, by itself, establish the connection.
Look at the evidence behind the pairing
- van Staa TP et al. (2000) J Bone Miner Res (glucocorticoids and fracture risk)
- Saag KG et al. (1998) N Engl J Med (GIOP therapy)
- Mankin HJ (1992) J Bone Joint Surg Am (avascular necrosis)
- Assouline-Dayan Y et al. (2002) Semin Arthritis Rheum.
Strong, Moderate, and Emerging are research categories assigned within this library. They are not VA determinations, promises of service connection, or estimates of your approval chances. Read the supporting research and consider how it applies to your own history. Association between conditions does not, by itself, establish that one caused or aggravated the other.
Build the link to your own history
A nexus is the link between the two conditions. Relevant evidence can include medical records, a reasoned medical opinion, and, in some circumstances, lay evidence. A private nexus letter can help, but is not universally required. An opinion should explain how the evidence in your case supports causation or aggravation, rather than only naming a possible association.
VA may arrange a C&P examination or request a medical opinion when needed to decide an initial or Supplemental Claim. You can submit an opinion from a treating or independent clinician, but VA does not require everyone to purchase a private nexus letter. Its duty to assist does not guarantee a favorable opinion or a granted claim.
Pairing-specific research notes
DEXA scan documenting osteoporosis (T-score ≤ -2.5) or osteopenia with fracture history. MRI of the femoral head (most sensitive test) or plain X-ray (late-stage) documenting avascular necrosis. Prescription records linking long-term corticosteroid use to a service-connected condition. A nexus letter from your rheumatologist, endocrinologist, or orthopedic surgeon connecting the steroid regimen to bone loss and/or AVN. Avascular necrosis requiring hip replacement is particularly debilitating and warrants a separate high-rating secondary claim.
A diagnosis does not guarantee an additional rating
A separately compensable secondary disability may receive its own evaluation, which VA combines with other ratings under 38 CFR § 4.25. Separate diagnoses do not always mean separate ratings: § 4.14 prohibits compensating the same manifestations more than once, and some body systems have additional rating rules. For aggravation, the compensable increase must account for the baseline severity.
The formula applies the whole-person concept: a 50% combined existing rating plus a new 30% rating yields 65% (rounded to 70%), not 80%.
This example starts with an unrounded combined value. If your current award was already rounded, use your individual ratings to calculate the new total. VA rounds to the nearest ten only after combining all applicable ratings.
Read the combined ratings ruleBoth causation and aggravation are forms of secondary service connection. Aggravation means an increase in severity attributable to a service-connected condition, beyond natural progression. Permanent worsening is not required under Ward v. Wilkie (2019). Section 3.310(b) also requires medical evidence establishing a baseline level of severity; VA deducts the baseline and any natural progression when determining the compensable increase.
Explore your combined rating
See how separately assigned ratings combine using VA math.
Open the calculatorSecondary claims, explained
What is a secondary service-connected condition?
A disability may qualify for secondary service connection when evidence shows that an existing service-connected condition caused it or increased its severity beyond natural progression. These are the causation and aggravation paths in 38 CFR § 3.310. Having both conditions does not, by itself, establish the connection.
What evidence can establish the connection?
A nexus is the link between the two conditions. Relevant evidence can include medical records, a reasoned medical opinion, and, in some circumstances, lay evidence. A private nexus letter can help, but is not universally required. An opinion should explain how the evidence in your case supports causation or aggravation, rather than only naming a possible association.
Do I have to pay for a private nexus letter?
VA may arrange a C&P examination or request a medical opinion when needed to decide an initial or Supplemental Claim. You can submit an opinion from a treating or independent clinician, but VA does not require everyone to purchase a private nexus letter. Its duty to assist does not guarantee a favorable opinion or a granted claim.
Does aggravation have to be permanent?
Both causation and aggravation are forms of secondary service connection. Aggravation means an increase in severity attributable to a service-connected condition, beyond natural progression. Permanent worsening is not required under Ward v. Wilkie (2019). Section 3.310(b) also requires medical evidence establishing a baseline level of severity; VA deducts the baseline and any natural progression when determining the compensable increase.
Will a secondary condition get a separate rating?
A separately compensable secondary disability may receive its own evaluation, which VA combines with other ratings under 38 CFR § 4.25. Separate diagnoses do not always mean separate ratings: § 4.14 prohibits compensating the same manifestations more than once, and some body systems have additional rating rules. For aggravation, the compensable increase must account for the baseline severity.
When can a secondary claim’s effective date begin?
An effective date generally depends on when VA received the claim and when entitlement arose, with exceptions. A qualifying intent to file may preserve an earlier claim date if VA receives the completed claim within one year. Review deadlines and continuous pursuit can affect the date; a prior denial does not automatically establish an earlier effective date.