Citation Nr: 1309303 Decision Date: 03/19/13 Archive Date: 04/01/13 DOCKET NO. 07-29 525 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUES 1. Entitlement to service connection for a right shoulder disorder. 2. Entitlement to service connection for a left shoulder disorder. 3. Entitlement to service connection for a left elbow disorder. 4. Entitlement to service connection for a right elbow disorder. 5. Entitlement to service connection for a left ankle disorder. 6. Entitlement to service connection for a disorder manifested by double vision and photophobia. REPRESENTATION Veteran represented by: Disabled American Veterans ATTORNEY FOR THE BOARD C. Fields, Associate Counsel INTRODUCTION The Veteran served on active duty from August 1974 to June 1980 and from June 1987 to November 1996. He retired from the military in early 2006 with a total of over 30 years of service, including on active duty and in the Reserves. This case comes before the Board of Veterans' Appeals (the Board) on appeal from rating decisions issued in January and May 2006 by the Department of Veterans Affairs (VA) Regional Office in Roanoke, Virginia (RO). In addition to the paper claims file, the Veteran also has a Virtual VA file (a highly electronic storage system). Both have been reviewed in conjunction with the present appeal. In April 2011, the Board adjudicated four issues of entitlement to increased ratings and remanded 18 issues of entitlement to service connection for further development and adjudication by the agency of original jurisdiction (AOJ). In an April 2011 rating decision, the RO implemented the Board's awards of higher ratings for bilateral plantar fasciitis, and assigned an effective date for such awards. The Veteran did not appeal those determinations. Further, in an August 2012 rating decision, the AOJ granted service connection and assigned an initial disability rating and effective date for 12 disorders that had been remanded: right knee chondromalacia, chronic cervical strain, lumbar strain, bilateral hearing loss, chronic sinusitis, traumatic brain disorder (TBI) due to head injury residuals, migraine headaches, tingling of the fingertips 5th cranial nerve (also claimed as 7th cranial nerve palsy), tingling of the mouth and lips 5th cranial nerve (also claimed as 7th cranial nerve palsy), right tarsal tunnel syndrome (claimed as right foot nerve damage), temporomandibular joint dysfunction (TMJ), and chronic right rectus abdominus muscle strain (abdominal pain). To date, the claims file does not include a notice of disagreement as to any of those determinations. The August 2011 determinations were a full grant of those benefits sought on appeal, and a jurisdiction-conferring notice of disagreement as to the effective date or compensation level has not been received. As such, those 12 issues are no longer before the Board. See Grantham v. Brown, 114 F.3d 1156, 1158 (Fed. Cir. 1997). At the time of the last Board remand, issue #6 as stated on the first page of this decision was characterized as entitlement to service connection for a disorder manifested by double vision. However, the evidence of record indicates that the Veteran also complains of constant photophobia as a result of in-service injuries. The scope of a claim includes any disability that may reasonably be encompassed by the claimant's description of the claim, including reference to a specific body part or system or a description of symptoms, as well as the other information of record. Brokowski v. Shinseki, 23 Vet. App. 79 (2009); see also Clemons v. Shinseki, 23 Vet. App. 1 (2009). Therefore, this issue has been recharacterized. FINDINGS OF FACT 1. The Veteran has had recurrent shoulder symptoms after injuries during active service, including in the Reserves, and the evidence establishes that the current bilateral shoulder tendonitis was incurred as a result of active service. 2. The Veteran has had recurrent elbow symptoms after injuries during active service, including in the Reserves, and the evidence establishes that the current bilateral elbow bursitis was incurred as a result of active service. 3. The Veteran has had recurrent ankle symptoms after injuries during active service, including in the Reserves, and the evidence establishes that the current chronic left ankle instability was incurred as a result of active service. 4. The Veteran has had intermittent double vision and constant photophobia since injury during active service, and this condition has been linked to his active service. CONCLUSIONS OF LAW 1. The criteria to establish service connection for right shoulder tendonitis have been met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304 (2012). 2. The criteria to establish service connection for left shoulder tendonitis have been met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304 (2012). 3. The criteria to establish service connection for left elbow bursitis have been met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304 (2012). 4. The criteria to establish service connection for right elbow bursitis have been met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304 (2012). 5. The criteria to establish service connection for left ankle chronic instability have been met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304 (2012). 6. The criteria to establish service connection for double vision and photophobia have been met. 38 U.S.C.A. §§ 101, 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Board's decision herein to grant service connection for bilateral shoulder and elbow disabilities, a left ankle disability, and double vision and photophobia constitutes a full grant of the disabilities sought on appeal. Therefore, no further development is needed under the Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations, and no prejudice results from any deficiencies. The Veteran contends that he currently has disorders of the shoulders, elbows, and the left ankle as a result of numerous injuries during active service, including from parachute jumps with bad landings and daily training that required carrying an 80-pound rucksack for over 20 years. He also contends that he has vision problems including double vision and photophobia due to a January 1995 injury. See, e.g., September 2005 statement with claim, September 2012 statement. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Where a disease is diagnosed after discharge, service connection may be granted when all of the evidence, including that pertinent to service, establishes that the disease was incurred in active service. 38 U.S.C.A. § 1113; 38 C.F.R. § 3.303(d). In this case, the Veteran had periods of active duty service and Reserves service, including active duty for training (ACDUTRA) and inactive duty for training (IDT). Active service includes active duty, any period of ACDUTRA during which the Veteran was disabled or died from a disease or injury incurred or aggravated in the line of duty, and any period of IDT during which the Veteran was disabled or died from an injury incurred or aggravated in line of duty. See 38 U.S.C.A. §§ 101(24), 106, 1110; 38 C.F.R. §§ 3.6, 3.303, 3.304; Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Further, arthritis (or degenerative joint disease) will be presumed to be service-connected as a chronic disability if it is shown to have manifested to a degree of at least 10 percent within one year after separation from active duty. 38 U.S.C.A. § 1112; 38 C.F.R. §§ 3.307, 3.309. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a condition manifested during service, or within the presumptive period after service, either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Generally, to establish direct service connection, there must be medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Barr v. Nicholson, 21 Vet. App. 303, 307 (2007); Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999). Under certain circumstances, lay statements may be sufficient for service connection by establishing the occurrence of lay-observable events, the presence of disability, or symptoms of disability that are susceptible to lay observation. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In particular, the nexus element may be established based on competent and credible medical or lay evidence of continuity of symptomatology for a listed chronic disability. See Barr, 21 Vet. App. at 307. When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt will be resolved in favor of the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. When all of the evidence is assembled, VA must determine whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim will be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 54-55 (1990); Alemany v. Brown, 9 Vet. App. 518 (1996). Bilateral shoulder and elbow disorders The Veteran states that he had specific injuries of the shoulders and elbows in service, as discussed below. He also states that he had pain throughout service and medics gave him Motrin and other pain relievers, but these were not always documented in the service records. See, e.g., September 2012 letter. The Veteran's service treatment records reflect several bad landings during parachute jumps in the line of duty, as well as injuries to the right shoulder and right elbow. Although not specifically related to the shoulders or elbows, a November 1981 statement of medical examination and duty status shows that he injured the entire left side of his body in a parachute landing on IDT, after being dragged approximately 100 feet along a concrete runway. Further, a June 1986 statement of medical examination and duty status records that the Veteran injured his right arm after landing in a tree during a parachute exercise in line of duty while on IDT. It was noted that this injury was likely to result in a claim for future medical care. Treatment records dated in June 1986 also document complaints of right elbow pain after jumping from a plane and landing in a tree. There was no evidence of fracture on x-rays, and the impression was hematoma. The Veteran was assigned a temporary T-3 profile. In October 1992, while on active duty, the Veteran complained of pain and discomfort in the right upper arm and shoulder that was aggravated by movement. A treatment record notes that the pain had been present since May 1992, and the diagnosis was chronic inflammation of the muscle group of the right upper arm. Thereafter, a December 1992 consult record states that the initial injury was unknown, and that the Veteran reinjured the shoulder in September or October 1992 when he fell from a ladder. There was pain with abduction and initial weakness, which were noted to be 90 percent resolved. X-rays were negative, and the diagnosis was muscular strain resolving. Private records dated in June 2000 note symptoms of arthralgia, in that the Veteran reported a burning sensation in the right elbow for three years (or since around 1997) that was intermittent in nature. The provider diagnosed right elbow tendonitis. In an April 2001 report of medical history, the Veteran denied any joint problems. An April 2005 MRI report for the left shoulder shows moderate tendinopathy of the rotator cuff, with no evidence of a full thickness tear, and very mild degenerative osteoarthritis of the acromioclavicular joint. Similarly, an April 2005 private record referenced MRI findings of tendinitis without a tear, and that the Veteran had obvious tendinitis of the rotator cuff with secondary weakness. Private records dated in December 2005 note complaints of right elbow pain, with a diagnosis of olecranon bursitis. In his January 2006 Reserve retirement examination and report of medical history, the Veteran reported pain in the shoulders and elbows from jump injuries, as well as tendinitis in the left shoulder and the right elbow. Examination showed crepitus, tenderness on range of motion above 90 degrees, and full abduction in the shoulders. The examiner recorded chronic pain in the shoulders with a notation of overuse, degenerative joint disease, and stated that a shoulder MRI in 2005 showed tendinitis. A VA orthopedic examination was conducted in July 2011. The examiner recorded that the Veteran had numerous acute shoulder sprains throughout his time in service, but each injury resolved, and he did not develop chronic shoulder problems until around 2006. He denied any injury or trauma to either shoulder at that time. The Veteran had been treated with physical therapy and steroid injections, but he continued to have bilateral shoulder problems. He complained of a current constant ache, stiffness, and weakness of both shoulders, especially with heavy lifting. Physical examination of the shoulders showed tenderness upon palpation of the acromioclavicular joints and objectively decreased range of motion with all movements bilaterally. X-rays showed minimal right acromioclavicular joint arthropathy, and otherwise normal shoulders bilaterally. The examiner diagnosed tendonitis of the rotator cuff in both shoulders with pain and decreased range of motion. He opined that the current bilateral shoulder condition was less likely as not caused by or a result of the Veteran's parachute jumps during service. The examiner reasoned that there were no documented shoulder complaints during service, and the Veteran now stated that he did not notice shoulder problems until 2006. The examiner stated that, if the Veteran did have shoulder problems while in service, it would not manifest itself ten years later. With regard to the elbows, the examiner recorded that the Veteran noticed bilateral elbow problems in 1994, with no direct injury or trauma, and he had continued to have bilateral elbow problems since that time. He complained of a current constant ache on the back of both elbows and daily stiffness. Physical examination of the elbows showed tenderness to palpation bilaterally, but full range of motion. X-rays showed normal elbows. The examiner diagnosed bursitis in both elbows with pain but normal range of motion. He opined that the current bilateral elbow condition was less likely as not caused by or a result of the Veteran's parachute jumps during service. The examiner reasoned that there were no documented elbow complaints during service, although the Veteran now stated that his problems began during service in 1994. The examiner also stated that parachute landings do not usually cause any tension, strain, or other stresses on the elbows. In a September 2012 letter, the Veteran denied telling the VA examiner that his shoulder problems first began in 2006, or that he did not have elbow problems until 1994. He indicated that he filed his claim in 2005 and also referred to his service records. He stated that it makes no sense for parachute injuries not to affect the elbows, describing his repeated jumps with 90 pounds of equipment at night. The Veteran also stated that he had visited a physician and chiropractor recently for neck and shoulder pain, and that the chiropractor told him that his neck disability can cause shoulder problems. He referred to "buddy" letters as showing that he had problems in the shoulders and elbows for years. The Board notes that, in his September 2005 claim for service connection, the Veteran reported that his bilateral elbow disability and his left shoulder disability began in 1981, and his right shoulder disability began in 1986. He stated that he had ongoing pain in the shoulders and elbows, and that he had tendonitis in the left rotator cuff and was also having weakness in the right shoulder. In a statement attached to his August 2007 substantive appeal, the Veteran indicated that his elbow and shoulder conditions were not present prior to service and occurred while in service, and he now had constant pain with decreased range of motion. The evidence includes three letters dated in May and June 2008, from a fellow service member and two friends, indicating that the Veteran has problems with pain in the feet and walking. There is also an April 2004 letter from the Veteran's employment team leader at the time, indicating that he had problems with his feet when he started the job in May 2003, and he later had unidentified health problems. There is no specific reference to the shoulders or elbows in these statements. The Board notes that there is an indication of degenerative joint disease in the 2006 retirement examination, and an April 2005 MRI showed osteoarthritis in the left shoulder. However, it is unclear whether there was arthritis of the shoulder to a compensable degree within one year after the Veteran's discharge from active duty. As such, presumptive service connection for chronic disability is not for application. Nevertheless, the Veteran is competent to report observable symptoms such as pain and limitation of motion after in-service injuries to the shoulders and elbows. See Barr, 21 Vet. App. at 307-08; Jandreau, 492 F.3d at 1376-77. He is also competent to report that he injured his shoulders and elbows during parachute jumps and while carrying heavy equipment during active and Reserves service, as well as taking medications to treat his ongoing pain. Id. There are several documented instances of treatment for injuries to the shoulders, the side of the body, and the elbow during ACDUTRA and IDT service. As such, although there are some inconsistencies, the Board finds the Veteran's testimony to this effect to be credible, as it is generally consistent with the other evidence of record. As noted above, the July 2011 VA examiner diagnosed bilateral tendinitis of the shoulders and bursitis of the elbows. These conditions are also shown in prior medical records, including during the Veteran's Reserves service. Although the VA examiner opined that the current shoulder and elbow conditions were less likely as not caused by or a result of the Veteran's service, including parachute jumps, both of these opinions were based largely on a finding that there were no documented complaints as to the shoulders and elbows during service. As summarized above, this is inconsistent with the Veteran's service treatment records, which document pertinent injuries on several occasions during active service. It appears that the examiner may have focused solely on the Veteran's active duty service, instead of considering the periods of ACDUTRA and IDT service when injuries to the shoulders and elbows occurred. Further, the Veteran's testimony that he sustained additional injuries and had ongoing observable symptoms in the shoulders and elbows is both competent and credible. It is unclear if all of the Veteran's service records pertaining to his Reserves service from 1996 forward were obtained, but he reported elbow and shoulder problems at his 2006 retirement examination. Additionally, the VA examiner's statement that parachute landings do not usually cause problems with the elbows is patently inconsistent with the Veteran's service records, including in 1986, that specifically reflect injury to the elbow as a result of a bad parachute landing. Accordingly, the VA examiner's etiological opinions for the elbows and shoulders have very low probative value. In contrast, the VA examiner gave positive nexus opinions as to many of the Veteran's other claimed conditions, based on his documented injuries and symptoms during service due to parachute jumps and his complaints of ongoing symptoms. Further, the Veteran reported shoulder and elbow problems due to parachuting injuries in his January 2006 service retirement examination. Under these circumstances, the Board finds that the evidence is in relative equipoise as to whether the Veteran's current bilateral shoulder tendonitis and elbow bursitis were incurred as a result of his periods of active service, including in the Reserves. Therefore, the benefit-of-the-doubt doctrine applies, and all reasonable doubt will be resolved in his favor. As a result, the evidence of record establishes that the Veteran's current bilateral shoulder and elbow disabilities were incurred during active service, and the claims are granted. 38 C.F.R. § 3.102. Left ankle disorder The Veteran states that he had a specific injury to the left ankle in service, as summarized below. He also states that he had pain throughout service and that medics gave him Motrin and other pain relievers, but these were not always documented in the service records. See, e.g., September 2012 letter. The Veteran's service treatment records reflect several bad landings during parachute jumps in line of duty, as well as injuries to the left ankle. Although not specifically related to the ankle, a November 1981 record shows contusions and abrasions of the left side of the body and left leg after being dragged approximately 100 feet along a runway due to a parachute landing on IDT. Additionally, a July 1984 statement of medical examination and duty status records that the Veteran cut or twisted his ankle when he hit an object on impact during a night parachute jump in line of duty on ACDUTRA. The Board acknowledges that the report does not specify which ankle was injured. However, it is observed that the grant of service connection for the right ankle was not predicated on this July 1984 injury and indeed, such injury was not even referenced in the January 2006 rating decision awarding service connection for that disability. This strongly suggests that the ankle injured in July 1984 was indeed to the left ankle. In light of this, and considering the Veteran's credible contentions, the Board resolves doubt in his favor and finds that the injury documented in July 1984 involved the left ankle. Post-service, private records dated from 1998 to 2001 indicate treatment for symptoms in the feet and heels, with no specific reference to the left ankle. In an April 2001 report of medical history, the Veteran denied any joint problems or foot trouble. However, during his January 2006 Reserve retirement examination and report of medical history, he indicated that his ankles would swell at times and that he received private treatment for ankle pain. At a February 2006 VA fee basis examination concerning other claims (including the feet/heels and the right ankle), the left ankle showed no signs of edema, effusion, weakness, tenderness, redness, heat, abnormal movement, or guarding of movement. There was no deformity upon examination of the ankles. As noted above, service connection is already in effect for disabilities of the right ankle and both feet, including plantar fasciitis with heels spurs, based symptoms in the feet and heels. In an April 2009 addendum report to a VA fee basis examination, a physician stated that there was a diagnosis of bilateral ankle strain to account for pain in the ankles, which was separate from the Veteran's foot/heel condition. The July 2011 VA orthopedic examiner recorded that the Veteran first noticed left ankle problems in the 1990s, with no initial injury or trauma, and had had left ankle problems since that time. He complained of current chronic instability and constant pain with occasional stiffness. Physical examination showed no instability, tendon abnormality, or varus or valgus angulation, and full range of motion of the left ankle. X-rays of the ankle were normal. The examiner diagnosed chronic left ankle instability with pain, which required the use of a cane for ambulating long distances. He opined that the current left ankle condition was less likely as not caused by or a result of the Veteran's parachute jumps during service. The examiner reasoned that there were no left ankle symptoms or complaints in service, although he acknowledged that parachute landings could cause strain and stress to the ankles. He stated that the service records showed numerous complaints concerning the right ankle and both feet, as well as other musculoskeletal problems, but there were no documented complaints of left ankle problems. In a September 2012 letter, the Veteran stated that he did have left ankle injuries in service, including as shown in the July 1984 record summarized above. He again described his repeated jumps with 90 pounds of equipment at night, and referred to his service records and to "buddy" letters as showing left ankle problems for years. The Board notes that, in his September 2005 claim for service connection, the Veteran reported that his left (and right) ankle disability began in 1981. He further stated that his ankles were sore all of the time and rolled on him. In a September 2007 statement attached to his substantive appeal, the Veteran explained that his left ankle disorder was not present prior to service and occurred during service, and that he now had chronic pain and impairment of function due to the ankle. In an April 2004 letter, the Veteran's employment team leader at the time indicated that he had problems with his feet when he started the job in May 2003, and he began to have unidentified health problems after that time. In a May 2008 statement, fellow service member J.T. (now a retired colonel) indicated that he served with the Veteran from 1996 until at least 2004, and that he had problems with the feet and a limp throughout that time. In another May 2008 statement, one of the Veteran's friends, L.M., indicated that he had known the Veteran for approximately five years (or since around 2003), and that the Veteran had a slight limp or shuffle due to pain with walking. In a statement received in June 2008, another friend, B.L., indicated that he had known the Veteran for nearly 25 years (or since around 1983), and that his gait when walking had changed dramatically during that time. In the last several years, the Veteran appeared to be in discomfort, with more difficulty walking and unsteadiness on his feet. There is no indication of arthritis or other listed chronic disability in this case, so presumptive service connection is not warranted for a left ankle disorder. However, the Veteran is competent to report injuring his left ankle and having observable symptoms such as pain, limitation of motion, and difficulty walking after in-service injury, as well as treating the symptoms with medication. See Barr, 21 Vet. App. at 307-08; Jandreau, 492 F.3d at 1376-77. There are documented instances of treatment for injuries to left side of the body and the left leg, as well as the left ankle during ACDUTRA and IDT. As such, although there are some inconsistencies, the Board finds the Veteran's testimony as to the nature and timing of his left ankle injuries and symptoms to be credible, as it is generally consistent with the other evidence of record. As noted above, the July 2011 VA examiner diagnosed chronic instability of the left ankle, although x-rays were negative. This is generally consistent with the April 2009 notation by the fee basis examiner that the Veteran had bilateral ankle strain to account for pain in the ankles, which was separate from his already service-connected foot/heel condition. Although the July 2011 examiner opined that the current left ankle disability was less likely as not caused by or a result of the Veteran's service, including parachute jumps, this opinion was based largely on a finding that there were no documented complaints as to the left ankle during service. As summarized above, this is inconsistent with the Veteran's service treatment records, which document pertinent injuries on several occasions during active service. It appears that the examiner may have focused solely on the Veteran's active duty service, instead of considering the periods of ACDUTRA and IDT service when the Veteran sustained injuries to the left leg and left ankle. Further, the Veteran's testimony that he had ongoing observable symptoms in the left ankle is both competent and credible. It is unclear if all of the Veteran's service records pertaining to his Reserves service from 1996 forward were obtained, but he reported ankle problems in his 2006 retirement examination. Accordingly, the VA examiner's etiological opinion for the left ankle has low probative value. In contrast, the July 2011 VA examiner provided positive nexus opinions as to many of the Veteran's other claimed conditions, including the right ankle, based on his documented injuries and symptoms during service due to parachute jumps and his complaints of ongoing symptoms. The examiner also acknowledged that parachute landings could cause strain and stress to the ankles. Under these circumstances, the Board finds that the evidence is in relative equipoise as to whether the Veteran's left ankle chronic instability was incurred as a result of his active service, including in the Reserves. Therefore, the benefit-of-the-doubt doctrine applies, and all reasonable doubt will be resolved in his favor. As a result, the evidence of record establishes that the Veteran's current left ankle disability as incurred during active service, and the claim is granted. 38 C.F.R. § 3.102. Vision problems The Veteran asserts that he has vision problems due to injuries in active service. He sustained several head injuries during active duty and Reserves service, and he has complained of double vision and/or photophobia since a January 1995 injury. An Air Evacuation Summary dated in January 1995 notes that the Veteran was admitted for double vision in both eyes, with an 8-day history of vertical diplopia that disappeared when he covered either eye. The diplopia had resolved three days prior to admission to the hospital, and a blepharospasm to the right eye with symptoms was also noted to have resolved. He also had paresthesias and finger tingling to the right side. The Veteran stated at that time that, although he was no longer seeing double, he just "[didn't] feel right," and he had periodic dull pain to the right eye as if it had been "stressed." He denied specific trauma to the eye. When he had been initially evaluated in Haiti, it was felt that he may have a slight droop to the nasolabial fold on the right side, and he was treated for possible diagnosis of Bell's palsy, which was later determined not to be the likely diagnosis. The Veteran again reported discomfort to the right eye without pain, and the results of vision testing were included. The admitting diagnosis was vertical diplopia etiology unknown, resolved without evidence of 7th nerve palsy or 4th nerve cranial palsy. During the hospital admission from January 14 to 30, 1995, the Veteran had two episodes of headaches with pain that was very intense in the right eye, and the headaches were noted to be associated with some mild photophobia without nausea or vomiting but no aura. Ophthalmic evaluation during these episodes was unremarkable with no pathology. The discharge diagnosis was headaches or cephalgia of unknown etiology, and tension headaches versus ocular migraine variant, but the provider stated that it was too early to tell with just two episodes documented. Ophthalmology and neurology were consulted, and they concurred with the diagnosis and treatment plan. During his January 2006 service retirement examination, the Veteran reported double vision and pain in the back of the right eye related to his January 1995 injury when he was medically evacuated from Haiti. He also reported needing glasses to read. Optometry examination was conducted, and there were clinical abnormalities of myopia and presbyopia. The examiner stated that there was no neurological deficit. In an August 2007 statement, the Veteran reported having double vision that began during service and had been present since that time. He stated that medical professionals had advised him that they could not treat this condition. During additional development upon remand, the Veteran was examined by a VA ophthalmologist and two VA neurology providers (for a neurology examination and a VA cranial nerves examination) over the course of three days in July 2011. In a July 11, 2011 report (signed on July 13), an ophthalmologist noted the Veteran's complaints of photophobia ever since having an episode of double vision during service in 1995. He also complained of foggy vision intermittently in both eyes. He denied any further episode of double vision after the one incident in service where he had an episode of double vision up and down that lasted for one week. A work-up was performed at that time, and no apparent diagnosis was made except for 7th nerve palsy. He denied having "droopy face" at that time, and he had migraines but did not have visual aura. The examiner noted that the Veteran had head trauma from parachute jumps. There was no current eye treatment at the time of this examination. After conducting vision testing, this examiner stated that the Veteran did not have double vision currently and had not had any past episode since the initial episode, and there was no residual defect. The examiner also stated that the Veteran did not have residual 7th nerve palsy by facial expression or examination. There was no eyelid dysfunction in either eye. Rather, the examiner diagnosed bilateral refractive error, and stated that there was no other active ocular pathology seen at the time of the examination. The examiner subsequently noted that the claims file was reviewed in September 2011, but no changes in diagnosis or opinion were provided at that time. In a July 13, 2011 report (also signed on July 13), a neurologist noted that the Veteran had several head injuries related to bad landings from parachute jumps in service, including in 1981 and 1994, as well as in January 1995 when he awoke with vertical diplopia without significant headache and tingling paresthesias in the right side of the mouth and the right fingertips. The diplopia resolved in about a week and had not recurred, but the Veteran reported onset of headaches in about 1994 or 1995. He was evaluated at that time without diagnosis. During the July 2011 examination, the Veteran reported that he had headaches two to three times per year that were occipital with severe throbbing pain, but were not accompanied by nausea, photophobia, or phonophobia. Instead, he reported constant photophobia since 1995. Upon neurological testing, the examiner stated that cranial nerves were normal except decreased down gaze of the left eye and decreased pin sensation of the left side of the face. The diagnoses were mild TBI, left cranial nerve 4 (CN4) palsy, and migraine headaches. No specific finding or diagnosis was given as to the Veteran's eyes or the reported photophobia. This examiner subsequently reviewed the claims file in September 2011, and there was no change in diagnosis or opinion. Another July 13, 2011 report (signed on July 15) was initiated by the same neurologist but was authored and signed by a neurology registered nurse (M.R.). This report noted problems of diplopia (or double vision), tingling of the fingertips and lips, and 7th cranial nerve palsy, all with onset in January 1995. The examiner again summarized the symptoms of vertical diplopia without significant headache in January 1995, which resolved in about a week and had not recurred, as well as tingling paresthesias in the right side of the mouth and the right fingertips. Medical history was noted to show no left or right eye symptoms. Upon testing of the cranial nerves, corneal reflexes were present bilaterally when testing cranial nerve V. The examiner stated that there was incomplete depression of the left eye on down gaze, with vertical diplopia, that was consistent with left CN4 palsy. A 1995 MRI of the brain showed no positive finding. The brain stem and anterior optic system anatomy appeared quite normal in all sequences, with no pathology or suggestion of pathology within the orbits. The examiner diagnosed vertical diplopia due to left CN4 palsy, and no evidence or history of 7th cranial nerve palsy, and residuals of left midbrain infarct. In assessing traumatic brain injury (TBI) in the July 13, 2011 report (signed on July 15), the examiner noted that the Veteran had several head injuries during service, including in 1981, 1994, and 1995. The Veteran reported headaches two to three times per year since about 1994 or 1995 and constant photophobia since 1995, although the headaches were not accompanied by photophobia. The headaches were most consistent with migraine, and the Veteran had hypersensitivity to light in the form of constant photophobia. The examiner stated that there was cranial nerve dysfunction of diplopia on down gaze and decreased sensation of the left side of the face, as shown in the cranial nerves portion above. The examiner diagnosed mild TBI. In the opinion section, this examiner stated that the Veteran most likely had a small midbrain infarct in January 1995 during military service resulting in vertical diplopia and tingling of the right side of the mouth and right fingertips. The Board notes that the evidence is conflicting as to whether Veteran actually has current double vision (or diplopia). Although he generally denied having double vision since the January 1995 incident in the July 2011 VA examinations, he reported having double vision in his January 2006 service retirement examination, as well as in other statements for the purposes of his claim on appeal. Further, although the July 11, 2011 ophthalmologic examiner found no evidence of double vision, the July 13, 2011 neurological examiner found evidence of diplopia during testing of the cranial nerves. As such, there is a suggestion of at least intermittent double vision. Additionally, the Veteran consistently reported having constant photophobia (or hypersensitivity to light) since the January 1995 injury during the July 2011 VA examinations, which is present at times other than when he is having a migraine headache. The Veteran is competent to report observable eye symptoms such as double vision and sensitivity to light. See Barr, 21 Vet. App. at 307-08; Jandreau, 492 F.3d at 1376-77. Further, the Board finds his statements to this effect to be credible, as they are generally consistent with the other evidence. The evidence is also conflicting as to the etiology of the Veteran's condition. As noted above, the July 2011 ophthalmologic examiner appears to indicate that there were no residual effects from the January 1995 injury based on a finding of no current double vision. However, the Board finds that the evidence establishes at least intermittent double vision since that time, and the Veteran has also competently and credibly testified to constant photophobia since January 1995. Neurological examiners indicated in the July 13, 2011 reports that the Veteran had decreased down gaze of the left eye and diplopia (or double vision) that were consistent with a diagnosis of left CN4 palsy and residuals of left midbrain infarct. The examiner opined that the Veteran most likely had a small midbrain infarct in January 1995 during military service resulting in vertical diplopia. Further, the neurological examiner listed the Veteran's hypersensitivity to light or constant photophobia under the assessment for TBI. Although migraine headaches may be associated with photophobia, the Veteran has generally indicated that he does not have photophobia during such attacks but, rather, as separate from the attacks. As noted above, the Veteran has been granted service connection for TBI due to head injury residuals, migraine headaches, and tingling of the fingertips, mouth and lips due to the 5th cranial nerve. Given his persistent symptoms of double vision and photophobia even without migraine headaches, and the evidence concerning left CN4 palsy, left midbrain infarct, and TBI as summarized above, the Board finds that the evidence is in relative equipoise as to whether the current disorder is due to the injury during active service. Therefore, the benefit-of-the-doubt doctrine applies and all reasonable doubt is resolved in the Veteran's favor. The Board notes that the evidence includes a current diagnosis of refractive error, as stated in the July 2011 ophthalmologic examination, and noted as presbyopia and myopia in the January 2006 service retirement examination. Refractive errors of the eye are not diseases or injuries for VA disability compensation purposes and, therefore, are not subject to service connection. See 38 C.F.R. §§ 3.303(c), 4.9; see also Terry v. Principi, 340 F.3d 1378 (Fed. Cir. 2003); Palczewski v. Nicholson, 21 Vet. App. 174, 179 (2007); Morris v. Shinseki, 678 F.3d 1346, 1353-54 (2012). Nevertheless, service connection may be granted for additional disability as a result of a superimposed disease or injury during active service. VAOPGCPREC 82-90 (July 18, 1990); see also Carpenter v. Brown, 8 Vet. App. 240, 245 (1995). Here, there is no indication that the Veteran's photophobia or double vision, as opposed to needing glasses for reading, are related to his refractive error. However, to the extent that they may be related, the evidence indicates that he did not have photophobia or double vision prior to the January 1995 head injury, and that he has had persistent symptoms since that time. Therefore, the evidence suggests that the photophobia and double vision would constitute additional disability as a result of superimposed injury during active service. Although the refractive error itself is not subject to service connection, an award of service connection for the photophobia and double vision is appropriate. In summary, the Board finds that the evidence is in relative equipoise as to whether current double vision and photophobia were incurred as a result of the Veteran's active service, including in the Reserves. Therefore, the benefit-of-the-doubt doctrine applies, and all reasonable doubt will be resolved in his favor. As a result, the evidence establishes that the Veteran's current double vision and photophobia was incurred during active service, and the claim is granted. 38 C.F.R. § 3.102. ORDER Service connection for right shoulder tendonitis is granted. Service connection for a left shoulder tendonitis is granted. Service connection for a left elbow bursitis is granted. Service connection for a right elbow bursitis is granted. Service connection for a left ankle chronic instability is granted. Service connection for double vision and photophobia is granted. ______________________________________________ ERIC S. LEBOFF Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs