Citation Nr: 1311894 Decision Date: 04/10/13 Archive Date: 04/19/13 DOCKET NO. 07-34 778A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for a left shoulder disability to include as secondary to a service-connected right shoulder disability. 2. Entitlement to service connection for a disability of the arms and hands to include as secondary to a service-connected right shoulder disability. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD T. Wishard, Counsel INTRODUCTION The Veteran had active military service from June 1966 to May 1970. These matters come before the Board of Veterans' Appeals (Board) from a July 2003 rating decision of the Department of Veterans Affairs (VA), Regional Office (RO) in Portland, Oregon. These matters were previously before the Board in October 2009 and August 2011 and were remanded for further development. They have now returned to the Board for further appellate consideration. As is discussed in further detail below, the Board finds that the RO substantially complied with the mandates of its remand and will proceed to adjudicate the appeal. See Dyment v. West, 13 Vet. App. 141 (1999) (noting that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In its August 2011 remand, the Board remanded the issue of entitlement to an evaluation in excess of 30 percent for service-connected right shoulder disability for the issuance of a statement of the case. The RO issued a statement of the case in November 2011. The claims file does not reflect that the Veteran has completed a timely substantive appeal on that issue. Therefore, it is not for appellate consideration. FINDINGS OF FACT 1. The Veteran is service-connected for a right shoulder disability. 2. The Veteran has denied that he has a left shoulder disability causally related to, or aggravated by, active service. 3. The most probative clinical evidence of record is against a finding that the Veteran has a left shoulder disability caused by, or aggravated by, a service-connected disability, to include a right shoulder disability. 4. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a left shoulder disability causally related to, or aggravated by, active service or a service-connected disability. 5. The Veteran has denied that he has a bilateral disability of the arms and hands causally related to, or aggravated by, active service. 6. The most probative clinical evidence of record is against a finding that the Veteran has a bilateral arms and hands disability caused by, or aggravated by, a service-connected disability, to include a right shoulder disability. 7. There has been no demonstration by competent medical, nor competent and credible lay, evidence of record, that the Veteran has a bilateral arms and hands disability causally related to, or aggravated by, active service or a service-connected disability. CONCLUSIONS OF LAW 1. A left shoulder disability (to include degenerative joint disease, impingement, and tendonitis) was not incurred in, or aggravated by, active service, and may not be presumed to have been so incurred or aggravated, nor is it proximately due to, the result of, or aggravated by, service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. § 3.310 (2006); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. Bilateral arm and hand disability (to include osteoarthritis and degenerative joint disease of the thumbs) was not incurred in, or aggravated by, active service, and may not be presumed to have been so incurred or aggravated, nor is it proximately due to, the result of, or aggravated by, service-connected disability. 38 U.S.C.A. §§ 1110, 1112, 1113, 1137 (West 2002); 38 C.F.R. § 3.310 (2006); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 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. §§ 5100, 5102, 5103, 5103A, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a). See also Pelegrini v. Principi, 18 Vet. App. 112 (2004); Quartuccio v. Principi, 16 Vet. App. 183 (2002); Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); Dingess v. Nicholson, 19 Vet. App. 473 (2006). Notice was provided to the Veteran in February 2003, November 2009, and August 2011. The claims were subsequently readjudicated in the September 2011 supplemental statement of the case. Mayfield, 444 F.3d at 1333. VA has a duty to assist the Veteran in the development of the claim. The claims file includes service treatment records (STRs), medical records, and the statements of the Veteran in support of his claims. It also includes notification that the Social Security Administration does not have records for the Veteran. The Board has considered the statements and perused the medical records for references to additional treatment reports not of record, but has found nothing to suggest that there is any outstanding evidence with respect to the Veteran's claims for which VA has a duty to obtain. On May 9, 2011, the Veteran stated that he did not have any additional evidence regarding his appeal and he wanted his case forwarded to the Board immediately; however, a statement dated on May 9, 2011 also notes that he has more information or evidence to submit in support of his appeal. He checked that he understood that if evidence was not submitted within 30 days, his case would be returned to the Board. It was noted "I am getting a statement from a 'buddy' and will send it when I receive it. Please process dependency claim while this is in process." The Veteran's claim has been on appeal for more than three years. The Board finds that the Veteran has had ample opportunity to submit evidence in support of his claim. In addition, there is no evidence that a "buddy statement" would be competent as to the etiology of a disability as secondary to another disability. A VA examination with opinion was obtained in February 2010 with addendums in March 2011 and September 2011. When VA undertakes to provide a VA examination or obtain a VA opinion, it must ensure that the examination or opinion is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). Initially, the Board remanded the Veteran's claim in August 2011 because it interpreted the February 2010 VA examination report with March 2011 addendum as indicating that the examiner could not provide an opinion without resort to mere speculation. In reviewing the examiner's opinion in whole, and in considering the opinion, along with the September 2011 addendum, the Board finds that VA has obtained an adequate examination and opinion. As discussed in further detail below, the examiner had opined in March 2011 that he could not provide an opinion in favor of the Veteran without resorting to mere speculation; however, he was able to provide an opinion, as noted in the September 2011 addendum. The Board finds that the examination/opinion is adequate, as it is predicated on an interview with the Veteran regarding his symptoms, a review of the claims file to include the Veteran's treatment records and x-rays, and includes a rationale for the opinions proffered. The report with addendums, when read as a whole, provides an adequate rationale for the opinions proffered. Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (citing Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012). Based on the foregoing, the Board finds that all relevant facts have been properly and sufficiently developed in this appeal and no further development is required to comply with the duty to assist the Veteran in developing the facts pertinent to the claims. Essentially, all available evidence that could substantiate the claims has been obtained. Legal Criteria Service Connection Establishing service connection generally requires medical evidence or, in certain circumstances, lay evidence of the following: (1) A current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) nexus between the claimed in-service disease and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009); Jandreau v. Nicholson, 492 F.3d 1372 (Fed.Cir.2007); Hickson v. West, 12 Vet. App. 247 (1999); Caluza v. Brown, 7 Vet.App. 498 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table). For some "chronic diseases," presumptive service connection is available. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. With "chronic disease" shown as such in service (or within the presumptive period under § 3.307), so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. 38 C.F.R. § 3.303(b). For the showing of a 'chronic disease' in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. If not manifest during service, where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and the 'chronic disease' became manifest to a degree of 10 percent within 1 year from date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307. The term "chronic disease", whether as shown during service or manifest to a compensable degree within a presumptive window following service, applies only to those disabilities listed in 38 C.F.R. § 3.309(a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Arthritis and organic diseases of the nervous system are included in 38 C.F.R. § 3.309(a). In each case where service connection for any disability is being sought, due consideration shall be given to the places, types, and circumstances of such Veteran's service as shown by such Veteran's service record, the official history of each organization in which such Veteran served, such Veteran's medical records, and all pertinent medical and lay evidence. 38 U.S.C.A. § 1154(a) (West 2002). Under 38 C.F.R. § 3.310, service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury, or for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). 38 C.F.R. § 3.310 was amended during the course of this appeal. Effective October 10, 2006, VA amended 38 C.F.R. § 3.310 to implement the decision in Allen, which addressed the subject of the granting of service connection for the aggravation of a nonservice-connected condition by a service-connected condition. See 71 Fed. Reg. 52,744 -47 (Sept. 7, 2006). The existing provision at 38 C.F.R. § 3.310 (b) was moved to sub-section (c). The amended 38 C.F.R. § 3.310 (b) institutes additional evidentiary requirements and hurdles that must be satisfied before aggravation may be conceded and service connection granted. To whatever extent the revised regulation may be more restrictive than the previous one, the Board will afford the Veteran review under both the old and new versions. See VAOPGCPREC 7-2003 (Nov. 19, 2003) Analysis The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the medical evidence pertinent to the claim on appeal. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence of record. Indeed, the U.S. Court of Appeals for the Federal Circuit has held that the Board must review the entire record, but does not have to discuss each piece of evidence. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Therefore, the Board will summarize the relevant evidence where appropriate, and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claims. Left shoulder disability to include secondary to a service-connected right shoulder disability Initially, the Board finds that service connection for a left shoulder disability is not warranted on a direct incurrence basis. The Veteran's February 1969 report of medical history reflects that he denied a painful or trick shoulder. The Veteran's April 1970 report of medical examination for separation purposes reflects that he had a shoulder abnormality. It was noted "prominence/clavicle at A-C joint". A clinical record reflects a right A-C separation occasional [September 1969] may warrant surgical repair. To VA [hospital]. Clear for ETS (expiration of term of service.)" The report is negative for any complaints of, or treatment for, a left shoulder disability. Post service clinical records in 1973 reflect that the Veteran had complaints of tenderness of the right A-C joint. Again, the records are negative for complaints with regard to the left shoulder. In addition, and importantly, the Veteran has alleged that his left shoulder disability is secondary to his right shoulder disability. In August 2002, the Veteran filed a claim for a left shoulder condition secondary to his right shoulder disability. In a June 2004 statement, he alleged that "because I have been right handed/sided all my life and the nature of my [service-connected] right shoulder has caused me to overuse my left side/shoulder." In a December 2009 statement, the Veteran stated that his left shoulder disability "did not occur in the service but [was] caused by the weakness and limitations of my [service-connected] condition." As the Veteran has not asserted that his left shoulder disability warrants service connection on a direct incurrence basis, and as the clinical evidence does not indicate that service connection is warranted on a direct incurrence basis, the Board finds against such. Next, the Board will consider whether service connection is warranted on a secondary basis. The Veteran is service connected, in pertinent part, for a right shoulder disability. A February 1980 VA Form 10-1000 reflects that the Veteran had a provisional diagnosis of rheumatoid arthritis and diabetic neuropathy. It was noted that he reported intermittent bilateral symmetrical pains and stiffness in the wrists, shoulders, knees, and hip joint areas since 1973, or the age of 23. The diagnosis was bilateral and peripheral arthritis or arthralgia since 1973, etiology unknown. A February 2003 VA examination report reflects that the Veteran was "not interested in filing any claim for a left shoulder disability as being service connected or secondary to service connection." He reported that he had developed a decrease in abduction range of motion of the left shoulder, but denied pain, weakness, or circulatory symptoms of any type. He was diagnosed with minimal degenerative change in the left shoulder/ and impingement syndrome left shoulder not related to Veteran's service-connected right shoulder condition. A February 2003 VA record reflects that an x-ray showed "some mild degenerative change at the acromioclavicular joint. The shoulder joint itself is unremarkable for age. The soft tissue are normal." A February 2010 VA examination report reflects that the Veteran lives on 88 acres of land and works in his garden four to five hours a week. He reported that his left shoulder started bothering him four years ago but had no specific dislocation, injury or trauma. He reported that he was getting pain with lifting overhead as well as pulling things when he flexed his biceps. The February 2010 report reflects an impression of left shoulder tendonitis with impingement syndrome. A February 2010 VA clinical record reflects that the left shoulder shows no evidence of an old fracture. "There is some mild AC joint arthritis, but no significant spurring. Glenohumeral joint shows no particular narrowing or irregularity or sclerosis. There is no rotator cuff calcification seen on the left." The impression was "left shoulder looks normal for patient's age." A March 2011 VA report reflects that the examiner was not able to identify injury to, or process in the left shoulder during military service which would as likely as not lead to his current left shoulder condition. He was not able to indentify injury or process after military service in the left shoulder which would as likely as not be secondary to the activity change caused by his service-connected right shoulder. He noted that with many shoulder disorders, increasing age predisposes to shoulder impingement syndrome. The examiner noted that with currently available information, to include treatment records, UpToDate (online medical reference source), MEDLINE, Cochrane Database, it would be speculation for him to attribute his current left shoulder impingement syndrome to military service or as a result of his service connected right shoulder problems. He stated that he could not identify significant aggravation of his left shoulder pathology to be as likely as not caused by his service-connected right shoulder condition, without speculation on his part. Importantly, the examiner did not decline to provide an opinion but rather stated that he could find no evidence to support the Veteran's assertion and it would be speculation to find in favor of the Veteran's assertion. A September 2011 VA addendum report reflects that in 1976, the Veteran bought 80 acres of rural property and had to clear brush over four months. He still lives on over 80 areas and was gardening four to five hours a week when he was examined in 2010. He was motorcycling until sometime in 2008. The examiner noted that with currently available information, the Veteran has left shoulder tendonitis and impingement syndrome. The September 2011 VA addendum report reflects the opinion of the examiner that with available information, his left shoulder condition is less likely than not secondary to military service or his service connected right shoulder. It is less likely than not that his left shoulder condition is significantly aggravated by his service-connected right shoulder. The Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g., pain). See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). To this extent, the Board finds that the Veteran is competent to report that he has a current painful left shoulder. The Veteran, however, has not been shown to have the experience, training, or knowledge necessary to provide a competent etiology opinion as to his left shoulder disability. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issue in this case, a left shoulder disability without evidence of any prior injury. The Board finds that such an etiology finding falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Although the Veteran has stated that he has overused his left side due to right shoulder injury, such an assertion does not adequately explain how his activities are as likely as not the cause of his current left shoulder disability. He has not cited sufficient competent credible literature or evidence to support his assertion. In the present claim, the competent clinical evidence is against a finding that the Veteran has a left shoulder disability causally related to, or aggravated by, service or a service-connected disability. There was no clinical indication that it was due to a service-connected disability. As the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Disability of the arms and hands to include as secondary to a service-connected right shoulder disability Initially, the Board finds that service connection for a disability of the arms and hands (other than the left shoulder disability) is not warranted on a direct incurrence basis. The STRs are negative for any complaints of, or treatment for, he hands and arms. In August 2002, the Veteran filed a claim for a circulatory condition of the arms and hands secondary to his right shoulder disability. In a June 2004 statement, he alleged that "because I have been right handed/sided all my life and the nature of my [service-connected] right shoulder has caused me to overuse my left side/shoulder." In a December 2009 statement, the Veteran stated that his hands and arm disability "did not occur in the service but [was] caused by the weakness and limitations of my [service-connected] condition." As the Veteran has not asserted that he has a disability of the arms and hands (other than the left shoulder disability) which warrants service connection on a direct incurrence basis, and as the clinical evidence does not indicate that service connection is warranted on a direct incurrence basis, the Board finds against such. As noted above, a February 1980 VA Form 10-1000 reflects that the Veteran had a provisional diagnosis of rheumatoid arthritis and diabetic neuropathy. It was noted that he reported intermittent bilateral symmetrical pains and stiffness in the wrists, shoulders, knees, and hip joint areas since 1973, or the age of 23. The diagnosis was bilateral and peripheral arthritis or arthralgia since 1973, etiology unknown. February 1980 A September 1982 VA examination report reflects that the Veteran reported that in February, he noted the onset of numbness in the right hand in episodes. He also reported that in the morning, his right arm feels like it is totally asleep. He reported numbness, and an electric shock like sensation. The report reflects "of particular note is his activity history. For the last four years he has been milking goats while resting his elbows on his knees. He also works as a dishwasher, and says that many of his friends have wrist problems from that activity." The examiner stated as follows: it seems, from examination, that the patient has entrapment neuropathy although the exact site is not clear on clinical grounds. He could have a carpal tunnel syndrome, or possibly thoracic outlet syndrome. His history is more suggestive of a tardy ulnar nerve palsy due to his goat-milking activities. A November 2003 VA clinical record reflects that the Veteran reported hand pain. The record reflects that past laboratory tests were negative for the rheumatoid factor or anti-nucleic antibody. His sedimentation rate was normal on the last checks. It was noted that it does "not appear rheumatoid at this point- no stiffness, swelling but does have [family history]" A December 2003 VA clinical record reflects that the Veteran reported bilateral thumb pain, greater in the left that in the right. It was noted that he was very active with yard work and cutting wood. The Veteran reported that his "thumbs have been painful for a few years now with a gradual increase in the pain level. Actually the pain isn't in the joints but sort of more beside the thumbs. I also have pain in my big toe." Upon examination, it was noted that the Veteran pointed to the painful area as the ulnar aspect of the 1st metacarpals and dorsal aspect of thumb web space. The Veteran reported that the pain was with strenuous yard work or household grasp/pinch, such as opening a jar, but not with magazines or small light items. He denied dropping small items from the hands, and denied numbness/tingling and had no pain with keyboarding or similar fine motor tasks. VA clinical records reflect that views of the hands revealed minor degree of generalized degenerative arthritic changes of the IP (interphalangeal) joints in both hands. Localized area of advanced degenerative arthritis with subluxation of the first MCC (metacarpophalangeal) joint with subluxation of the thumb. In a statement dated in June 2004 (notice of disagreement), the Veteran stated that he has had "to overuse my hands due to the [service-connected] shoulder condition. Both thumbs are totally worn out and pop out of joint. There is no other explanation for this condition." July 2004 VA records reflect an assessment of osteoarthritis of the hand, pain of the left thumb. A December 2006 VA clinical record reflects that the Veteran reported that he was taking glucosamine and chondroitin and MSM (methyl sulfonylmethane) and that the pain is much better. He reported that card dealing aggravates it because he deals with the left hand. The Veteran had severe left hand degenerative joint disease with thumb triggering. It was noted that pain causes him to drop things so that he uses his right hand for most activities. A January 2007 VA clinical record reflects that the Veteran had severe left hand degenerative joint disease with thumb triggering. Occupational therapy evaluation indicated a nodule was felt on the FDP (Flexor digitorum profundus) tendon. No locking was observed in the clinic, but the Veteran reported pain from near locking. A February 2010 VA clinical record reflects that views of the hands revealed moderate development of osteoarthritis of the left first carpometacarpal, minimal osteoarthritis at the right first carpometacarapl joint space, minimal arthritis in both thumbs at the metacarpopalangeal and IP joints. As noted above, a February 2010 VA examination report reflects that the Veteran lives on 88 acres of land and works in his garden four to five hours a week. He reported that he can lift and carry 20 pounds limited by pain in his thumbs when grasping. He can lift one gallon of water over his head with pain on his left hand. He can brush his teeth with his right hand if he keeps his elbow next to his trunk and can lift half a gallon up chest height and is limited by hand and shoulder pain. the Veteran reported that "about seven years ago" or in approximately February 2003, he began getting pain at the base of both of his thumbs. The Veteran was diagnosed with bilateral thumb degenerative joint disease. A March 2011 VA report reflects that the examiner was not able to identify injury to, or process in either thumb during military service which would as likely as not lead to his current thumb condition. The examiner stated that according to literature "[a]lmost everyone over the age of 60 develops some degree of CMC osteoarthritis, although only 5 to 10 percent develop loss of function and pain. He was not able to indentify injury or process after military service in the either thumb which would as likely as not be secondary to the activity change caused by his service connected right shoulder. The examiner noted that with currently available information, to include treatment records, UpToDate (online medical reference source), MEDLINE, Cochrane Database, it would be speculation for him to attribute the Veteran's current bilateral thumb disability to military service or as a result of his service connected right shoulder problems. He stated that he could not identify significant aggravation of his bilateral thumb disability to be as likely as not caused by his service-connected right shoulder condition, without speculation on his part. As noted above, the examiner did not decline to provide an opinion but rather stated that he could find no evidence to support the Veteran's assertion and it would be speculation to find in favor of the Veteran's assertion. A September 2011 VA report reflects that in 1976, the Veteran bought 80 acres of rural property and had to clear brush over four months. He still lives on over 80 acres and was gardening four to five hours a week when he was examined in 2010. He was motorcycling until sometime in 2008. The examiner noted that with currently available information, the Veteran has degenerative joint disease of the thumbs, which is less likely than not secondary to military service or his service-connected right shoulder. It is less likely than not that his bilateral DJD of his thumbs is significantly aggravated by his service-connected right shoulder. The Veteran is competent to attest to factual matters of which he has first-hand knowledge (e.g., pain). See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). To this extent, the Board finds that the Veteran is competent to report that he has current painful thumbs. The Veteran, however, has not been shown to have the experience, training, or knowledge necessary to provide a competent etiology opinion as to his thumbs. Although lay persons are competent to provide opinions on some medical issues, the Board finds that a lay person is not competent to provide a probative opinion as to the specific issue in this case, bilateral thumb disability without evidence of any prior injury and with past history of many years of milking goats. The Board finds that such an etiology finding falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In the present claim, the competent clinical evidence is against a finding that the Veteran has a bilateral hand and arm disability causally related to, or aggravated by, service or a service-connected disability. It was clinically indicated that Veteran's disability may be due to his advanced age and/or years of milking goats. There was no clinical indication that it was due to a service-connected disability. Although the Veteran has stated that he has overused his left side due to right shoulder injury, such an assertion does not adequately explain how his activities are as likely as not the cause of his current bilateral hand and thumb disability. He has not cited sufficient credible and competent literature to support his assertion. The Board has considered the doctrine of giving the benefit of the doubt to the appellant, under 38 U.S.C.A. § 5107 (West 2002), and 38 C.F.R. § 3.102 (2010), but does not find that the evidence is of such approximate balance as to warrant its application. Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). ORDER Entitlement to service connection for a left shoulder disability to include as secondary to a service-connected right shoulder disability is denied. Entitlement to service connection for a disability of the arms and hands to include as secondary to a service-connected right shoulder disability is denied. ______________________________________________ M. E. LARKIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs