Citation Nr: 1318219 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 10-04 892 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Waco, Texas THE ISSUES 1. Entitlement to service connection for gouty arthritis of the right wrist. 2. Entitlement to service connection for gouty arthritis of the right shoulder. 3. Entitlement to service connection for gouty arthritis of the bilateral knees. REPRESENTATION Veteran represented by: Texas Veterans Commission ATTORNEY FOR THE BOARD R. Anderson, Associate Counsel INTRODUCTION The Veteran, who is the appellant in this case, served on active duty from August 1965 to August 1967 and March 1968 to May 1987. This case comes before the Board of Veterans' Appeals (Board) on appeal from December 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Waco, Texas. The claims for service connection for gouty arthritis of the right hand and bilateral legs have been recharacterized as claims for gouty arthritis of the right wrist and bilateral knees, as explained in further detail below. FINDINGS OF FACT 1. The Veteran has a diagnosis of gouty arthritis, which is a systemic disease and a systemic polyarticular inflammatory progressive destructive arthritis. 2. The Veteran's current gouty arthritis of the right wrist, is directly related to, and a progression of, his service-connected gouty arthritis of the feet and ankles. 3. The Veteran's current gouty arthritis of the right shoulder is directly related to, and a progression of, his service-connected gouty arthritis of the feet and ankles. 4. The Veteran's current gouty arthritis of the knees is directly related to, and a progression of, his service-connected gouty arthritis of the feet and ankles. CONCLUSION OF LAW 1. Service connection for gouty arthritis of the right wrist is warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 2. Service connection for gouty arthritis of the right shoulder is warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). 3. Service connection for gouty arthritis of the bilateral knees is warranted. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, in part, describes VA's duties to notify and assist claimants in substantiating a claim for VA benefits. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a). The VCAA applies to the instant claim. However, inasmuch as the benefits sought are being granted there is no reason to belabor the impact of the VCAA on this matter, as any notice error or duty to assist omission is harmless. II. Factual Background, Legal Criteria and Analysis The Board notes that it has reviewed all of the evidence in the Veteran's claims file and in Virtual VA (VA's electronic data storage system), with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence as appropriate and the Board's analysis will focus specifically on what the evidence shows, or fails to show, as to the claim. The issues before the Board involve claims of entitlement to service connection for gout (diagnosed as gouty arthritis) of the Veteran's right wrist, right shoulder, and bilateral knees. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of 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 disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b); 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 veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is to be denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Historically, the Veteran's February 1987 separation examination showed that he had a diagnosis of gout. He was service-connected for arthritis of both knees with gout and arthritis of the great toes in June 1987. The Veteran filed the present claim in April 2008. On October 2008 VA examination, the examiner was asked to provide an opinion as to whether the Veteran's claimed gout in the ankles, knees and feet were related to the previously service-connected arthritis of the knees with gout and arthritis of the great toes. The examiner concluded that the Veteran had gouty arthritis of the ankles. The December 2008 rating decision recharacterized the service-connected disabilities as gouty arthritis, first metatarsophalangeal joints, both feet; degenerative joint disease and chondromalacia, right knee; and degenerative joint disease and chondromalacia, left knee. That rating decision also service-connected gouty arthritis of the right and left ankles, but denied service connection for the right hand, right shoulder, and bilateral legs. In support of his claim, the Veteran submitted a statement, dated in February 2010, from his treating private physician, Dr. D. M. Cooper, a rheumatologist. Dr. Cooper stated that gouty arthritis is a systemic disease involving hyperuricemia, accumulation of urate in the system, which can, and eventually does, accumulate in the soft tissues and the synovial linings, causing irritation and then destruction of bony tissue, resulting in gouty arthritis, a systemic polyarticular inflammatory progressive destructive arthritis. Dr. Cooper stated that the Veteran suffers with gout in multiple joints and currently has aggravated gouty arthritis that is being treated in joints such as his right wrist, on a chronic, ongoing basis, the bilateral knees and right shoulder. Dr. Cooper states that the Veteran's medical records show that he has received multiple injection therapies over several years for acute treatment for inflammation in those given joints. Dr. Cooper opined that the Veteran's medical and treatment history demonstrates that the gouty arthritis in his right wrist, bilateral knees and right shoulder "does stem back to the original inflammatory problem in his service years." The Veteran reported that he began having pain in a migrating pattern affecting his wrist at the October 2008 VA examination. However, the examiner's report does not address the Veteran's claims of gout for his right wrist or right shoulder, and he has not been afforded a VA examination to assess these claims. Regardless, the Board finds no reason in this case to reject out-of-hand the medical opinion offered by the Veteran's private rheumatologist who has been treating the Veteran since 2007. All the competent medical evidence in the matter shows that the Veteran has a diagnosis of gouty arthritis, which is a systemic disease; and the Veteran's private physician has related the disability to the gouty arthritis diagnosed in, and previously connected to, service. Accordingly, the factual and legal requirements for substantiating the Veteran's claim are met and service connection for gouty arthritis of the right shoulder, the right wrist, and the bilateral knees are warranted. With respect to the grant of service connection herein for gouty arthritis of the knees, the Board notes that any additional compensation for such disability must incorporate persistent or recurrent symptoms that are not contemplated by the current ratings assigned for degenerative joint disease and chondromalacia of the knees. The Board emphasizes that in order to not violate the principle against "pyramiding," or employing the rating schedule as a vehicle for compensating a claimant twice (or more) for the same symptomatology, there would have to be some disability of the bilateral knees that is not contemplated by the rating assigned for degenerative joint disease and chondromalacia in order for additional compensation to be awarded for the knee joints. 38 C.F.R. § 4.14; Brady v. Brown, 4 Vet. App. 203, 206 (1993); see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994) (it is possible for a Veteran to have separate and distinct manifestations from the same injury which would permit rating under several diagnostic codes, however, the critical element in permitting the assignment of several ratings under various diagnostic codes is that none of the symptomatology for any one of the conditions is duplicative or overlapping with the symptomatology of the other condition). While the Board notes that the Veteran has consistently made a claim for service connection of gout to his right hand, the medical evidence of record makes clear that the Veteran has a diagnosis of, and is being treated for, gouty arthritis of the right wrist. In particular, as it relates to the period on appeal, an April 2008 record shows that the Veteran was diagnosed with, and treated for, gout in the right wrist. There is no evidence, other than his statements, that the Veteran has gout of the right hand, beyond the diagnosed (and service-connected) gouty arthritis of his right wrist. Furthermore, to the extent the Veteran claims any disability to the right hand-other than gouty arthritis of the right wrist as granted herein-the Board finds that there is no claim for, and no indication of, any such disability. Absent proof of a present disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Gout by definition is "acute inflammatory arthritis induced by crystals of monosodium urate monohydrate and tophececous deposits of these crystals in and around the joints of the extremities . . ." See Dorland's Illustrated Medical Dictionary, 32nd edition, p. 799 (emphasis added). Arthritis by definition is "inflammation of a joint." Id., at 150 (emphasis added). Since the Veteran was previously service connected for gouty arthritis of the feet and ankles, with the award of service connection for gouty arthritis of the knees herein, the Board finds the Veteran's claim for gout of the "legs" has been granted. There is no evidence, other than his statements, that the Veteran has gout of the legs, beyond the diagnosed (and service-connected) gouty arthritis of his bilateral knees, ankles, and feet. Furthermore, to the extent the Veteran claims any other disability to the legs, the Board finds that there is no claim for, and no indication of, any such disability. ORDER Service connection for gouty arthritis of the right hand, to include the right wrist, is granted. Service connection for gouty arthritis of the right shoulder is granted. Service connection for gouty arthritis of the bilateral knees is granted. ____________________________________________ M. C. GRAHAM Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs