Citation Nr: 1328904 Decision Date: 09/10/13 Archive Date: 09/17/13 DOCKET NO. 09-36 415 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Portland, Oregon THE ISSUES 1. Entitlement to service connection for left hand arthritis, including as secondary to the service-connected left shoulder disability. 2. Entitlement to service connection for left arm numbness, including as secondary to the service-connected left shoulder disability. 3. Entitlement to service connection for degenerative joint disease of the cervical spine, including as secondary to the service-connected left shoulder disability. REPRESENTATION Veteran represented by: Oregon Department of Veterans' Affairs ATTORNEY FOR THE BOARD J. Meawad, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from March 1988 to March 1992. The issues (claims) are before the Board of Veterans' Appeals (Board) on appeal of rating decisions in March 2008 and in November 2009 of a Department of Veterans Affairs (VA) Regional Office (RO). In March 2011, the Board remanded the case for further development. No further action to ensure compliance with the Board's remand directives is required. Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. Left hand arthritis was not affirmatively shown to have been present during service; left hand arthritis as a chronic disease was not manifested to a compensable degree within one year after the separation from service; left hand arthritis is not related to an injury, disease, or event in service; and left hand arthritis is not caused by or made worse by the service-connected left shoulder disability. 2. Left arm numbness was not affirmatively shown to have been present during service; left arm numbness is not related to an injury, disease, or event in service; and left arm numbness is not caused by or made worse by the service-connected left shoulder disability. 3. The disability of the cervical spine, degenerative joint disease, was not affirmatively shown to have had onset during service; degenerative joint disease as a chronic disease was not manifested to a compensable degree within one year after the separation from service; the disability of the cervical spine, degenerative joint disease, is not related to an injury, disease, or event in service; and the disability of the cervical spine, degenerative joint disease, is not caused by or made worse by the service-connected left shoulder disability. CONCLUSIONS OF LAW 1. The criteria for service connection for left hand arthritis on a direct and presumptive basis and as secondary to the service-connected left shoulder disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). 2. The criteria for service connection for left arm numbness on a direct and basis and as secondary to the service-connected left shoulder disability have not been met. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.310 (2013). 3. The criteria for service connection for the disability of the cervical spine, degenerative joint disease, on a direct and presumptive basis and as secondary to the service-connected left shoulder disability have not been met. 38 U.S.C.A. §§ 1110, 1112, 1131, 1137, 5107(b) (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310 (2013). The Veterans Claims Assistance Act of 2000 (VCAA) The VCAA, codified in part at 38 U.S.C.A. §§ 5103, 5103A, and implemented in part at 38 C.F.R § 3.159, amended VA's duties to notify and to assist a claimant in developing information and evidence necessary to substantiate a claim. Duty to Notify Under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b), when VA receives a complete or substantially complete application for benefits, it will notify the claimant of the following: (1) any information and medical or lay evidence that is necessary to substantiate the claim, (2) what portion of the information and evidence VA will obtain, and (3) what portion of the information and evidence the claimant is to provide. Also, the VCAA notice requirements apply to all five elements of a service connection claim. The five elements are: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. See Dingess v. Nicholson, 19 Vet. App. 473, 484-86 (2006) (notice of the elements of the claim). The RO provided pre-adjudication VCAA notice by letters, dated in August 2007, in July 2009, and in August 2009. As for the content and the timing of the VCAA notice, the documents complied with the specificity requirements of Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002) (identifying evidence to substantiate a claim and the relative duties of VA and the claimant to obtain evidence); of Charles v. Principi, 16 Vet. App. 370, 374 (2002) (identifying the document that satisfies VCAA notice); of Pelegrini v. Principi, 18 Vet. App. 112, 119-120 (2004) (pre-adjudication VCAA notice); and of Dingess v. Nicholson, 19 Vet. App. 47399-at (2006) (notice of the elements of the claim). Duty to Assist Under 38 U.S.C.A. § 5103A, VA must make reasonable efforts to assist the claimant in obtaining evidence necessary to substantiate a claim. The RO has obtained the service treatment records, VA records, and private medical records. The Veteran was afforded VA examinations in September 2007, March 2009, July 2009, October 2009, and May 2011. In May 2013, in accordance with 38 U.S.C.A. § 7109 and 38 C.F.R. § 20.901, the Board obtained a medical expert opinion from the Veterans Health Administration (VHA) on the question of a causal relationship between the disabilities of the left hand and the cervical spine and the service-connected left shoulder disability. As the VA examiner in May 2011 and the VHA expert considered the Veteran's medical history and described the disabilities in sufficient detail and provided a rationale to support the conclusions reached in the opinion, the Board finds that the VHA opinion adequate decide the claims of service connection for left hand arthritis and the cervical spine disability. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007) (a medical opinion must be based on consideration of the veteran's prior medical history and examinations and also describe the disability, if any, in sufficient detail so that the Board's evaluation of the claimed disability will be a fully informed one). The Veteran and his representative were provided a copy of the VHA opinion and afforded the opportunity to submit additional evidence and argument. The Veteran has not responded and the Board is proceeding with appellate review. As there is no indication of the existence of additional evidence to substantiate the claims, the Board concludes that no further assistance to the Veteran in developing the facts pertinent to the claims is required to comply with the duty to assist. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Principles and Theories of Service Connection A Veteran is entitled to VA disability compensation (service connection) for a disability resulting from personal injury suffered or disease contracted in line of duty in active military service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active military service. 38 U.S.C.A. § 1110 (wartime service) and § 1131 (peacetime service). Generally, to establish entitlement to VA disability compensation, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. All three elements must be proved. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). Service connection means that the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). The showing of a chronic disease in service requires a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303(b). Service connection may also be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). If a Veteran served 90 days or more on active duty, service incurrence will be presumed for certain chronic diseases, including arthritis or degenerative joint, if manifest to a compensable degree within the year after active service. 38 U.S.C.A. §§ 1112, 1137; 38 C.F.R. §§ 3.307(a), 3.309(a). Service connection may be granted on a secondary basis for a disability that is proximately due to or is aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Evidentiary Standards VA must give due consideration to all pertinent lay and medical evidence in a case where a Veteran is seeking service connection. 38 U.S.C.A. § 1154(a). As the Veteran did not serve in combat, the provisions of 38 U.S.C.A. § 1154(b) do not apply. Competency is a legal concept in determining whether lay or medical evidence may be considered, in other words, whether the evidence is admissible as distinguished from credibility and weight, factual determinations going to the probative value of the evidence, that is, does the evidence tend to prove a fact, once the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Competency is a question of fact, which is to be addressed by the Board. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (2007). When the evidence is admissible, the Board must then determine whether the evidence is credible. "Credible evidence" is that which is plausible or capable of being believed. See Caluza v. Brown, 7 Vet. App. 478, 511 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (the determination of credibility is a finding of fact to be made by the Board in the first instance). If the evidence is credible, the Board, as fact finder, must determine the probative value or weight of the admissible evidence, that is, does the evidence tend to prove a material fact. Washington v. Nicholson, 19 Vet. App. 362, 369 (2005). If the evidence is not credible, the evidence has no probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C.A. § 5107(b). Evidence The service treatment records show that in September 1989, while on leave, the Veteran injured his left shoulder playing football, resulting in pain in the left acromioclavicular joint. After conservative treatment, including physical therapy, limited duty, and injections, the acromioclavicular joint remained symptomatic. In October 1990, the distal end of clavicle was surgically removed to relieve the pain. The final diagnosis was acromioclavicular joint dislocation. The service treatment records contain no complaint, finding, history, symptoms, treatment, or diagnosis of left hand arthritis, left arm numbness, or a disability of the cervical spine. After service, on VA examination in June 1992, the Veteran had minimal left shoulder complaints. The assessment was remote surgical procedure and good functional status. In a rating decision in December 1992 the RO granted service connection for a left acromioclavicular joint injury (minor extremity) with excision of the distal end of the left clavicle. In March 2003, X-rays showed disc space narrowing at C5-6. History included a vehicle accident with vertigo with neck movement. VA records show that in February 2007 the Veteran's problem list included chronic neck pain and a "broken" collar bone in 1990 and minor injuries from a vehicle accident in 2003. In a statement in April 2007, the Veteran associated arthritis in his left hand and left arm numbness with his service-connected left shoulder disability. In September 2007, the Veteran stated that from 1994 to 2000 he had muscles spasms on the left side of his shoulder and neck and he still had pain and numbness in his left shoulder and neck pain. On VA examination in September 2007, the Veteran complained of shoulder pain and neck problems. The VA examiner stated there was no arthritis of the left hand clinically or radiographically or numbness in the left arm. In March 2009 on a consultation by VA rehabilitation medicine the Veteran was evaluated for left shoulder pain and left wrist pain. The Veteran described the onset of muscle spasms across the shoulder and neck since 1992. The VA physician found no physical evidence of myopathy, brachioplexopathy, peripheral neuropathy, entrapment neuropathy in the left upper extremity or radiculopathy of the cervical spine. The VA physician stated that trapezial spasms were the source of the shoulder pain. On VA examination in March 2009, the Veteran asserted that his service-connected shoulder disability caused left hand numbness and pain. The Veteran stated that he had no previous left hand injury, including in service, and that he first noticed numbness in about 2004. The VA examiner found no direct evidence of a neck problem in service. Repetitive testing of range of motion of the left shoulder produced muscle spasm in the left trapezius muscle along with transient numbness in the left hand. The pertinent diagnoses were trapezius muscle strain and arthritis of the left shoulder due to the service-connected left shoulder disability and arthritis at the first left carpal-metacarpal joint (hand) by X-ray. The VA examiner expressed the opinion that the left hand arthritis was not caused by or the result of the left shoulder disability. In June 2009, when seen by a VA occupational therapist, the Veteran stated that his left wrist began to hurt when he injured his left shoulder in 1989. He complained of numbness in his fingers. On VA examination in July 2009 with an addendum in October 2009, the Veteran stated that the left-side of his neck started to hurt in 1994 and that he continued to have left neck muscle spasms, which were due to his left shoulder disability. X-rays showed disc space narrowing at C5-6 with osteophytes. The VA examiner stated that the cervical disability was limited to disc disease by MRI, which was not linked to service and as it was shown first in 2003, 11 years after service. On VA examination in May 2011, the physical findings for the left shoulder were deformity, instability, limitation of motion, pain, stiffness, tenderness, and weakness, but no dislocation, locking, or effusion. There was no functional impairment of the left wrist, but there was tenderness to deep palpation at the lunate area of the wrist. X-rays of the left shoulder, when compared to the X-rays in March 2009, showed the prior resection of the distal clavicle with no change. There was also reference to arthritis of the first left carpal-metacarpal joint by X-ray in March 2009. The diagnoses were distal left clavicle resection with degenerative changes of the left shoulder and degenerative changes of the left wrist. On evaluation of the left hand, the Veteran complained of intermittent left hand pain and weakness with onset in 2009. X-rays of the left hand, when compared to the X-rays, showed no significant bony abnormality. The diagnosis was degenerative changed of the left wrist by X-ray, but no left hand arthritis by X-ray. On evaluation of the peripheral nerves, the Veteran complained of intermittent left arm numbness after awakening with onset around 2005. The reflexes were normal and the motor and sensory examinations were normal without dysesthesia. There was reference to the consultation by VA rehabilitation medicine in March 2009 and the findings of no physical evidence of myopathy, brachioplexopathy, peripheral neuropathy, entrapment neuropathy in the left upper extremity or radiculopathy of the cervical spine. The diagnosis was intermittent compression neuropathy by history with a history of a normal EMG and a current normal examination. On evaluation of the spine, the Veteran complained of muscle spasms and neck stiffness with onset around 1995. The reflexes were normal and the motor and sensory examinations were normal without dysesthesia. There was reference to the consultation by VA rehabilitation medicine in March 2009 and the findings of no physical evidence of myopathy, brachioplexopathy, peripheral neuropathy, entrapment neuropathy in the left upper extremity or radiculopathy of the cervical spine. X-rays of the cervical spine, when compared to the X-rays in March 2009, showed no change. The diagnosis was degenerative changes of the cervical spine. After a review of the service treatment records, the VA examinations, and the Veteran's file, the VA examiner expressed the opinion that it was less likely than not that the degenerative joint disease of the cervical spine, left arm numbness, or left hand arthritis were caused by or aggravated by the service-connected left shoulder disability. The VA examiner explained that while the service-connected left shoulder disability could cause neck pain and spasm, the left shoulder disability does not cause cervical arthritis. Also, the VA examiner stated that the left arm numbness was distal to the shoulder surgery in a glove-like distribution years after the surgery and therefore the left shoulder disability was less likely than not the cause of the numbness and did not aggravate the symptoms of numbness. The VA examiner stated that there was no evidence of arthritis of the left hand and that the arthritis of the left wrist was not caused by or aggravated by the left shoulder disability, because of a lack of biologic plausibility. In May 2013, the Board obtained a medical opinion from a VHA expert in orthopaedic surgery on the following questions: Is it more likely than not (probability greater than 50 percent), at least as likely as not (probability of 50 percent), or less likely than not (probability less than 50 percent) that: a). Degenerative joint disease of the cervical spine is caused by or aggravated by the service-connected left shoulder disability; and, b). The first carpal metacarpal joint osteoarthritis of the left hand is caused by or aggravated by the service-connected left shoulder disability? The VHA expert was provided the meaning of the term "aggravation," that is, a permanent increase in severity, that is, an irreversible or permanent worsening of a claimed disability as a result of the service-connected left shoulder disability, beyond the expected clinical course of the claimed disability as contrasted to a temporary worsening of symptoms. The VHA expert expressed the opinion that it was less likely than not that degenerative joint disease of the cervical spine was caused by or aggravated by the service-connected left shoulder disability, because there was no plausible etiopathogenetic relationship between the shoulder pathology (distal resection of the clavicle) and the neck pathology (degenerative disease of the cervical spine at C5-C-6). The VHA expert also expressed the opinion that it was less likely than not that the first carpal-metacarpal joint osteoarthritis of the left hand was caused by or aggravated by the service-connected left shoulder disability, because there was no plausible etiopathogenetic relationship between carpal-metacarpal joint osteoarthritis and the service-connected the shoulder pathology (distal resection of the clavicle). Analysis Excluding the theory of secondary service connection, which is addressed separately, to establish entitlement to VA disability compensation, service connection, a Veteran must show: (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the so-called "nexus" requirement. All three elements must be proved. Shedden, at 1167. Theories of Direct and Presumptive Service Connection Excluding the service-connected left shoulder disability, on the basis of the service treatment records alone, there was no complaint, finding, history, symptom, treatment, or diagnosis of left hand arthritis, left arm numbness, or degenerative joint disease (arthritis) of the cervical spine. And the Veteran does not assert and the evidence does not show that either left hand arthritis, left arm numbness, or degenerative joint disease (arthritis) of the cervical spine was affirmatively shown to have had onset in service and service connection under 38 C.F.R. § 3.303(a) is not established. Excluding the service-connected left shoulder disability, the Veteran does not assert and the evidence does not show that arthritis, which is listed as a chronic disease under 38 C.F.R. § 3.309(a), was noted in service and the provisions of 38 C.F.R. § 3.303(b), pertaining to chronicity and continuity of symptomatology do not apply, and service connection for left hand arthritis and degenerative joint disease (arthritis) of the cervical spine under 38 C.F.R. § 3.303(b) is not warranted. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (chronicity and continuity of symptomatology apply to a "chronic" disease listed under 38 C.F.R. § 3.309(a) and "noted" in service). Numbness is not listed as "chronic" disability under 38 C.F.R. § 3.309(a), and chronicity and continuity of symptomatology do not apply. See Walker at 1338-40. Excluding the service-connected left shoulder disability, the Veteran does not assert and the evidence does not show that either left hand arthritis, namely, arthritis of the first left carpal-metacarpal joint (hand) by X-ray in 2009; or left arm numbness with onset around 2004 as described by the Veteran in statements in 2007 and on VA examination in March 2009, and described as transient numbness or intermittent compression neuropathy in the left hand by VA in March 2009; or degenerative joint disease (arthritis) of the cervical spine, namely, disc space narrowing at C5-6 by X-ray and disc space narrowing at C5-6 and degenerative changes by X-ray in 2003 and in 2009, respectively, first shown after service, is related to an injury, disease, or event in service and service connection under 38 C.F.R. § 3.303(d) is not warranted. Excluding the service-connected left shoulder disability, the Veteran does not assert and the evidence does not show that either left hand arthritis or degenerative joint disease (arthritis) of the cervical spine as a chronic disease was manifested to a compensable degree within the year period after service in 1992 as disc space narrowing at C5-6 by X-ray and disc space narrowing at C5-6 and degenerative changes by X-ray were first documented in 2003 and in 2009, respectively, and arthritis at the first left carpal-metacarpal joint (hand) by X-ray was shown in 2009. In each instance more than one year beyond separation from service in 1992 and presumptive service connection under 38 U.S.C.A. §§ 1112, 1137 and 38 C.F.R. §§ 3.307(a) and 3.309(a) is not warranted. Excluding the service-connected left shoulder disability, the preponderance of the evidence is against the claims of service connection for left hand arthritis, left arm numbness, and degenerative joint disease (arthritis) of the cervical spine on the theories of direct and presumptive service connection, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). Theory of Secondary Service Connection To prevail on a claim of secondary service connection, the record must show evidence of a current disability; evidence of a service-connected disability; and, evidence of causation or aggravation of the nonservice-connected disability and the service-connected disability, the so-called "nexus" requirement. As for evidence of a current disability, there is evidence of left hand arthritis, that is, namely, arthritis of the first left carpal-metacarpal joint (hand) by X-ray in 2009; of left arm numbness as described by the Veteran in statements in 2007 and on VA examination in March 2009 and described as transient numbness or intermittent compression neuropathy in the left hand by VA in March 2009; and of degenerative joint disease (arthritis) of the cervical spine, namely, disc space narrowing at C5-6 by X-ray and disc space narrowing at C5-6 and degenerative changes by X-ray in 2003 and in 2009. As for evidence of a service-connected disability, service connection has been granted for a left acromioclavicular joint injury with excision of the distal end of the left clavicle. The remaining element is evidence of causation or aggravation of a nonservice-connected disability by the service-connected left shoulder disability, the so-called "nexus" requirement. The Veteran does assert that left hand arthritis, left arm numbness, and degenerative joint disease (arthritis) of the cervical spine were caused by the service-connected left shoulder disability. As the Veteran's statements are inferences based on facts, it is an opinion rather than a statement of fact. The Veteran as a lay person is also competent to offer an opinion on a simple medical condition. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). And the Veteran as a lay person is competent to identify a simple medical condition, or describe a contemporaneous medical diagnosis, or symptoms that later support a diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Veteran is competent to describe symptoms of hand pain, arm numbness, and neck spasms and pain, which are capable of lay observation. See 38 C.F.R. § 3.159 (Competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience; lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person.). See Layno v. Brown, 6 Vet. App. 465, 469-71 (1994) (Lay testimony is competent as to symptoms of an injury or illness, which are within the realm of one's personal knowledge; personal knowledge is that which comes to the witness through the use of the senses). But the question is whether the Veteran as layperson is competent to offer an opinion on a causal relationship between the current left hand arthritis, left arm numbness, or degenerative joint disease (arthritis) of the cervical spine and the service-connected left shoulder disability. Whether any current disability is caused by, that is, proximately due to or the result of the service-connected left shoulder disability or is aggravated by, that is, made permanently worse by the service-connected left shoulder disability are not simple medical questions that can be competently answered by the Veteran as a lay person based on mere personal observation because either causation or aggravation falls outside the realm of common knowledge of a lay person, that is, the questions are not capable of lay observation without specialized education, training, or experience. And no factual foundation has been established to show that the Veteran is qualified through specialized education, training, or experience to diagnose or to render an opinion on causation or aggravation. Although Veteran as a lay person is competent to describe a contemporaneous medical diagnosis or symptoms that later support a diagnosis by a medical professional, no medical professional has provided an opinion linking the claimed disabilities to the service-connected left shoulder disability. Since the Veteran's lay evidence is not competent evidence, the Veteran's lay opinion is excluded, that is, not admissible as evidence and cannot be considered as competent lay evidence favorable to the claims. As the Veteran's lay evidence is not competent evidence on the questions of causation and aggravation, the Board looks to the medical evidence. Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer a medical diagnosis, statement, or opinion. 38 C.F.R. § 3.159. The probative value or evidentiary weight to be attached to a medical opinion is within the Board's province as finder of fact. The guiding factors in evaluating the probative value of a medical opinion include whether the opinion is based upon sufficient facts, and whether the expert applied valid medical analysis to the significant facts of the case in order to reach the conclusion rendered in the opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-3 (2008). On VA examination in May 2011, after a review of the service treatment records, the VA examinations, and the Veteran's file, the VA examiner, a health-care professional, expressed the opinion that it was less likely than not that the degenerative joint disease of the cervical spine, left arm numbness, or left hand arthritis were caused by or aggravated by the service-connected left shoulder disability. The VA examiner explained that while the service-connected left shoulder disability could cause neck pain and spasm, the left shoulder disability does not cause cervical arthritis. Also, the VA examiner stated that the left arm numbness was distal to the shoulder surgery in a glove-like distribution years after the surgery and therefore the left shoulder disability was less likely than not the cause of the numbness and did not aggravate the symptoms of numbness. In May 2013, the VHA expert in orthopaedic surgery expressed the opinion that it was less likely than not that degenerative joint disease of the cervical spine was caused by or aggravated by the service-connected left shoulder disability, because there was no plausible etiopathogenetic relationship between the shoulder pathology (distal resection of the clavicle) and the neck pathology (degenerative disease of the cervical spine at C5-C-6). The VHA expert also expressed the opinion that it was less likely than not that the first carpal-metacarpal joint osteoarthritis of the left hand was caused by or aggravated by the service-connected left shoulder disability, because there was no plausible etiopathogenetic relationship between carpal-metacarpal joint osteoarthritis and the service-connected the shoulder pathology (distal resection of the clavicle). The VA examiner and VHA expert are qualified through education, training, or experience to offer an opinion on the questions of causation and aggravation. As the opinions of the VA examiner and the VHA expert were based on a review of the Veteran's history and a review of the Veteran's file and provided a rationale for the conclusions reached in the opinions, the Board finds that the opinions are persuasive evidence, which opposes, rather than supports, the claims on the question of whether the current left hand arthritis, left arm numbness, or degenerative joint disease (arthritis) of the cervical spine were caused by or aggravated by service-connected left shoulder disability. As the medical opinions oppose the claims and as there is no medical evidence in favor of the claims, the preponderance of the evidence is against the claims on theory of secondary service connection, and the benefit-of-the-doubt standard of proof does not apply. 38 U.S.C.A. § 5107(b). (The Order follows on the next page.) ORDER Service connection for left hand arthritis, including as secondary to the service-connected left shoulder disability, is denied. Service connection for left arm numbness, including as secondary to the service-connected left shoulder disability, is denied. Service connection for degenerative joint disease of the cervical spine, including as secondary to the service-connected left shoulder disability, is denied. ____________________________________________ George E. Guido Jr. Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs