Citation Nr: 1335317 Decision Date: 11/04/13 Archive Date: 11/13/13 DOCKET NO. 09-41 361 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUE Entitlement to service connection for arthropathy of the hands, elbows and hips, secondary to service-connected pulmonary sarcoidosis, claimed as joint and neurological problems. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Davitian, Counsel INTRODUCTION The Veteran had active service from April 1984 to June 1996. This matter comes before the Board of Veterans' Appeals (BVA or Board) on appeal from a June 2008 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. FINDING OF FACT The competent clinical evidence and competent and credible lay evidence demonstrates that the Veteran's arthropathy of the hands, elbows and hips was caused by service-connected disability. CONCLUSION OF LAW Arthropathy of the hands, elbows and hips is proximately due to or the result of service-connected disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107 (West 2002 & Supp. 2009); 38 C.F.R. § 3.310(a) (2013). REASONS AND BASES FOR FINDING AND CONCLUSION VA has a duty to notify and assist claimants in substantiating a claim for VA benefits. 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5107, 5126 (West 2002 & Supp. 2009); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a) (2013). The Veteran was afforded a notice letter in January 2008 which satisfied the duty to notify. The letter advised him of the evidence necessary to substantiate a claim for secondary service connection, and explained what evidence VA would obtain and what evidence the Veteran was responsible for obtaining. The Board also fidns that the duty to develop evidence has been fulfilled. The RO obtained the Veteran's medical treatment records and his Social Security disability records. The Veteran was also afforded a VA examination. The Board finds that the examination was adequate to allow proper adjudication of the issue on appeal. The examiner conducted a complete examination, recorded all findings considered relevant under the applicable law and regulations, and offered well supported opinions based on consideration of the full history of the disability. A veteran is entitled to secondary service connection for a disability which is proximately due to, the result of, or aggravated by an established service-connected disorder. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439 (1995). Secondary service connection includes instances in which an established service-connected disorder results in additional disability of another condition by means of aggravation. Allen, supra. In each case where a veteran is seeking service connection for any disability, 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). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 38 U.S.C.A. § 5107(b). The Veteran contends that his service-connected pulmonary sarcoidosis results in joint and neurological problems. The Veteran's pulmonary sarcoidosis is evaluated as 30 percent disabling. The Veteran submitted an excerpt from Merck.com in support of his contentions that his joint and neurological symptoms are due to his service-connected pulmonary sarcoidosis. VA and private medical records show treatment for a number of different joint complaints and diagnoses. A VA record dated in December 2007 contains a diagnosis of sarcoidosis with possible sarcoid arthritis. A VA treatment record dated in April 2008 contains a note indicating that the "sarcoid was cause of joint and bone symptoms," but no explanation or specific information was provided. A private treatment record dated in May 2008 indicates that the Veteran has sarcoidosis and admitted to multiple other joint pains and had polyarthropathy secondary to sarcoidosis. The physician did not specify exactly which joints were affected. A February 2008 VA examination contains a conclusion that the Veteran has polyarthralgia of the ankles, knees, shoulders and hands. The examiner stated that he could not say without resorting to mere speculation if it was caused by or related to sarcoidosis. The examiner also stated that he Veteran had cephalgia that was less likely than not caused by or related to sarcoidosis. The report of a February 2012 VA Disability Benefits Questionnaire (DBQ) provides thorough results of examinations for peripheral nerve conditions, shoulder and arm conditions, elbow and forearm conditions, hand and finger conditions, miscellaneous foot conditions, knee and lower leg conditions, and hip and thigh conditions. The report provides that the examiner reviewed the Veteran's claims file, and sets forth the relevant history and the Veteran's subjective complaints. The report provides several diagnoses and nexus opinions. First, it provides a diagnosis of status-post right shoulder subacromial depression, status-post left shoulder partial rotator cuff tear. The examiner stated that this condition was less likely than not (less than 50 percent) proximately due to or the result of the Veteran's service-connected pulmonary sarcoidosis. He explained that the Veteran's bilateral shoulder condition started after an injury in 2008, and the Veteran then had shoulder surgeries. A December 2011 pulmonary note indicated sarcoidosis - stage 3 pulmonary sarcoidosis, and stated that the pulmonary disease had been stable with no active treatment indicated at this time. The examiner stated the opinion that the Veteran's current bilateral shoulder condition was as likely as not related to the injury with status-post osteoarthritis, and less likely as not caused by or related to service-connected sarcoidosis. The examiner also stated that there was no objective evidence for polyneuropathy. The examiner stated that this condition was less likely than not (less than 50 percent) proximately due to or the result of the Veteran's service-connected pulmonary sarcoidosis. He explained that although the Veteran had subjective symptoms with pain and numbness in the hands and feet, decreased pinprick and not pushing against resistance, there was no objective evidence of polyneuropathy by a 2009 EMG or a review of the records and no objective evidence for progressive neuropathy. The examiner further provided a diagnosis of status-post bilateral fifth metatarsal fracture, and moderate size left plantar heel spur. The examiner stated that upon review of the records and current findings, the Veteran's subjective symptoms of pain in the feet were less likely as not caused by or related to service connected pulmonary sarcoidosis. The examiner provided a diagnosis of degenerative joint disease bilateral knees, with an X-ray showing minimal bilateral patellar spurring. The examiner stated that the degenerative changes were at least as likely as not caused by or related to the process of aging. It was less likely as not caused by or related to service-connected pulmonary sarcoidosis. The final diagnosis was arthropathy of the elbows, hands and hips. The examiner stated that the diagnosis of sarcoid arthropathy was based upon suggestive clinical, imaging, synovial fluid and in selected cases synovial tissue biopsy. With the Veteran's long history of sarcoid, arthropathy in the elbows, hands and hips was clinically at least as likely as not caused by or related to his service-connected sarcoidosis. Based on the foregoing, the Board finds that service connection is warranted for arthropathy of the hands, elbows and hips. In this regard, the Board finds that the February 2012 medical opinion linking the Veteran's arthropathy to his service-connected disability is probative evidence in support of service connection. It is based on current examination results and a review of the medical record. The examiner explained his opinion with references to the Veteran's post-service medical history and general medical principles. This fact is particularly important, in the Board's judgment, as the references make for a more convincing rationale. See Bloom v. West, 12 Vet. App. 185, 187 (1999) (the probative value of a physician's statement is dependent, in part, upon the extent to which it reflects "clinical data or other rationale to support his opinion"). See Prejean v. West, 13 Vet. App. 444, 448-9 (2000) (factors for assessing the probative value of a medical opinion include the thoroughness and detail of the opinion.); Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (medical opinions as to a nexus may decline in probative value where the physician fails to discuss relevant medical history). The Board finds that the remaining February 2012 diagnoses regarding the Veteran's shoulders, feet, knees, and subjective neurological symptoms are not relevant to the Veteran's claim or this decision. By identifying these diagnoses separately from the Veteran's arthropathy, the examiner made it clear that they are unrelated to and distinct from the arthropathy that is caused by the Veteran's service-connected pulmonary sarcoidosis. In this regard, a private July 2012 examination report also provides a diagnosis of polyarthropathy, secondary to sarcoidosis, as well as separate diagnoses related to the Veteran's low back, right wrist and elbow, bilateral feet, and bilateral shoulders. Like the February 2012 VA examiner, the private physician made no link between the Veteran's sarcoidosis and/or arthropathy and the other diagnoses in any way. The Board is aware of the Veteran's contentions that his arthropathy includes additional joints, such as the shoulders. Although lay persons are competent to provide opinions on some medical issues, the specific issue of whether the Veteran's arthropathy includes joints other than the hands, elbows and hips falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer). Thus, the Veteran's assertions cannot constitute competent medical evidence in support of his claim. For the foregoing reasons, the Board fidns that the competent clinical evidence and competent and credible lay evidence demonstrates that the Veteran's arthropathy of the hands, elbows and hips was caused by service-connected disability. Arthropathy of the hands, elbows and hips is proximately due to or the result of service-connected disability. To this extent only, the appeal is granted. ORDER Service connection for arthropathy of the hands, elbows and hips is granted. ____________________________________________ MICHAEL MARTIN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs