Citation Nr: 1619877 Decision Date: 05/16/16 Archive Date: 05/27/16 DOCKET NO. 10-33 646 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Huntington, West Virginia THE ISSUES 1. Entitlement to service connection for a cervical spine disorder, claimed as degenerative joint disease, cervical spine, with foramina stenosis C3 4, C5-6, C7-T1, with radiculopathy. 2. Entitlement to service connection for a right shoulder disorder, to include as secondary to a cervical spine disorder. 3. Entitlement to compensation under 38 U.S.C.A. § 1151 (West 2014) for muscle deterioration in the right shoulder and arm resulting from the use of fluoroquinolone antibiotics prescribed by VA. REPRESENTATION Veteran represented by: The American Legion WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had service from April 1966 to April 1970. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2009 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Huntington, West Virginia. The Veteran testified at a hearing in April 2010 before a Decision Review Officer at the RO. A hearing transcript has been associated with the record. The Board remanded the instant matters in March 2014. As will be discussed herein, the Board finds that the agency of original jurisdiction (AOJ) has substantially complied with the remand orders with regard to the instant claims and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand 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). This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing system. FINDINGS OF FACT 1. A cervical spine disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service or a service-connected disability and arthritis did not manifest within one year of the Veteran's discharge from service. 2. A right shoulder disorder is not shown to be causally or etiologically related to any disease, injury, or incident in service or a service-connected disability, and arthritis did not manifest within one year of the Veteran's discharge from service and was not caused or aggravated by a service-connected disability. 3. The Veteran's right shoulder and arm disability did not undergo an increase in disability, nor was it incurred as an additional disability, as a result of fluoroquinolone antibiotics prescribed by a VA provider. CONCLUSIONS OF LAW 1. The criteria for service connection for a cervical spine disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2015). 2. The criteria for service connection for a right shoulder disorder have not been met. 38 U.S.C.A. §§ 1101, 1110, 1112, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2015). 3. The criteria for compensation under the provisions of 38 U.S.C.A. § 1151 for muscle deterioration in the right shoulder and arm resulting from the use of fluoroquinolone antibiotics prescribed by VA, are not met. 38 U.S.C.A. §§ 1151, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.361 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2015). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between a Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. In the instant case, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a June 2009 letter, sent prior to the October 2009 rating decision, advised the Veteran of the evidence and information necessary to substantiate his claims for service connection for cervical spine degenerative joint disease and right shoulder condition on a direct basis, as well as his and VA's respective responsibilities in obtaining such evidence and information. A March 2014 letter, sent after the October 2009 rating decision, provided such notice on a secondary basis. Additionally, these letters advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. With regards to the Veteran's claim of entitlement under the provisions of 38 U.S.C.A. § 1151, a May 2010 letter advised the Veteran of the evidence and information necessary to substantiate his claim on that basis as well as his and VA's respective responsibilities in obtaining such evidence and information. Additionally, this letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman, supra. While the May 2010 and March 2014 letters were issued after the initial October 2009 rating decision, the United States Court of Appeals for the Federal Circuit has held that VA could cure such a timing problem by readjudicating the Veteran's claims following a compliant VCAA notification letter. Mayfield v. Nicholson, 444 F. 3d 1328, 1333-34 (Fed. Cir. 2006). The Court clarified that the issuance of a statement of the case could constitute a readjudication of the Veteran's claims. See Prickett v. Nicholson, 20 Vet. App. 370 (2006). In the instant case, after the May 2010 and March 2014 letters were issued, the Veteran's claims were readjudicated in the September 2014 supplemental statement of the case. Therefore, any defect with respect to the timing of the VCAA notice has been cured. Moreover, neither the Veteran nor his representative has alleged prejudice with respect to notice. See Shinseki v. Sanders, 129 S. Ct. 1696 (2009); Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007); Goodwin v. Peake, 22 Vet. App. 128 (2008); Dunlap v. Nicholson, 21 Vet. App. 112 (2007). Relevant to the duty to assist, the Veteran's service treatment and personnel records as well as post-service VA and private treatment records have been obtained and considered. Moreover, the Veteran has not identified any additional, outstanding records that have not been requested or obtained. In this regard, the Veteran was asked to identify the VA and non-VA providers who had treated him for his claimed disabilities and complete appropriate authorization forms in a March 2014 letter. No response was received. The Board emphasizes that "the duty to assist is not always a one-way street. If a Veteran wishes help, he cannot passively wait for it in those circumstances where he may or should have information that is essential in obtaining the putative evidence." Wood v. Derwinski, 1 Vet. App. 190, 193 (1991). Therefore, the Board finds that VA has satisfied its duty to assist in this regard. Additionally, the Board obtained a VA medical opinion in June 2014 in order to adjudicate the Veteran's claims for service connection. In addition, he underwent VA examination in August 2009 and an addendum opinion was obtained in August 2014 to adjudicate his claim for benefits under the provisions of 38 U.S.C.A. § 1151. The opinions were based his conclusions on a review of the record, to include an interview with the Veteran and a full examination. Moreover, the opinions offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Board notes that neither the Veteran nor his representative have argued that the opinions as to the claims for service connection for a right shoulder disorder and for compensation under the provisions of 38 U.S.C.A. § 1151 are inadequate. See Scott v. McDonald, 789 F. 3d 1375 (Fed. Cir. 2015). Accordingly, the Board finds that VA's duty to assist with respect to obtaining a VA examination and opinion regarding the issues decided herein has been met. The Board notes that the Veteran's representative argued in its April 2016 Informal Hearing Presentation that the June 2014 VA opinion was inadequate because the examiner relied on the lack of evidence in the Veteran's service treatment records to deny the claim and did not address whether the Veteran's in-service trauma made him more likely to suffer a neck disability due to his post-service employment. However, the June 2014 VA examiner clearly discussed a variety of other factors when rendering his negative etiology opinion, to include the length and nature of the Veteran's post-service employment and the length of time between service discharge and the onset of the disability, and commented on the Veteran's reports of sustaining an in-service neck injury. See Dalton v. Nicholson, 21 Vet. App. 23 (2007) (an examination was inadequate where the examiner did not comment on a Veteran's reports of in-service injury and instead relied on the absence of evidence in a Veteran's service treatment records to provide a negative opinion). Moreover, the June 2014 VA examiner specifically opined that the likely cause of the Veteran's cervical spine condition was normal age-related degeneration and the accumulation of physical stressors and duration in his post-military employment history, thereby finding that the Veteran's in-service neck traumas did not increase the likelihood of sustaining a post-service disability. This argument is therefore without merit. The Board further finds that the AOJ has substantially complied with the March 2014 remand directives by providing the Veteran with notice regarding secondary service connection in a March 2014 letter, requesting that the Veteran identify any VA or non-VA providers in a March 2014 letter, and obtaining VA examinations with opinions adequate to decide the instant claims. Therefore, no further action is necessary in this regard. See D'Aries, supra. Additionally, in April 2010, the Veteran was provided an opportunity set forth his contentions during a before a Decision Review Officer. In Bryant v. Shinseki, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the April 2010 hearing, the presiding Decision Review Officer enumerated the issues on appeal, which were then characterized as service connection for cervical spine disorder and a right shoulder disorder. Information was solicited regarding the type and onset of his disabilities and the nature of his current disorders. In addition, the Veteran detailed his assertion that his right shoulder and arm disorder was caused by a medication prescribed by VA. Therefore, not only were the issues "explained . . . in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim," were also fully explained. See Bryant, 23 Vet. App. at 497. Furthermore, additional development was undertaken subsequent to the hearing in order to ensure that all necessary evidence was of record, which included obtaining the Veteran's VA treatment records as well as an opinion to determine the nature and etiology of the Veteran's cervical spine disorder and right shoulder disorder. As such, the Board finds that, consistent with Bryant, the presiding Decision Review Officer complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430(1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Certain chronic diseases, such as arthritis, shall be presumed to have been incurred in service if manifested to a compensable degree within a prescribed period post service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113; 38 C.F.R. §§ 3.307, 3.309. With chronic disease shown as such in service (or within the presumptive period) 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 attributed to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is questioned. When the fact of chronicity in service is not adequately supported, then the showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). The United States Court of Appeals for the Federal Circuit has clarified that the provisions of 38 C.F.R. § 3.303(b) pertaining to the award of service connection on the basis of continuity of symptomatology apply to chronic diseases as defined in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Here, to the extent that the Veteran has not been diagnosed with a chronic disease subject to presumptive service connection, he cannot establish service connection solely on the basis of continuity of symptoms. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). The Board must consider that 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 claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). The Veteran contends that his current cervical spine disorder is the result of his service, specifically his in-service boxing. With regards to his claimed right shoulder disorder, the Veteran alleges that it was caused or aggravated by his cervical spine disorder. During an April 2010 hearing, the Veteran testified that he received treatment during service for pain in the back of his neck and that he has had continuous headaches since service. Service treatment records reflect complaints of headaches for one week in January 1967 and complaints of sinus congestion, headaches and swollen glands in April 1968. A July 1969 treatment note reflects the Veteran's complaints of recurring headaches due to sinusitis. An April 1970 service discharge examination found the Veteran's spine to be normal. The remaining service treatment records were negative for complaints, treatments or diagnoses related to a cervical spine disorder and/or a right shoulder disorder. Post-service treatment records contain a February 2004 VA computed tomography scan, which found multi-level neural foramina encroachment and mild central canal stenosis. An August 2004 VA treatment note, reflected an assessment of cervical degenerative joint disease with foraminal stenosis. A September 2008 VA treatment note reflects the Veteran's complaints of a two month history of right shoulder pain that began one evening when he felt something pop in bed. A diagnosis of a right shoulder supraspinatus rotator cuff tear was noted in a September 2008 VA treatment note. A June 2014 VA neck Disability Benefits Questionnaire (DBQ) report reflects the Veteran's reports that he participated in boxing for about one year during service, that he drove a semi tractor and trailer for about 10 years after service and that he crashed during his first year as a truck driver. He reported that he later worked as a maintenance worker and supervisor in a coal mine for five years and in automobile body work for about 10 years. Following a physical examination and a review of the Veteran's VBMS case file, Virtual VA records, VA medical records and relevant medical records, the examiner opined that the Veteran's cervical spine conditions were not incurred during or caused by injury sustained in military service. The examiner reasoned that there was no documentation in the service treatment records to support his contention that he injured his neck during service due to boxing or other cause. The examiner noted that the Veteran's April 1970 separation physical documents normal upper extremities and spine examinations, that the most likely cause of his disabilities was his work as a truck driver for ten years after service and that truck drivers have a higher rate of cervical spine disease than the general population. The examiner further reasoned that the Veteran worked as a laborer, maintenance supervisor and autobody mechanic after service, that the first documented report of cervical spine issues was in 2004 and that while one would expect any significant neck trauma incurred during service to be documented during or shortly after his military service, there is no such documentation presented. The June 2014 VA examiner further opined that the most likely cause of the Veteran's cervical spine condition was normal age-related degeneration and the accumulation of the physical stressors and duration of those stressors in his post-military employment history, which included being a truck driver for 10 years, a coal mine laborer for five years and an autobody mechanic for 10 years, and not the one year he spent intermittently participating in sport boxing while in service. The examiner cited to several medical treatise articles suggesting that there was a higher incident of back pain and spinal degenerative disease among cigarette smokers than nonsmokers, that high risks of locomotor diseases have been reported for bus and truck drivers in general and that professional drivers experienced a high risk of various disorders of the locomotor system. The Board has first considered whether service connection may be granted for arthritis; however, cervical degenerative joint disease was not diagnosed until 2004, more than 34 years after the Veteran was discharged from service and the Veteran has not been diagnosed with right shoulder arthritis. Further, the Board notes that the passage of several years between discharge from active service and the medical documentation of the claimed disability is a factor that tends to weigh against a claim for service connection. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000); Shaw v. Principi, 3 Vet. App. 365 (1992). In this case, the lack of any lay or medical evidence of related symptoms during or continuing after service preponderates against a finding that he manifested a chronic disability in service and that he experienced continuity of symptomatology thereafter, which preponderates against his claim. In this regard, the April 1970 VA examinations were negative for complaints, treatments, or diagnoses related to the cervical spine. As such, presumptive service connection, to include on the basis of continuity of symptomatology, for arthritis as chronic disease is not warranted in this case. See 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. § 3.307, 3.309; Walker, supra. Moreover, based on the foregoing, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a cervical spine disorder. While the evidence of record shows that the Veteran has a currently diagnosed cervical spine disorder, the probative evidence of record demonstrates that such is not related to his service. In this regard, the Board places great probative weight on the June 2014 VA examiner's opinion that the Veteran's cervical spine disorder was less likely than not related to service and that the disability was more likely related to his history of tobacco abuse, employment history, and normal age progression. This opinion had clear conclusions and supporting data, as well as a reasoned medical explanation connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. No contrary medical opinion is of record. In addition, the Board notes that, although the RO considered the claim for service connection for a right shoulder disorder on both direct and secondary theories of entitlement, there is actually no evidence or allegation that a right shoulder disorder had its onset during, or is otherwise medically-related to service. The evidentiary record does not contain any evidence which establishes an in-service event, injury, or disease to which the claimed right shoulder disorder may be related. In this regard, the Board notes that the Veteran has not alleged sustaining an in-service injury, that the onset of such disorder occurred during service or that there was an in-service event which resulted in the claimed disorder. Further, the service treatment records were negative for complaints, treatments, or findings related to such a claimed right shoulder disorder. Significantly, there is also no competent, probative evidence or opinion of record which suggests that there exists a nexus between any incident in service and the Veteran's claimed right shoulder disorder, which were diagnosed many years thereafter. Indeed, none of the medical treatment records reflect any such opinion or comment to that effect, and neither the Veteran nor his representative have presented or identified any such existing evidence or opinion. Furthermore, as discussed above, VA is not required to obtain a medical opinion addressing the etiology of the Veteran's claimed right shoulder disorder, as he has not alleges an in-service event, injury of disease and no probative indication that such disease is otherwise related to service. See McLendon, supra. The Board notes that the Veteran and his representative have generally contended on his behalf that his cervical spine disorder had its onset in service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to" and a mere conclusory generalized lay statement that service event or illness caused the claimant's current condition is insufficient to require the Secretary to provide an examination. Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's cervical spine disorder and any instance of his service to be complex in nature. See Woehlaert v. Nicholson, 21 Vet. App. 456 (2007) (although the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Specifically, while the Veteran is competent to describe his current manifestations of cervical spine disorder and his representative is competent to describe his observations of the Veteran's symptoms, the Board accords their statements regarding the etiology of such disorder little probative value as they are not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Specifically, the determination of etiology of cervical spine disorder requires the interpretation of results found on physical examination and knowledge of the internal musculo-skeletal system. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran and his representative are nonprobative evidence. Finally, to the extent that the Veteran has alleged that his right shoulder disorder was caused or aggravated by a cervical spine disorder, the Board notes that, under 38 C.F.R. § 3.310(a), service connection may be granted for disability that is proximately due to or the result of a service-connected disease or injury. That regulation permits service connection not only for disability caused by service-connected disability, but for the degree of disability resulting from aggravation of a nonservice-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). Here, however, as service connection for a cervical spine disorder has not been established, there is no legal basis for award of service connection for any disability secondary thereto. As the Veteran's claim for service connection for right shoulder disorder is based on his assertion that it was caused by his cervical spine disorder (i.e. secondary service connection), it must be denied as a matter of law. Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims of entitlement to service connection for cervical spine disorder and/or a right shoulder disorder. As such, that doctrine is not applicable in the instant appeals, and his claims must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. III. 38 U.S.C.A. § 1151 The Veteran contends that his use of medication prescribed by his VA provider resulted in his right arm and shoulder disability. During an April 2010 hearing, the Veteran testified that he noticed that the muscle in his bicep had come lose while laying in bed, that he later found out that his bicep had come loose from his shoulder and that he believed that his problem was a side effect of medication which had been prescribed by his VA provider. He also testified that he had been prescribed the medication a few months prior to his bicep coming loose. Compensation under 38 U.S.C.A. § 1151 is awarded for a qualifying additional disability caused by improper VA treatment. A disability is a qualifying additional disability if the disability was not the result of the Veteran's willful misconduct and the disability was caused by hospital care, medical or surgical treatment, or examination furnished the Veteran under any law administered by the Secretary of the VA, either by a Department employee or in a Department facility and the proximate cause of the disability was carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical or surgical treatment, or examination; or an event not reasonably foreseeable. 38 U.S.C.A. § 1151; 38 C.F.R. § 3.361. In Viegas v. Shinseki, the Federal Circuit noted that section 1151 delineates three prerequisites for obtaining disability compensation. First, a putative claimant must incur a "qualifying additional disability" that was not the result of his own "willful misconduct." 38 U.S.C. § 1151(a). Second, that disability must have been "caused by hospital care, medical or surgical treatment, or examination furnished the Veteran" by VA or in a VA facility. Finally, the "proximate cause" of the Veteran's disability must be "carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part" of VA, or "an event not reasonably foreseeable." See Viegas v. Shinseki, 705 F.3d 1374 (Fed. Cir. 2013); § 1151(a)(1)(A), (a)(1)(B). Thus, section 1151 contains two causation elements-a Veteran's disability must not only be caused by the hospital care or medical treatment he received from VA, but also must be proximately caused by the VA's fault or an unforeseen event. In determining whether a Veteran has an additional disability, VA compares the Veteran's condition immediately before the beginning of the hospital care or medical or surgical treatment upon which the claim is based to the Veteran's condition after care or treatment is rendered. 38 C.F.R. § 3.361(b). To establish causation, the evidence must show that the hospital care or medical or surgical treatment resulted in the Veteran's additional disability. Merely showing that a Veteran received care or treatment and that the Veteran has an additional disability does not establish causation. 38 C.F.R. § 3.361(c)(1). Hospital care or medical or surgical treatment cannot cause the continuance or natural progress of a disease of injury for which the care or treatment was furnished unless VA's failure to timely diagnose and properly treat the disease or injury proximately caused the continuance or natural progress. 38 C.F.R. § 3.361(c)(2). To establish that carelessness, negligence, lack of proper skill, error in judgment, or similar instance on VA's part in furnishing hospital care, medical or surgical treatment, or examination proximately caused a Veteran's additional disability, it must be shown that the hospital care or medical or surgical treatment caused the Veteran's additional disability; and (i) VA failed to exercise the degree of care that would be expected of a reasonable health care provider, or (ii) VA furnished the hospital care or medical or surgical treatment without the Veteran's informed consent. Determinations of whether there was informed consent involve consideration of whether the health care providers substantially complied with the requirements of 38 C.F.R. § 17.32. Minor deviations from the requirements of 38 C.F.R. § 17.32 that are immaterial under the circumstances of a case will not defeat a finding of informed consent. 38 C.F.R. § 3.361(d)(1). Whether the proximate cause of a Veteran's additional disability was an event not reasonably foreseeable is in each claim to be determined based on what a reasonable health care provider would have foreseen. The event need not be completely unforeseeable or unimaginable but must be one that a reasonable health care provider would not have considered to be an ordinary risk of the treatment provided. In determining whether an event was reasonably foreseeable, VA will consider whether the risk of that event was the type of risk that a reasonable health care provider would have disclosed in connection with the informed consent procedures of 38 C.F.R. § 17.32. 38 C.F.R. § 3.361(d)(2). The record contains an April 2008 VA treatment note in which the Veteran complained of bruising and swelling on the top of his right arm for the past four days. A May 2008 VA treatment note reflects the Veteran's reports of waking up one morning about three weeks ago with pain in his right arm and that he did not recall injuring it or doing anything traumatic that might have injured it. Following a physical examination, a diagnosis of a distal biceps tendon tear of the right biceps muscle was made. An August 2009 VA examination report reflects the Veteran's complaints that the medication he had been prescribed caused his muscles to deteriorate and made it impossible for his bicep tear to be repaired. The examiner noted that the Veteran had been prescribed moxifloxacin and ciprofloxacin for epididymitis in April and May 2009 and that he had consulted up to date, a Physician Desk Reference and the Physician Prescribing Reference but could find no link between these antibiotics and the Veteran's claimed muscle deterioration. The examiner noted that there was a black box warning associated with both moxifloxacin and ciprofloxacin which stated that there had been reports of tendon inflammation and/or rupture with quinolone antibiotics and that the risk may be increased with concurrent corticosteroids, organ transplant recipients and in patients over 60 years of age. The examiner noted that rupture of the Achilles tendon sometimes required surgical repair had been reported most frequently but other tendon sites (e.g., rotator cuff, biceps) had also been reported. The examiner noted that the Veteran's bicep rupture pre-existed the use of the antibiotic as he presented in April 2008 with complaints of right biceps and shoulder pain and swelling two to three days and a July 2008 Magnetic Resonance Imaging (MRI) scan noted findings suggestive of dislocation or a complete tear of the long head of the biceps tendon. The examiner opined that the Veteran's biceps tendon tear was not caused by or a result of carelessness, negligence, lack of proper skill, error in judgment, or similar instance of fault on the part of the Department in furnishing the hospital care, medical care or surgical treatment. The examiner reasoned that while the Veteran alleged that the medication caused muscle deterioration, these medications were not associated with muscle deterioration and that the medications did not cause the rupture as it existed prior to his taking the medication. An August 2014 VA addendum opinion noted that the Veteran had presented at VA with complaints of right shoulder pain of two to three days duration and that he subsequently underwent evaluation by an orthopedic specialist. The examiner noted that a May 2008 right shoulder X-ray was conducted and that a July 2008 MRI scan revealed a chronic labral injury, full thickness rotator cuff tear and a biceps tendon rupture. The examiner noted that such injuries were most consistent with trauma and not with fluoroquinolone-induce tendinopathy. The examiner noted that the Veteran had been prescribed fluoroquinolone antibiotics on at least four occasions, with the most proximal being approximately eight months prior to the onset of this right shoulder condition. The examiner further noted that while fluoroquinolone antibiotics were known to cause an increase in tendinopathy and tendon ruptures, most are concurrent with the antibiotic therapy with the median onset of within six days and 85-95 percent occur of such injuries within the first month of antibiotic therapy. The examiner opined that a review of the Veteran's medical record indicates that he had no tendonitis or tendinopathy before the rupture of his right biceps tendon and that the most likely cause of his right biceps tendon rupture was underlying degenerative joint disease as evidenced by contemporaneous radiologic imaging studies. The examiner further opined that there was no evidence of aggravation of an underlying medical condition beyond its nature cause. The examiner also noted that the actual length of antibiotic use was 10 days for each prescribed course of antibiotics and not 30-days as originally indicated in the Board's remand. The Board finds that the VA examiners considered all of the pertinent evidence of record, to include the statements of the Veteran, his pertinent medical records, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, the VA examiners offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. See Nieves-Rodriguez, supra; Stefl, supra. Consequently, the Board assigns great probative value to the VA examiners' opinions. There are no contrary opinions of record. Therefore, the Board finds that compensation under 38 U.S.C.A. § 1151 for a right shoulder/arm disorder is not warranted as use of fluoroquinolone antibiotics did not result in an additional disability or an increase in severity of existing disorder. The Board acknowledges the Veteran's sincerely held belief that his use of medication prescribed by a VA provider and that it had resulted in additional disability. However, the record does demonstrate that he possesses any clinical or diagnostic medical knowledge or skills. Although the Veteran, as a lay person, may report on his observable symptoms and discomfort and the nature of the treatment he received in the past for his existing disorders, an assessment of the severity and proper treatment for his symptoms on a specific occasions is a complex medical matter requiring training and clinical experience that the Veteran does not possess. Therefore, his own assessment of the cause of his symptoms or disabilities is not competent as such are complex medical questions and his statements in this regard are non-probative. See Woehlaert, supra. As the weight of competent evidence shows that the Veteran did not incur an additional disability or an increase in the severity of an existing disability as a result medication prescribed by a VA provider, the "benefit of the doubt" rule is not for application, and the Board must deny the claim. See 38 U.S.C.A. § 5107(b); Gilbert, supra. ORDER Service connection for a cervical spine disorder is denied. Service connection for a right shoulder disorder, to include as secondary to a cervical spine disorder, is denied. Compensation under the provisions of 38 C.F.R. § 1151 for muscle deterioration in the right shoulder and arm resulting from the use of fluoroquinolone antibiotics prescribed by VA, is denied. ____________________________________________ R. FEINBERG Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs