Citation Nr: 1643722 Decision Date: 11/17/16 Archive Date: 12/01/16 DOCKET NO. 09-33 162 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement for service connection for residuals of an injury to the coccyx area. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL The Veteran ATTORNEY FOR THE BOARD D. Jimerfield, Associate Counsel INTRODUCTION The Veteran served on active duty from May 1967 to September 1969. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a February 2008 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in New Orleans, Louisiana, which declined to reopen a previously denied claim for service connection for residuals of an injury to the coccyx area. In August 2010, the Veteran testified at a Board video-conference hearing before an Acting Veterans Law Judge (AVLJ). A transcript of that hearing has been associated with the record. Thereafter, in May 2011, the Board reopened the Veteran's claim and remanded it to the Agency of Original Jurisdiction (AOJ) for additional development and adjudication on the merits. Following additional development, the AOJ denied the claim on the merits in a March 2012 supplemental statement of the case and returned the case to the Board. Subsequently, in May 2012, the Board remanded the case to afford the Veteran an opportunity to appear at another Board hearing, inasmuch as the AVLJ who conducted the hearing in August 2010 was no longer employed by the Board. Pursuant to this remand, in August 2012, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge (VLJ) sitting at the RO. A transcript of that hearing has been associated with the record. Thereafter, in December 2012, the Board remanded the claim for additional development. Upon the case's return to the Board, it was determined that further medical inquiry was necessary to decide the claim. As such, the Board sought an expert medical opinion from the Veterans Health Administration (VHA) pursuant to VHA Directive 1602-01 in February 2016. Such opinion was rendered in October 2016. This appeal was processed using the Veterans Benefits Management System (VBMS) and Virtual VA paperless claims processing systems. FINDING OF FACT Resolving all doubt in the Veteran's favor, his residuals of an injury to the coccyx area, diagnosed as coccydynia, is related to his military service. CONCLUSION OF LAW The criteria for service connection for coccydynia have been met. 38 U.S.C.A. §§ 1110, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2015). REASONS AND BASES FOR FINDING AND CONCLUSION As the Board's decision to grant service connection for coccydynia is a complete grant of the benefits sought on appeal, no further action is required to comply with the Veterans Claims Assistance Act of 2000 or its implementing regulations. In this case, the Veteran testified that he fell hard and injured his coccyx bone during pugil stick training at Parris Island, South Carolina. Since the incident, he has had persistent pain in that area which eventually caused him to have surgery to remove his coccyx bone. The Veteran further testified that this pain has persisted despite the surgery, particularly when he sits or lies down. 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 (West 2014); 38 C.F.R. § 3.303(a) (2015). 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 C.F.R. § 3.303; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996). A Veteran will be considered to have been in sound condition when examined, accepted and enrolled for service, except as to defects, infirmities, or disorders noted at entrance into service, or where clear and unmistakable (obvious or manifest) evidence demonstrates that an injury or disease existed prior thereto and was not aggravated by such service. 38 U.S.C.A. § 1111. Only such conditions as are recorded in examination reports are to be considered as noted. 38 C.F.R. § 3.304(b). Notably, congenital or developmental defects are not injuries or diseases within the meaning of the applicable law and regulations for VA compensation purposes. 38 C.F.R. §§ 3.303(c), 4.9. A defect is a structural or inherent abnormality or condition which is more or less stationary in nature. VAOPGCPREC 82-90. A disease may be defined as any deviation from, or interruption of, the normal structure or function of any part, organ, or system of the body that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown. Id. Service connection may be granted for diseases of congenital, developmental, or familial origin, but not for defects, unless such defect was subject to a superimposed disease or injury during military service. Id. Such a disease, by its very nature, pre-exists a claimant's military service. 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). At the outset, the Board finds that the presumption of soundness attaches to the Veteran's claimed coccyx disorder. In this regard, at his May 1966 induction physical, the Veteran reported a history of back pain and a prior car accident with a minor back injury; however, upon clinical evaluation, no relevant abnormalities were noted. Subsequently, in December 1966, a military physician referred the Veteran to a specialist for an evaluation based on a history of back injury due to an automobile accident six months previously. However, the specialist reported there was no residual injury and that x-rays of the Veteran's lumbar spine revealed no evidence of bony abnormality. In addition, upon clinical evaluation at the Veteran's May 1967, no relevant abnormalities were noted. Mistakenly, in the March 2013 addendum opinion, a VA examiner stated that the entrance examination noted a displaced coccyx bone protruding to the left. In fact, this diagnosis is reported in the Veteran's service treatment records (STRs) in an entry dated January 1968 rather than on the entrance examination. Also of relevance, in the Board's May 2011 remand, the AVLJ indicated that this claim was originally denied because "the coccyx bone was a congenital disorder." However, the January 1999 rating decision and the March 1999 statement of the case both indicated that denial was based on a lack of in-service treatment for a coccyx injury, although this conclusion itself is also incorrect as evidenced by the Veteran's STRs. Instead, it was the Veteran's claim for a coccygeal mass that was denied based on the fact that such was a congenital condition. Furthermore, an STR dated February 1968 lists a "congenital anomaly" related to the Veteran's coccygeal region, but as the VHA examiner noted in her October 2016 opinion (discussed in greater depth below), it cannot be determined if that diagnosis referred to a coccyx bone disorder or a pilonidal cyst which was also diagnosed at that time. Based on the foregoing, the Board finds that the Veteran does not have a congenital disease or defect of the coccyx, and there is no clear and unmistakable evidence that a coccyx disorder existed prior to his service. The Board also finds that the competent evidence of record confirms that the Veteran has a currently diagnosed coccyx disorder. In this regard, in December 2012, the Veteran's private physician diagnosed coccydynia. Turning to the next element, in-service incurrence, the Veteran's STRs show a pilonidal cyst in October 1967. In January 1968, the Veteran complained of back pain for five years and, upon physical examination, there appeared to be a small incision, scar, or cyst at the coccyx. Additionally, the coccyx seemed to be set to the left one inch and was protruding slightly. In February 1968, it was noted that the Veteran had a pilonidal cyst with a hard bony mass underneath. The diagnoses included pilonidal cyst and displacement of the distal coccygeal segment. Upon referral to a surgeon the same month, it was noted that the Veteran had a pilonidal cyst over a large coccygeal mass, which was a congenital anomaly. Additionally, on the Veteran's September 1969 separation examination, his anus and rectum were noted to be abnormal with an inactive pilonidal cyst. However, to establish service connection there must also be probative evidence linking the Veteran's currently diagnosed coccyx disorder with his in-service treatment. In this regard, in accordance with the May 2011 Board remand, the Veteran was afforded a VA examination in June 2011. Following a review of the file and an examination of the Veteran's spine, the examiner endorsed the presence of a current disability, indicating that the Veteran suffered from "residuals of excision of [the] coccyx" manifested by pain. However, the examiner failed to provide an etiological opinion as requested by the Board. Furthermore, while his private physician offered an opinion in May 2012 that his coccyx pain is more likely than not related to the February 1968 injury documented as coccyx displacement, a rationale for such opinion was not provided. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). Accordingly, the Board remanded for an addendum opinion in December 2012. Pursuant to this remand, an addendum opinion was obtained from the June 2011 examiner in March 2013. In the opinion, the examiner noted that the Veteran had reported back pain prior to service and, as noted above, erroneously reported that the Veteran had a displaced coccyx bone at the time of entry into service. The examiner also noted that the Veteran received treatment for a cyst during service and his separation examination did not note pain in the coccygeal area. The examiner concluded there is no evidence that the coccyx bone area was aggravated by military service. However, such opinion failed to address all of the Board's inquiries as directed in the December 2012 remand. Furthermore, as indicated previously, such opinion was based on an inaccurate factual premise regarding when the Veteran's displaced coccyx bone was noted and did not address his in-service complaints of pain in the coccyx area. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Thus, as there remained some question as to whether the Veteran had a pre-existing coccyx abnormality, to include a congenital defect or disease, and, if so, whether such was subject to a superimposed disease or injury during service that resulted in additional disability or was aggravated during service, or if not, whether any acquired coccyx disorder was directly related to service, the Board requested an expert opinion from a VHA general surgeon in February 2016. In October 2016, the VHA examiner provided the requested opinion. In this regard, she indicated that she reviewed the record and found that "[i]t is not clear that the patient had a defect [or disease] of the coccygeal area prior to service." In support of such opinion, she noted that, while the February 1968 record indicated a congenital anomaly, which, by definition was present prior to service, such was not specific and there was unclear significance between such anomaly and the Veteran's displacement of the coccyx. The examiner further opined: The reported "congenital anomaly" is of unknown significance given th[e] lack of specifics and documentation provided. However, the presence of the "inactive pilonidal cyst," is not likely causing pain in the coccygeal area given the reported "inactive" nature. Based on the available history, the trauma to the coccygeal area causing "fractured coccyx" and "displacement of coccyx", was more likely than not, to be the inciting event that caused the [Veteran]'s pain in the coccygeal area. The most common etiology of coccygeal pain or "coccydynia" is trauma - which is present in this [Veteran]'s documented history. [A] [m]ajority of patients do get better with time and nonsurgical treatments. However, a small group of patients have intractable coccydynia where surgical excision or partial surgical excision of the coccyx is indicated, as coccydynia can impact quality of life to varying degrees. Even with surgical treatment, 25 [percent] of patients are not cured and have persistent disability." Based on the foregoing, the Board finds that the October 2016 VHA opinion is highly probative regarding a connection between the Veteran's in-service injury and residual coccyx disorder. While the VA examiner who conducted the 2011 VA examination and provided the 2013 addendum opinion reached a different conclusion regarding the etiology of the Veteran's disorder than the VHA examiner, the March 2013 opinion was based on an inaccurate factual premise and did not address all the relevant facts. In contrast, the October 2016 VHA opinion is supported by a review of the record, to include consideration of the Veteran's accurate medical history, and citation to medically accepted principles. Thus, the Board finds that the October 2016 opinion is the most probative evidence of record regarding the relationship between the Veteran's service and his diagnosed coccyx disorder. Nieves-Rodriguez, supra. 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, supra. Therefore, the Board resolves all doubt in the Veteran's favor and finds that service connection for coccydynia is warranted. ORDER Service connection for coccydynia is granted. ____________________________________________ A. JAEGER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs