Citation Nr: 1647427 Decision Date: 12/20/16 Archive Date: 12/30/16 DOCKET NO. 12-16 519 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUE Entitlement to service connection for joint pain affecting the back, neck, shoulders, arms, elbows, wrists, hands/fingers, hips and legs to include as due to an undiagnosed illness. REPRESENTATION Appellant represented by: Paul Bunn, Accredited Representative WITNESSES AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Lamb, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1989 to April 1993. This matter is before the Board of Veterans' Appeals (Board) on appeal from an August 2009 rating decision of the North Little Rock, Arkansas, Department of Veterans Affairs (VA) Regional Office (RO). In November 2014, the Veteran testified at a Board videoconference hearing before the undersigned. A copy of the transcript of that hearing has been associated with the claims file. In August 2015 the Board remanded this case and instructed the RO to obtain a medical opinion addressing the nature, extent and likely etiology of the Veteran's reports of joint pain affecting his back, neck, shoulders, elbows, wrists and hands/fingers. In addition, if the joint pains were not attributable to a diagnosed medical condition, then the Remand instructed the VA examiner to provide an opinion as to whether they were attributable to an undiagnosed illness related to the Veteran's Persian Gulf War service or a medically unexplained chronic multisystem illness defined by a cluster of signs or symptoms. The Board notes that a VA examination was obtained in December 2015. The Board has reviewed the examination report and finds that it is adequate and complied with the Remand directives. Accordingly, after reviewing the actions of the Agency of Original Jurisdiction, the Board finds there was substantial compliance with the requested development. Dyment v. West, 13 Vet. App. 141 (1999); Stegall v. West, 11 Vet. App. 268 (1998). FINDINGS OF FACT 1. The Veteran served in the Southwest Asia theater of operations during the Persian Gulf War. 2. The Veteran's joint pain affecting his back, neck, shoulders, arms, elbows, wrists, hands/fingers, hips and legs have been attributed to clinical diagnoses; the clinical diagnosis include degenerative disc disease (DDD) and degenerative joint disease (DJD) of the lumbar spine with bilateral lower extremity radiculopathy, DDD and DJD of the cervical spine with bilateral upper extremity radiculopathy, bilateral shoulder, arm, hand and finger tendonitis, and chronic bilateral wrist sprain. 3. The Veteran's disabilities affecting his back, neck, shoulders, elbows, wrists, hands/fingers, hips and legs did not originate in service or within a year of service, and are not otherwise etiologically related to the Veteran's active service. CONCLUSION OF LAW The criteria for service connection for joint pain affecting the back, neck, shoulders, arms, elbows, wrists, hands/fingers, hips and legs have not been met. 38 U.S.C.A. §§ 1110, 1112, 1117, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.317, 3.385 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist Upon receipt of a substantially complete application, VA must notify the claimant and any representative of any information, medical evidence, or lay evidence not previously provided to VA that is necessary to substantiate the claim. The notice must: (1) inform the claimant about the information and evidence not of record that is necessary to substantiate the claim; (2) inform the claimant about the information and evidence that VA will seek to provide; and (3) inform the claimant about the information and evidence the claimant is expected to provide. 38 U.S.C.A. §§ 5103, 5103A, 5107 (West 2014); 38 C.F.R. § 3.159 (2015); Pelegrini v. Principi, 18 Vet. App. 112 (2004). The Board notes that the Veteran was provided 38 U.S.C.A. § 5103(a)-compliant notices in February 2009, prior to the initial adverse decision in this case. Thereafter, the claim was readjudicated in a June 2016 supplemental statement of the case. Thus, VA has satisfied its duty to notify the appellant and had satisfied that duty prior to the adjudication in the most recent June 2016 supplemental statement of the case. The Board also finds the duty to assist requirements have been fulfilled. The RO obtained VA medical examinations with respect to the Veteran's claim on appeal that occurred in June 2009, August 2012, and May 2015. In August 2015, the Board remanded this case in order to obtain adequate VA examinations of the Veteran's back, neck, shoulders, elbows, wrists, and hands/fingers. A series of VA examinations were obtained in December 2015. The Board has reviewed the examination reports and finds that they are adequate to adjudicate the claim on appeal. Additionally, all relevant, identified, and available evidence has been obtained, and VA has notified the appellant of any evidence that could not be obtained. The appellant has not referred to any additional, unobtained, relevant, available evidence. Thus, the Board finds that VA has satisfied the duty to assist provisions of law. No further notice or assistance to the Veteran is required to fulfill VA's duty to assist in development. Smith v. Gober, 14 Vet. App. 227 (2000); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C.A. § 1110, 1131 (West 2014); 38 C.F.R. § 3.303 (2015). In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may be presumed for certain chronic diseases, such as arthritis, which develop to a compensable degree within one year after discharge from service, even though there is no evidence of the disease during the period of service. That presumption is rebuttable by probative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2014); 38 C.F.R. 3.307, 3.309(a) (2015). Lay evidence presented by a Veteran concerning continuity of symptoms after service may not be deemed to lack credibility solely because of a lack of contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331 (2006). The Board has the authority to discount the weight and probity of evidence in light of its own inherent characteristics and its relationship to other evidence. Madden v. Gober, 125 F.3d 1477 (Fed. Cir. 1997). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Joint Pain The Veteran seeks service connection for joint pain affecting his back, neck, shoulders, arms, elbows, wrists, hands/fingers, hips and legs that he asserts is related to his period of service. Specifically, the Veteran asserts that the joint pain affecting the above represents an undiagnosed illness and is related to exposure to environmental conditions as a result of his unit serving in the area of the Khamisiyah demolition site and burning oil wells during the Persian Gulf War. 1. Factual Background The Board notes that the Veteran's service treatment records (STRs) are completely silent as to any complaints or treatment for musculoskeletal pain involving his lumbar or cervical spine, neck, shoulders, arms, elbows, hands/fingers, hips or legs. A July 1997 letter from the Department of Defense (DoD) informed the Veteran that he might have been exposed to a very low level of chemical warfare agents - sarin or cyclosarin - released during demolitions at Khamisiyah, Iraq. An April 2008 VA medical record noted that a musculoskeletal examination showed normal range of motion without pain, no deformities, normal muscle strength, normal gait and an erect posture. The Veteran reported back pain and arthritis. The Veteran further reported severe pain in the past, but that the pain had subsided after epidural injections and nerve blocks. In addition, the Veteran denied morning stiffness but claimed that the symptoms were worse at rest and improved with activity. The Veteran also underwent radiographic examinations of his cervical and lumbar spine that same month. The radiographic examination of the cervical spine revealed well-preserved vertebral heights, disc spaces and intervertebral foramina. In addition a radiographic examination of the lumbar spine revealed mild arthritic changes involving the facet joints from L3-S1 on both sides. A June 2008 VA medical record noted that blood work showed a high rheumatoid factor. The physician further noted unremarkable X-rays, except for arthritis noted in the lower back. Another June 2008 VA medical record noted chronic neck and lower back pain. In addition, the medical record noted hand pain with a positive rheumatoid factor but with other negative serologies and inflammatory markers. The physician noted possible early Sjogren's syndrome as a cause of the elevated rheumatoid factors. A December 2008 VA rheumatology medical record noted that the Veteran had a history of chronic lower back and cervical pain with no evidence of inflammatory arthritis. The Veteran reported back pain that radiated down his right hip and leg. He further reported stiffness in the morning. In his January 2009 claim, the Veteran stated that he had a current diagnosis for arthritis. In addition, a January 2009 VA medical record shows that the Veteran reported neck and back pain for the past seven to eight years. Further, the Veteran reported no injuries but some swelling of the joints. The Veteran underwent a VA examination in June 2009. He reported symptoms including stiffness involving his neck, shoulders and both upper extremities. In addition, the Veteran reported stiffness affecting his hands with symptoms beginning around 1998 to 1999. He further reported no significant injuries in service and no numbness or tingling. The examiner noted that X-ray studies revealed normal alignment of the cervical spine with some straightening and loss of lordosis. X-ray studies of the hands revealed normal bony anatomy, unremarkable oblique and lateral, and no typical rheumatoid type erosions. No X-ray of the lumbar spine was conducted. The examiner diagnosed the Veteran with "probable early rheumatoid arthralgia involving neck, shoulders and both upper extremities." The examiner opined that it was "less likely than not" that the Veteran's musculoskeletal complaints involving his neck and upper extremities are related to service incidents. This opinion was based on a history void of injury or incidents in service and the examiner's finding of apparent early stage rheumatoid arthritis. In an August 2009 addendum, the examiner stated that laboratory tests showed the Veteran had a positive rheumatoid factor that was "quite high." The physician further stated that the clinical diagnosis of rheumatoid arthritis in addition to multiple tests supporting an elevated rheumatoid factor were the reason for his June 2009 statement. In a June 2010 VA medical record, the Veteran reported suffering from stiffness in his lower back and hands for two hours each morning as well as arthralgia in his hands and shoulders. The Veteran also reported numbness in both hands. The physician noted DJD of the lumbar and cervical spine which he attributed to probable radiculopathy in the upper extremities as there was no evidence of inflammatory arthritis or spondyloarthropathy. An X-ray study showed normal sacroiliac joints. In August 2012, a VA examiner noted no mention of any type of undiagnosed illness in the Veteran's claims file or VA records. He did note a diagnosis for dyspepsia. During a November 2014 Board videoconference hearing, the Veteran testified that, in addition to his back and neck symptoms, he had been having problems with joint pain in his hands, fingers and hips. The Veteran further testified that no doctor had been able to clearly diagnose his conditions, and that he had been misdiagnosed in the past. Following a Board remand, the Veteran underwent another VA examination in May 2015. The VA examiner opined that the Veteran's claimed conditions "[were] less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness." The rationale provided by the examiner stated that the Veteran's "STR exit exam and current exam does not support and 2008 rheum exam and assessment was for sjogrens syndrome causing inc RA but normal sed rate thus 'no inflammatory arthritis' diagnosed." The Board notes that it previously found this statement almost indecipherable. The examiner further noted that the Veteran had diagnosed conditions for each of the claimed musculoskeletal groups except for his shoulders and arms. Other diagnosed conditions included: DDD of the lumbar spine with radiculopathy and intervertebral disc syndrome (IVDS); cervical strain from 1998-1999; bilateral Sjogren's syndrome of the elbow; bilateral Sjogren's syndrome of the hand/fingers; and bilateral Sjogren's syndrome of the wrist. A May 2015 VA medical record noted that the Veteran reported pain in his neck, shoulders and hands which he stated was present for over ten years, but which had developed slowly and had worsened over the past seven years. The Veteran further expressed concern that his joint pains were secondary to exposure to sarin gas among other possible exposures during his military service. X-rays were negative for signs of fractures or degeneration. Following another Board remand, the Veteran underwent a series of VA examinations in December 2015 for each claimed musculoskeletal region. Following the examinations, the VA examiner noted there were no undiagnosed illnesses. In addition, the examiner noted that etiologies had been established for each diagnosis. The examination report for the neck/cervical spine shows that the examiner diagnosed the Veteran with DDD and DJD with a date of diagnosis of 2010. In addition, the examiner diagnosed the Veteran with bilateral upper extremity radiculopathy with a date of diagnosis of 2010. The Veteran reported paraspinal muscle pain with the right side greater than the left. The examiner noted that MRI studies revealed DJD/DDD and found that radiation of the pain would affect the shoulders and arms. The examiner further found mild intermittent radicular pain as a symptom of radiculopathy. Nerve roots involved were noted to be C5/C6. IVDS was also found. The examiner opined that the Veteran's neck condition was "less likely as not related to his active duty service or Gulf War exposures." This opinion was based on a diagnosed condition, STRs silent as to any neck or cervical spine condition, and the Veteran's post-service occupation as a truck driver. The shoulder and arm examination resulted in a diagnosis for bilateral tenosynovitis (tendonitis), with a date of diagnosis of 2015. The Veteran reported flare-ups causing functional impairment described as increased pain with use. The examiner found that the Veteran's cervical DDD could be a component of his shoulder pain. The examiner found no additional contributing factors for the Veteran's bilateral shoulder disability. In addition, the examiner found that a rotator cuff condition was suspected, although the Veteran tested negative for related rotator cuff tests including Hawkins' impingement, empty-can, external rotation/infraspinatus strength test, and lift-off subscapularis test. The examiner opined that the Veteran's tendonitis with possible radicular component was "less likely as not related to his active duty service and Gulf War exposure." The examiner based his opinion on the fact that there were no undiagnosed illnesses or conditions, STRs silent as to any shoulder or arm condition, and the Veteran's post-service occupation as a truck driver. The examiner also diagnosed the Veteran with bilateral elbow and forearm tendonitis with a date of diagnosis of 2015. The examiner noted a history of bilateral pain near his elbows. The Veteran reported discomfort distal to the elbows, with pain in the right elbow worse than the left. Repetitive gripping was reported to cause flare-ups resulting in pain. The Veteran also reported using a tennis elbow strap on occasion. Based on a diagnosed bilateral elbow condition, and STRs silent as to treatment for tendonitis, the examiner opined that it was "less likely as not related to his active duty service or Gulf War exposures." An examination of the Veteran's wrists revealed a diagnosis of chronic bilateral wrist sprain with a date of diagnosis of 2008. The examiner noted a history of joint pain with ruled out rheumatoid arthritis. The Veteran complained of stiffness in his wrists that improved with hot baths. The Veteran also reported some difficulty with repetitive gripping that caused flare-ups resulting in increased pain. No other contributing factors were found. The examiner opinion that, based on STRs silent as to any wrist disability and post-service occupation as a truck driver requiring repetitive use of the Veteran's extremities, his bilateral wrist condition was "less likely as not related to his active duty service or Gulf War exposures." The examiner also diagnosed the Veteran with bilateral tendonitis of the hand/fingers with a date of diagnosis of 2008. The Veteran reported hand and finger stiffness and treatments for his condition included hot baths to "loosen" his joints. The Veteran further reported that he experienced episodic pain causing him to have difficulty holding objects. The examiner noted that the medical history taken by rheumatology in the past was consistent with radicular symptoms. Flare-ups were reportedly caused by repetitive gripping. The examiner opined that the Veteran's diagnosed hand and finger condition was "less likely as not related to his active duty service or Gulf War exposures." This opinion was based on a rheumatology medical history that found the condition had a radicular component from the Veteran's cervical disc disease. In addition the rheumatology medical history found a repetitive motion component such as tendonitis. Further, the examiner based his opinion on the Veteran's STRs that were silent as to any complaint for this condition and as well as a post-service occupation as a truck driver. During an examination of the Veteran's back, the examiner diagnosed the Veteran with DDD and DJD with a date of diagnosis of 2008. In addition, the examiner diagnosed the Veteran with bilateral lower extremity radiculopathy with a date of diagnosis of 2015. The nerve roots involved with the bilateral radiculopathy were noted as L4/L5/S1/S2 and S3, and the severity was noted as mild. The examiner noted that a rheumatology work up was negative for inflammatory arthritis. The Veteran reported daily pain in his lower back with episodic radicular symptoms in both legs with his right being more frequent that the left. Flare-ups were reportedly caused by prolonged lifting or sitting resulting in increased pain. IVDS was also found. Additionally, the examiner noted that imaging studies of the thoracolumbar spine documented arthritis. The examiner opined that the Veteran's conditions related to the back were "less likely as not related to his active duty service or Gulf War exposures." The opinion was based on the Veteran having a diagnosed condition and STRs silent as to any complaints for a back condition. Lastly, in July 2016 the Veteran submitted a private medical opinion from a board certified adult gerontology-clinical nurse specialist (AG-CNS). The AG-CNS opined that the "Veteran's symptoms...are more likely than not related to his Gulf War service." The opinion was based on a review of the Veteran's VA examination reports and all medical evidence in the claims file. The medical opinion also noted that the Veteran's symptoms and complaints of muscle fatigability with repeated use or prolonged standing "align with the requirements of the presumptive illnesses of the Gulf War medically unexplained chronic multi-symptom illness." 2. Legal Analysis The Board will first address the Veteran's claim for service connection for joint pain due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness under 38 C.F.R. § 3.317. Initially, as there is evidence that the Veteran served on active military duty during the Persian Gulf War he is deemed a Persian Gulf veteran. 38 C.F.R. § 3.317 (e) (2015). For purposes of section 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness; and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C.A. § 1117 (d) warrants a presumption of service connection. 38 C.F.R. § 3.317(a)(2) (2015). An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. 38 C.F.R. § 3.317(a)(1)(ii) (2015). In the case of claims based on an undiagnosed illness, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Further, lay persons are competent to report objective signs of illness. A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, and specifically includes chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (e.g. irritable bowel syndrome). A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. 38 C.F.R. § 3.317(a)(2)(i) (2015). Also, 38 C.F.R. § 3.317 also allows for service connection on a presumptive basis for certain enumerated infectious diseases. 38 C.F.R. § 3.317 (c)(2015). As none of the enumerated diseases are at issue in this case, the Board has omitted listing the diseases or discussing them. Objective indications of chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. 38 C.F.R. § 3.317(a)(3) (2015). Signs or symptoms that may be manifestations of undiagnosed illness or medically unexplained chronic multi-symptom illness include, but are not limited to, the following: (1) fatigue; (2) signs or symptoms involving skin; (3) headache; (4) muscle pain; (5) joint pain; (6) neurologic signs or symptoms; (7) neuropsychological signs or symptoms; (8) signs or symptoms involving the respiratory system (upper or lower); (9) sleep disturbances; (10) gastrointestinal signs or symptoms; (11) cardiovascular signs or symptoms; (12) abnormal weight loss; and (13) menstrual disorders. 38 C.F.R. § 3.317(b) (2015). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4) (2015). Lastly, compensation shall not be paid under section 3.317 if there is affirmative evidence that an undiagnosed illness was not incurred during active military service in the Southwest Asia theater of operations during the Persian Gulf War; if there is affirmative evidence that an undiagnosed illness was caused by a supervening condition or event that occurred between the veteran's most recent departure from active duty in the Southwest Asia theater of operations during the Persian Gulf War and the onset of the illness; or if there is affirmative evidence that the illness is the result of the veteran's own willful misconduct or the abuse of alcohol or drugs. 38 C.F.R. § 3.317(a)(7) (2015). The medical record shows that each of the Veteran's claimed musculoskeletal disabilities has received a diagnosis. These diagnoses include DDD/DJD of the cervical spine with radiculopathy of the upper extremities, DDD/DJD of the lumbar spine with radiculopathy of the lower extremities, tendonitis of the shoulder, arms, elbows and hand/fingers, and chronic bilateral wrist sprain. The Board recognizes the Veteran has had various diagnoses for his disabilities, including Sjogren's syndrome and "probable early rheumatoid arthralgia." Although these diagnoses proved to be incorrect, the medical record has consistently noted a diagnosis for degenerative changes of the lumbar spine based on radiographic examinations. The Veteran acknowledged this diagnosis in his January 2009 claim and radiographic evidence supports the diagnosis for degenerative changes of the cervical spine. Furthermore, the Veteran's muscle and joint pain affecting his upper and lower extremities were found related to his cervical and lumbar spine disabilities. In addition, the December 2015 VA examiner established separate diagnoses for muscle and joint pains affecting the Veteran's upper and lower extremities including diagnosis for tendonitis and chronic wrist sprain. The Veteran has not submitted any evidence to the contrary. Accordingly, the Board finds that the Veteran does not have an undiagnosed disability or a medically unexplained chronic multi-symptom illness pursuant to 38 C.F.R. § 3.317. The Board also recognizes the July 2016 private medical opinion linking the Veteran's symptoms to his Gulf War service and aligned with the "requirements of the presumptive illnesses of the Gulf War medically unexplained chronic multi-symptom illness." As noted above, the Veteran's claimed joint pain has been attributed to known diagnoses. The Board also notes that this medical opinion is dated seven months after the December 2015 VA examination that provided the diagnoses. However, although the AG-CNS asserted that she based her opinion on a review of the Veteran's VA examination reports and all medical evidence in the claims file, she failed to address any conflicting medical evidence or provide reasoning why the Veteran's medically diagnosed conditions were an "unexplained chronic multi-system illness." As such, the Board finds this medical opinion to be speculative in nature and of little probative value. Therefore, because the Veteran's muscle and joint pain has been specifically attributed to known diagnoses and such are not a condition for which the Secretary has determined a presumption of service connection is warranted under 38 C.F.R. § 3.317(c), service connection for muscle pain and joint pain as a result of an undiagnosed illness is not warranted. Accordingly, the Board finds that the preponderance of the evidence is against the claim for service connection for muscle and joint pain due to an undiagnosed illness under 38 C.F.R. § 3.317. The Board will now address whether the Veteran's diagnosed disabilities are directly related to active duty service. As noted above, the Veteran's STRs are silent as to any complaints or treatment for musculoskeletal pain involving his lumbar or cervical spine, neck, shoulders, elbow, arms, hands/fingers, hips or legs. Moreover, the record shows that the Veteran denied any service connected incident in service related to these musculoskeletal regions, as documented by a January 2009 VA medical record and the June 2009 VA examination report. Thus, there are no lay statements linking his current disabilities to service. As noted above, in order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Thus, after reviewing the evidence of record the Board finds no competent evidence establishing an in-service event or injury concerning the Veteran's claimed musculoskeletal disabilities. Accordingly, as the second Shedden element has not been met, the Veteran's claim for service connection on a direct service connection basis is not warranted. In sum, the Board concludes that service connection for muscle and joint pain, to include as due to an undiagnosed illness, is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection. The claim is denied. See 38 U.S.C.A. § 5107 (b) (West 2014); 38 C.F.R. § 3.102, 3.317 (2015); Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). ORDER Entitlement to service connection for joint pain affecting the back, neck, shoulders, arms, elbows, wrists, and hands/fingers, hips, to include as due to an undiagnosed illness, is denied. ____________________________________________ Thomas H. O'Shay Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs