Citation Nr: 1751947 Decision Date: 11/14/17 Archive Date: 11/22/17 DOCKET NO. 14-01 682 DATE THE ISSUES 1. Entitlement to service connection for nerve pain, right upper extremity, to include as secondary to service-connected cervical thoracic spine sprain. 2. Entitlement to service connection for nerve pain, left upper extremity, to include as secondary to service-connected cervical thoracic spine sprain. 3. Entitlement to service connection for foot drop, right lower extremity, to include as secondary to service-connected cervical thoracic spine sprain. ORDER Service connection for nerve pain of the right and left upper extremities and for foot drop, right lower extremity, is denied. FINDINGS OF FACT 1. There is no diagnosis in the record accounting for the Veteran's nerve pain in the right upper extremity other than functional neurological disorder. 2. There is no diagnosis in the record accounting for the Veteran's nerve pain in the left upper extremity other than functional neurological disorder. 3. There is no diagnosis in the record accounting for the Veteran's foot drop in the right lower extremity other than functional neurological disorder. 4. There is no competent evidence in the record suggesting a relationship between functional neurological disorder and any of the Veteran's service-connected disabilities. CONCLUSIONS OF LAW 1. The criteria for service connection for nerve pain, right upper extremity, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1154, 5103, 5103A, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). 2. The criteria for service connection for nerve pain, left upper extremity, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1154, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. 3. The criteria for service connection for foot drop, right lower extremity, have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1154, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Navy from February 1993 to July 2000. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The Veteran testified before the undersigned Veterans Law Judge (VLJ) at a videoconference hearing in September 2014. This case was previously before the Board in July 2015, when it was remanded for Agency of Original Jurisdiction (AOJ) development. The case has been returned to the Board at this time for further appellate review. Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical 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) medical evidence of a nexus between the current disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also 38 C.F.R. § 3.303, Hickson v. West, 12 Vet. App. 247, 252-53 (1999). Service connection may be granted on a secondary basis for a disability that is shown to be proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Service connection on a secondary basis may not be granted without medical evidence of a current disability and medical evidence of a nexus between the current disability and a service-connected disability. See Wallin v. West, 11 Vet. App. 509, 512-14 (1998); see also Allen v. Brown, 7 Vet. App. 439, 488 (1995). Here, the Veteran seeks service connection for complaints of burning sensations in her right and left upper extremities. The Veteran's VA treatment records reflect multiple reports of pain and tingling in the left arm and hand prior to a December 2011 cervical spine surgery, as well as a May 2012 report of bilateral shooting pain in both upper extremities. A December 2016 VA treatment note reported complaints of a burning sensation in the Veteran's left upper extremity that would occur approximately every 12 hours during periods when her facet blocks wear off, approximately every 3-4 months; at that visit, the Veteran denied weakness or numbness in her extremities. A May 2012 VA treatment record noted that the physical examination of the Veteran was not consistent with cervical radiculopathy of the upper extremities, as the Veteran exhibited normal strength bilaterally and no exacerbation of the reported symptoms with changes in position. Imaging reviewed at this visit showed only changes associated with the December 2011 surgery. In September 2012, the Veteran underwent a VA examination, in which she reported a sensation of "hot rain" pouring down her hands and her right leg since the surgery. There was no radicular pain noted on the cervical spine examination, and the sensory examinations of the shoulder, inner and outer forearm, and hand and fingers were all normal. The examiner noted that, at that point in time, there was no physiologic cause for the Veteran's reported symptoms. The examiner provided no diagnoses for any cranial or peripheral nerve conditions, and all the nerve groups tested were noted to be normal. A July 2014 MRI showed moderate-to-severe left neural foraminal narrowing at C6-C7, with potentially mildly compressed nerve roots on the left. The neuroradiologist noted considering correlation for bilateral C7 radiculopathy. The VA treatment records also reflect a November 2015 MRI that showed mild retrolisthesis of C6-C7, which was associated with degenerative change. The neurologist at this visit noted that the Veteran's work-ups for "multiple variable complaints including numbness/weakness/myoclonic jerking/gait problems/PNEA episodes as well as possible cervical dystonia" over several years had been extensive but "unrevealing," although they did determine that the associated spells of her arms shaking were non-epileptic in origin. The neurologist diagnosed the Veteran with functional neurological disorder, and recommended cognitive behavior therapy as treatment. The Veteran underwent another VA examination in March 2016, in which she reported a burning sensation in her left arm extending from the deltoid area to her forearm. The Veteran denied any numbness, tingling, or weakness in her right upper extremity. Upon examination, the Veteran was not found to have any symptoms attributable to any peripheral nerve conditions, and her muscle strength testing, sensory testing, and reflexes were all normal. All the nerve groups tested were noted to be normal. The only abnormalities noted were findings of focal slowing across both wrists, associated with carpal tunnel syndrome, which is not related to peripheral nerve damage. There was no electrodiagnostic evidence of neuropathy or radiculopathy. The examiner concluded that there was no peripheral nerve condition or cervical radiculopathy diagnosed to explain the reported burning pain in her left arm. The Veteran also seeks service connection for foot drop in her right foot. She testified at the September 2014 hearing that the symptoms began occurring after the December 2011 surgery. The VA treatment records reflect that she wears an ankle foot othosis (AFO) to help with these symptoms. The September 2012 VA examination returned normal results for the sensory examination of the Veteran's upper anterior thigh, thigh and knee area, lower leg and ankle, and feet and toes. The examiner noted that the etiology of the slight dragging of the right leg was unknown, and possibly psychogenic, but the examination was not conclusive. All of the nerve groups affecting the lower extremities were noted to be normal. In the March 2016 VA examination, the Veteran again reported difficulty walking that developed after the December 2011 cervical spine surgery, in that she dragged her right foot when she walked. The Veteran reported that she was able to dorsiflex and plantar flex her right foot without any difficulty, and the strength of the foot was noted to be normal upon examination. She was not using the AFO on the day of the examination. The Veteran was not found to have any symptoms attributable to any peripheral nerve conditions, and her muscle strength testing, sensory testing, and reflexes were all normal. There was no etiology identified for the right foot drag, which again was identified as possibly psychogenic. All of the nerve groups affecting the lower extremities were noted to be normal, and there was no electrodiagnostic evidence of neuropathy or radiculopathy. The examiner concluded that the normal muscle strength in the Veteran's foot was inconsistent with a diagnosis of true foot drop, and that there was no peripheral nerve condition or lumbosacral radiculopathy diagnosed to explain this symptom. The Board notes that in the March 2016 medical opinion, the examiner discussed the Veteran's left foot and not the right foot. However, all the specific references were to data points that had identical results between the left and right feet in the examination. Therefore, the rationale appears to apply equally to the Veteran's right foot. There is no diagnosis in the record of a physical/neurological cause of the Veteran's reported nerve pain and foot drop. The VA examinations did not identify radiculopathy, sensory abnormalities, peripheral nerve conditions, or neuropathy in the upper extremities. Although a July 2014 MRI raised the possibility of bilateral C7 radiculopathy, physicians and neurologists treating the Veteran after this test never confirmed a diagnosis of radiculopathy. Similarly, all physical examination results of the Veteran's right lower extremity were normal, including strength, reflexes, and flexion, and no diagnosis of neuropathy or radiculopathy was made in the record or reported by the Veteran. The March 2016 examiner noted that normal muscle strength is inconsistent with foot drop. The existence of a current disability is the cornerstone of a claim for VA disability compensation. 38 U.S.C.A. § 1110; see Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Having found no competent and credible evidence of record that the Veteran has a diagnosis causing right or left upper extremity nerve pain or right lower extremity foot drop, the first element of service connection has not been met for any of these three issues. See 38 C.F.R. §§ 3.102, 3.303. There is a diagnosis in the record that addresses the reported nerve pain and foot drop as symptoms of a psychological disorder - the functional neurological disorder diagnosed in November 2015. However, there is no evidence in the record suggesting a relationship between this disorder and the Veteran's active service or to any of her service-connected disabilities. The neurologist emphasized working closely with the mental health clinic as the preferred course of treatment, and did not, for instance, suggest follow-ups with specialists to treat the left foot and right knee in an attempt to improve the functional neurological disorder. Accordingly, service connection is not warranted for the Veteran's reported nerve pain and foot drop as part of the functional neurological disorder, as there is no evidence of record that the disorder is related in any way to the Veteran's active duty service. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claims, that doctrine is not applicable in this case. See 38 U.S.C. § 5.107(b); 38 C.F.R. § 3.102. ____________________________________________ M. HYLAND Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD: K. Josey, Associate Counsel Copy mailed to: Disabled American Veterans Department of Veterans Affairs