Citation Nr: 1805393 Decision Date: 01/26/18 Archive Date: 02/07/18 DOCKET NO. 07-19 383 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Baltimore, Maryland THE ISSUE 1. Entitlement to service connection for arthritis of multiple joints, to include bilateral ankles and elbows. 2. Entitlement to service connection for arthritis of the bilateral shoulders. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD D. Whitehead, Senior Counsel INTRODUCTION The Veteran served on active duty from July 1970 to July 1974 with the United States Coast Guard. He also served with the Army National Guard and was discharged in March 2004. This case comes before the Board of Veterans' Appeals (Board) on appeal from a June 2005 rating decision issued by the Department of Veterans Affairs (VA) Hartford Regional Office (RO) in Newington, Connecticut, and a March 2006 rating decision issued by the Baltimore, Maryland RO. Jurisdiction is with the Baltimore RO. The claim was remanded by the Board in April 2011, August 2013, and April 2015. Although service connection for arthritis of the wrists was initially part of this appeal, service connection for osteoarthritis of the left wrist and traumatic arthritis of the right wrist was granted in a June 2012 rating decision. The initial appeal also included claims for service connection for arthritis of the bilateral hips and knees, and these claims were granted in a 2017 rating decision. This represents a full grant of benefits as to the wrists, hips, and knees. The Veteran testified before the undersigned during a VA Central Office hearing in September 2010. The transcript of the proceeding is of record. FINDINGS OF FACT 1. The Veteran does not have currently diagnosed ankle and elbow disorders. 2. The Veteran's arthritis of the left and right shoulders was incurred during active service. CONCLUSIONS OF LAW 1. The criteria for service connection for arthritis of multiple joints, to include bilateral ankles and elbows, have not been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.34, 3.307, 3.309 (2017). 2. The criteria for service connection for arthritis of the left and right shoulders have been met. 38 U.S.C. §§ 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS At the outset, the Board notes that it has reviewed all of the evidence of record, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record, but does not have to discuss each piece of evidence). Hence, the Board will summarize the relevant evidence where appropriate and the Board's analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim on appeal. In order to obtain service connection under 38 U.S.C. §§ 1110, 1131 and 38 C.F.R. § 3.303(a) a Veteran must satisfy a three element test: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service - the so- called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Walker v. Shinseki, 708 F.3d 1331, 1333 (Fed. Cir. 2013). For a Veteran who served 90 days or more of active service after December 31, 1946, there is a presumption of service connection for certain chronic diseases, to include arthritis, if the disability is manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "chronic." Continuity of symptomatology after discharge is required where the condition noted during service is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. 38 C.F.R. § 3.303 (b); See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (the theory of continuity of symptomatology can be used only in cases involving those conditions explicitly recognized as chronic as per 38 C.F.R. § 3.309 (a)). Service connection may also be granted for any disease diagnosed after discharge when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection may also be granted for disability resulting from disease or injury incurred or aggravated while performing active duty for training (ACDUTRA), or from an injury incurred or aggravated while performing inactive duty for training (INACDUTRA). 38 U.S.C.A. §§ 101(24), 106. ACDUTRA includes full-time duty performed by members of the National Guard of any state. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(1). INACDUTRA includes part-time duty by members of the National Guard of any state. 38 U.S.C.A. § 101(22); 38 C.F.R. § 3.6(c)(1). The Veteran claims that he currently has arthritis of the bilateral ankles, shoulders, and elbows due to service. He essentially claims to have sustained injuries to these joints while on active duty and to have experienced related symptomatology since service. Bilateral Ankles and Elbows Regarding the bilateral ankle and right elbow claims, the medical evidence of record fails to show current diagnoses for these disorders. Lack of current ankle and right elbow disabilities was confirmed by VA joint examinations in September 2004 and October 2013. The examiners, who reviewed the claims folder and interviewed the Veteran, determined there was no current diagnosis of an ankle or elbow disorder. Notably, the 2004 and 2013 physical examinations of the ankles and elbows were normal, as were the associated 2004 and 2011 X-ray examinations. The examiners confirmed that the Veteran has not been diagnosed with ankle or elbow disorders since he filed his claim in 2004. Similarly, non-VA and VA treatment records show no complaints of or treatment for an elbow or ankle disorder. Although the service treatment records reflect treatment for a sprained ankle in September 1973, subsequent service treatment and post-service medical records are silent for any reported symptoms or clinical diagnoses related to the ankle. Thus, the medical evidence is clear in that bilateral elbow or ankle disorders are not present. The Board finds the 2004 and 2013 VA examination findings in this regard to be well-supported and highly relevant to the determination that there are no currently diagnosed elbow and ankle disorders. In order to warrant service connection, the threshold requirement is competent evidence of the existence of the claimed chronic disability at some point during a veteran's appeal. See McClain v. Nicholson, 21 Vet. App. 319 (2007) (requirement that a current disability be present is satisfied "when a claimant has a disability at the time a claim for VA disability compensation is filed or during the pendency of that claim...even though the disability resolves prior to the Secretary's adjudication of the claim"); see also Degmetich v. Brown, 104 F.3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223 (1992). Although the Board recognizes the Veteran's sincere belief in his claim and description of his symptoms, the most competent medical evidence of record shows that the Veteran does not have a currently diagnosed bilateral elbow or ankle disorder during any period of his appeal. His assertions are outweighed by the 2004 and 2013 VA examination findings. Based on the above, the Board finds that the preponderance of the evidence is against the claim, and entitlement to service connection for arthritis of the bilateral ankles and elbows must be denied. There is no reasonable doubt to be resolved. See 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Bilateral Shoulders As for this claim, the medical evidence indicates that the Veteran has a current diagnosis of arthritis of the left and right shoulder, as confirmed during the October 2013 VA examination. Thus, the pertinent question before the Board is whether his currently diagnosed bilateral shoulder disorders are related to his active duty service. Service treatment records dated during the Veteran's period of active duty document the identified incidents during which he claims to have sustained injuries to his right and left shoulder. A September 1973 service treatment record reflects that the Veteran fell from a ladder and suffered injuries on his right side, but does not include specific notations for the right shoulder. A June 1974 service treatment record documents his report of left shoulder pain after a car that he was working under fell off of the jack onto his shoulder and shows a diagnosis of contusion to the left shoulder with resultant tenderness. The remaining records dated during the Veteran's active duty service are silent for reports of any pertinent symptomatology or diagnoses. Subsequent records dated during the Veteran's service in the National Guard document additional reports of shoulder symptomatology and diagnoses. A December 1993 physical examination revealed that the Veteran's acromioclavicular (AC) joint was "much more prominent" on the right. On the associated report of medical history, the Veteran indicated that he had a painful or "trick" shoulder or elbow. The examiner noted the Veteran had a painful, "separated" right AC joint due to injuries. A February 1999 report of medical history includes the Veteran's additional report of a painful or trick shoulder or elbow and the examiner's notations of arthritis and AC strain of the right shoulder. The associated February 1999 medical examination did not reveal any abnormalities of the upper extremities. A June 2003 record notes the Veteran had polyarthralgias of multiple joints and includes his report of pain in his shoulders and a history of trauma to his right shoulder/AC joint in the 1970s. The physical examination was negative for any pertinent findings. The record includes multiple VA examination reports and medical opinions. The Board determined in April 2014 that a September 2012 VA medical opinion is inadequate for adjudication purposes, and thus requires no further discussion. A September 2004 examination did not show any abnormalities of the shoulders, other than decreased range of motion for the right shoulder, and resulted in a diagnosis of arthralgias of multiple joints. The September 2004 examiner identified past strains as the likely etiology of the Veteran's joint pain. Following an October 2013 VA examination, the examiner opined that the shoulder disorders were less likely than not due to the claimed in-service injury because, in part, bilateral shoulder osteoarthritis was not noted during active service or for many years thereafter. In April 2017, a VA examiner who reviewed the evidence noted that the medical evidence "fails to show that this disability has been clinically diagnosed during active military service" and opined that the Veteran's shoulder disorders were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. Resolving all doubt in favor of the Veteran, the Board finds that service connection for osteoarthritis of the left and right shoulder is warranted because the evidence satisfactorily establishes that the claimed disability originated during the Veteran's active service. The Board notes that the Veteran's lay statements have consistently presented reports of shoulder injuries during service and his continued bilateral shoulder disability symptoms thereafter. Although his service treatment records while on active duty do not contain specific notations of a right shoulder injury or a diagnosis of arthritis of either shoulder, the Board finds this of limited probative value when compared to his current specific and consistent statements endorsing continued complaints of pain and injuries while on active duty. Notably, the service treatment records document the cited in-service incidents the Veteran attributes to his current left and right shoulder disorders, and he has provided credible evidence of bilateral shoulder symptoms, to include continued complaints of pain during and since his active. His symptoms were later associated with a diagnosis of osteoarthritis of the left and right shoulders and, thus warrants service connection based on a continuity of symptomatology. See 38 C.F.R. § 3.303(b). In reaching this conclusion, the Board acknowledges the October 2013 and April 2017 VA examiners' opinions that the Veteran's bilateral shoulder disorder was not incurred during active service. However, these opinions are primarily based on the absence of treatment records in service and do not give adequate consideration of the Veteran's competent and credible lay statements. Therefore, these opinions are of limited probative value and do not outweigh the credible lay evidence of record. The Board also acknowledges the VA opinions of record that address whether the Veteran's shoulder disorders were incurred during a period of ACDUTRA or INACDUTRA service. However, as the Board finds that the Veteran's left and right shoulder disorders were incurred during his active duty service, no discussion regarding the relationship between the disorders and his reservist service is warranted. The Veteran has reported experiencing recurrent left shoulder disability symptomatology since service and the Board finds his lay accounts to be credible. Therefore, as the evidence is at least in relative equipoise, the Board finds that the Veteran experienced recurrent left and right shoulder disability symptomatology in service and since service discharge. Resolving reasonable doubt in the Veteran's favor, the Board finds that service connection for arthritis of the left and right shoulder is warranted. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for arthritis of multiple joints, to include bilateral ankles and elbows, is denied. Service connection for arthritis of the bilateral shoulders is granted ____________________________________________ N. Rippel Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs