Citation Nr: 18144762 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 09-42 039A DATE: October 25, 2018 ORDER Entitlement to service connection for a bilateral arm disability, to include shoulder strain, and to include as secondary to service connected disabilities is denied. Entitlement to service connection for a bilateral knee disability, to include patellofemoral syndrome, and to include as secondary to service connected disabilities is denied. Entitlement to service connection for a bilateral foot disability, to include pes planus, and to include as secondary to service connected disabilities is denied. FINDINGS OF FACT 1. The Veteran’s bilateral arm disability, to include shoulder strain, was not present in service or within one year of separation therefrom, is not etiologically related to his active duty, and was not caused or permanently worsened by his service connected disabilities. 2. The Veteran’s bilateral knee disability, to include patellofemoral syndrome, was not present in service or within one year of separation therefrom, is not etiologically related to his active duty, and was not caused or permanently worsened by his service connected disabilities. 3. The Veteran’s bilateral foot disability, to include pes planus, was not present in service or within one year of separation therefrom, is not etiologically related to his active duty, and was not caused or permanently worsened by his service connected disabilities. CONCLUSIONS OF LAW 1. The Veteran’s bilateral arm disability was not incurred in or aggravated by active service, may not be presumed to have been so incurred, and is not proximately due to or aggravated by his service-connected disabilities. 38 U.S.C. §§ 1101, 1110, 1112, 1131; 38 C.F.R. § 3.310 (2018); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). 2. The Veteran’s bilateral knee disability was not incurred in or aggravated by active service, may not be presumed to have been so incurred, and is not proximately due to or aggravated by his service-connected disabilities. 38 U.S.C. §§ 1101, 1110, 1112, 1131; 38 C.F.R. § 3.310 (2018); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). 3. The Veteran’s bilateral foot disability was not incurred in or aggravated by active service, may not be presumed to have been so incurred, and is not proximately due to or aggravated by his service-connected disabilities. 38 U.S.C. §§ 1101, 1110, 1112, 1131; 38 C.F.R. § 3.310 (2018); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2018). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active service from September 1972 to September 1975. The Veteran testified at a videoconference Board hearing in March 2012. A transcript is of record. This case was remanded by the Board in March 2016, April 2017, and in January 2018 for further development. That development has been accomplished, and the claim has now been returned to the Board for further action. Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence must show: (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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). It is not enough that an injury or disease occurred in service; there must be chronic disability resulting from that injury or disease. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303 (b). When an organic disease of the nervous system such as hearing loss is manifested to a compensable degree within a year of separation from qualifying service, it may be presumed to have been incurred in or aggravated by active military service. 38 C.F.R. §§ 3.307, 3.309. Service connection may also be awarded on secondary basis for a disability that is either (1) proximately due to or the result of an already service-connected disease or injury or (2) aggravated by an already service-connected disease or injury. See Allen v. Brown, 7 Vet. App. 439, 448 (1995); 38 C.F.R. § 3.310 (2016). 1. Entitlement to service connection for a bilateral arm disability, to include shoulder strain, and to include as secondary to service connected disabilities 2. Entitlement to service connection for a bilateral knee disability, to include patellofemoral syndrome, and to include as secondary to service connected disabilities 3. Entitlement to service connection for a bilateral foot disability, to include pes planus, plantar fasciitis, hallux valgus, and hammertoe, and to include as secondary to service connected disabilities Here, the Veteran essentially contends that he has a bilateral arm, knee, and foot disabilities began in service. Alternately, he maintains that his bilateral arm, knee, and foot disabilities were caused, or aggravated, by his service connected disabilities. Initially, and in this regard, the Board notes that service treatment records are silent as to diagnoses for a bilateral arm, knee, and foot disorder. Various in-service examinations reflected normal musculoskeletal evaluations. A January 2003 VA examination report stated the Veteran was seen for knee pain once in service and was given liniment, but no definitive diagnosis of a knee disability was made. The Veteran reported aching and swelling in both of his knees, and he did not recall any knee injury in service. The Veteran also reported several episodes of left great toe swelling which subsides and was diagnosed as gout. There was no record found in service, x-ray of the foot, or further description of any arthritis of the foot or any other change. The examiner diagnosed bilateral pes planus. The examiner opined there was no reason to relate the single knee complaint in service to the present condition of the right knee nor of the left foot. A May 2014 VA examination report noted that after review of limited records, it was less likely than not that the Veteran’s claimed bilateral knee condition was related to service. As rationale, the examiner stated there was not enough evidence of record to connect the claimed bilateral knee condition to service. In a May 2017 VA examination report, the examiner opined that it was less likely than not that the claimed bilateral arm disability was related to his active service as there was no service treatment record for either elbow or forearm treatment or diagnosis, and the first reported complaint of right elbow pain was not until December 2009, or well after service discharge. The examiner added that there was insufficient evidence found during the current examination to warrant a diagnosis for a current bilateral arm disability. The examiner also opined the Veteran’s claimed bilateral foot disability, diagnosed as bilateral pes planus, was less likely than not related to his active service. The examiner’s rationale included that there was only a singular service treatment record which noted gout in 1975 without specificity, there was no service treatment record for pes planus, and x-rays taken in February 2014 reflected normal feet. Finally, the examiner stated the Veteran’s claimed bilateral knee disability was less likely than not related to his active service as there were no service treatment records which reflected a bilateral knee treatment or diagnosis, no diagnosis of a bilateral knee condition had been made, February 2014 x-rays of the bilateral knees were normal, and the current examination had insufficient evidence to diagnose any bilateral knee condition. In regard to secondary service connection, the examiner opined it was less likely than not that the Veteran’s claimed bilateral arm disability or bilateral knee disability was proximately due to or aggravated by his service connected neck, back, or radiculopathy as there was no current diagnosis of a bilateral arm or bilateral knee disability. The examiner also opined that it was less likely than not that the Veteran’s claimed bilateral foot disability was proximately due to or aggravated by his service connected neck, back, or radiculopathy as the claimed foot disability and service connected disabilities were separate and distinct diagnoses which were not causative of each other. At a July 2017 VA examination, the examiner diagnosed shoulder strain but did not provide a direct etiological opinion. The examiner did opine that the diagnosed shoulder strain was unaffected by the Veteran’s service connected neck disability as there was no pathophysiologic connection between spinal or lower extremity problems and orthopedic shoulder problems. A May 2018 addendum examiner opined that it was less likely than not incurred in or related to the Veteran’s active service as there was no bilateral arm disability, to include arm strain, noted during active service or noted on his service discharge examination. He also opined that the claimed bilateral arm disability was less likely than not proximately due to, caused by, or aggravated by his service connected lumbar strain, right leg radiculopathy, left leg radiculopathy, or cervical strain as there is no anatomical relationship to establish an etiological basis between a bilateral arm disability and the service connected disabilities. He further opined that while the trapezius muscle has attachments with the neck and shoulder, and there is no established medical record of the neck condition in relation to the upper arms, to include shoulder strain. Concerning the claimed bilateral foot condition, the examiner opined it was less likely than not related to his active service as there was no diagnosis of plantar fasciitis on the day of the most recent examination, the singular episode of gout noted in service treatment records is not a condition that could lead to any diagnosed foot condition per supporting medical literature, and the Veteran’s claimed bilateral foot disabilities first began after service discharge. He also opined that the claimed bilateral foot disability was less likely than not proximately due to, caused by, or aggravated by his service connected lumbar strain, right leg radiculopathy, left leg radiculopathy, or cervical strain as there is no anatomical relationship to establish an etiological basis between a bilateral foot disability and the unrelated musculoskeletal service connected disabilities. Finally, the examiner opined the Veteran’s bilateral knee condition, to include patellofemoral syndrome, was less likely than not incurred in or related to active service as there was no diagnosis or treatment of a bilateral knee condition while in service or on service discharge relationship. He also opined the claimed bilateral knee condition was less likely than not proximately due to, caused by, or aggravated by his service connected lumbar strain, right leg radiculopathy, left leg radiculopathy, or cervical strain as patellofemoral pain syndrome is related to the tracking of the patella over the anterior knee joint, and there is no anatomical relationship between that and lumbar strain (which involves the stretching of paraspinous muscles), lumbar radiculopathy (which is related to irritation of the sciatic nerve), or cervical strain (which is related to stretching of paravertebral muscles of the neck). Medical treatment records provide no etiological opinion concerning the claimed bilateral arm, bilateral knee, or bilateral foot condition. As such, the Board finds that service connection for a bilateral arm, bilateral foot, and/or a bilateral knee is not warranted. Although medical evidence of record reflects the Veteran has or had diagnoses of shoulder strain, bilateral patellofemoral syndrome, and bilateral pes planus, there is no medical evidence supporting a finding that any of the claimed conditions are related to active service or proximately related to or aggravated by any of the Veteran’s service connected disabilities. On the contrary, every VA examination report of record all provided negative nexus opinions for the claimed disabilities and stated there was no relationship between the Veteran’s claimed disabilities and his active service or any of his service connected disabilities. The Board finds these opinions highly probative against the Veteran’s claims for service connection as the opinions were based on the Veteran’s pertinent medical history as well as the results of a physical examination, and they give a thorough, well-explained rationale for all opinions; the reports provide an adequate basis for the diagnosis and opinions rendered. See generally Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The only evidence of record suggesting a link or nexus between the Veteran’s claimed disabilities and his active service or service connected disabilities comes from the Veteran himself. While the Veteran is competent to provide statements relating to symptoms or facts of events that he has observed and is within the realm of his personal knowledge, he is not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-470 (1994). The record does not show, nor does the Veteran contend, that he has specialized education, training, or expertise that would qualify him to render a diagnosis or render a medical opinion on this matter. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the issues in this case are outside the realm of common knowledge of a lay person because it involves a complex medical issue that goes beyond a simple and immediately observable cause-and-effect relationship. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). For the reasons stated above, the Board concludes that the preponderance of evidence is against granting service connection for a bilateral arm condition, a bilateral knee condition, and/or a bilateral foot condition on any theory of entitlement raised by the Veteran or the record. Thus, there is no reasonable doubt to be resolved in the Veteran’s favor, and the claims must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. THOMAS H. O'SHAY Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD N. Peden, Associate Counsel