Citation Nr: 1809205 Decision Date: 02/13/18 Archive Date: 02/23/18 DOCKET NO. 10-29 939 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Juan, the Commonwealth of Puerto Rico THE ISSUE Entitlement to service connection for degenerative joint disease of the bilateral shoulders, to include as secondary to service-connected palindromic rheumatism. REPRESENTATION Appellant represented by: Jonathan Bruce, Attorney at Law ATTORNEY FOR THE BOARD I. Altendorfer, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1952 to May 1955. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a March 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico. In February 2013 and December 2016, the Board remanded the claim for further development of the evidence. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2017). 38 U.S.C. § 7107(a)(2) (2012). FINDINGS OF FACT 1. The Veteran has a current diagnosis of degenerative joint disease of the bilateral shoulders. See January 2009 and August 2010 reports of VA examination. 2. The Veteran's service treatment records do not document complaints of or treatment for shoulder problems, including degenerative joint disease. 3. In a September 1971 rating decision, the RO granted service connection for rheumatoid arthritis that was later determined to be palindromic in nature. He has continued to receive treatment for palindromic rheumatoid arthritis since that time. 4. In March 12, 1997, the Veteran was diagnosed with degenerative osteoarthritis of both shoulders. 5. In December 2011, Dr. J.M.P. issued a medical opinion addressing the Veteran's rheumatoid arthritis and history of shoulder pain. The examiner noted evidence of degenerative changes in the shoulders and lumbar spine. In addressing the issue whether rheumatoid arthritis caused the Veteran's shoulder condition, the examiner stated "[t]he bilateral shoulder pain is more likely than not due to palindromic rheumatism." Further, the examiner opined, "[b]ased on the available medical records and what is evidenced in medical literature, it is more likely than not (i.e. at least 51%) that . . . he suffered intermittent episodes of arthritis affecting joints, especially the wrists, knees and ankles due to Palindromic rheumatism. The prognosis was guarded at the time." In addressing the issue of whether the Veteran's rheumatoid arthritis aggravated the severity of his shoulder condition, the examiner stated "[w]hile the lumbar spine disabilities are more likely that not due to degenerative disease relate to age, they are more than not aggravating the symptoms caused by his palindromic rheumatism. 6. A January 2009 VA examination report noted the Veteran's pain related to sudden inflammation of several articulations including both shoulders. The VA examiner reported findings of subchondral lytic defect on the humeral heads and recorded an impression of degenerative joint disease of the shoulders. In addressing whether the Veteran's palindromic rheumatism caused the Veteran's current bilateral shoulder condition, the examiner noted signs of fever, erythema, swelling and range of motion. Ultimately, the examiner opined that "bilateral shoulder degenerative changes . . . is less likely as not caused by or a result of palindromic rheumatism." He explained that the signs and symptoms observed "favor an inflammatory etiology such as palindromic rheumatism with a superimposed degenerative joint disease as seen in osteoarthritis; nevertheless due to intermittent nature of palindromic rheumatism there is a low probability of degenerative joint disease secondary to these episodes." 7. A November 2017 VA medical opinion stated that "there is no evidence in medical literature to support that palindromic rheumatism can cause or aggravate shoulder osteoarthritis (degenerative joint disease." The examiner explained that "due to intermittent nature of palindromic rheumatism there is a very low probability of degenerative joint disease secondary to these episodes (service connected condition). 8. The Veteran's bilateral shoulder condition, diagnosed as degenerative joint disease of the shoulder, was not shown to be causally or etiologically related to any disease, injury, or incident during service, did not manifest within one year of service discharge, and was not caused or aggravated by a service-connected disability. CONCLUSION OF LAW The requirements for establishing service connection for degenerative joint disease of the bilateral shoulders have not been met. 38 U.S.C. §§ 1101, 1110, 5107 (2012); 38 C.F.R. §§ 3.303, 3.310, 4.14 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Veteran contends that his bilateral shoulder condition, diagnosed as degenerative joint disease, is related to his military service. Specifically, the Veteran attributes his shoulder condition to cold exposure while serving in Korea. Alternatively, he asserts that his service-connected palindromic rheumatoid arthritis caused or aggravated his shoulder condition. In this regard, the Veteran reports that the severity of shoulder condition is worse during attacks of rheumatoid arthritis. Following careful review of the evidence of record, however, the Board finds that service connection for degenerative joint disease of the shoulders is not warranted, to include as secondary to service-connected palindromic rheumatism. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Regulations also provide that service connection is warranted for a disease first 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). Establishing service connection generally requires competent evidence of three things: (1) a current disability; (2) an in-service precipitating disease, injury, or event; and (3) a causal relationship, i.e., a nexus, between the current disability and the in-service event. Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009); 38 C.F.R. § 3.303(a). Service connection may also be established for a disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(a) (2017). With respect to service connection on a direct basis, the Veteran's service treatment records and post-service treatment records do not reflect complaints, treatment, or diagnoses referable to degenerative joint disease of the shoulder during active duty or for many years after the Veteran's separation from service. The first medical evidence of degenerative changes in the shoulders appeared in a March 1997 orthopedic examination reported, over forty years of separation from service. The November 2017 VA examiner opined that it was less likely than not that the Veteran's shoulder disorders were related to his military service, to reports of cold exposure in Korea. The VA examiner noted the separation physical was silent for any evidence of a chronic shoulder condition related to events in service. Further, the VA examiner based the opinion on the lack of evidence of a chronic shoulder pain until ten years after separation from service. Given the length of time between service and the initial diagnosis, the examiner found that the physical findings best correlated with degenerative joint disease secondary to the aging process. For support, the examiner noted that "it is very well known on medical literature that shoulder osteoarthritis is considered part of normal aging process in patients older than 40 years old." Consequently, the Board finds that the Veteran's bilateral shoulder osteoarthritis may not be presumed to have been incurred in service as it did not manifest to a compensable degree within one year of discharge from service. As a result, the Board finds the evidence does not support entitlement to service connection on a direct basis. See U.S.C. §§ 1101, 1112, 1137; 38 C.F.R. §§ 3.307. Next, the Board addresses service connection on a secondary basis. Service connection may be established on a secondary basis for a disability which is proximately due to or the result of service-connected disease or injury. 38 U.S.C. § 1131; 38 C.F.R. § 3.310 (a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a Veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Id. Regarding whether the Veteran's palindromic rheumatism caused the Veteran's degenerative joint disease of the bilateral shoulders, the January 2009 VA examiner opined that such a relationship was less likely than not. The examiner explained that despite the inflammatory relationship between palindromic rheumatism and degenerative joint disease, there was a low probability that degenerative joint disease could be caused by palindromic rheumatism due to the intermittent nature of palindromic rheumatism, and the fact that it resolved completely in between flares, such that the affected joint sustained no permanent damage. The November 2017 VA examiner opined similarly, noting that there is no evidence in medical literature to support that palindromic rheumatism can cause osteoarthritis. Next, the Board addresses the question of whether the Veteran's palindromic rheumatism has aggravated his bilateral shoulder osteoarthritis. Here, the November 2017 VA examiner opined that there was a very low possibility (i.e., that it was less likely than not) that the rheumatoid arthritis had aggravated the Veteran's shoulder condition "due to the intermittent nature of palindromic rheumatism," which resolves completely in between flares. Monzingo v. Shinseki, 26 Vet. App. 97, 105 (2012); see also Acevedo v. Shinseki, 25 Vet. App. 286, 293 (2012). The Board finds this opinion to be highly probative due to the examiner's supporting evidence and review of the claims file. In finding that the preponderance of the evidence weighs against a relationship between the bilateral shoulder osteoarthritis and the service-connected palindromic rheumatoid arthritis, the Board acknowledges that in December 2011 Dr. J.M.P opined generally that the Veteran's palindromic rheumatoid arthritis aggravated the symptoms of his degenerative joint disease. This opinion, however, provides only limited probative weight in favor of the Veteran's claim because the examiner did not provide a specific medical opinion as to whether the Veteran's service-connected palindromic rheumatism either caused or aggravated the Veteran's shoulder condition. While the examiner noted shoulder pain related to palindromic syndrome, the examiner did not specify whether the pain was associated with the Veteran's degenerative joint disease of the shoulders. In this regard, Dr. J.M.P. specifically addressed the wrists, knees, and ankles, but omitted the shoulders when discussing "joints." Even when read broadly to include the shoulders, the Board concludes that the opinion lacks sufficient probative value as it is generally speculative in nature. See Jones v. Shinseki, 23, Vet. App. 382, 389-90 (2010). Turning next to the Veteran's own assertions as to the relationship between his palindromic rheumatoid arthritis and his bilateral shoulder osteoarthritis, it is well established that a layperson without medical training is not qualified to render medical opinions regarding the etiology of certain disorders and disabilities. See 38 C.F.R. § 3.159 (a)(1). Here, the Veteran is not competent to attribute any increased symptoms of his shoulder condition to an attack of his rheumatoid arthritis. Therefore, the Board finds that the Veteran is not competent to speak to any element of aggravation. In summary, the Board finds the Veteran's current degenerative joint disease is not causally or etiologically related to any disease, injury, or incident of service, did not manifest within one year of his separation from active duty, and was not caused or aggravated by a service-connected disability. Consequently, the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable, and service connection is not warranted. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for degenerative joint disease of the bilateral shoulders is denied. ____________________________________________ S.C. KREMBS Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs