Citation Nr: 20031548 Decision Date: 05/05/20 Archive Date: 05/05/20 DOCKET NO. 15-02 445 DATE: May 5, 2020 ORDER Entitlement to service connection for premature ventricular contraction (PVC) (claimed as irregular heartbeat) secondary to service-connected hypertension is denied. Entitlement to service connection for right hand arthritis (degenerative and rheumatoid) is denied. FINDINGS OF FACT 1. The Veteran’s PVC is not caused or aggravated by her service-connected hypertension. 2. The preponderance of the evidence is against finding that right hand arthritis (degenerative and rheumatoid), began during active service, or is otherwise related to an in-service injury or disease; arthritis also did not manifest within a presumptive period. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for PVC (claimed as irregular heartbeat) secondary to service-connected hypertension have not been met. 38 U.S.C. §§ 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.310. 2. The criteria for entitlement to service connection for right hand arthritis (degenerative and rheumatoid) have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.306, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1979 to March 1980 and from March 1986 to September 2005. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from February 2012 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded the appeal for further development in March 2018. There has been substantial compliance with the remand directives. Service Connection Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases (such as arthritis), will be presumed related to service if they were shown as chronic (reliably diagnosed) in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service, with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013); Fountain v. McDonald, 27 Vet. App. 258 (2015); 38 C.F.R. §§ 3.303, 3.307, 3.309. Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for PVC secondary to service-connected disability, hypertension The Veteran contends that premature ventricular contraction is related to her service-connected hypertension. She has limited her claim and contentions to secondary service connection. Consistent with the Veteran’s contentions, her service treatment records do not reflect diagnoses of PVC and there is no competent evidence suggesting the current PVC disability onset in service or is otherwise related to service. See Robinson v. Mansfield, 21 Vet. App. 545, 552-56 (2008). Thus, the question for the Board is whether the Veteran’s PVC is proximately due to or the result of, or aggravated beyond its natural progress by service-connected hypertension. The Board concludes that, while the Veteran has a current disability of premature ventricular contraction, the competent and probative evidence is against finding that her PVC is proximately due to or the result of, or aggravated beyond its natural progression by service-connected hypertension. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). At a December 2011 VA examination, the Veteran reported a history of irregular heartbeats beginning a year earlier. After reviewing the claim file and a physical examination of the Veteran, the examiner opined that is less likely than not that the Veteran’s heart condition is proximately due to or the result of her service-connected hypertension. The examiner’s rationale was that an echocardiogram study from January 2011 was normal with no evidence of cardiac complications secondary to hypertension. The examiner furthered that the review of research articles did not show any evidence that hypertension is directly linked to premature ventricular contractions. As the December 2011 VA examiner did not address whether the Veteran’s service-connected hypertension aggravated her PVC, the Board remanded the appeal in March 2018 for the Veteran to be afforded a new examination. In May 2019, the Veteran underwent a contract VA examination. After reviewing the claim file and a physical examination of the Veteran, the examiner opined that it is less likely than not that the Veteran’s heart condition is proximately due to or the result of her service-connected hypertension. The examiner explained that the echocardiogram studies from January 2011 and August 2018 (done for hypertension) were normal with no evidence of cardiac complication secondary to hypertension; both the December 2010 and September 2018 Lexiscan SPECT MPI’s were normal; and the Holter monitor 24-hour VRMC showed predominant sinus rhythm with frequent PVC’s. The examiner furthered, that a review of the Veteran’s records demonstrated that she had a long history of smoking that spanned over forty years, with attempts to quit. Additionally, the examiner noted that the Veteran’s caffeine usage as well as alcohol in the past are habits known to affect the heart and predispose one to PVC’s or other arrythmia. The examiner noted that while the etiology of PVC’s is not well understood, the review of research articles does not show any evidence that hypertension is directly linked to premature ventricular contractions. As for the whether the Veteran’s PVC was aggravated beyond its natural progression by her service-connected hypertension, the examiner opined that hypertension would not aggravate PVC. The examiner’s rationale was that the echocardiogram results did not show any complications due to hypertension that would predispose one to irregular heartbeats or cause aggravation. The examiner indicated that no opinion could be given as to any possible aggravating factor as there is only one quantitative study found in 2011. The examiner furthered that in order to determine aggravation of irregular heartbeat, serial Holter monitor evaluations would be required to document frequency. However, the only Holter monitor report is from 2011 and it notes predominantly sinus rhythm with frequent PVC’s and PVC density of 13.7 percent. The examiner continued that the Veteran’s irregular heartbeat is not caused by her service-connected hypertension but is more likely due to smoking, caffeine usage, as well as medication used for chronic lung disease due to smoking (Advair). Based on the evidence of record, the preponderance of the evidence weighs against finding that the Veteran’s PVC is proximately due to or aggravated by her service-connected hypertension. The VA medical opinions are unfavorable on the question of causal nexus. The Board finds these combined opinions are competent and persuasive, as the examiners thoroughly reviewed and discussed the relevant evidence, considered the contentions of the Veteran, and provided thorough supporting rationale for the conclusions reached. See Barr v. Nicholson, 21 Vet. App. 303 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120 (2007). There is no competent medical evidence attributing the Veteran’s PVC to her service-connected hypertension. Thus, service connection is not warranted on a secondary basis. The Veteran believes her PVC is proximately due to or the result of her service-connected hypertension. The Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran because the record does not show that she has the skills or medical training to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the December 2011 and May 2019 VA examiners’ combined medical opinions. In sum, the preponderance of the evidence is against the claim and the benefit of the doubt rule is inapplicable.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection for PVC as secondary to the service-connected hypertension is denied. 2. Entitlement to service connection for right hand arthritis (degenerative and rheumatoid) The Veteran contends that her right hand degenerative and rheumatoid arthritis is due to a pipe that fell on her right hand while on active duty and asserts that she has had trouble with that hand since the injury. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnosis of right hand degenerative and rheumatoid arthritis, and evidence shows that in-service injury, occurred, the preponderance of the evidence weighs against finding that the Veteran’s diagnosis of degenerative and rheumatoid arthritis in the right hand began during service or is otherwise related to an in-service injury, event, or disease. VA treatment records show the Veteran was diagnosed with rheumatoid arthritis, March 2011, years after her separation from service. While the Veteran is competent to report having experienced symptoms of pain in her wrist and hand consistently since service, she is not competent to determine whether those symptoms were manifestations of arthritis. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). The Veteran was afforded a VA examination in December 2011. There she reported pain, tenderness and limited range of motion of the right wrist. The Veteran reported a history of wrist pain for several years. She reported an in-service injury involving a metal container lid which fell on her right hand and indicated that the wrist pain got better after a few days. The Veteran indicated that she was diagnosed with rheumatoid arthritis and carpal tunnel syndrome (CTS) and that she underwent CTS release surgery in 2009. Yet she continued to have right wrist pain. The examiner opined that it is less likely than not that the Veteran’s right wrist arthritis is caused by a metal container lid falling on the Veteran’s hand in 1986. The examiner’s rationale was based on the review of the claims file. The examiner explained that service treatment records (STRs) show that in September 1986 the Veteran dropped a steel lined lid onto her right hand. The examiner noted that the x-ray showed slight swelling in the right [hand] with tenderness to palpation however, the x-ray was negative for fracture in hand or wrist. The examiner noted that there was no other documented evidence of treatment for a chronic right wrist condition in the military. The examiner furthered that upon the Veteran’s discharge from military service, there was no evidence of treatment for a right wrist condition within one year after discharge. The examiner indicated that while the Veteran’s file shows evidence of degenerative changes in 2009, the medical reports were silent for twenty years after the initial injury in 1986, instead of the first few years following the initial injury as would be expected. The examiner concluded that there was no documented evidence of a fracture of the right wrist or hand in the military which could have led to degenerative changes of the wrist. The Board remanded the appeal in March 2018 for a new examination because the prior opinion did not address her rheumatoid arthritis specifically. At the May 2019 contract VA examination, the Veteran indicated that her condition began when a pipe was dropped on her hand, causing pain. Following review of the claim file and physical examination, the examiner opined that it is less likely than not that the Veteran’s right-hand arthritis is caused by a metal container lid falling on her hand in 1986. The examiner’s rationale was based on a review of the Veteran’s claims file. The examiner noted that STRs showed evidence that the Veteran was treated in September 1986 when she dropped a steel lined lid onto the right hand and the lid fell on her fingers. The examiner reported that a physical examination showed slight swelling in the right [hand] with tenderness to palpation; however, an x-ray performed after the incident was negative for fracture in the hand or wrist. The examiner also noted that there was no other evidence of treatment for a chronic right wrist condition in the military. The examiner furthered that upon the Veteran’s discharge from military service, there was no evidence of treatment for a right wrist condition within one year after discharge. The examiner indicated that causation of the current osteoarthritis from the Veteran’s in-service injury would be expected in the first few years following the initial injury. Regarding the Veteran’s rheumatoid arthritis diagnosis, the examiner noted that it was first diagnosed in 2011 and explained that as an autoimmune disease, rheumatoid arthritis is not caused by injury. The examiner furthered, there is no documented evidence for a fracture of the right hand in the military which could lead to degenerative changes or a rheumatoid arthritis of the hand. Additionally, the examiner indicated that rheumatoid arthritis affects both hands, not just the right. Therefore, it is less likely than not that the Veteran’s right-hand arthritis was caused by a metal container lid falling on her hand in 1986. Based on the evidence of record, the preponderance of the evidence weighs against finding that the Veteran’s right-hand arthritis onset during service, or is otherwise related to service. Taken together, the December 2011 and May 2019 VA examiners’ opinions establish that the Veteran’s right-hand arthritis is not at least as likely as not related to an in-service injury, event, or disease, including a metal lid falling on her hand and fingers. The examiners’ combined opinions are probative, because they are based on an accurate medical history and provide explanation that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes her arthritis is related to an in-service injury she sustained when a metal container lid fell on her right hand. While her STRs contain evidence of an in-service injury and treatment, they do not reflect an on-going condition or diagnosis for her right-hand condition. The Board acknowledges the Veteran’s contention that she’s had trouble with her right hand ever since the injury but did not seek treatment in service every time because she learned to live with it. The Veteran is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that she has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the May 2019 VA examiner medical opinion. Finally, a chronic disease, such as degenerative or rheumatoid arthritis of the right hand, was not shown in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. VA treatment records show the Veteran was not diagnosed with arthritis of the hand until years after her separation from service and years outside of the applicable presumptive period. As such, the preponderance of the evidence is against the claim and the benefit of the doubt rule is inapplicable.  38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Service connection is not warranted for right hand arthritis (degenerative and rheumatoid). D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Telamour, Associate Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.