Citation Nr: 20043364 Decision Date: 06/26/20 Archive Date: 06/26/20 DOCKET NO. 11-27 921 DATE: June 26, 2020 ORDER Entitlement to service connection for costochondritis is denied. FINDING OF FACT The Veteran’s costochondritis is not related to service. CONCLUSION OF LAW The criteria for service connection for costochondritis have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from July 1976 to August 1983. This appeal arises from a June 2010 rating decision, denying a petition to reopen a previously denied service-connection claim for costochondritis. On appeal, the Board’s September 2017 decision found new and material evidence to reopen the costochondritis claim and remanded the service-connection claim for costochondritis to the AOJ for additional development and consideration. The file is again before the Board for further appellate review. Notably, in September 2017, the Board remanded an additional claim, for service connection for an acquired psychiatric disability. On remand, in a December 2019 rating decision, the AOJ granted service connection for an acquired psychiatric disability, characterized as “somatic disorder with persistent depressive disorder.” As this determination constitutes a full grant of the benefits sought as to that claim, it is no longer in appellate status. See Grantham v. Brown, 114 F.3d. 1156 (Fed. Cir. 1997). The Veteran testified at a VA Central Office hearing in Washington, D.C. (Board hearing) in May 2017 before a Veterans Law Judge (VLJ) of the Board. A transcript is of record. In April 2020, the Veteran was notified that the VLJ who conducted the May 2017 hearing was no longer employed with the Board. The Veteran was provided the opportunity to testify at another hearing but in May 2020, he declined another Board hearing. So, the Board proceeds to address the claim on appeal. Entitlement to service connection for costochondritis The Veteran testified that he believes his costochondritis is related to service, and asserts he has had a history of chest wall pain and spasms since serving in the Army. See generally May 2017 Board hearing transcript. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). The Board first addresses the initial element of service connection, namely that of a current disability. In this case, there is conflicting evidence of whether the Veteran has a current diagnosis of costochondritis. Most recently, a November 2019 VA examiner found a diagnosis of “history of costochondritis, resolved” and noted no functional impact of a muscle injury on his ability to work. Similarly, on review of the claims file, a December 2017 VA compensation physician opined that the Veteran does not meet the diagnostic criteria for costochondritis. In contrast, however, a March 2016 private chest X-ray revealed “Heavy costochondral calcification is present.” The Veteran also complained of costochondritis to an April 2010 VA examiner, and on physical evaluation, the examiner found he was tender in the chest wall, second rib bilateral at the costochondral junction. Thus, the Board finds there are sufficient indications of a current costochondritis disability. Next, the Board finds there are indications of in-service incurrence of costochondritis. The Veteran’s service treatment records show that in June 1977, the Veteran complained of intermittent pain to the chest and sides for the prior 2 weeks. By August 1977, the Veteran sought treatment for complaints of “chest pain all the time,” and was diagnosed with costochondritis and prescribed Motrin. In March 1978, he complained of recurring chest pain, but with negative X-ray testing. On examination in February 1982, the Veteran reported a medical history of pain or pressure in chest, and examiner found “typical costochondritis, off and on”. The February 1982 examiner found that he had a history of mild costochondritis, but not active at the time, and physical evaluation of the Veteran was within normal limits. However, at the July 1983 service separation examination, the Veteran denied a history of pain or pressure in the chest and reported, “I’m in good health.” The July 1983 separation examiner did not find any costochondritis, and he had a normal clinical evaluation of the spine and other musculoskeletal areas. Shortly after separation, at a March 1984 VA general examination, the Veteran reported sharp, localized, shooting pains in the anterior chest since 1977. He also reported that there had been no diagnosis of the condition and admitted he had not had the problem in “a while.” The March 1984 VA examiner diagnosed chest wall pain. The question remains whether the Veteran’s current costochondritis is related to service. Initially, an April 2010 VA examiner provided a negative nexus opinion on this possibility, but the Board finds this opinion is of limited probative value since the examiner did not indicate a review of the complete set of service treatment records, nor provide a clear rationale. Inadequate medical examinations include examinations that contain only data and conclusions, do not provide an etiological opinion, are not based upon a review of medical records, or provide unsupported conclusions. Nieves- Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). When VA undertakes to examine a Veteran, VA is obligated to ensure that that examination is adequate. See Barr v. Nicholson, 21. Vet. App. 303 (2007). In this regard, the Board primarily remanded this case in September 2018 for the AOJ to obtain any outstanding private treatment records, since obtained; and arrange for another VA examination to obtain a medical opinion addressing the etiology of the Veteran’s costochondritis. On remand, such development was accomplished, so that the AOJ substantially complied with the remand directives. The record now contains a November 2019 VA examination and a negative medical nexus opinion, as well as another negative VA medical nexus opinion provided in November 2017. The Board acknowledges the Veteran submitted February 2020 correspondence that asserts both the November 2017 and November 2019 VA medical opinions are inadequate, particularly in that they agree with the April 2010 examiner’s conclusion. However, the Board finds these medical opinions are based on detailed and thorough rationale, with clear discussion of the medical principles involved and application to the facts in this case. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) ("It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion."). The Board is therefore satisfied there was substantial compliance with the remand directives. See D’Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (holding that there was no violation of the principles of Stegall v. West, 11 Vet. App. 268, 271 (1998), when the examiner made the ultimate determination required by remand). On remand, a November 2017 VA compensation physician reviewed the claims file and provided an addendum opinion against the possibility that his current claimed costochondritis condition was incurred in or caused by service. The examiner reasoned that, “Since discharge from active duty service, and even at the time of discharge from active duty service based on his exam in July 1983, veteran has not had isolated chest wall pain but diffuse musculoskeletal pain due to fibromyalgia and other skeletal conditions.” The examiner also cited relevant medical literature in supporting such finding, and added, “Based on this examiner’s review of current peer-reviewed literature, Chest pain occurs in fibromyalgia with frequency estimates of up to 71 percent. However, 85 percent of patients with fibromyalgia have tenderness over the second anterior costochondral junctions (over 60 percent characterized as moderate or greater), making this one of the most common sites of tenderness in fibromyalgia. Also, this veteran had pain out of proportion to exam, which is seen with fibromyalgia, not costochondritis.” Based on the VA physician’s detailed and comprehensive review of the claims file, and discussion of the rationale of the opinion, including relevant medical literature, the Board finds the VA examiner’s opinion is highly probative evidence against the claim. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (“It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.”). The Board finds that the November 2017 VA physician’s negative medical opinion is highly probative evidence against the claim.  Also, on remand, a November 2019 VA examiner reviewed the claims file and provided an opinion against the possibility that his current claimed costochondritis condition was incurred in or caused by service. The examiner reasoned, “Review of the Service Treatment Record shows no complaints of chest pain from 1980 through separation in 1983. From review of the Service Treatment Record[s], it appears the chest pain had resolved. A review of the available clinical notes post service shows visits of chest pain in 2001, [or] 18 years after separation from service. The clinical notes by the [April 2001 VA treating] Rheumatology Specialists attribute the symptoms to the diagnosed condition of fibromyalgia. On today’s Compensation exam, the Veteran reports diffuse chest pain more consistent with fibromyalgia rather than his previous symptoms of costochondritis.” Based on the November 2019 VA examiner’s review of the claims file, personal interview of the Veteran, in-person physical evaluation, and discussion of the rationale of the opinion, the Board finds the VA examiner’s opinion is highly probative evidence against the claim. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (“It is the factually accurate, fully articulated, sound reasoning for the conclusion, not the mere fact that the claims file was reviewed, that contributes probative value to a medical opinion.”). The Board finds that the VA examiner’s negative medical opinion is highly probative evidence against the claim.  The Veteran has provided lay statements that this disability is related to service, but he is not competent to provide a nexus opinion in this case. This issue is medically complex, as it involves internal disease processes and requires knowledge of interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007).  Additionally, the Board acknowledges the Veteran’s articles addressing his disorder, but the articles are of little or no probative value because they do not relate the Veteran’s specific disorder to service or any event of service. (Continued on the next page)   Accordingly, the preponderance of the evidence weighs against the claim and does not support entitlement to service connection.  There is no doubt to be resolved.  C. CRAWFORD Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Biswajit Chatterjee, 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.