Citation Nr: 20054745 Decision Date: 08/18/20 Archive Date: 08/18/20 DOCKET NO. 16-15 821A DATE: August 18, 2020 ORDER Entitlement to service connection, to include on a secondary basis, for costochondritis is denied. FINDING OF FACT The Veteran’s costochondritis did not originate in service, within a year of service, and is not otherwise etiologically related to the Veteran’s active service. CONCLUSION OF LAW The criteria for service connection for costochondritis have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1968 to January 1970. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision by a Department of Veterans Affairs Regional Office (RO). In October 2018, the Board remanded this case and instructed the Agency of Original Jurisdiction (AOJ) to obtain a VA examination. This case was remanded again in April 2020 to obtain an addendum VA examination report. The Board notes that the requested VA examination report was obtained in April 2020 and has been associated with the claims file. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated during service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In order to establish entitlement to service connection, there must be (1) evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) a causal connection between the claimed in-service disease or injury and the current disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Service connection may also be established on a secondary basis for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). To prevail on the issue of entitlement to secondary service connection, there must be: (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) nexus evidence establishing a connection between the service-connected disability and the current disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995). The Board must determine whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either case, or whether the preponderance of the evidence is against the claim, in which case, service connection must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Costochondritis The Veteran seeks entitlement to service connection for costochondritis. Specifically, the Veteran asserts that his costochondritis is related to an in-service rib injury. See September 2012 Letter. Alternatively, the Veteran asserts that his costochondritis is secondary to his service-connected non-Hodgkin’s Lymphoma (NHL) and/or diabetes. See October 2015 VA Psychiatric Medical Record and October 2016 Letter. The evidence of record includes the Veteran’s service treatment records (STRs) showing that in October 1967, the Veteran fractured his left 9th rib due to a pugil stick injury. A December 1969 separation examination noted a negative chest X-ray study. The examining clinician noted several medical conditions during service, but did not note any rib fracture residuals or complaints. The Veteran denied any pain or pressure in his chest or a history of broken bones. In November 2007, the Veteran submitted private medical records including a January 2007 record showing complaints of chest discomfort to touch the past 1 to 2 weeks. The Veteran was assessed with costochondritis. Also included is an April 2007 medical record showing the Veteran complained of intermittent chest and back pain since the previous January. He also reported being diagnosed with costochondritis at that time. Thereafter, in May 2007, the Veteran reported that his costochondritis was better. A September 2007 record noted severe chest and back pain 1 week prior. The physician noted recurrent costochondritis since January 2007 of unclear etiology. Specifically, the physician noted no preceding factors such as repetitive activities including exercise, trauma or coughing illnesses. The Veteran reported feeling better in October 2007. In October 2008, the Veteran reported a flare-up over the past month with intermittent symptoms the past 3 years. A cough and cold reportedly had been irritating his ribs and back. The Veteran was assessed with recurrent costochondritis and an upper respiratory infection. A December 2008 private medical record noted a history of costochondritis with intermittent flare-ups over the past 2 years. See Private Medical Records Received May 2018. An April 2009 CT scan revealed a lobular 8.1 x 5.1 cm mass in the anterior chest wall with an underlying lytic lesion appearing to involve the right rib. Approximately two weeks later, a private medical record noted a report of questionable chest pain and further noted costochondritis. See Private Medical Records Received March 2013. The Veteran underwent a VA general medical examination in October 2012 during which the examiner noted a miscellaneous muscle injury diagnosed as costochondritis with 2007 listed as the date of diagnosis. The Veteran reported a history of costochondritis due to an in-service pugil stick injury. The Veteran further reported having chest discomfort with deep breathing five-years prior and being diagnosed with costochondritis. No medical opinion was provided. A VA medical opinion was obtained in February 2013. The Veteran reported that he was hit with a pugil stick during service that had broken and cracked his ribs. The Veteran described his condition as arthritis of the inner lining of his rib cage. He reported debilitating flare-ups resulting in a stabbing pain with episodes lasting two week periods. The examiner also noted a March 2009 diagnosis for NHL which was discovered as a result of a lump found on the center of the Veteran’s chest. The Veteran reported that his tumor had “fingers” that had extended throughout his thoracic rib cage. Additionally, the Veteran reported that the location of the tumor was the same location he was injured during service as a result of being hit with a pugil stick. The examiner opined that the diagnosed costochondritis was “less likely than not (less than 50 percent probability)” etiologically related to the service-connected NHL. The examiner based this opinion on a finding that the record did not contain a 2007 medical record noting a diagnosis of costochondritis, and that the Veteran’s NHL was diagnosed in 2009. The examiner further noted that the in-service injury affected the left rib and that the NHL initially progressed from the right side. No medical opinion as to direct service connection was provided. In a March 2013 letter, the Veteran asserted that he was diagnosed with costochondritis in January 2007 which was an idiopathic occurrence of inflammation. The Veteran related his currently diagnosed costochondritis to a pugil stick injury during service. A June 2015 VA medical record noted a diagnosis of costochondritis “related to an injury he received in service.” An October 2015 VA mental health record noted a diagnosis for costochondritis and that a discussion was had about various ailments related to dioxin exposure including diabetes and NHL which led to a vitamin D deficiency which led to his costochondritis. See VA Medical Records Received March 2017. In January 2016, the Veteran reported continued symptoms of costochondritis. See VA Medical Records Received January 2019. In a March 2016 VA Form 27-0820, Statement in Support of Claim, the Veteran stated that a doctor had told him that his costochondritis was caused by his in-service trauma. An April 2016 private medical record noted a diagnosis for costochondritis as a result of trauma to the chest which was further noted as occurring during service between 1967 and 1970. A May 2016 private medical record noted costochondritis as a health issue reviewed. Chronic costochondritis was noted as attributable to an old injury in 1967, and that the Veteran was using Indocin for exacerbation of symptoms. The same medication was also noted as being used for exacerbation of gout. Costochondritis was not noted as an active problem. See Private Medical Records Received May 2018. The Veteran’s then representative submitted a letter in October 2016 in which he asserted that costochondritis was an acute inflammation of the costal cartilage and that the condition might resolve on its own, but that it could also be a recurring condition. The representative also stated that the medical evidence established that the Veteran’s costochondritis results from an in-service rib injury. Alternatively, the representative asserted that costochondritis should be granted on a secondary basis due to a vitamin D deficiency caused by the service-connected NHL. In this regard, the representative noted that medical literature supported a finding that vitamin D deficiency could cause costochondritis. In support of these assertions, the representative cited medical literature. In January 2017, it was noted that the Veteran’s costochondritis and osteoarthritis continued to mitigate his ability to work. The Veteran stated that it was initially hard to distinguish between his costochondritis symptoms and his panic attack symptoms. See VA Medical Records Received January 2019. The Veteran underwent another VA examination in February 2020. The examiner noted a diagnosis for costochondritis. The examiner noted that a non-penetrating muscle injury in 1967, and that the Veteran was diagnosed with costochondritis at that time. In this regard, the examiner noted that the STRs showed a fractured 9th left rib in October 1967, but that he was not diagnosed with costochondritis at that time. Accordingly, the examiner found that the in-service rib injury seemed to have resolved as the December 1969 separation examination was silent for any chest pain, and that the next complaint of chest pain occurred 30 years later in 2007. The examiner opined that it was “less likely as not” that the Veteran’s costochondritis was etiologically related to service. In support of this opinion, the examiner noted that there were no current objective findings of chronic costochondritis including negative chest X-ray findings, and that the last documented complaint for chest wall pain occurred in 2008. The examiner further found that the Veteran’s continued subjective complaints of intermittent chest pain were not confirmed by a review of the medical evidence of record. Specifically, the examiner found that the medical records did not document the progression of the condition since 2008. The examiner further found that the in-service rib fracture appeared to have resolved based on the following: the fact that the separation examination conducted 2 years following the in-service incident was silent as to any residuals; the fact that the Veteran was not diagnosed with costochondritis during service; and, that he was first diagnosed in 2007, 40 years after separation from service. The examiner also opined that it was “less likely” that the Veteran’s costochondritis was caused by or related to his NHL or diabetes as there was no known etiopathogenic connections or relationships between either of those conditions. With regard to whether the Veteran’s service-connected NHL or diabetes aggravated his costochondritis, the examiner again opined that it was “less likely as not” as there were no objective findings for a current diagnosis for costochondritis. Lastly, a VA addendum examination report was obtained in April 2020. The examiner opined that it was “less likely than not” that the Veteran had a diagnosis of costochondritis that was etiologically related to service. In support of this opinion, the examiner found no evidence contrary to any of the findings in the February 2013 VA or the February 2020 VA examination reports. Specifically, the examiner noted that costochondritis was an acute inflammation of the junctions of the ribs and sternum, and that the condition usually had no known cause and tended to occur later in life. The condition was further noted to last for weeks to months, but typically resolved completely. In this regard, the 2007 diagnosis was found most likely idiopathic based on the medical treatment record noting “chest discomfort tender to touch past 1 to 2 weeks,” and a September 2007 medical record noting “CC of unclear etiology.” Thereafter, the examiner noted an October 2017 medical record noting the Veteran was feeling better and that costochondritis was not listed on the medical assessment. The examiner further noted that while costochondritis might be caused by muscle strain or trauma to the chest, that trauma-related occurrences were acute and did not result in delayed onset of the condition. Additionally, if the condition did reoccur, the examiner noted that that was typically due to new trauma or new etiology. Moreover, the examiner noted that only a small percentage of chest trauma resulted in costochondritis, and, therefore, evidence of chest trauma was not usable as evidence of costochondritis. Accordingly, based on the fact that a December 1969 STR was silent for chest pain, and that the next complaint of chest pain did not occur until many years later in 2007, that the evidence did not support a finding of costochondritis during service, during the year proceeding service, and did not support a nexus between the 2007 diagnosis and service. With regard to medical evidence to the contrary, the examiner noted that the May 2016 medical record which attributed the Veteran’s costochondritis to an old injury during service was issued 9 years after the physician saw the Veteran for costochondritis, and that there was no evidence that the Veteran’s medical record was reviewed. The examiner further noted that the same physician had originally issued a diagnosis of “CC of unclear etiology” (i.e. idiopathic) which the examiner found significantly more likely. The examiner further noted the June 2015 psychiatric record noting “costochondritis related to an injury he received in service.” However, the examiner noted that the statement was not a diagnosis, that the psychiatrist did not review the records, and that the psychiatrist was likely unfamiliar with costochondritis or the clinical manifestations of the condition. Turning to the question of secondary service connection, the examiner opined that it was “less likely than not” that the Veteran’s costochondritis was caused or aggravated by his service-connected NHL and/or diabetes. In this regard, the examiner noted that when the Veteran was put on vitamin D by his oncologist, that his low vitamin D was diagnosed after his 2007 episode of costochondritis. Additionally, while the Veteran’s vitamin D was found low, it was not found deficient. The examiner further noted that a review of the Veteran’s oncology record did not mention NHL causing the vitamin D insufficiency. In addition, the examiner noted that vitamin D deficiency was a very common condition in older people and was usually caused by diet, had clearly been causatively linked with osteoporosis, but not with costochondritis as suggested by the Veteran’s psychiatrist. Therefore, the examiner found no evidence of a vitamin D deficiency that caused or aggravated the Veteran’s costochondritis. The evidence shows that the Veteran meets the threshold criterion for service connection of a current disability. Boyer v. West, 210 F.3d 1351 (Fed. Cir. 2000). Specifically, a January 2007 medical record noted a diagnosis for costochondritis, a condition also noted in an October 2012 VA examination report and a June 2015 VA medical record during the period on appeal. Accordingly, the remaining question is whether the Veteran’s costochondritis is otherwise related to service. In this regard, the Board finds the April 2020 VA examination report the most probative evidence of record. The examiner conducted a thorough review of the claims file and considered the evidence of record with regard to whether the Veteran had costochondritis that was either directly related to service or secondary to his service-connected NHL and/or diabetes. However, based on a review of the claims file, the examiner opined that it was “less likely than not” that the Veteran had a diagnosis of costochondritis that was either directly related to service, or secondary to a service-connected condition. The Board finds the examiner’s rationales for his opinions are well supported. Specifically, with regard to the Veteran’s theory of direct service connection, the examiner noted that the STRs did not note any diagnosis for costochondritis, nor did the Veteran report pain or pressure in his chest as separation from service. The Board further notes that the Veteran underwent a chest X-ray study as part of his separation examination which was negative. The examiner further noted the approximate 40 year gap in time between the Veteran’s in-service fractured rib and the first medical record noting an assessment for costochondritis. Importantly, the examiner noted that the 2007 diagnosis for costochondritis noted that the condition was of unclear etiology and, thus, was idiopathic in nature. In this regard, the Board also notes that the Veteran reported that his costochondritis was initially diagnosed as an idiopathic condition in January 2007. See Veteran’s March 2013 letter. Lastly, the examiner’s findings are supported by the 40 year gap in time between the in-service pugil stick injury and the initial January 2007 record noting costochondritis of unknown etiology. The Board recognizes the June 2015 VA medical record noting costochondritis related to an in-service injury, and the April and May 2016 private medical records noting the same. However, neither of those medical records include any information as to what those findings are based on, nor do they note that the Veteran’s claims file, including his STRs, were reviewed. Importantly, no rationale was provided with either of those statements. The April 2020 VA examiner further noted and dismissed the May 2016 medical record as it was issued 9 years after same physician initially concluded that the Veteran’s costochondritis was of unclear etiology and that there was no indication that that physician had reviewed the claims file. A medical opinion that is unsupported and unexplained is purely speculative and does not provide the degree of certainty required for medical nexus evidence. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also Miller v. West, 11 Vet. App. 345, 348 (1998) (medical opinions must be supported by clinical findings in the record; bare conclusions, even those made by medical professionals, which are not accompanied by a factual predicate in the record, are not probative medical opinions). Accordingly, the Board finds the above-mentioned medical records attributing costochondritis to an in-service injury of little probative value. With regard to the Veteran’s theory of secondary service connection, the Board again finds the April 2020 VA examination report the most probative evidence of record. The examiner opined that it was “less likely than not” that the Veteran’s costochondritis was caused or aggravated by his service-connected NHL or diabetes. Addressing the assertion that the service-connected conditions caused a vitamin D deficiency which thereby caused his costochondritis, the examiner noted that while the Veteran’s vitamin D low was found low, it was not found deficient, nor did the oncology records mention that NHL caused the low vitamin D level. The examiner further noted that vitamin D deficiency had not been causatively linked with costochondritis as suggested by the Veteran’s psychiatrist. The Board notes that the April 2020 examiner’s opinion is further bolstered by the February 2020 VA examiner’s negative nexus opinion which was based on a finding that NHL and diabetes had no known etiological association with costochondritis. The Board recognizes the October 2015 VA mental health record in which the Veteran’s treating psychiatrist noted that the Veteran’s diabetes and NHL led to his vitamin D deficiency which led to the development of his costochondritis. However, as noted by the April 2020 VA examiner, there is no indication that the psychiatrist reviewed the claims file, and as noted by the February 2013 VA examiner, the costochondritis diagnosis predated the NHL diagnosis. Accordingly, the Board finds the October 2014 VA mental health record speculative and not supported by the evidence of record, and, therefore, of little probative value. The Board further recognizes the representative’s October 2016 letter in which he cited to medical literature in support of the assertions that vitamin D deficiency caused by NHL could potentially cause costochondritis. However, as noted above, the April 2020 VA examiner dismissed the representative’s assertion by noting that the Veteran’s vitamin D low was found low, not deficient, and that oncology records did not mention that NHL caused a low vitamin D level. Accordingly, the Board finds that the representative’s assertions are not well supported. Lastly, the Board recognizes the Veteran’s lay statements linking his costochondritis to his in-service pugil stick injury as well to his service-connected diabetes and NHL. The Veteran is competent to report purported symptoms such as chest pain or whether he has received a diagnosis from a medical professional. 38 C.F.R. § 3.159(a)(2); Barr v. Nicholson, 21 Vet. App. 303 (2007). However, without evidence showing that he has medical training or expertise, he cannot competently provide a medical nexus opinion between a current diagnosis, costochondritis, and an in-service event, such as a pugil stick injury or to a service-connected condition. 38 C.F.R. § 3.159(a)(1)-(2); Jandreau v. Nicholson, 492 F.3d 1372 (2007). In any event, to the extent the Veteran may be competent to opine as to medical etiology, the Board finds that the Veteran’s lay assertions in the present case are outweighed by the April 2020 VA medical examiner’s opinion, who determined that there was no nexus between the Veteran’s costochondritis and service. The examiner has training, knowledge, and expertise on which he relied to form his opinion, and he provided a persuasive rationale. Importantly, the April 2020 VA examination is bolstered by the cumulative VA examination reports and there is no competent medical evidence to the contrary. Thus, the Board finds that the third Shedden requirement has not been met. Although the Veteran is entitled to the benefit-of-the-doubt where the evidence is in approximate balance, the benefit-of-the-doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection for costochondritis. The claim is denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 58 (1990). S. HENEKS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Lamb, 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.