Citation Nr: 21000850 Decision Date: 01/06/21 Archive Date: 01/06/21 DOCKET NO. 16-61 210 DATE: January 6, 2021 ORDER Entitlement to service connection for Still's disease is denied. Entitlement to service connection for bilateral hip avascular necrosis, associated with Still's disease is denied. Entitlement to service connection for post-traumatic stress disorder (PTSD) is denied. FINDINGS OF FACT 1. The Veteran’s Still’s Disease was not manifest during service or within one-year post service and is not attributable to service. 2. The Veterans bilateral hip condition was not manifest during service or within one-year post service and is not attributable to service. 3. The Veteran does not have posttraumatic stress disorder (PTSD); and his depression did not manifest in-service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for Still’s disease are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113 (2012); 38 C.F.R. §§ 3.303, 3.304(f), 3.307, 3.309 (2019). 2. The criteria for entitlement to service connection for a bilateral hip condition is not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.303, 3.304(f), 3.307, 3.309. 3. The criteria for entitlement to service connection for PTSD are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113; 38 C.F.R. §§ 3.303, 3.304(f), 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Navy from March 1991 to February 1994. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In February 2020, the Veteran testified before the undersigned Veterans Law Judge (VLJ) via videoconference (virtual hearing). A transcript of the hearing is of record. Service Connection A Veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a Veteran 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" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 Fed. Cir. (2004). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303(b), 3.309. A disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. 38 C.F.R. § 3.310(a). Any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice connected disease or injury will be service connected. 38 C.F.R. § 3.310 (b). Evidence Personnel records show that the Veteran served as a machinist’s mate aboard a cruiser with deployment to Southwest Asia. The Veteran’s service treatment records (STR’s) are associated with the claims file. In a January 1991 report of medical enlistment examination, the Veteran indicated he had a history of hay fever. See July 2015 STR-Medical, p.24. In a January 1994 STR, the Veteran complained of sinus congestion that had been present for four days. The Veteran stated he had a runny nose and was coughing up mucus. See July 2015 STR-Medical, p.72. Several dental treatment medical history questionnaires in 1992 and 1993 are silent for any chronic abnormalities. In a January 1994 report of medical examination at discharge, the clinical evaluation was normal. In addition, the Veteran stated he was in good health with no allergies and denied ever having scarlet fever, chronic or frequent colds; depression or excessive worry, nervous trouble of any sort or arthritis. However, he indicated that he had hay fever. The records are silent for any episodes of fever, night sweats, or chronic fatigue. See July 2015 STR-Medical, p.14;16. In May 2003, a VA clinician noted that the Veteran was seen to establish VA care. The history noted was silent for any hospitalizations other than treatment for a gunshot wound to the left leg in February 2003. There was no mention of chronic fatigue, night sweats, or weight loss. In May 2006, a clinician noted that the Veteran’s depression/ PTSD was not caused by service. The clinician acknowledged that the Veteran was treated by VA in 1995 for night sweats and weight loss but that no diagnosis was made during the hospitalization and the symptoms resolved. See October 2016 Capri, p.347. In June 2014, the Veteran was diagnosed with avascular necrosis of the left hip. See October 2016 Medical Treatment Record-Government Facility, p.2. In September 2014, the Veteran had a negative PTSD screening. See October 2016 Medical Treatment Record-Government Facility, p.4. In June 2015, a clinician diagnosed Still’s disease. See October 2016 Medical Treatment Record-Government Facility, p.45. In June 2015, the Veteran submitted a statement. The Veteran stated that while he was in-service, he heard helicopter being shot over him. He stated he thought he was going to die. The Veteran noted that the shot hit the helicopter not the pilot or co-pilot. He said he had nightmares for years, thinking ship was going to sink and he did not talk about it with family or friends. See June 2015 VA 21-0781, Statement in Support of Claim for PTSD. In July 2015, a private physician submitted a letter. The physician stated that she reviewed the records provided by the Veteran and his attorney and indicated that the disabilities the Veteran were seeking service connection for may have been related to exposure in-service. Also, that it was possible that the Veteran’s disabilities were caused during his time in-service. However, the physician failed to give a rationale and indicated that it was “possible” that the conditions were related to service. Also, the physician did not state what records she reviewed of the Veteran’s or if she had reviewed his entire claims file. See July 2015 Third Party Correspondence. In September 2015, the Veteran was afforded a mental health examination. The examiner reviewed the claims file; considered the Veteran’s accounts and conducted an evaluation. The examiner indicated that the Veteran did not have a diagnosis of PTSD according to the DSM-5. However, the Veteran had a diagnosis of persistent major depressive disorder and dysthymic disorder. The examiner noted that the Veteran had depressed mood no more than two years. The symptoms the Veteran experienced were insomnia, low energy, fatigue, low self-esteem, poor concentration, difficulty making decisions, hopelessness and helplessness. The examiner stated that the symptoms caused significant distress or impairment in social, occupational or other important areas of functioning. The Veteran reported that he was arrested for driving while intoxicated while serving in the Navy and two months after separating from service was arrested for aggravated driving while intoxicated (DWI); where several people were seriously injured. The Veteran was charged with a felony and spent 1 year in jail and was on probation for 5 years. The Veteran indicated that the conviction affected his employability. After the incident the Veteran stated he received another DWI and lost his license completely. The examiner noted that the Veteran had one stressor in service where he saw some helicopters that came back from refueling had taken on small arms fire but none of the pilots or crew members were injured. The Veteran stated that he experienced fear that small Somali boats could get close enough to the ship he was on and if loaded with bombs sink the ship. However, that incident never occurred. The examiner found the stressor did not meet any of the criteria. The examiner found that it was less likely than not that the Veteran’s claimed PTSD was less likely than not caused by or a result of the Veteran’s thought and fears of the ship sinking. The rationale was that being in a combat theater is not sufficient for the diagnosis of PTSD and also due to the Veteran stating that no one was injured or killed. The examiner further stated that the Veteran’s history of alcohol abuse and possible dependence and depressive disorder appeared to be caused by the consequences of his legal issues, and his medical and physical issues that arose after he separated from service. In October 2015, the Veteran was afforded a hip and thigh VA examination. The examiner reviewed the claims file; considered the Veteran’s accounts and conducted an evaluation. The examiner noted a diagnoses of a hip joint replacement, left hip in 2014, and bilateral avascular necrosis, diagnosed in 2013. The examiner the condition impacted the Veteran’s ability to perform occupational tasks. The Veteran’s right hip pain was worse with bending, lifting and walking. The Veteran stated that his left hip was improved since his surgery, but he was told not to cross his legs. The Veteran was also afforded an examination for Still’s disease on the same day. The examiner reviewed the claims file; considered the Veteran’s accounts and conducted an evaluation. The Veteran reported that he was hospitalized for 8 days for a high temperature, body aches and rashes in 1995. However, he was not diagnosed until 2006 with Still’s disease. The Veteran stated that he believed he had Gulf War disease and not Still’s disease. The Veteran indicated that his condition impacted his ability to perform occupational tasks because his bones were to fragile and he was to fatigued from his chronic pain. He also stated that his joint pain came and went randomly, and his Still disease flared up every 8 to 10 years; leaving him incapacitated for up to a month. The examiner found that Still’s disease and the bilateral hip condition were less likely than not incurred in or caused by service. The rationale was that Still’s disease and bilateral hip avascular necrosis are diseases with clear and specific etiology and diagnoses. The examiner noted that the Veteran was diagnosed with Still’s disease in 1995 at the age of 24; and was an inflammatory arthritis with age being the main risk factor in adults. The examiner referenced medical literature and indicated that Still’s disease peaked twice in adults; once from age 15 to 25 and again from age 36 to 46. In addition, the examiner indicated that the Veteran’s bilateral hip condition was at least as likely as not as due to the Veteran’s use of steroids for his Still’s disease because use of glucocorticoids and excessive alcohol intake are associated with 80 percent of atraumatic cases. The Board also notes that the Veteran underwent a VA Gulf War examination. However, the examiner found that the Veteran did not have an undiagnosed illness or an a diagnosed medically unexplained chronic multi symptom illness. In December 2015, a psychologist indicated that the Veteran had symptoms of depression appeared related to chronic pain and anger regarding his health. See October 2016 Capri, p.81. In March 2016, the Veteran submitted another statement. The Veteran stated that in November 1994 he began getting sick with high fevers, night sweats and joint pain. Eventually he went to the hospital and was there for 8 to ten days. The Veteran stated that he was diagnosed in November 2011 with avascular necrosis. The Veteran indicated that he believed that he was misdiagnosed with Still’s disease and believed he had Gulf War illness which was passed down from his father who served in the Vietnam war. However, the Veteran’s father exposure in-service would not be related to the Veteran’s service. In addition, the Veteran ‘s statements for PTSD and depression were inconsistent with previous statements he made. In his statement he indicated that he did see dead bodies floating in the Persian Gulf, oil wells burning, enemy gunships, mines exploding, helicopter being shot and having hazardous duty on a flight deck in a combat area. See March 2016 Email Correspondence. In March 2016, the Veteran was seen for a complaint of Still’s disease. The Veteran reported that he had begun experiencing symptoms of high fevers, rashes, night sweats, nausea and joint/ arthritis pain since he got out of service. The Veteran also stated that he developed avascular necrosis of the left hip secondary to steroid treatment and had to undergo left hip replacement. The Veteran stated that he was diagnosed with Still’s disease but believed he had Gulf War illness. See October 2016 Capri, p.59. In February 2020, the Veteran attended a Board hearing. During the hearing, the Veteran and his representative indicated that while the Veteran was not diagnosed with Still’s disease in service there were service treatment records (STR’s) and information on his exit examination; where undiagnosed symptomology could have led to a diagnosed condition. See February 2020 Hearing Transcript, p.2. The Veteran testified that while in-service the symptoms he experienced related to still’s disease were, fatigue; sweats; and high temperatures that he would experience sporadically. The Veteran stated the symptoms began in-service but were minor and he did not have any similar symptoms prior to service. Furthermore, the Veteran testified that medical professionals acknowledged something was going on but could not figure out what it was. The Veteran stated that the doctors would just give him something to keep his fevers down. The Veteran testified that 6 months to a year after service he began to experience high temperatures of 103 or 102 degrees; his night sweats got worse and his night sweats and fatigue had gotten to the point where he could not go to work. He stated he took lots of cold medicine to help with his symptoms. See February 2020 Hearing Transcript, p.4. The Veteran stated that he tried to go to work but after four months he ended up in the hospital; around October or November of 1994. Several tests were run, but the Veteran was told they could not figure it out. The Veteran stated that he was told it was an allergy. The Veteran stated that he was diagnosed with Still’s disease around 8 years after the hospital visit; which was around 2002. The Veteran testified that he was prescribed medication; it helped; but the side effects caused his avascular necrosis. The Veteran stated that during the eight-year time frame before he was diagnosed, he was not seeing a doctor, he was just self-medicating. The contention was that although the Veteran was not diagnosed in-service or within 1 year; his symptoms progressed into Still’s disease. The representative contended that the condition is diagnosed through process of elimination like chronic fatigue and Lyme’s disease without reference to a medical authority. In addition, the Veteran’s representative stated that a medical professional stated that his hip condition was caused by the initial medication he was on for Still’s disease. The Veteran testified that he thought his hip condition was caused by his back pain, so he dealt with it until he fell one day, and it collapsed. The Veteran stated that he had a hip replacement five years prior to the hearing. P.8. The Veteran stated that his other hip was also starting to deteriorate, and he would probably need a replacement. Next, the Veteran testified that he was diagnosed with depression, but he did not have the condition prior to service, and it was not in his family. The Veteran stated that he believed the depression was caused by service and getting shot after service contributed to it as well. The Veteran felt it was related to service since he was jittery and no longer outgoing when he came home. The Veteran testified he was in combat operations in the Somalia area in approximately 92-93, although personnel records showed that he served as a machinist mate. He stated he was on a ship and that there was combat during that time. The Veteran testified he was in fear for his life at that time, but he was not directly shot at. The Veteran stated he had gotten better with counseling but was not taking any medication or going to therapy at that time. He stated at one point he was in a psychiatric ward at a VA facility. The Veteran stated that it had been more than a year since he had a DSM-V examination. The Veteran’s representative indicated that while the Veteran may not have had PTSD; it was their contention that his depression was related to service. See February 2020 Hearing Transcript. PTSD The Veteran does not have posttraumatic stress disorder (PTSD); and his depression did not manifest in-service. There is no probative evidence of record which suggests the Veteran has ever been diagnosed with PTSD, to include during the pendency of the claim. The Veteran was assessed by a VA physician in May 2006. The Veteran did not report any stressful events in service, and the physician determined that the Veteran’s depression was not caused by service but rather by lack of work, alcohol use, and pain in the arm, left leg (from gunshot wound), and back. In this case, the Veteran has never been diagnosed with PTSD. The Board acknowledges that the Veteran does have a diagnosis of depression; however the September 2015 VA examiner stated the condition was not related to the Veteran’s time in-service but likely due to his legal issues and alcohol dependence. As the competent, relevant medical evidence of record affirmatively concludes that the Veteran does not have PTSD, the preponderance of the evidence is against the claim for PTSD; there is no doubt to be resolved; and service connection for PTSD is not warranted. Still’s Disease and Bilateral Hip As noted above the Veteran has a current diagnosis of Still’s disease and Bilateral avascular necrosis of the hip. The question of whether a nexus exists is a medical determination that requires a competent nexus opinion, as the determination of the etiology of the Veteran's still’s disease and bilateral hip condition is a complex medical condition. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). As noted above the Veteran did not have any complaints related to bilateral avascular necrosis of the hip in-service; and at separation the Veteran’s examination was normal and he stated he was in good health. Although the Veteran believes that the symptoms of fatigue, night sweats, and fevers that he experienced in 1995 started in service, continued up to the diagnosis of Still’s disease, this is not consistent with the record. These symptoms were not reported or denied in service and not reported in 2003 when there was an opportunity to provide that history. VA clinicians later considered the reports but found that the 1995 symptoms had resolved. The Veteran has been treated at VA since the diagnosis and none of his clinicians referred to the history described by the Veteran but rather annotated the disorder as adult onset Still’s disease. Clinicians specifically found that the disease had a clear diagnosis and was not a medically unexplained multisymptom illness associated with service in Southwest Asia. After consideration of all the evidence of record the Board finds that the preponderance of the evidence is against finding that service connection for Still’s disease and bilateral avascular necrosis of the hip is warranted. The Board concludes that service connection is not warranted as the Veteran's conditions are not related to service. The Veteran is competent to report that he continued to have symptoms since service. The Board places less probative weight on the contention of continuity since it is not consistent with the discharge physical examination and history questionnaire. While the Veteran reports that her current symptoms and in-service events are related, the record does not reflect that she has the requisite training or expertise to offer a medical opinion linking a current disability to service decades earlier and she is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board assigns significant probative weight to the findings of the October 2015 VA examiner, as the examiner conducted an in-person examination, reviewed the Veteran's medical records, and provided a rationale supported by the record. In sum, the Board finds the October 2015 VA examiner's nexus opinion is of significant probative value, and that there are no competing competent nexus opinions of record. Accordingly, the Board finds the Veteran's claim must be denied as there is no nexus between the Veteran's still’s disease, bilateral hip avascular necrosis disability and his military service. In addition, secondary service connection is not warranted for bilateral avascular necrosis because Still’s disease is not service-connected. As a matter of law, secondary service connection cannot be established upon a non-service-connected disability. See Sabonis v. Brown, 6 Vet. App. 426 (1994). The benefit-of-the doubt doctrine is not for application, and the claim for service connection for Still’s disease and hip necrosis must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Long-Ellis, 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.