Citation Nr: 21004069 Decision Date: 01/25/21 Archive Date: 01/25/21 DOCKET NO. 15-14 431 DATE: January 25, 2021 ORDER Entitlement to service connection for a back disability, to include as due to secondary to service-connected disabilities, is denied. Entitlement to service connection for a left hand disability is denied. Entitlement to service connection for a left arm disability as secondary to a left hand disability is denied. Entitlement to service connection for left cubital tunnel syndrome as secondary to a left hand disability is denied. FINDINGS OF FACT 1. The Veteran’s back disability was not incurred in service and was not caused or aggravated by his service-connected disabilities. 2. The Veteran does not have a left hand diagnosis that was incurred or aggravated during service. 3. The Veteran’s claimed left arm disability was not caused or aggravated by a service-connected left hand disability. 4. The Veteran’s left cubital tunnel syndrome was not caused or aggravated by a service-connected left hand disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a back disability, to include as secondary to service-connected disabilities, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for entitlement to service connection for a left hand disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for entitlement to service connection for a left arm disability secondary to a left hand disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. 4. The criteria for entitlement to service connection for left cubital tunnel syndrome secondary to a left hand disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1987 to February 1990. The matter comes before the Board of Veterans’ Appeals (Board) on appeal from January 2014 and December 2014 rating decisions by a Department of Veterans Affairs (VA) Regional Office (RO). The Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ) in June 2018. The hearing transcript is of record. The Board remanded the claim in August 2018 for further development by the RO. The case has been returned to the Board for further appellate action. 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). Service connection may also be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 U.S.C. §§ 1110, 1131; Allen v. Brown, 7 Vet. App. 439 (1995) (en banc); 38 C.F.R. § 3.310(a). 1. Entitlement to service connection for a back disability secondary to service-connected disabilities The Board concludes that, while the Veteran has a currently diagnosed back disability, and is currently service connected for multiple musculoskeletal or orthopedic conditions, the preponderance of the evidence weighs against finding that the Veteran’s back disability is proximately due to or the result of, or aggravated beyond its natural progression by the Veteran’s service-connected disabilities, or is otherwise related to an in-service injury, event, or disease. The Veteran asserts that his back disability is secondary to his other orthopedic disabilities. The Veteran is service connected for bilateral pes planus with plantar fasciitis, bilateral hip strain with impairment of thigh and limitation of extension and flexion, bilateral ankle sprain, bilateral knee sprain, right knee limitation of extension, and shin splints. The Veteran’s service treatment records (STRs) indicate that his January 1990 exit examination, report of medical examination, indicate that his spine and other musculoskeletal systems were normal. His January 1990 exit examination, report of medical history, indicate that the Veteran reported no swollen or painful joints and no recurrent back pain. There are no records of complaints of or treatment for back symptoms. The Veteran underwent a VA examination in March 2015. The examiner noted a diagnosis of lumbosacral strain. The Veteran reported that he experienced symptoms of back strain since leaving service. Physical examination results included normal range of motion on initial testing and on repetitive use and a negative straight leg test. The examiner opined that the condition was not proximately due to, the result of or aggravated beyond its natural progression by bilateral pes planus. The examiner stated that the Veteran’s pes planus was mild without medial deviation or any sign of medial angulation of calcaneus, or heel cords, which could theoretically affect alignment of knee or hip joints. There is no scientific basis on which to relate his back disability to his bilateral pes planus condition. In the June 2018 Board hearing, the Veteran stated that in approximately 1988 following physical training, his feet, ankles, knees, hips and back all began hurting, akin to a domino effect. These symptoms continued after separation. The Veteran underwent a second VA examination in August 2019. The examiner noted a diagnosis of degenerative disk disease pursuant to a November 2016 X-ray. The Veteran reported the onset of low back pain in service following physical training runs in parachute jumps that worsened over time to manifest in severe low back pain, tension, stiffness and radiating pain and numbness. Physical examination results showed that the Veteran was unable to perform the straight leg raise test. These also showed an abnormal range of motion, although the motion results were noted to be invalid due to probable intentional manipulation. The examiner included remarks that the current examination was challenging, with gross inconsistencies noted among observed range of motion during the examination and also during transitions, which indicated probably intentional manipulation of examination results. Additionally, the examination findings were grossly inconsistent with the mild pathology found on objective imagery. The examiner indicated that the Veteran had poor cooperation on the current examination, further noting that the Veteran was unable to conduct a straight leg raise test due to poor cooperation. The Veteran reported severe pain at 10 degrees of elevation, in sharp contrast to 90-degree hip flexion without pain during transitions. In a June 2020 addendum, the examiner opined that the Veteran’s back condition is not at least as likely as not incurred in or caused by an in-service back condition. The Veteran’s service treatment records (STRs) do not indicate any significant injury to or chronic pathology or problems affecting his back during service. The examiner further opined that the back condition is less likely than not incurred in, caused by, or aggravated by the Veteran’s service-connected orthopedic disabilities, to include those of the feet, hips, ankles, and knees. There is no specific pathophysiologic connection that would establish likelihood of cause or aggravation of the current back disability by these orthopedic issues. Secondary causation is possible in some cases where there is extreme gait alteration due to unilateral orthopedic issues, which can occasionally lead to chronic spinal disability. However, the Veteran’s widespread unilateral orthopedic issues are in this case are likely protective against spinal injury and degeneration as these issues likely reduce the Veteran’s appetite for high-impact activities. Thus, these conditions are protective against and not causative of, or potentially aggravating for, the Veteran’s back problems. The examiners opinions are probative, because they are based on an accurate medical history and provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). As the Veteran was not diagnosed with any back condition until many years after service and the service treatment records contain no record of complaints of or treatment for back pain, to include the January 1990 exit examinations indicating that the Veteran’s back was normal and asymptomatic, the Board finds that the weight of the evidence is against a finding of any continuity of symptomatology. See Maxson v. West, 12 Vet. App. 453 (1999), aff’d, 230 F.3d 1330 (Fed. Cir. 2000). The Board acknowledges the lay statements of record and the assertion that the Veteran’s back disability is related to his service-connected orthopedic disabilities. However, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex. He does not have the requisite specialized knowledge, 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). Neither the Veteran nor his representative has presented or identified any contrary medical treatments or medical opinion evidence that supports a finding of a nexus between his back condition and his service-connected orthopedic conditions. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine cannot be applied. 38 U.S.C. § 5107(b); Gilbert v. Derwinksi, 1 Vet. App. 49, 53-56 (1990). Thus, service connection for a back disability is not warranted. 2. Entitlement to service connection for a left hand disability The Board concludes that the Veteran does not have a current diagnosis of left hand disability, to include a disability of pain with accompanying functional impairment, and has not had one at any time during the pendency of the claim or recent to the filing of the claim. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). The Veteran asserts that his left hand condition is related to service. The Veteran’s STRs indicate that the Veteran injured his left ring finger in service and repeatedly sought treatment. The injury was noted as a boutonniere deformity. The Veteran underwent a VA examination in December 2013. The Veteran reported a military accident but that he was unsure if, to date, the condition had been formally diagnosed. He described his symptoms as pain, numbness, and tingling in the second through fifth fingers of his left hand. The VA examiner found that the Veteran did not have a hand or finger condition, but that trace narrowing proximal interphalangeal of the fourth digit and first carpometacarpal joint of the left hand was not clinically significant. Additionally, there was no functional loss or functional impairment of any of the fingers or thumb. The VA examination included a December 2013 radiology report of AP, oblique, and lateral views of the hand, noting negative results for fracture, dislocation, or bony destructive lesion. Only trace narrowing was noted. A private treatment record dated February 7, 2014, noted a three-view X-ray report of mild degenerative changes affecting the proximal interphalangeal and distal interphalangeal joints. No X-ray image is attached. The clinician noted symptomatic DJD and that “I feel that that the stiffness and pain [in these joints] are due to DJD.” A VA treatment record dated February 12, 2014, noted a three-view X-ray report showing no displaced fracture, dislocation, abnormal periarticular soft tissue calcifications or substantial changes of erosive or degenerative arthritis. The impression was no osseous abnormality of the left hand. In May 2018, the Veteran submitted a private examination from Dr. B.B. dated April 2013. The Veteran reported that he had left finger and left hand pain and that he had a previous injury on his left ring finger. He described his symptoms as painful with repetitive motion on a daily basis and reported that he noticed pain in his joints constantly, with occasional swelling of the digits. Dr. B.B. noted “possible” degenerative joint disease (DJD) and included a notation that the Veteran’s symptoms were “likely related to hand trauma.” It is unclear whether this is an etiological opinion from Dr. B.B. or from the Veteran. Dr. B.B. noted functional loss of the left hand, including weakened movement, excess fatigability, pain on movement, and swelling. In the June 2018 Board hearing, the Veteran reported that he had sought treatment for his symptoms since service. He was told his pain was possibly due to trauma from and unhealed finger and that he had “possible” arthritis. The Veteran reported his current symptoms as severe pain on weekly occasions. He reported pain on gripping the steering wheel; that picking up items causes weakness and pain; and that grabbing or handling things for a long period of time causes swelling. The Veteran underwent a second VA examination in August 2019. The Veteran reported injuring his left ring finger in 1988 and that this was the onset of his symptoms, to include long-standing fairly severe pain, weakness and numbness affecting his entire hand and lower arm. He also reported significant difficulty with grasping, twisting and lifting motions. The examiner noted that the examination was normal and consistent with previous examinations and with a general tendency for bones to heal over time. The examiner found that initial range of motion was normal and there was no additional loss of function or range of motion after three repetitions. No additional factors contributing to disability were noted. Muscle strength was normal. No other pertinent physical findings, complications, conditions, signs or symptoms were noted. No functional impact on the Veteran’s ability to perform any type of occupational task was noted. The examiner found no current diagnosis associated with the claimed condition. The examiner opined that the Veteran’s left finger pain could not be said to produce identifiable functional impairment, further noting that making a diagnosis in the absence of physical findings requires a dependable historian. The examiner did not find the Veteran to be a dependable historian in this instance. The examiner stated that the Veteran’s statements were not credible given significant, objective and undeniable mismatches between the statements and objective findings and records. As to the lack of diagnosis, the examiner further opined that the examination is consistent with the December 2013 examination indicating that the boutonniere deformity had resolved. The Board finds that the examiner’s opinion provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board notes two flaws in the medical opinion and finds that, despite these flaws, the examination is adequate and probative. First, the examiner noted that the STRs are silent for any left ring finger fracture, when the STRs do in fact note a left finger injury and boutonniere deformity. This mistake, however, does not affect the examiner’s threshold determination that there is no current diagnosis, to include pain with accompanying functional impairment. The examiner did properly take into consideration a boutonniere deformity that had long since resolved, even if he was apparently unaware such deformity was incurred in service. Second, the examiner failed to address the private treatment record dated February 7, 2014, noting a three-view X-ray report of mild degenerative changes affecting the proximal interphalangeal and distal interphalangeal joints, to which no X-ray image was attached. However, this report is contradicted by two VA treatment records. The subsequent VA treatment record dated February 12, 2014, noted a three-view X-ray report showing no displaced fracture, dislocation, abnormal periarticular soft tissue calcifications or substantial changes of erosive or degenerative arthritis. The impression was no osseous abnormality of the left hand. This is consistent with the prior December 2013 X-ray report, which noted only trace joint narrowing deemed insignificant. The December 2013 VA treatment record is proximate in time to the February 2014 treatment records, which further bolsters its probative value. Furthermore, the private clinician qualified his findings stating that he “felt” the symptoms were due to DJD. This statement is not conclusive; it is also contradicted by two separate medical reports. Thus, the Board finds that the private treatment record dated February 7, 2014, is less probative than both the subsequent and prior, but proximal in time, VA radiographic records. Further, to date, neither the Veteran nor his representative has presented or identified any X-ray imaging, medical treatment or medical opinion evidence that supports a finding of a current diagnosis associated with the claimed condition. See Wood v. Derwinski, 1 Vet. App. 190 (1991). The Board does not find that a remand to address these omissions in the examination is necessary, as there is no indication that the additional delay to do so would actually avail the Veteran of any benefit, and the current evidence is adequate for adjudication. The Board acknowledges the lay statements of record, to include descriptions of his current symptoms and continuation of symptomatology since service, as well as the assertion that the Veteran’s left hand disability is related to his in-service left finger injury. However, the Veteran in this case is not competent to provide a diagnosis of his condition or a nexus opinion regarding this issue. The issue is medically complex. He does not have the requisite specialized knowledge, training, or credentials to make such determinations. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine cannot be applied. 38 U.S.C. § 5107(b); Gilbert v. Derwinksi, 1 Vet. App. 49, 53-56 (1990). Thus, service connection for a left hand disability is not warranted.   3. Entitlement to service connection for a left arm disability as secondary to a left hand disability 4. Entitlement to service connection for left cubital tunnel syndrome as secondary to a left hand disability The Veteran contended at the June 2018 Board hearing that his claimed left arm disability and left cubital tunnel syndrome are secondary to a left hand disability stemming from the in-service left finger injury. However, as noted above, the Veteran is not service connected for a left hand disability. Furthermore, because the Veteran has not raised, and the record does not reasonably raise, entitlement to direct service connection, the Board’s adjudication will consider only entitlement to secondary service connection. The Board concludes that there is no basis on which to grant service connection, and service connection for a claimed left arm disability or cubital tunnel syndrome is not warranted. Nathaniel J. Doan Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M. Minaya, 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.