Citation Nr: 21004484 Decision Date: 01/27/21 Archive Date: 01/27/21 DOCKET NO. 17-17 140 DATE: January 27, 2021 ORDER Entitlement to service connection for valvular heart disease is denied. REMANDED Entitlement to service connection for left shoulder condition is remanded. FINDING OF FACT There is no current diagnosis of a heart condition, to include any valvular heart disease. CONCLUSION OF LAW The criteria for entitlement to service connection for valvular heart disease have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably on active duty from September 1988 to January 2009, to include service in Southwest Asia. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a November 2015 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). As a preliminary matter, the Board notes that these claims were previously before the Board in March 2019, at which time they were both remanded to the Agency of Original Jurisdiction (AOJ) for further evidentiary development. Although the Board regrets the additional delay, an additional remand is warranted, as discussed in further detail below. 1. Entitlement to service connection for valvular heart disease is denied. The Veteran contends that he suffered chest pain during his active duty military service, and that subsequently, he underwent testing and examination for cardiac conditions, including an echocardiogram, which reflected that he has valvular heart disease. As such, he asserts service connection is warranted for his claimed current heart disability. See e.g., August 2015 correspondence. Service connection will be granted if it is shown that the veteran suffers from a disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty, during active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d); see also Combee v. Brown, 34 F.3d 1039, 1043 (Fed. Cir. 1994). In order to establish service connection on a direct basis, the record must contain competent evidence of: (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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Some chronic diseases may be presumed to have been incurred in service, if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C.§§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). The Board finds that ultimately, the preponderance of the evidence is against service connection for a heart condition, to include valvular heart disease, as there has been no diagnosed heart disability during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Therefore, service connection cannot be granted. The Veteran is competent to report his noticeable symptoms, including chest pains or tightness and shortness of breath. However, the Veteran is not competent to identify whether he has a heart disease or current heart condition because this is a complex medical issue that requires specialized knowledge and expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). The objective medical evidence of record shows no current disability. Turning to the evidence of record, the Veteran’s service treatment records (STRs) reflect several complaints of chest pain. Significantly, he was noted to have possible cardiomegaly in May 2005 and December 2006, as well as mild mitral and tricuspid valve regurgitation in January 2007. Prior to his separation from service, he was afforded a general VA examination in September 2008, which reflected no heart disorder. The September 2008 VA examiner noted that there was no sign of congestive heart failure, cardiomegaly, or cor pulmonale. The Veteran submitted a statement from a nurse practitioner, G. G. U., in December 2015. This statement indicates that G. G. U. concluded that the Veteran has a diagnosis of valvular heart disease, based upon an echocardiogram completed in service in January 2007, which demonstrated both mitral and tricuspid valve regurgitation. G. G. U. also noted that the Veteran had in-service notations showing an enlarged heart on two occasions (in May 2005 and December 2006), which support a chronic finding as the x-rays were more than six months apart. Based on this evidence, G. G. U. opined that the Veteran should be entitled to presumptive service connection for endocarditis, pursuant to 38 C.F.R. § 3.309(a), which covers all forms of valvular heart disease. The Veteran was then afforded a VA examination for heart conditions in December 2019, following a March 2019 remand by the Board. The December 2019 VA examiner determined that the Veteran does not have a current heart condition. Regarding medical history, the VA examiner indicated that the Veteran was seen for shortness of breath at the troop medical clinic (during service) and was noted to have possible cardiomegaly in May 2005 and December 2006, as well as mild mitral and tricuspid valve regurgitation in January 2007. However, the VA examiner indicated, that upon VA examination in September 2008, no heart disorder was found, and that the Veteran has had no medical follow up for his heart since that time. As such, the VA examiner confirmed that the Veteran has no currently diagnosed heart condition. The VA examiner did note that the Veteran has had a heart valve condition, affecting the mitral and tricuspid valves. The VA examiner explained that an echocardiogram was done on the Veteran in 2007, and trace mitral and tricuspid valve regurgitation was found at that time; however, he also determined that the findings were “of no clinical significance.” The December 2019 VA examiner performed a full physical examination of the Veteran, with all measures returning normal; the VA examiner also performed an EKG and indicated that the 2007 echocardiogram indicated normal results. The December 2019 VA examiner also performed an interview based METs Test, and the Veteran denied experiencing any symptoms attributable to a cardiac condition with any level of physical activity. The December 2019 VA examiner opined that the Veteran’s claimed condition was less likely than not incurred in or caused by an in-service injury, event, or illness. The VA examiner stated “[a] chest x-ray done in May 2005 and 2006 was questionable for heart size upper limit of normal versus horizontal axis. A cardiac ultrasound was advised for confirmation. ECHO done in January 2007 was negative for heart enlargement. There was trace mitral valve and tricuspid valve regurgitation, with normal valve morphology. A chest x-ray done June 2008 was unremarkable. Specifically, [the Veteran’s] heart was normal in size. No further cardiac care has been provided since clearance from cardiology in 2007. He is not under the care of a cardiologist, and he does not have a diagnosis of a heart condition. The Veteran does not have a diagnosis for service connection for a heart disorder that is at least as likely as not incurred in or caused by the in-service findings of cardiomegaly and/or abnormal mitral and tricuspid valve findings.” VA treatment records following service reflect that the Veteran has occasionally complained of chest pain. See e.g., October 18, 2011 telephone note. However, there is no consistent cardiac care or noted diagnoses within this evidence of record. The Board finds the December 2019 VA examiner’s opinion regarding the issue of current disability to be highly probative, as it was predicated on a detailed and thorough review of the record, including pertinent medical records, as well as an extensive examination and cardiac work up of the Veteran. The statement submitted by G. G. U. in December 2015 is found to be less probative because it is unclear whether she personally examined the Veteran and performed such extensive cardiac testing contemporaneously, as the December 2019 VA examiner did. Although laypersons, such as the Veteran, are sometimes competent to provide opinions on certain medical questions, the specific issue in this case falls outside the realm of common knowledge of a lay person as it involves making a definitive clinical determination of the nature and etiology of the Veteran's heart condition based on knowledge of cardiology. See Kahuna v. Shinseki, 24 Vet. App. 428, 435 (2011). While the Veteran can report that he experiences symptoms that may be associated with a heart disorder, he is not able to provide competent evidence as to the diagnosis or etiology of any condition. Accordingly, the Board finds that the claim of entitlement to service connection for a heart condition, to include valvular heart disease, must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim of entitlement to service connection, that doctrine is not applicable. REASONS FOR REMAND 1. Entitlement to service connection for left shoulder condition is remanded. The Veteran contends he has a current left shoulder condition, along with symptoms such as pain and limited range of motion, that is related to his active military service. Specifically, the Veteran asserts that he injured his shoulder during service and has continued to experience residuals of such injury since. This issue was first remanded by the Board in March 2019. The Board noted that the Veteran’s STRs contain several complaints of left shoulder pain, as well as a diagnosis of muscle strain of the deltoid in March 1997. Prior to his discharge from service, the Veteran was afforded a VA examination which was negative for a left shoulder disability. However, the Board found that subsequent VA treatment records continued to show complaints and treatment for left shoulder pain. As such, the claim was remanded to the AOJ to obtain an additional VA examination. The Veteran was examined in December 2019. The VA examiner indicated that the Veteran has a current diagnosis of left shoulder strain, with an abnormal range of motion and pain noted upon examination. Regarding a nexus between the Veteran’s left shoulder strain and service, the December 2019 VA examiner stated that the claimed condition was less likely than not incurred in or caused by an in-service injury or event. The VA examiner stated “[d]uring service, the condition was acute only. The Veteran sustained a left shoulder injury in 1997. He was diagnosed with a muscle strain secondary to deltoid and prescribed NSAIDs for three days. The Report of Medical Examination from May 2005 indicated no shoulder issues. There is no evidence in the claims file of continued complaints of left shoulder pain or issues. There is no evidence of chronicity of care. A nexus has not been established.” However, this is directly contradictory to the post-service medical evidence of record, including VA treatment records. Post-service VA treatment records do reflect continued complaints of left shoulder pain and issues with the Veteran’s left shoulder. The Veteran has repeatedly reported experiencing symptoms, such as pain or limited motion, of his left shoulder condition to VA treatment providers since 2008. See e.g., July 30, 2012 VA clinic note; August 2, 2012 VA physiatry clinic note; July 2010 C&P evaluation for left shoulder; March 28, 2008 MRI of left shoulder; June 17, 2010 VA primary care note (where Veteran is complaining of left shoulder pain, by scapular area); May 13, 2009 VA primary care note; April 28, 2008 VA rehab med clinic note (where the Veteran complains of shoulder pain and is referred for evaluation). As such, the Board finds the December 2019 VA examiner’s opinion to be inadequate because it did not consider other medical evidence in the file, as mentioned above. The Veteran has contended that his left shoulder pain, which was noted during service, continued after discharge. VA treatment records reflect that this assertion is accurate and credible. Therefore, the Board finds an addendum opinion is necessary to adequately address the etiology of the Veteran’s chronic left shoulder strain. The matters are REMANDED for the following action: 1. Obtain an addendum medical opinion regarding the nature and etiology of the Veteran’s current left shoulder condition (chronic left shoulder strain). The examiner is asked specifically to review the Veteran’s claims file in its entirety and render opinions as to the following: (a.) Whether the in-service injury to the Veteran’s left shoulder caused or is related to his current chronic left shoulder strain. (b.) Otherwise, whether it is at least as likely as not that that the Veteran’s current left shoulder condition is due to his active military service. The examiner is asked to provide the underlying reasons for all opinions expressed, and is reminded that the term “as likely as not” does not mean ‘within the realm of medical possibility,” but rather that the evidence of record is so evenly divided that, in the examiner’s expert opinion, it is as medically sound to find in favor of the proposition as against it. Bethany L. Buck Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. M. Lowman, 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.