Citation Nr: 21062362 Decision Date: 10/07/21 Archive Date: 10/07/21 DOCKET NO. 15-06 374A DATE: October 7, 2021 ORDER Entitlement to service connection for a disability manifested by chest pain, also claimed as costochondritis is denied. Entitlement to service connection for a disability manifested by bilateral shooting leg pains, to include medial tibial stress syndrome also known as shin splints is denied. FINDINGS OF FACT 1. The Veteran does not have a current disability manifested by chest pain, also claimed as costochondritis, resulting in a functional impairment, that was incurred in or is otherwise causally active service. 2. The Veteran does not have a current disability manifested by bilateral shooting leg pains, to include medial tibial stress syndrome also known as shin splints; resulting in a functional impairment, that was incurred in or is otherwise causally active service. CONCLUSIONS OF LAW 1. The criteria for establishing entitlement to service connection for a disability manifested by chest pain, also claimed as costochondritis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). 2. The criteria for establishing entitlement to service connection for a disability manifested by bilateral shooting leg pains, to include medial tibial stress syndrome also known as shin splints have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from January 1989 to June 1992 and from July 1994 to August 1998. Pursuant to an October 2019 Board decision, this matter was remanded for additional development to include scheduling the Veteran for new VA examinations to consider pain resulting in functional impairment of earning capacity pursuant to Saunders. As the requested development is now complete, this matter has been returned to the Board for appellate consideration. Duty to Assist and to Notify VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2020). Copies of compliant VCAA notices were located in the claim's file. VA's duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994). In this case, neither the Veteran nor her representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). Service connection, generally Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active-duty service. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303 (a), 3.304 (2020). Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of 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 disease or injury incurred or aggravated during service (the medical 'nexus' requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2020). Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2020). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order 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. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that "[w]hether lay evidence is competent and sufficient in a particular case is a factual issue. 1. Entitlement to service connection for a disability manifested by chest pain, also claimed as costochondritis The Veteran contends that she is entitled to service connection for a disability manifested by chest pain, also claimed as costochondritis. As discussed in more detail below, the preponderance of the evidence weighs against her claim. In analyzing her claim, the threshold inquiry for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury or disease. On review of the record, the Board concludes that although the medical evidence confirms reports of chest pain with post-service suspicion of costochondritis, the preponderance of the evidence fails to show that the noted symptoms are manifestations of a functional impairment that is causally related to active service, to include as due to an in-service event, injury, or disease. Service treatment records confirm sporadic complaints of chest and bilateral leg pain. At enlistment, no disqualifying defects were observed on examination in May 1994. In a pre-enlistment questionnaire, dated December 1988, the Veteran reported an admission to the hospital at the age of 12, due to a broken ankle with soft tissue infection described as group A beta streptococcus. X-rays of the underlying fibula were unremarkable. No residual symptoms were reported. In April 1990 and again in August 1994, the Veteran was treated for bilateral leg pain. A physical examination revealed tenderness over the distal aspects of the tibia, with swelling. A temporary profile was granted. Possible diagnoses were listed as shin splints and left ankle sprain. X-rays found no evidence of stress fractures. An acute medical care screening note, dated February 1995, referenced right-sided chest pain with no history of a heart condition. An onset of symptoms was reported following unplugging a generator that appeared to be smoking. Pain was reported with deep breathing. Although, possible costochondritis was noted; the heart rhythm was observed as normal with clear lung sounds. In March 1997, the Veteran was evaluated for left lower rib pain with soreness, and cramping. The pain was also described as sharp, with walking downhill. A physical examination failed to show tenderness to palpation. The Veteran denied any prior history of trauma. Complaints of muscle failure with prolonged walking and physical training was noted. Other symptoms included pelvic pain. A CT scan of the chest was recommended. Motrin was prescribed to treat pain. A screening note of acute medical care referenced complaints of nasal congestion, sore throat, and intermittent chest pain in February 1998. A possible upper respiratory infection was indicated. The same month, the Veteran was referred to a medical evaluation board due to possible pulmonary disease. A physical examination revealed reduced pulmonary function with increased physical activity. Reportedly, similar symptoms were experienced over the previous 3 years. The Veteran's military occupation was listed as a traffic manager. Regular use of antihistamines had not resolved her symptoms. The diagnostic impression indicated that the Veteran suffers from exercise induced asthma in poor control. In connection with a medical evaluation board examination, a report of medical history referenced lay assertions of frequent headaches, painful joints, ear infections, sinusitis, asthma or shortness of breath, chest pain, chronic cough, high blood pressure, cramps in legs, stomach pain, and foot trouble in February 1998. Following the medical examination, no disqualifying abnormalities were identified. Post-service VA treatment records document intermittent complaints of symptoms. Complaints of midsternum chest pain was noted in December 2009. In April 2011, the Veteran was evaluated for a history of migraines, chest pain, and asthma. Chest pain was described as periodic bouts of sharp symptoms, which lasted several seconds to several minutes after onset. No cardiovascular risk factors were indicated. Other symptoms included allergic rhinitis and recurrent bouts of chest pain. Diagnostic imaging of the chest and lungs revealed normal findings. A cardiovascular examination was also normal. The Veteran's complaints of symptoms were deemed consistent with costochondritis. Similar complaints of recurrent left-side chest pain were reported in July and December 2018. A cardiovascular evaluation revealed a regular heart rhythm with no evidence of murmur, rub or gallop. During a Board hearing in April 2019, the Veteran testified regarding chest pain in service and a post-service diagnosis of costochondritis rendered in 2011. Current symptoms include tenderness, palpitation in chest, with use of non-steroidal anti-inflammatory drugs (NSAIDS) to treat pain. The same month, the Veteran's claim was remanded to schedule a VA examination. On examination in August 2019, a previous diagnosis of left costochondritis was acknowledged. During active service, the Veteran reported tenderness on the lower mid-sternum consistent with costochondritis. A physical examination found no evidence of pain or tenderness on the lower mid-sternum. Breath sounds were described as normal with no evidence of rhonchi, wheezing, or rales on auscultation. There was no evidence of a penetrating muscle injury. However, a non-penetrating muscle injury was listed, due to the Veteran's complaints of symptoms. Following the clinical evaluation, the examiner opined that the initial diagnosis of costochondritis in October 1998 was in error. Costochondritis is essentially a muscular strain involving the left or right intercostal muscle in the mid-sternum. While VA recent treatment records reportedly show a recent diagnosis of costochondritis, the VA examiner did not review them in connection with the current examination. As there was no evidence of pain or tenderness on either chest wall or mid-sternum, the examiner found no objective evidence of acute or chronic costochondritis. The examiner also stated that an opinion could not be offered as to the cause of the lower mid-sternum pain noted in service or more recent complaints of similar symptoms. Therefore, an opinion on direct service connection is not necessary. A subsequent Board remand decision, dated October 2019, noted that an additional examination was required as the examiner failed to fully consider VA treatment records which suggest recent treatment for costochondritis. On VA examination in March 2020, the VA examiner reached the same findings noted in August 2019. There was no objective evidence to support a current diagnosis of costochondritis. In June 2020, a primary care physician's note referenced complaints of left-sided chest pain. Prior X-ray films from 2018 revealed a minor rib deformity of the left ninth and tenth ribs. A subsequent Board decision, dated October 2020, found that an additional VA opinion was required to address the nature and etiology of the Veteran's reported symptoms, to include pain resulting in functional impairment of earning capacity pursuant to Saunders. On examination in June 2021, the examiner evaluated the Veteran's complaints of intermittent chest pain dating back to active service. A physical examination found no evidence of a diagnosable cardiac condition, nor any related abnormality. A chest x-ray failed to show any evidence of fracture or acute abnormality. An echocardiogram revealed normal findings. During an interview-based METS test, the Veteran denied experiencing symptoms attributable to a cardiac condition while engaging in any level of physical activity. Following the clinical evaluation, the examiner found no objective evidence of current diagnosis, to include costochondritis. Thus, an etiological opinion was not deemed warranted. In reaching the stated conclusion, the examiner noted that the Veteran's complaints of pain are subjective in nature. Medical records are positive for complaints of chest pain during service. While similar complaints of pain were noted in service and the previous VA examiner noted post-service treatment records documenting a current diagnosis of costochondritis, the diagnosis was deemed acute. There was no evidence of tenderness to palpation during the current examination. No functional impacted was reported or documented. Over the course of the appeal period, the Veteran has submitted multiple lay statements in which she reported intermittent chest pain and shooting bilateral leg pain dating back to active service. The medical evidence is inconsistent with her contentions. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. While the Veteran is presumed competent to report on her current symptoms and their onset, there is no evidence that she possesses the necessary medical expertise to provide an etiological opinion in this matter. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, the Veteran has been afforded multiple VA examinations. Although intermittent chest pain with possible costochondritis was documented both in-service and many years after separation, the medical evidence does not confirm the presence of a persistent disability or that the reported symptoms result in a functional impairment of earning capacity. In fact, more than a decade passed between in-service complaints of symptoms and post-service treatment for similar symptoms until on or about December 2009. The Board is cognizant of the Veteran's complaints of intermittent chest pain dating back to active service. In a recent precedential decision, Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), the Federal Circuit held that pain, even in the absence of a presently diagnosed condition, can be viewed as a "disability" when there is evidence of functional impairment. However, a veteran cannot demonstrate service connection simply by asserting subjective pain; to establish a disability, the pain must amount to a functional impairment. Id. at 1367-68. In this case, no functional impairments, to include as causally related to an in-service injury, event, or disease, have been shown. While the Board is sympathetic to the Veteran's subjective belief that she suffers from a disability manifested by intermittent chest pain as causally related to active service, the evidence of record does not support her assertion. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The claim of entitlement to service connection for a disability manifested by chest pain, also claimed as costochondritis must be denied. 2. Entitlement to service connection for a disability manifested by bilateral shooting leg pains, to include medial tibial stress syndrome also known as shin splints The Veteran contends that she is entitled to service connection for a disability manifested by bilateral shooting leg pains, to include medial tibial stress syndrome also known as shin splints. As discussed in more detail below, the preponderance of the evidence weighs against her claim. In analyzing her claim, the threshold inquiry for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury or disease. On review of the record, the Board concludes that, while service treatment records confirm complaints of bilateral pain with possible shin splints and post-service complaints of similar symptoms, the preponderance of the evidence fails to show that the noted symptoms are manifestations of a functional impairment that is causally related to active service, to include as due to an in-service event, injury, or disease. Service treatment records confirm sporadic complaints of bilateral leg pain. Although a prior history of treatment for a right leg condition occurred years before enlistment, no residual symptoms or disqualifying defects were observed at enlistment or separation. Post-service treatment records show sporadic complaints of intermittent bilateral leg pain from 2002 to 2009. X-ray findings were unremarkable. In February 2009, an electromyography (EMG) of the bilateral lower extremities was also normal. In October 2010, a physical examination of the bilateral legs revealed normal findings. No reduction in range of motion, muscle strength, or decrease in sensation or reflexes was identified. A December 2011 VA examination acknowledged the Veteran's complaints of shin splints several times per month, but x-rays of both tibia and fibula revealed no evidence of abnormalities and soft tissue was unremarkable. In a July 2012 addendum VA medical opinion report, the VA examiner concluded that there was no confirmed diagnosis of shin splint and current complaints of right leg pain may be due to another etiology. The VA examiner did not provide any further statement regarding the possible diagnosis or etiology. In December 2018, the Veteran's primary care physician provided a medical statement. A treatment history dating back to 2006 was reported. Periodic complaints of symptoms included low back pain, costochondritis, right leg, and knee pain, with left ankle pain and weakness. During a Board hearing in April 2019, the Veteran reported seeking treatment for pain that radiated down both legs during active service. Reportedly, a diagnosis of bilateral shin splints was rendered, and she received related treatment. Post-service, she complains of frequent bouts of symptoms. She denied seeking treatment recently. To treat pain, the Veteran endorsed use of Naproxen. Pursuant to a Board remand decision, the Veteran was afforded an additional VA examination in August 2019. During the clinical interview, the examiner acknowledged a suggestion of right leg shin splints and complaints of bilateral leg pain in service. Post-service treatment records document sporadic reports of similar symptoms. Current symptoms include mild intermittent pain in the bilateral lower extremities. The Veteran denied any experience with numbness or tingling. A physical examination found no evidence of pain or tenderness to the bilateral lower extremities; to include shin splints. The service-related incident of right leg shin splints was deemed resolved. X-rays of the bilateral knees revealed bilateral patellar enthesophytes. There was no evidence of bilateral shin splints. The Veteran's gait was observed as normal. Only a slight reduction in range of motion of the bilateral knees was indicated. On examination, there was no evidence of pain with range of motion testing. There was also no evidence of pain on passive motion, or pain with non-weight bearing. No additional factors were listed as contributing to the Veteran's disability. Muscle strength testing was normal. There was no evidence of muscle atrophy, ankylosis, or recurrent effusion. Joint stability testing was normal. No functional impact was documented. Following the clinical evaluation, the examiner found no objective evidence of bilateral shin splints, either acute or chronic. A subsequent Board decision, dated October 2019, found that an additional VA opinion was required to address recent treatment evidence suggesting that the Veteran experienced tingling in the ankles and dorsum of both feet. In March 2020, a VA medical opinion noted inconsistent symptom reporting. No explanation or opinion was offered regarding the Veteran's subjective complaints of shooting bilateral leg pain. Magnetic resonance imaging (MRI) of the lumbar spine was unremarkable. There was no evidence of fracture nor a bony abnormality that would cause a nerve impingement, to include sciatica or radiculopathy. The examiner suggested that the only condition likely to cause nerve impingement or radiculopathy is degenerative disc disease with spinal stenosis, neuroforaminal stenosis, facet arthroses or disc protrusion. While a current diagnosis of a muscle strain in the lumbar spine was noted, the examiner indicated that a muscle strain does not cause a nerve impingement or radiculopathy. In a subsequent opinion, dated May 2021, the VA examiner considered the Veteran's complaints of intermittent bilateral leg pain dating back to active service. Specifically, current symptoms include intermittent and shooting pain, with aching and swelling to the lower extremities. During the clinical interview, the Veteran suggested that her bilateral lower leg pain was secondary to a right leg injury sustained in an accident at the age of 12. She also asserted that her experience of intermittent bilateral leg pain results from aggravation during active service. Service treatment records show isolated reports of leg pain with a temporary profile. However, there was no evidence of chronicity, thereafter. Post-service treatment records show sporadic complaints of bilateral leg pain. The Veteran endorsed use of Naproxen to treat pain. A physical examination revealed normal muscle strength and deep tendon reflexes. Sensation was also normal. No trophic changes or impairments to the gait were observed. A peripheral nerve examination of the lower extremities found no evidence of radiculopathy. Considering the above, the examiner concluded that no diagnosis was warranted. Therefore, no etiological opinion was provided. While the Veteran's subjective reporting of leg pain was noted, it was not deemed attributable to her service- connected bilateral pes planus nor iliotibial band friction syndrome right knee. No functional impairment was observed as due to the Veteran's subjective symptoms. In multiple lay statements, the Veteran has reported intermittent chest pain and shooting bilateral leg pain dating back to active service. The medical evidence does not support her contentions. In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. While the Veteran is presumed competent to report on her current symptoms and their onset, there is no evidence that she possesses the necessary medical expertise to provide an etiological opinion in this matter. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In this case, the Veteran has been afforded multiple VA examinations. While the record confirms a right leg jury that predated active service, sporadic complaints of intermittent bilateral leg pain in-service, and again, years after separation, the medical evidence does not confirm the presence of a persistent disability nor a related functional impairment of earning capacity. While the Board is sympathetic to the Veteran's subjective belief that she suffers from a disability manifested by bilateral shooting leg pains, to include medial tibial stress syndrome also known as shin splints as causally related to active service, the evidence of record does not support her assertion. Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The claim of entitlement to service connection for a disability manifested by bilateral shooting leg pains, to include medial tibial stress syndrome also known as shin splints must be denied. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Whitaker, 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.