Citation Nr: 21063418 Decision Date: 10/14/21 Archive Date: 10/14/21 DOCKET NO. 14-38 557A DATE: October 14, 2021 ORDER Entitlement to service connection for a bilateral knee disability secondary to service-connected scleroderma, is denied. REMANDED Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected disability, is remanded. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected disability, is remanded. FINDING OF FACT The Veteran's bilateral knee disability is not secondary to service-connected scleroderma. CONCLUSION OF LAW The criteria for entitlement to service connection for a bilateral knee disability, to include as secondary to service-connected disability, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1983 to July 1987. These matters come before the Board of Veterans' Appeals (Board) from July 2013 and September 2014 rating decisions of a Department of Veterans Affairs (VA) Regional Office (RO). The above issues were previously before the Board in May 2018 and November 2020. Most recently, in November 2020, the Board remanded the following service connection issues: (1) a right shoulder disability, (2) a bilateral knee disability, (3) left hand and finger numbness, and (4) obstructive sleep apnea (OSA). In an April 2021 rating decision, the VA Regional Office (RO) granted the Veteran's service connection claim for left hand and finger numbness. As the grant represents a full grant of benefits sought on appeal, this issue is no longer before the Board. The remaining service connection issues for a right shoulder disability, bilateral knee disability, and OSA have since returned to the Board for further appellate review. Service Connection 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. Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected. Any increase in severity of a nonservice-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, will be service connected. However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury. 38 C.F.R. § 3.310. 1. Entitlement to service connection for a bilateral knee disability, to include as secondary to service-connected disability, is denied. The Veteran contends that he has a bilateral knee condition that is secondary to his service-connected scleroderma. Specifically, the Veteran contends that his scleroderma has attacked the joints in his knees, causing weakness and disability in his knees. See September 2013 Notice of Disagreement (NOD). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. At the outset, the Board notes that the Veteran has a February 2020 diagnosis of bilateral knee degenerative arthritis. See March 2020 VA examination. Therefore, the first element of service connection, a diagnosis, has been met. Second, the Veteran is service connected for scleroderma. Thus, this element of secondary service connection is met. Therefore, the only remaining issue is whether a nexus may be established between his bilateral knee disability and his service-connected scleroderma. In March 2020, the VA examiner concluded that the Veteran's bilateral knee condition, to include bilateral knee arthritis, was less likely than not (less than 50 percent probability) proximately due to or the result of Veteran's service-connected scleroderma. The examiner reasoned that it was more likely that the arthritis was the result of multiple trauma that has occurred over his lifetime. Therefore, the examiner concluded that no nexus or plausible secondary relationship was established. In January 2021, the VA examiner concluded that the Veteran's right shoulder disability, bilateral knee disability, and OSA were less likely than not proximately due to or the result of or aggravated beyond its natural progression by the Veteran's service-connected scleroderma. The examiner reasoned that there is no medical literature review that supports that scleroderma causes complications such as a right shoulder disability, bilateral knee disability, and OSA. According to medical literature review, the examiner noted that scleroderma complications range from mild to severe and can affect the Veteran's fingertips, lungs, kidneys, heart, teeth, digestive system, and sexual function. Based on the medical literature, the examiner then concluded that the Veteran's right shoulder disability, bilateral knee disability, and OSA were less likely than not (less than 50 percent probability) proximately due to or the result of or aggravated beyond its natural progression by the Veteran's service-connected condition. The Board finds the March 2020 and January 2020 opinions, taken together, probative because they are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Veteran believes his bilateral knee disability is proximately due to, the result of, or aggravated beyond its natural progression by his service-connected scleroderma. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the skills or medical training 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). Consequently, the Board gives more probative weight to the March 2020 and January 2021 VA opinions. Lacking a nexus, entitlement to service connection for a bilateral knee disability secondary to service-connected scleroderma is denied. REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected disability, is denied. The Veteran contends that he has a right shoulder disability that is directly related to his military service. Alternatively, he contends that his right shoulder disability is secondary to his service-connected scleroderma. At the outset, the Board notes that the Veteran has a diagnosis of right shoulder degenerative arthritis. The Veteran also underwent a total right shoulder replacement in December 2013. See April 2019 and February 2020 VA examinations. Therefore, the first element of service connection, a right shoulder diagnosis, has been met. Second, as to an in-service incurrence, in the February 2020 VA examination, the Veteran contends that he has a right shoulder disability due to carrying heavy machine guns when he was in the Marine Corps. He reported that he had to hump caring the machine gun parts that he believes caused the original injury to his right shoulder. The Veteran also reported that he used over the counter Motrin to alleviate his shoulder pain while in service. The Board also notes that the Veteran's service treatment records (STRs) do show treatment for bursitis in 1984 and 1986. As to a nexus, upon VA examination in April 2019, the examiner diagnosed right shoulder degenerative arthritis, noting that this disability was first diagnosed in December 2013 when the Veteran underwent a right shoulder joint replacement. The examiner provided a negative opinion as to its etiology as the STRs were negative for a right shoulder injury or complaints. Additional opinions addressed secondary service connection. While the Board regrets the additional delay, the Board finds the April 2019 opinion inadequate, as the VA examiner did not discuss treatment for bursitis in service as noted above. The examiner also did not address the Veteran's lay statements that he had to hump caring the machine gun parts that he believes caused the original injury to his right shoulder. The Veteran also reported that he used over the counter Motrin to alleviate his shoulder pain while in service. Therefore, a remand is necessary to obtain another VA opinion that addresses the Veteran's in-service treatment as well as his lay statements that his right shoulder disability is directly related to his military service. 2. Entitlement to service connection for obstructive sleep apnea (OSA), to include as secondary to service-connected disability, is remanded. The Veteran contends that his sleep apnea is either directly related to his military service or secondary to his service-connected scleroderma and/or PTSD. See September 2013 NOD. At the outset, the Board notes that the Veteran has an October 2011 diagnosis of obstructive sleep apnea. See February 2020 VA examination. Therefore, the first element of service connection, a diagnosis, has been met. In July 2020 and June 2021, the Veteran was provided examinations and nexus opinions were obtained. While the Board regrets the additional delay, the Board finds the July 2020 and June 2021 opinions inadequate. First, neither opinion addresses whether the Veteran's OSA is directly related to his military service. Secondly, the Board notes that the Veteran has submitted articles that discuss the relationship between OSA and PTSD. See articles submitted April 2014. Neither of the opinions have addressed these articles. Therefore, a remand is necessary to obtain another VA opinion that adequately addresses all of the Veteran's contentions and considers all evidence of record, to include the articles the Veteran has submitted regarding the relationship between OSA and PTSD. The matters are REMANDED for the following action: 1. RIGHT SHOULDER: Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's right shoulder disability, to include right shoulder degenerative arthritis and total right shoulder replacement. The examiner should identify all right shoulder conditions present. For each diagnosis of a right shoulder disability, to include right shoulder degenerative arthritis and total right shoulder replacement, the examiner is asked to provide a response to the following: a. Is the Veteran's right shoulder disability at least as likely as not proximately due to a service-connected disability, to include his service-connected scleroderma. b. Is the Veteran's right shoulder disability at least as likely as not aggravated, i.e., worsened beyond its natural progression, by a service-connected disability, to include his service-connected scleroderma. c. Is the Veteran's right shoulder disability at least as likely as not related to service. The examiner must address the Veteran's episodes of bursitis in service. The examiner also must address the Veteran's lay statements that he has a right shoulder disability due to carrying heavy machine guns when he was in the Marine Corps. He reported that he had to hump caring the machine gun parts that he believes caused the original injury to his right shoulder. The examiner is also requested to address the Veteran's reports that he used over the counter Motrin to alleviate his shoulder pain while in service. Provide a rationale to support the opinion(s). 2. SLEEP APNEA: Obtain an addendum opinion from an appropriate clinician regarding the etiology of the Veteran's obstructive sleep apnea (OSA). The examiner is asked to provide a response to the following: a. Is the Veteran's OSA at least as likely as not proximately due to a service-connected disability, to include his service-connected posttraumatic stress disorder (PTSD), scleroderma, median and ulnar neuropathy of the left hand and fingers as well as the right upper extremity, hypertension, erectile dysfunction, bilateral hearing loss, and/or tinnitus. b. Is the Veteran's OSA at least as likely as not aggravated, i.e., worsened beyond its natural progression, by a service-connected disability, to include his service-connected posttraumatic stress disorder (PTSD), scleroderma, median and ulnar neuropathy of the left hand and fingers as well as the right upper extremity, hypertension, erectile dysfunction, bilateral hearing loss, and/or tinnitus. c. Is the Veteran's OSA at least as likely as not related to service. The examiner must address the articles that the Veteran submitted in April 2014 that discuss the relationship between PTSD and OSA. Provide a rationale to support the opinion(s). 3. Then, adjudicate the claims. GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. E. Grossman, 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.