Citation Nr: 21069330 Decision Date: 11/18/21 Archive Date: 11/18/21 DOCKET NO. 16-59 193 DATE: November 18, 2021 ORDER 1. Entitlement to service connection for a testicular growth is denied. REMANDED 2. Entitlement to service connection for a right elbow disability is remanded. 3. Entitlement to service connection for a left elbow disability is remanded. 4. Entitlement to service connection for a right shoulder disability is remanded. 5. Entitlement to service connection for a left shoulder disability is remanded. FINDING OF FACT The Veteran is not shown to have a current diagnosis of a testicle growth disability. CONCLUSION OF LAW Service connection for a testicular growth is not warranted. 38 U.S.C. §§ 1110, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The appellant is a Veteran who served on active duty from July 2005 to July 2011 and had additional service in the Army National Guard. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2012 Department of Veterans Affairs (VA) rating decision (which denied service connection for right shoulder, left shoulder, right elbow, left elbow, lumbar spine with bilateral pain and numbness, left knee, right knee, right ankle, and testicular growth disabilities.) A September 2017 rating decision granted service connection for a left ankle disability, a lumbar spine with bilateral pain and numbness, and right and left knee disabilities, resolving the appeals in those matters. In his October 2016 Form 9, the Veteran requested a Board hearing. In a December 2019 statement, two days prior to the date of the scheduled hearing, the Veteran requested that his hearing be rescheduled as he no longer lived near the location of the scheduled hearing. He was scheduled for two videoconference hearings, in January 2020 and August 2021, but failed to appear on both occasions, and his representative requested that the Board proceed with adjudication of the case. See October 2021 written argument. Entitlement to service connection for testicular growth is denied. Service connection may be granted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). To substantiate a claim of service connection, there must be evidence of: a present disability; incurrence or aggravation of a disease or injury in service; and 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). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1999); 38 C.F.R. § 3.303(a). The Veteran's service treatment records (STRs) note a June 2011 report of "left testicle that feels like it has a sack of jelly" (first noticed a few months prior) and tenderness to the lower pole testicle. Physical examination revealed no gross findings on the left testicle itself and noted prominent epididymis. A June 2021 ultrasound was interpreted as showing no masses. On February 2012 VA (male reproductive systems conditions) examination, the Veteran reported that he noticed a lump in 2010 that has not changed in size since. He underwent an ultrasound in service, but no mass was found. The provider examined the Veteran and indicated the findings were unremarkable, to include normal testes and epididymis. The provider opined that there was no pathology warranting a diagnosis was shown. A May 2014 VA treatment record notes a rash on the Veteran's arms, armpits, and penis. His VA primary care provider prescribed antibiotics for the condition, but he returned to the VA emergency room as the rash continued to persist. On August 2017 VA (male reproductive systems conditions) examination, the Veteran reported a 2011 diagnosis in service of an enlarged left testicle and a normal ultrasound. He indicated the condition "stayed the same," denied pain, and reported having a prescription for Viagra. He declined an examination of his reproductive organs and stated that his erectile dysfunction (ED) is likely due to his history of depression. The examiner opined that the Veteran's testicular growth was less likely than not incurred in or caused by the claimed injury, event, or illness in service as records, to include a report of an ultrasound in service, show a completely normal testicle. The provider noted that the Veteran did not report sustaining an injury to his reproductive organ in service or post-service. The threshold requirement that must be met with respect to this claim (as with any claim seeking service connection) is that there must be competent evidence that the Veteran currently has (during the pendency of the claim has had) the disability for which service connection is sought, a testicular growth. See 38 U.S.C. § 1110. The record does not include any such evidence. Following service VA and private treatment records associated with the record do not show a diagnosis of, or treatment for, a testicular growth to include testicular pain. On examination scheduled in connection with the claim, in part to assist him in establishing he has a testicle disability, he declined physical examination. Consequently, such disability simply is not shown. The Veteran is competent to describe any lay-discernible symptoms of a testicular growth. See Barr, 21 Vet. App. at 303, 309. However, his own unsupported opinion he has a testicle disability underlying his complaints is not competent evidence that he has a diagnosis of such disability. He is a layperson, and does not cite to supporting medical opinion or clinical or medical treatise evidence which pertains to his own specific disability picture. The diagnosis and etiology of a disability manifested by a "lump" on the testes are medical question beyond the scope of lay observation. See Jandreau, 492 F. 3d at 1372. They require medical knowledge, informed by clinical evaluation and perhaps also diagnostic studies (which in the past, prior to the instant claim, did not find such disability. The Veteran has not submitted any competent (medical) evidence he has had a testicular growth disability during the pendency of the instant claim; and his declining in August 2017 a physical examination to establish he has such disability (and if so, determine its etiology) suggests such disability is not evident. Notably, an earlier (2012) VA examiner found there was no pathology to support that the Veteran currently had a left disability.) In the absence of proof of the disability for which service connection is sought (a testicular growth), there is no valid claim of service connection for such disability. See Brammer v. Derwinski, 3 Vet. App. 223 (1992). The preponderance of the evidence is against this claim, and the appeal in this matter must be denied. REASONS FOR REMAND 1., 2. Entitlement to service connection for right and left elbow disabilities. The Veteran's STRs note that during his active service he was seen for bilateral posterior elbow pain centered around the triceps tendon. He reported that the pain started when he was lifting weights during a 2011 deployment. May 2011 x-rays were interpreted as normal. The Veteran's post-deployment health assessments note his reports of swollen or stiff joints. August 2015 VA treatment records note the Veteran's report that he experiences numbness from the elbows to the fingers when weightlifting, and that his right elbow is worse than the left. On February 2012 VA (elbow and forearm conditions) examination, the Veteran reported falling and injuring his elbows in October 2010, resulting in sharp pains when exerting force. He related flare-ups of his elbow pain when he engages in a pushing motion. The provider noted there was no functional impairment, and opined that there is no pathology to render a diagnosis for either elbow. On August 2017 VA (elbow and forearm conditions) examination, the Veteran reported an onset of elbow disability in 2011 during his deployment to Afghanistan. He related that he experienced pain off and on the entire deployment and received a diagnosis of triceps tendonitis. He reported flareups on pushing heavy objects or with push-ups (described as pain that last a few seconds during the activity). The examiner opined that Veteran's bilateral elbow condition was less likely than not incurred in or caused by a claimed injury, event, or illness in service. The examiner noted the Veteran did not have a specific event or injury to which his bilateral elbow pain could be attributed, and that the Veteran's STRs show a diagnosis of triceps tendonitis, which is a self-limiting process. The examiner concluded that the physical examination of the Veteran was normal, and she was unable to render a diagnosis for his bilateral elbow pain. Neither VA examiner has provided an explanation that accounts for the Veteran's current reported symptoms of bilateral elbow pain. In Saunders v. Wilkie, No. 17-1466 (Fed. Cir. 2018), the Federal Circuit held that "pain alone can serve as a functional impairment and therefore qualify as a disability." In other words, where pain alone results in functional impairment, even if there is no identified underlying diagnosis, it can constitute a disability. To establish the presence of a disability, the Veteran must show that his elbow pain reaches a level that results in functional impairment of earning capacity. Subjective pain in and of itself will not establish a current disability. Consideration should be given to the impact, or lack thereof, from pain, focusing on evidence of functional limitation caused by the Veteran's pain symptoms. Accordingly, development for a fully adequate medical advisory opinion in this matter is necessary. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). 4., 5. Entitlement to service connection for right and left shoulder disabilities. The Veteran's STRs note March and May 2011 visits for left shoulder pain that he attributed to a 2010 ten-foot fall onto his left arm and shoulder. He reported a grinding/popping in his left shoulder with overhead movement, and described the pain as seven on a scale of ten when provoked with pushups or bench press. His left shoulder range of motion was noted by the provider to be normal with pain reported on external rotation and full flexion of the left shoulder. The Veteran's post deployment health assessments note his reports of swollen or stiff joints. February 2012 VA treatment records note the Veteran's report that he had a severe fall in service on his right side to which he attributed bilateral shoulder pain. On February 2012 VA (shoulder and arm conditions) examination, the Veteran reported falling and injuring his shoulders in October 2010 resulting in sharp pains and a grinding feeling experienced when exerting force. He reported flareups of shoulder pain after excessive use. X-rays were interpreted as not showing arthritis and the examiner indicated the Veteran had functional impairment attributable to shoulder disability, as he is unable to lift heavy objects above his head or perform actions that require rotation of his arm. The examiner opined that there is no pathology to render a diagnosis. On August 2017 VA examination, the Veteran reported onset of left shoulder pain in 2009 following a fall on his left shoulder. He related that the condition has stayed the same the past couple of years and that symptoms included pain when lifting objects above his head. The examiner found that the Veteran does not have a current diagnosis of a left shoulder disability, and opined that the Veteran's left shoulder impingement syndrome was at least as likely as not incurred in or caused by the claimed injury, event, or illness in service. It was noted that the Veteran was seen on multiple times while serving on active duty, starting in 2010, following a 10 foot fall onto his left shoulder. The examiner noted that inflammation and subsequent thickening of the subacromial bursa following an injury may cause impingement. Regarding the left shoulder, both the February 2012 and August 2017 VA examiners found that there is no pathology to render a diagnosis (however, with the 2012 examiner also indicating that the Veteran had functional impairment of inability to lift overhead (findings that are inconsistent). The August 2017 VA examiner also opined that that there was no pathology for a diagnosis (but indicated the condition was related to the Veteran's service and noted a previously not mentioned left shoulder impingement syndrome diagnosis), which are also inconsistent findings. Accordingly, development for a fully adequate medical opinion in this matter is necessary. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Regarding the right shoulder, the February 2012 VA consulting provider noted the Veteran's reports of pain when holding objects overhead and opined that there is no pathology to render a diagnosis. The consulting provider did account for the Veteran's current symptoms of right shoulder pain. Accordingly, development for a fully adequate medical opinion that addresses the Veteran's reports of right shoulder pain, and considers that pain that limits function may of itself be a disability, is necessary. Saunders v. Wilkie, No. 17-1466 (Fed. Cir. 2018), The matters are REMANDED for the following: Arrange for the Veteran to examined by an appropriate clinician (in orthopedics) to determine whether he has current right shoulder, left shoulder, right elbow, and left elbow disabilities (to include based on pain that causes functional impairment of such joints), and if so, determine the likely etiology of each such disability found. The Veteran's claims file, to include this remand, must be reviewed by the examiner. The examiner should provide responses to the following: (a.) Does the Veteran have (i) a right shoulder, (ii) a left shoulder (iii) a right elbow (iv) a left elbow disability? Identify each such disability by diagnosis. If a disability in any of those joints is not diagnosed, but the Veteran reports pain in the joint, indicate whether the pain is found to limit function of the joint. [Note that pain that limits function is considered under governing law and caselaw to constitute a compensable disability.] (b.) Identify the likely etiology for each shoulder and elbow disability found (including on the basis of pain that limits function of the joint). Specifically, is it at least as likely as not (a 50 percent or better probability) that the disability is etiologically related to the Veteran's active-duty service, to include as related to his complaints and injuries noted and activities therein? (c.) If a shoulder or elbow disability found is determined to be unrelated to complaints, injury, or activities in service, identify the etiology that is considered to be more likely, and explain why that is so. All opinions must include rationale that cites to supporting factual data and medical principles, as deemed appropriate. If an opinion sought cannot be provided without resort to mere speculation, there must be explanation why that is so. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Lederman, Michael 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.