Citation Nr: 21069807 Decision Date: 11/19/21 Archive Date: 11/19/21 DOCKET NO. 18-07 068 DATE: November 19, 2021 ORDER Service connection for a right wrist disability, to include as secondary to service-connected right thumb disability is denied. Service connection for right forearm disability, to include as secondary to service-connected right thumb disability is denied. Service connection for right humerus disability, to include as secondary to service-connected right thumb disability is denied. Service connection for a right elbow disability, to include as secondary to service-connected right thumb disability is denied. Service connection for a right shoulder disability, to include as secondary to service-connected right thumb disability is denied. Service connection for a cervical spine condition, to include as secondary to service-connected right thumb disability is denied. An initial disability rating in excess of 10 percent for right gamekeeper's thumb with degenerative arthritis is denied. FINDINGS OF FACT 1. The Veteran's diagnosed carpal tunnel syndrome (CTS) and degenerative arthritis of the right wrist is not due to disease or injury in service and not caused or aggravated by his service-connected right thumb disability. 2. The Veteran's diagnosed ulnar and median neuropathy of the right arm is not due to disease or injury in service and not caused or aggravated by his service-connected right thumb disability. 3. The Veteran does not have a diagnosis, condition, or impairment of the right humerus. 4. The Veteran's diagnosed right elbow degenerative arthritis is not due to disease or injury in service and not caused or aggravated by his service-connected right thumb disability. 5. The Veteran's diagnosed right shoulder's mass is not due to disease or injury in service and not caused or aggravated by his service-connected right thumb disability. 6. The Veteran's diagnosed degenerative arthritis of the cervical spine is not due to disease or injury in service and not caused or aggravated by his service-connected right thumb disability. 7. The preponderance of the evidence shows that right gamekeeper's thumb with degenerative arthritis is manifested by pain and does not more nearly approximate a gap of more than two inches (5.1 cm.) between the right thumb pad and the right fingers, amputation of the right thumb, ankylosis of the right thumb joints, or loss of use of the right hand. CONCLUSIONS OF LAW 1. The criteria for service connection for a right wrist disability, to include as secondary to service-connected right thumb disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 2. The criteria for service connection for a right forearm disability, to include as secondary to service-connected right thumb disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 3. The criteria for service connection for a right humerus disability, to include as secondary to service-connected right thumb disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 4. The criteria for service connection for a right elbow disability, to include as secondary to service-connected right thumb disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 5. The criteria for service connection for a right shoulder disability, to include as secondary to service-connected right thumb disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 6. The criteria for service connection for a cervical spine disability, to include as secondary to service-connected right thumb disability, are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. 7. The criteria for an initial disability rating in excess of 10 percent for right gamekeeper's thumb with degenerative arthritis are not met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.10, 4.20, 4.27, 4.40, 4.45, 4.56, 4.59, 4.71a, Diagnostic Code (DC) 5228-5003. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty with the United States Army from April 1964 to October 1964. While the Veteran served during the Vietnam Era, he had no foreign service. These matters came before the Board of Veterans' Appeals (Board) on appeal from a June 2016 and a July 2017 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran timely filed a notice of disagreement (NOD) to the respective rating decisions. A January 2018 statement of the case (SOC) was issued, addressing all of the issues as decided herein. The Veteran timely filed a substantive appeal. In April 2019, the Veteran testified before a Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. In September 2021, the Board sent a letter to the Veteran, which explained that the VLJ who presided over his hearing was no longer available to participate in the appeal and offered the Veteran a hearing before a different VLJ; otherwise, the case would be reassigned. In October 2021, the Veteran selected that he did not wish to appear at another Board hearing. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection for a claimed disability may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). Establishing service-connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a). 1. Entitlement to service connection for right wrist, forearm, and humerus disability, to include as secondary to the service-connected right thumb disability The Veteran contends that pain, numbness, tingling, and weakness in his upper right extremity is due to his service-connected right thumb disability. Service treatment records (STRs) reflect that the Veteran's military occupational specialty (MOS) was as an automobile mechanic. In 1964, he had a right thumb injury, later diagnosed as right gamekeeper's thumb. In his October 1964 separation report of medical history, he denied history of swollen or painful joints and his concurrent report of medical examination reflects a normal clinical evaluation for the upper extremities. Post-service, the Veteran submitted statements reporting that he has pain that radiates up his right arm. An October 2017 VA examination report for peripheral nerve conditions reflects that the Veteran had a diagnosis of ulnar and median neuropathy of the right extremity, described as mild. The Veteran reported that in the last four to five years, he has increased pain from the neck down the arm. He reported a history of diabetes mellitus (DM) type II. He also reported that he has worked as a radiation technologist for 51 years. In 2017, he was found to have compression neuropathies of both the median nerve and ulnar nerve. The clinician opined that the Veteran's pain in upper right extremities from thumb to his neck is not proximately due to or the result of right gamekeeper's thumb with degenerative arthritis. As rationale, she reported that his symptoms are more likely to be associated with diabetic etiology. He had worsening of pain a few years ago, where it awakens him from sleep. This history provided is consistent with the EMG diagnosis of carpal tunnel syndrome and ulnar nerve compression at Guyon's canal. A remote injury to the distal phalanx of the thumb is not pathophysiological capable of causing or aggravating an ulnar or median compression neuropathy. Compression neuropathies are more common in those with DM II. During the April 2019 Board hearing, the Veteran testified that after his in-service injury, he was told by a doctor that he would eventually have nerve damage. He reported pain through the upper extremity that he attributed to his service-connected right thumb disability. A November 2019 DBQ report for wrist conditions reflects that the Veteran had a diagnosis of degenerative arthritis. There was no pain noted on examination. The diagnosis did not impact his ability to perform any type of occupational task. During the examination, the Veteran denied pain in the right wrist joint. He described nerve pain that initiates in the right thumb and radiates up to his neck. A November 2019 DBQ report for arm conditions reflects that the Veteran did not have conditions or impairments of the humerus. There was no loss of head, nonunion, of fibrous union of the humerus. There was no marked deformity. In a December 2019 VA medical opinion, the clinician opined that the claimed conditions are less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. As rationale, she reported that the two conditions are not medically related. The claimed disorder is a separate entity entirely from the service-connected condition and unrelated to it. She reported that the medical literature does not support a medical relationship. She reported that according to the claims file, the Veteran has cervical disc disease that is causing radiculopathy in the right arm and hand. This disease process is not related to right game keeper's thumb diagnosed in 1964. However, she reported, it justifies the nerve pain acknowledged in the right arm and hand. On the day of the examination, the Veteran was diagnosed with a mass in the right shoulder joint. A mass in the right shoulder can compress nerves, causing nerve pain. In August 2016, the Veteran was diagnosed with right wrist degenerative arthritis that is caused by wear and tear of the joint completing daily activities. This disease process is not related to right gamekeeper's thumb. An EMG completed in March 2017 revealed right CTS to the right and right ulnar neuropathy at the right wrist. The disease processes will also cause nerve damage and symptoms in the right arm and hand. Carpal tunnel syndrome and right ulnar neuropathy is caused by repetitive use of the wrist, which is not related to right gamekeeper's thumb. The clinician reported that the Veteran was diagnosed with right thumb gamekeeper's disease in 1964. According to medical literature, the complication to right thumb gamekeeper's disease is arthritis. She reported that right thumb gamekeeper's disease that has progressed to arthritis of the right thumb is the only medical diagnosis in connection with the right thumb injury. She cited medical treatise in support of her claim. In an April 2021 VA addendum medical opinion, the clinician opined that the claimed right wrist carpal tunnel syndrome and arthritic condition is less likely than not (less than 50 percent probability) aggravated beyond its natural progression by right gamekeeper's thumb with degenerative arthritis. He reviewed the claims file and found no evidence in the claims file that demonstrated objectively that the wrist conditions are in any way aggravated and if so, aggravated as a result of the nail injury to the thumb. He reported that the medical literature is controversial regarding secondary causes of musculoskeletal biomechanical degenerative changes and is based on empirical evidence and not on randomly controlled double-blind studies. He found no evidence of any kind that objectively links these conditions in the entire claims file. The Veteran worked as an X-ray technician for 51 years, frequently using his upper extremities. The current arthritis and CTS are almost certainly due to his decades of manual work, age, and usage. Any attribution of aggravation to the thumb nail injury would be completely and entirely speculative. He also opined that the claimed right CTS and arthritis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As rationale, he reported that he reviewed the claims file as well as the Veteran's testimony and found no record of chronic or recurrent wrist problems beginning in service to correlate to the current conditions. There was no permanent residual or chronic disability shown by STRs or in the evidence immediately following discharge from service to reflect the current condition. VA treatment records reflect that the Veteran complained of chronic right hand/wrist pain. The clinician noted that radiology imaging showed advanced degenerative arthritis, however, the Veteran reported that his pain is not due to the arthritis. Additionally, the Veteran was seen for a neurology consult in 2017 following complaint of right hand and arm pain since the 1960s. He was diagnosed with CTS and right ulnar neuropathy at the wrist, mild. Upon review of the evidence of record, service connection for a right wrist, forearm, and humerus disability is not warranted. Initially, the Veteran has diagnoses as it pertains to his right wrist and forearm. Specifically, he has been diagnosed with CTS, degenerative arthritis and ulnar and median neuropathy. The question remains as to whether there is a nexus between the disability and service or whether it was caused or aggravated by his service-connected right thumb disability. The VA medical clinicians have all agreed that the Veteran's right upper extremity disabilities are due to his diagnosis of DM II as well as his physical employment post-service as an X-ray technician for 51 years. Based on a review of the available records, particular expertise, and medical literature, the April 2021 VA clinician found that the Veteran's right wrist CTS, degenerative arthritis, and ulnar and median neuropathy was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Specifically, the clinician noted that he reviewed the medical evidence as well as the Veteran's testimony, and provided an adequate rationale for the conclusion that the Veteran's disabilities were not due to service. Likewise, the October 2017, December 2019, and April 2021 VA clinicians based their opinions on a review of the available records, their particular expertise, and medical literature and found that the Veteran's right upper extremity disabilities was caused or aggravated by the other medical diagnoses not related to his right thumb and his employmentnot due to his service-connected right thumb disability. As the clinicians explained the reasons for their conclusions based on an accurate characterization of the evidence of record, the opinions, as a whole, are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). While the December 2019 VA clinician reported that the Veteran's cervical spine disability is causing radiculopathy in the right arm and hand, and the record reflects that the Veteran does not have a diagnosis of cervical radiculopathy, the Veteran's nerve complaints have been attributed to CTS and ulnar and median neuropathy. Moreover, even if the Veteran has a diagnosis of cervical radiculopathy, no medical professional has linked this to his service-connected thumb injury, or, to any other in-service injury or disease. As to the Veteran's general claim for a right humerus disability, the weight of the above evidence does not indicate the presence of a right humerus disability during the pendency of the claim. See 38 U.S.C. § 1701 (1); Allen v. Brown, 7 Vet. App. 439, 444-45 (1995) (applying definition of disability in section 1701(1) to statutes describing "eligibility for disability compensation for service-connected disabilities"). The available medical evidence of a nerve condition has been attributed to the diagnosed CTS and ulnar and median nerve neuropathy. Furthermore, the Veteran has not expressed complaint of a joint condition outside of his submission of the claim. Specifically, in his written statements and during his April 2019 Board hearing, the Veteran complained of pain, weakness, tingling, and numbness of the upper extremity. These symptoms are not joint related and have been attributed to nerve diagnoses. As such, entitlement to service connection is not warranted. Palczewski v. Nicholson, 21 Vet. App. 174, 181 (2007) ("Without a current disability, of course, there can be no service connection and, thus, no disability compensation"). Furthermore, the Veteran has not presented any evidence or argument to support such a claim. To the extent that the Veteran, including through his representative, has opined that his upper extremity disabilities are related to service or his service-connected right thumb disability, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, the Veteran's contentions as to the etiology of his upper right extremity disabilities relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) (witness capable of diagnosing dislocated shoulder). The Veteran's statements regarding causation are therefore not competent in this regard. To the extent that these lay statements regarding an injury in service and pain in the arm since the 1960's are credible, the specific, reasoned opinion of the VA clinicians with regard to causation carries greater probative weight than the Veteran's more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for a right wrist disability, a right forearm disability, and a right humerus disability, to include on a secondary basis. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for a right elbow disability, to include as secondary to service-connected right thumb disability The Veteran generally contends that his right elbow disability is due to his service-connected right thumb disability. As noted, the STRs reflect that the Veteran's MOS was as an automobile mechanic. In 1964, he had a right thumb injury, later diagnosed as right gamekeeper's thumb. In his October 1964 separation report of medical history, he denied history of swollen or painful joints and his concurrent report of medical examination reflects a normal clinical evaluation for the upper extremities. Post-service, during the April 2019 Board hearing, the Veteran testified that he has pain that radiated from his right thumb up his arm that he contends is due to his service-connected right thumb disability. A November 2019 DBQ report reflects that the Veteran reported that when he moves his right thumb in any direction, it causes a sharp pain to radiate from the thumb up to the neck. The symptoms were described as numbness, tingling, and weakness to the right hand and arm. The Veteran reported functional loss/impairment described as sharp pain when moving the right thumb that travels up the arm to the neck. Therefore, he limits movement that will aggravate his right arm. He reported weakness in the right hand and arm and nerve pain in the right hand and arm. There was no pain noted on examination. The clinician found that the Veteran's right arm disability did not impact his ability to perform any type of occupational tasks. In a December 2019 VA medical opinion, the clinician opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. As rationale, the clinician reported that the two conditions are not medically related. The claimed disorder is a separate entity entirely from the service-connected condition and unrelated to it. She reported that the medical literature does not support a medical relationship. On examination, the Veteran was diagnosed with right elbow degenerative arthritis. She reported that it is caused by wear and tear of the joint by completing daily activities. The disease process in the right elbow is not related to right gamekeeper's thumb. She reported that right thumb gamekeeper's disease that has progressed to arthritis of the right thumb is the only medical diagnosis in connection with the right thumb injury. She cited medical treatise in support of her claim. In an April 2021 addendum medical opinion, the clinician opined that the claimed right elbow degenerative arthritis is less likely than not aggravated beyond natural progression due to the right gamekeeper's thumb with degenerative arthritis. As rationale, he reported that he reviewed the claims file and the Veteran's testimony. He found no evidence that demonstrated objectively that the elbow condition was in any way affected as a result of the right thumb injury. He reported that the medical literature is controversial regarding secondary causes of musculoskeletal biomechanical degenerative changes and is based on empirical evidence and not on randomly controlled blind studies. The elbow and distal tip of the thumb do not have shared joints, ligaments, or muscles in order to attribute the claimed aggravation of the elbow arthritis condition to the thumb. He found no evidence of any kind that objectively links these conditions in the claims file. The Veteran worked as an X-ray tech for 51 years, frequently using his upper extremities. The current arthritis is almost certainly due to his decades of manual work, age, and usage. Any correlation of aggravation to the thumb nail injury would be completely and entirely speculative. He also opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale, the clinician reported that he reviewed the claims file as well as the Veteran's testimony and found no record of chronic or recurrent elbow problems beginning in service to correlate to the current condition. He reported that there was no permanent residual or chronic disability subject to service connection shown by the STRs or in the evidence immediately following discharge from the service to reflect the current condition. Upon review of the evidence of record, service connection for right elbow degenerative arthritis is not warranted. Initially, the Veteran has a current diagnosis of degenerative arthritis in the right elbow. As the current disability requirement has been met, the question remains as to whether there is a nexus between the disability and service or whether it was caused or aggravated by his service-connected right thumb disability. The VA medical clinicians have all agreed that the Veteran's right elbow disability is due to his physical employment post-service as well as aging and usage. Based on a review of the available records, particular expertise, and medical literature, the April 2021 VA clinician found that the Veteran's right elbow degenerative arthritis was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Specifically, the examiner noted the Veteran's statements regarding his nerve complaints and provided an adequate rationale for the conclusion that the Veteran's disability was not due to service. Likewise, the December 2019 and April 2021 VA clinician based their opinions on a review of the available records, particular expertise, and medical literature and found that the Veteran's right elbow degenerative arthritis was not caused or aggravated by the service-connected right thumb disability. The clinicians explained in detail how the right elbow and right thumb are not medically related and provided an etiology, separate from the right thumb, as to his right elbow disability. As the clinicians explained the reasons for their conclusions based on an accurate characterization of the evidence of record, their opinions, as a whole, are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). To the extent that the Veteran, including through his representative, has opined that his right elbow disability is related to service or his service-connected right thumb disability, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, the Veteran's contentions as to the etiology of his right elbow disability relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) (witness capable of diagnosing dislocated shoulder). The Veteran's statements as to causation are therefore not competent in this regard. To the extent that these lay statements regarding an injury in service are credible, the specific, reasoned opinion of the VA clinicians with regard to causation carries greater probative weight than the Veteran's more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for a right elbow disability, to include on a secondary basis. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 3. Entitlement to service connection for a right shoulder disability, to include as secondary to service-connected right thumb disability The Veteran generally contends that his right shoulder disability is due to his service-connected right thumb disability. As noted, the STRs reflect that the Veteran's MOS was as an automobile mechanic. In 1964, he had a right thumb injury, later diagnosed as right gamekeeper's thumb. In his October 1964 separation report of medical history, he denied history of swollen or painful joints and his concurrent report of medical examination reflects a normal clinical evaluation for the upper extremities. Post-service, in a December 2016 statement, the Veteran reported that since the in-service injury, he has experienced hand and wrist pain that radiates up his forearm and into his shoulder and neck. During the April 2019 Board hearing, the Veteran testified that pain that radiated from right thumb up his arm that he contends is due to his service-connected right thumb disability. A November 2019 DBQ report reflects that the clinician reported that the Veteran's right shoulder joint was normal per radiology. A mass was noted in the joint space that needed further assessment and the clinician determined it was unrelated to the claim. There was no pain noted on examination. The clinician specified that during the examination, the Veteran described nerve pain and denied pain in the right shoulder joint. A December 2019 VA medical opinion reflects that the clinician opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. As rationale, the clinician reported that the two conditions are not medically related. The claimed disorder is a separate entity entirely from the service-connected condition and unrelated to it. She reported that the medical literature does not support a medical relationship. On the day of the examination, the Veteran was diagnosed with a mass in the right shoulder joint. A mass in the right shoulder can compress nerves, causing nerve pain. However, she found that the symptoms in the right shoulder are not related to right game keeper's thumb. The clinician reported that the Veteran was diagnosed with right thumb gamekeeper's disease in 1964. According to medical literature, the complication to right thumb gamekeeper's disease is arthritis. She reported that right thumb gamekeeper's disease that has progressed to arthritis of the right thumb is the only medical diagnosis in connection with the right thumb injury. She cited medical treatise in support of her claim. An April 2021 VA addendum medical opinion reflects that the clinician opined that the claimed shoulder mass condition is less likely than not (less than 50 percent probability) aggravated beyond its natural progression by service-connected right gamekeeper's thumb with degenerative arthritis. The clinician reported that he reviewed the claims file and acknowledged the Veteran's thumb diagnosis. However, he found no evidence that demonstrated objectively that the claimed shoulder mass condition was in any way aggravated by any cause, specifically as a result of the nail injury to the thumb. The shoulder and distal tip of the thumb where the nail is located do not have shared joints, ligaments, or muscles in order to attribute the mass to the thumb. He found no evidence of any kind that objectively links these conditions in the entire claims file. The underlying etiology of the mass is not known and any correlation of claimed aggravation to the thumb nail injury would be completely and entirely speculative. VA treatment records do not reflect any treatment for the Veteran's right shoulder disability. Upon review of the evidence of record, service connection for a right shoulder disability is not warranted. Initially, the Veteran's only diagnosis of the right shoulder is a mass found on radiology in November 2019. As the current disability requirement has been met, the question remains as to whether there is a nexus between the disability and service or whether it was caused or aggravated by his service-connected right thumb disability. Based on a review of the available records, particular expertise, and medical literature, the November 2019 and April 2021 VA clinicians found that the Veteran's right shoulder mass was less likely than not (less than 50 percent probability) proximately due to, aggravated or the result of the Veteran's service-connected condition. Specifically, the November 2019 clinician noted the Veteran's shoulder mas can compress nerves, causing nerve pain. However, the clinician determined that this was not due to the Veteran's right thumb disability. The April 2021 clinician explained in detail how the shoulder and right thumb do not have shared joints, ligaments, or muscles. As the clinicians explained the reasons for their conclusions based on an accurate characterization of the evidence of record, their opinions, as a whole, are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). To the extent that the Veteran, including through his representative, has opined that his right shoulder mass is related to service or his service-connected right thumb disability, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, the Veteran's contentions as to the etiology of his right shoulder mass relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) (witness capable of diagnosing dislocated shoulder). The Veteran's statements regarding causation are therefore not competent in this regard. To the extent that these lay statements regarding an injury in service are credible, the specific, reasoned opinion of the VA clinicians with regard to causation carries greater probative weight than the Veteran's more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for a right shoulder disability, to include on a secondary basis. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. 4. Entitlement to service connection for a cervical spine condition, to include as secondary to service-connected right thumb disability The Veteran generally contends that his diagnosed degenerative arthritis of the cervical spine is due to his service-connected right thumb disability. The STRs reflect that the Veteran's MOS was as an automobile mechanic. In 1964, he had a right thumb injury, later diagnosed as right gamekeeper's thumb. The October 1964 separation report of medical examination reflects a normal clinical evaluation for the spine. Post service, in a December 2016 statement, the Veteran reported that since the in-service injury, he has experienced hand and wrist pain which has progressively worsened. The pain radiates up his forearm and into his shoulder and neck. In the October 2017 VA examination report, the clinician noted that the Veteran reported a neck condition described as right neck pain radiating. He concluded that this neck pain is unrelated to a remote thumb condition. During the April 2019 Board hearing, the Veteran testified that he has pain that radiated from his right thumb up his arm that he contends is due to his service-connected right thumb disability. He testified that when he is weeding his yard, the pain goes all the way up to his neck. A November 2019 DBQ report reflects that the Veteran had a diagnosis of degenerative arthritis of the cervical spine. He denied pain in the neck spinal column. There was no pain noted on examination. The Veteran did not have radicular pain or any other signs or symptoms due to radiculopathy. Radiology imaging of the cervical spine reveals C4-C5, C5-C6, and C6-C7 degenerative disc disease with osteophytosis along bilateral neural foramina at C4-C5, C5-C6, and C6-C7 levels. His cervical spine disability did not impact his ability to work. A December 2019 VA medical opinion reflects that the clinician opined that the claimed condition is less likely than not (less than 50 percent probability) proximately due to or the result of the Veteran's service-connected condition. As rationale, the clinician reported that the two conditions are not medically related. The claimed disorder is a separate entity entirely from the service-connected condition and unrelated to it. She reported that the medical literature does not support a medical relationship. She reported that according to the claims file, the Veteran has cervical disc disease that is causing radiculopathy in the right arm and hand. This disease process is not related to right game keeper's thumb, diagnosed in 1964. However, she reported, it justifies the nerve pain acknowledged in the right arm and hand. The clinician reported that the Veteran was diagnosed with right thumb gamekeeper's disease in 1964. According to medical literature, the complication to right thumb gamekeeper's disease is arthritis. She reported that right thumb gamekeeper's disease that has progressed to arthritis of the right thumb is the only medical diagnosis in connection with the right thumb injury. She cited medical treatise in support of her claim. An April 2021 VA medical opinion reflects that the clinician found that the claimed cervical condition is less likely than not (less than 50 percent probability) aggravated beyond its natural progression by right gamekeeper's thumb with degenerative arthritis. As rationale, he reported that he reviewed the claims file and found no evidence that demonstrated objectively that the claimed neck arthritis/DDD condition was at all aggravated and if so, as a result of the nail injury to the thumb. He explained that the neck and the distal tip of the thumb where the nail is located do not have shared joints, ligaments, or muscles. He found no evidence of any kind that objectively links this condition. He reported that the Veteran worked as an X-ray tech for 51 years. The current arthritis is almost certainly due to his decades of manual work, age, and weight-bearing activities. Any attribution of aggravation to the thumb nail injury would be completely and entirely speculative. The clinician opined that the claimed condition was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. As rationale, he reported that he reviewed the claims file as well as the Veteran's testimony. He found no record of chronic or recurrent neck problems beginning in service to correlate to the current condition. There was no permanent residual or chronic disability subject to service connection shown by the STRs or in the evidence immediately following discharge from service to reflect the current condition. Based on a review of the available records, particular expertise, and medical literature, the April 2021 VA clinician found that the Veteran's cervical spine degenerative arthritis was less likely than not (less than 50 percent probability) incurred in or caused by the claimed in-service injury, event, or illness. Specifically, the clinician noted how the medical evidence as well as the Veteran's testimony do not reflect that his neck disability was due to service. Likewise, the December 2019 and April 2021 VA clinicians based their opinions on a review of the available records, particular expertise, and medical literature and found that the Veteran's cervical degenerative arthritis was not caused or aggravated by the service-connected right thumb disability. The clinicians explained in detail how the cervical spine and right thumb are not medically related. As the clinicians explained the reasons for their conclusions based on an accurate characterization of the evidence of record, their opinions, as a whole, are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). To the extent that the Veteran, including through his representative, has opined that his cervical spine disability is related to service or his service-connected right thumb disability, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case-by-case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, the Veteran's contentions as to the etiology of his cervical spine disability relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship that is of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) (witness capable of diagnosing dislocated shoulder). The Veteran's statements are therefore not competent in this regard. To the extent that these lay statements regarding an injury in service are credible, the specific, reasoned opinion of the VA clinicians with regard to causation carries greater probative weight than the Veteran's more general lay assertions. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim of service connection for a cervical spine disability, to include on a secondary basis. The benefit of the doubt doctrine is therefore not for application and the claim must be denied. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Increased Rating Disability evaluations are determined by the application of VA's Schedule for Rating Disabilities, which is based on average impairment of earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. Where there is a question as to which of two evaluations shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the veteran. 38 C.F.R. § 4.3. When evaluating musculoskeletal disabilities based on limitation of motion, 38 C.F.R. § 4.40 requires consideration of functional loss caused by pain or other factors listed in that section that could occur during flare-ups or after repeated use and, therefore, not be reflected on range-of-motion testing. 38 C.F.R. § 4.45 requires consideration also be given to less movement than normal, more movement than normal, weakened movement, excess fatigability, incoordination, and pain on movement. See DeLuca v. Brown, 8 Vet. App. 202 (1995); see also Mitchell v. Shinseki, 25 Vet. App. 32, 44 (2011). Nonetheless, even when the background factors listed in § 4.40 or 4.45 are relevant when evaluating a disability, the rating is assigned based on the extent to which motion is limited, pursuant to 38 C.F.R. § 4.71a; a separate or higher rating under § 4.40 or 4.45 itself is not appropriate. See Thompson v. McDonald, 815 F.3d 781, 785 (Fed. Cir. 2016) ("[I]t is clear that the guidance of § 4.40 is intended to be used in understanding the nature of the veteran's disability, after which a rating is determined based on the § 4.71a criteria."). Under 38 C.F.R. § 4.59, painful motion is a factor to be considered with any form of arthritis; however, 38 C.F.R. § 4.59 is not limited to disabilities involving arthritis. See Burton v. Shinseki, 25 Vet. App. 1 (2011). The United States Court of Appeals for Veterans Claims (Court) held that the final sentence of 38 C.F.R. § 4.59 requires that the examiner record the results of range of motion testing "for pain on both active and passive motion [and] in weight-bearing and non-weight-bearing and, if possible, with range of motion measurements of the opposite undamaged joint." Correia v. McDonald, 28 Vet. App. 158 (2016). Furthermore, in Sharp v. Shulkin, 29 Vet. App. 26 (2017), the Court held that VA examiners must obtain information about the severity, frequency, duration, precipitating and alleviating factors, and extent of functional impairment of flares from the veterans themselves, when a flare-up is not observable at the time of examination. The January 2021 Disability Benefits Questionnaire (DBQ) is fully complaint with Correia and Sharp. During the pendency of the appeal, the rating criteria for evaluating musculo-skeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 83 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110 (g). If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. However, this amendment did not affect the diagnostic code assigned for the Veteran's service-connected right thumb disability. 5. Entitlement to an initial disability rating in excess of 10 percent for right gamekeeper's thumb with degenerative arthritis The Veteran contends that the symptoms of his right gamekeeper's thumb with degenerative arthritis warrant an increased disability rating. His service-connected right thumb disability is rated as 10 percent disabling under 38 C.F.R. § 4.71a, Diagnostic Code 5228-5003. Hyphenated diagnostic codes are used when a rating under one code requires use of an additional code to identify the basis for the evaluation assigned. See 38 C.F.R. § 4.27. In this case, Diagnostic Code 5003 rates degenerative arthritis and instructs to evaluate on the basis of limitation of motion of the affected parts. Diagnostic Codes 5228 rates limitation of motion of the thumb. 38 C.F.R. § 4.71a, Diagnostic Codes 5228 (thumb), 5259 (index or long finger), and 5230 (right or little finger) evaluate limitation of motion of the fingers. For limitation of the motion of the thumb, a gap of less than one inch (2.5 cm) between the thumb pad and the fingers, with the thumb attempting to oppose the fingers warrants a noncompensable disability rating, whether on the major (dominant) or minor (non-dominant) hand. A gap of one to two inches (2.5 cm to 5.1 cm) between the thumb pad and the fingers with the thumb attempting to oppose the fingers warrants a 10 percent disability rating, whether on the major (dominant) or minor (non-dominant) hand. A 20 percent rating is warranted when the gap is more than two inches (5.1 cm), with the thumb attempting to oppose the fingers. 38 C.F.R. § 4.71a, Diagnostic Code 5228. Under Diagnostic Code 5003, degenerative arthritis, when established by x-ray findings, will be rated on the basis of limitation of motion under the appropriate diagnostic codes for the specific joint or joints involved. When the limitation of motion of the specific joint or joints involved is noncompensable under the appropriate diagnostic codes, a rating of 10 percent is for application for each such major joint or group of minor joints affected by limitation of motion to be combined, not added under Diagnostic Code 5003. Limitation of motion must be objectively confirmed by findings such as swelling, muscle spasm or satisfactory evidence of painful motion. 38 C.F.R. § 4.71a, Diagnostic Code 5003. Turning to the evidence of record, a May 2016 DBQ report reflects that the Veteran has a diagnosis of gamekeeper's thumb and arthritis, degenerative. He reported flare ups described as pain in the right thumb and pointer, halfway. He reported that the pain goes into his wrist and up to his shoulder. He described functional loss/impairment described as a bad grip and worsening symptoms when he attempts to grip. Initial range of motion (ROM) testing for the right thumb revealed maximum flexion to 80 degrees of the metacarpophalangeal joint (MCP) and 80 degrees of the interphalangeal joint (IP). There was no gap between the pad of the thumb and the fingers and no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. The ROM itself did not contribute to a functional loss. Pain was noted on examination but did not result in or cause functional loss. His ROM exhibited pain on finger flexion, finger extension, and opposition with thumb. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. He was able to perform repetitive-use testing with at least three repetitions with no additional functional loss or ROM after the repetitions. The Veteran was examined immediately after repetitive use over time. There was no pain, weakness, fatigability, or incoordination that significantly limit functional ability with repeated use over a period of time. Pain, weakness, fatigability, or incoordination did not significantly limit functional ability with flare ups. The Veteran had swelling and deformity. There was no muscle atrophy and no ankylosis. He had degenerative or traumatic arthritis of the right hand. The examiner reported that based on the examination, he was able to use his right hand. He can feed himself, clean, cook, tie and untie shoelaces, and button and unbutton shirts with both hands. However, he was not able use his right hand continuously repetitively for more than five minutes. He was not able to carry and lift anything heavier than 5 or maximally 10 pounds. He was able to hold a pen and was able to write. In a December 2016 statement, the Veteran reported that since the in-service injury, he has experienced hand and wrist pain which has progressively worsened. The Veteran noted that the pain increased and is almost unbearable at times. He has increased difficulty when he works around his house and with any routine yardwork and maintenance. The pain radiates up his forearm and into his shoulder and neck. He reported a loss of strength in his hand and grip. He reported that he has a diagnosis of neuropathy. A June 2017 DBQ report reflects that the Veteran reported that his condition is worsening. He reported pain in his right thumb up to his neck with numbness and tingling in the right thumb and right arm. His dominant hand was his right hand. He reported flare-ups described as losing grip of things. He described functional loss or impairment as the inability to grasp items with his right thumb. Initial ROM was normal for the right hand, including the thumb. There was no gap between the pad of the thumb and the finger and no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. Pain was noted on examination of finger flexion, opposition with thumb, and finger extension. There was evidence of pain with use of the hand. There was objective evidence of localized tenderness or pain on palpation of the right MCP described as moderate related to his right gamekeeper's thumb with degenerative arthritis. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or range of motion. The Veteran was not examined immediately after repetitive use over time, so the examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with repeated use over a period of time. The examination was not conducted during a flare-up so the examiner was unable to say without mere speculation whether pain, weakness, fatigability, or incoordination significantly limit functional ability with flare ups. The examiner also did not provide a ROM estimate based on the same reasoning. The Veteran had less movement than normal and swelling. His hand grip was 4/5. There was no muscle atrophy and ankylosis. In an August 2017 statement, the Veteran reported that the diagnosis of degenerative disease of the right thumb and hand is incorrect. He reported that he has nerve damage. During the April 2019 Board hearing, the Veteran testified that the symptoms of his thumb disability have gotten worse. He reported that the pain goes all the way up to his neck. He was told he had nerve damage. A December 2019 DBQ focusing on non-degenerative arthritis report reflects that the examiner reported that the Veteran was diagnosed with right gamekeeper's thumb in 1964. He reported that the damage to the right thumb is degenerative. The Veteran reported numbness, tingling, and weakness from the right thumb radiating into the neck. He described the pain in the right thumb as 8/10 intermittently. He reported that when he moves the right thumb, it causes a shooting pain to radiate up the right arm and neck. He described numbness, tingling, and weakness to the right hand and arm. The clinician found that the Veteran's right thumb disability impacts his ability to work. His thumb causes pain with movement noted as an 8/10. There was a sharp shooting pain with numbness and tingling that travels to the Veteran's right wrist, arm, elbow, shoulder, and neck. He had difficulty lifting or carrying items, because of the weakness in his right extremity. The January 2021 DBQ report reflects that the Veteran's symptoms were described as pain in proximal interphalangeal joint. He did not report any flare-ups. He did not report any functional loss or impairment. Active ROM of the thumb revealed flexion endpoint to 90 degrees of MCP and flexion to IP at 80 degrees. Extension was normal. There was no gap between the pad of the thumb and fingers. There was no gap between the finger and proximal transverse crease of the hand on maximal finger flexion. There was no objective evidence of localized tenderness or pain on palpation of the joint or associated soft tissue. Passive ROM revealed flexion and extension the same as active ROM for the thumb. There was no gap. There was no evidence of pain. The Veteran was able to perform repetitive-use testing with at least three repetitions with no additional loss of function or ROM. The Veteran was not examined immediately after repeated use over time. Pain significantly limits functional ability with repeated use over time. Estimated ROM in degrees immediately after repeated use was flexion to 80 degrees and IP to 70 degrees with normal extension. Additionally, the estimated gap was 0. There was no reduction in muscle strength. There was no muscle atrophy and ankylosis. In a January 2021 VA medical opinion to ensure that the clinician addressed the entirety of the August 2019 Board remand, the clinician reported that the injury the Veteran sustained in service was a subungual hematoma to the right thumb nailbed. There are no other incidents of additional treatment except to decompress the subungual hematoma using a hot paper clip. This would not be the cause of the Veteran's osteoarthritis at the right MCP joint. However, given that this is not the issue, the assessment of the right thumb, specifically, did not show any significant decrease in ROM of the right thumb during active and passive examination. The hand grasps were equal and strong (5/5). There was no pain noted during active and passive ROM. There was no functional loss, muscle atrophy, or any gap between the pad of the right thumb and fingers. There was no ankylosis. The clinician believed the Veteran's flare-ups to be minimal, approximately 10 degrees less than measured ROM. The Veteran had good strength in his right thumb when he applied pressure to the right middle finger. The examiner reported that based on the physical examination and a review of the medical evidence, the Veteran is able to effectively use his right thumb. The examiner further reported that it is obvious that anyone with arthritis will eventually experience pain with overuse or prolonged physical activity. The examiner noted that the Veteran testified that he works in his yard and does weeding. He can function in an occupational environment performing light to moderate activities. Upon review of the evidence of record, a disability rating in excess of 10 percent for right gamekeeper's thumb with degenerative arthritis is not warranted. As to any limitation of motion involving the thumb, the evidence reflect that there was no gap between the right thumb pad and the fingers with the thumb, to include consideration of additional limitation caused by repetitive use and or flare-ups. While the Veteran reported flare-ups during his 2016 and 2017 examinations, his flare-ups were described as pain and a loose grip. His hand grip was noted as a 4/5. As the Veteran had no gap, a 10 percent disability rating was assigned based on painful motion. A compensable rating is warranted for joint pain pursuant to 38 C.F.R. § 4.59 for orthopedic disabilities rated under diagnostic codes containing a compensable rating, and the criteria for such a rating can be satisfied with lay and other non-medical evidence. See Sowers v. McDonald, 27 Vet. App. 472, 480 (2016); Petitti v. McDonald, 27 Vet. App. 415, 428-29 (2015). Disability evaluations are also available for ankylosis of the finger joints. The medical evidence of record shows the Veteran does not have any ankylosis of the right thumb. The medical and lay evidence also does not reflect that the Veteran's symptoms are analogous to ankylosis of the thumb to include after repetitive use over time or during flare-ups. For the foregoing reasons, an initial disability rating in excess of 10 percent is not warranted right gamekeeper's thumb with degenerative arthritis. In denying such a rating, the benefit of the doubt doctrine is not applicable. 38 U.S.C. § 5107; 38 C.F.R. §§ 4.3, 4.7. L. B. CRYAN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Laroche, N. 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.