Citation Nr: 21071051 Decision Date: 11/29/21 Archive Date: 11/29/21 DOCKET NO. 16-57 450 DATE: November 29, 2021 ORDER Service connection for right shoulder disability is denied. FINDING OF FACT The weight of the evidence is against finding right shoulder arthritis and rotator cuff tear/syndrome are related to service or caused or aggravated by service-connected disabilities. CONCLUSION OF LAW The criteria for service connection for right shoulder disability have not been met. 38 U.S.C. § 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from September 1972 to January 1979. 1. Service connection for right shoulder disability Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" also known as the "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010). Service connection may also be granted on a secondary basis for a disability that is proximately due to or the result of (caused) or worsened beyond its natural progression (aggravated) by a service-connected disease or injury. 38 C.F.R. § 3.310; Allen v. Brown, 7 Vet. App. 439, 448-49 (1995) (en banc). The Board must consider all the evidence of record and make appropriate determinations of competence, credibility, and weight. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). When there is an approximate balance of positive and negative evidence regarding any material issue, all reasonable doubt is resolved in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Based on the evidence, the Board finds the criteria for service connection for a right shoulder disability have not been met. 38 C.F.R. § 3.303. First, the evidence shows a current disability. The July 2012 VA examiner diagnosed chronic rotator cuff syndrome. The November 2019 examiner diagnosed degenerative arthritis of the shoulder. VA treatment records also show right shoulder AC joint separation and arthritis. The first element of service connection is established. See Holton, 557 F.3d 1366. Next, the weight of the evidence is against finding the current right shoulder disability is related to service. The Veteran reported injuring his shoulders in service when lifting heavy boxes, doing physical training drills, and digging fox holes. His service treatment records show he was treated multiple times in 1978 for trapezius pain. However, his September 1978 separation examination revealed normal musculoskeletal system and upper extremities, apart from a wrist laceration, and he did not endorse shoulder problems on the September 1978 report of medical history, despite reporting several other ailments, including back pain and foot trouble. A January 1980 VA examination does not show any complaints or abnormal findings of the shoulders. VA treatment records, including from February 2009, note the Veteran was involved in a motor vehicle accident in March 2007 and reported right shoulder pain since the accident. A February 2009 x-ray of the right shoulder revealed slight separation of the AC joint with minimal degenerative changes. The available VA treatment records from 2004 to 2007 do not show right shoulder complaints or treatment prior to the accident. The July 2012 VA examiner provided a positive opinion noting the Veteran's reported complaints of bilateral shoulder pain beginning during service and finding that stressors placed on the shoulders can lead to an inflammation that can manifest as chronic rotator cuff syndrome years later. The examiner was not able to review the Veteran's claim file. The Board finds the July 2012 examiner's opinion holds less probative value because the inability to review the claims folder prevented the examiner from considering the severity of the in-service injury as shown in service treatment records and the intervening injury from the motor vehicle accident. The November 2019 VA examiner provided a negative opinion that the Veteran's current shoulder disability was less likely than not related to service. The examiner noted the in-service injuries were acute and there was a lack of treatment between 1978 and 2007. The examiner noted that it was plausible that years of shoulder strain could lead to rotator cuff disease because of repetitive stress or strain on the shoulder, but in the Veteran's case, there is no record of chronic right shoulder strain since leaving the service. As noted above, treatment records show the Veteran injured his shoulder in a motor vehicle accident in 2007. Moreover, to the extent that the Veteran has reported muscle spasms since service, there is conflicting evidence of post-service injuries and onset of symptoms such that the Board does not find evidence of continuity in the lay statements. In addition to the 2007 motor vehicle accident, the Veteran reported injuring the shoulder in 1983 or 1984 during the November 2019 examination and an undated, gym injury to the shoulder during the June 2021 examination. Given the November 2019 examiner's opinion that the in-service injuries were acute only, the fact that the Veteran did not report shoulder problems on his separation report of medical history when he reported other ailments, the lack of record of complaints of right shoulder problems in the intervening years, and the post-service injury from a motor vehicle accident, the Board finds the greater weight of the evidence is against a connection to service. The Board further finds the weight of the evidence is against finding the Veteran's right shoulder disability is caused or aggravated by his service-connected back and neck disabilities. During the October 2018 Board hearing, the Veteran asserted that his shoulder disability might be secondary to his neck and back disabilities. In an August 2020 opinion, a VA expert found the Veteran's shoulder was less likely than not caused or worsened by his service-connected disabilities. The examiner explained that the conditions were completely unrelated and medically separate from shoulder arthritis. The examiner further explained that arthritis is part of normal aging or wear and tear, and medical literature shows that arthritis is caused by aging, genetics, gender, obesity, anatomic factors, and/or posttraumatic joint injury, rather than disability in another area of the body. The examiner also stated that the natural progression of arthritis is to worsen with aging and there are no known medical relationships between the Veteran's service-connected disabilities and his shoulder arthritis from which to base aggravation. The January 2021 expert addressed the newly service-connected neck disability, finding the right shoulder was less likely than not related to the neck. The expert explained that there is no association between the cervical condition and the right shoulder rotator cuff syndrome, because rotator cuff tears are due to intrinsic tears of the muscles of the shoulder often from tension overload that is thought to occur when the ability of the rotator cuff is compressed and the stability of the glenohumeral joint is overwhelmed by forces of throwing or trauma to the shoulder. The expert found there was no evidence to support that the right shoulder condition had been aggravated beyond the natural progression. The June 2021 examiner found the Veteran's right shoulder arthritis was less likely than not caused or aggravated by the service-connected neck disability. The examiner explained that arthritis in one joint does not cause arthritis in another joint, and a thorough review of the medical literature failed to show such causal relationship. The examiner noted that it is not unusual for two joints to share properties in the same person, but one joint's disease does not "spread" to another or cause damage to it. Similarly, radiating pain from the neck to the shoulder that is caused by C5-C6 root compression does not create a predisposition for clinical, radiologic, and functional pathologies in the shoulder joint. The Board finds the VA experts' opinions highly probative as they considered the relevant evidence and medical literature, explained the disease processes of arthritis and rotator cuff tears/syndrome, and offered alternate etiologies for the Veteran's right shoulder disabilities trauma or aging. The Board finds these opinions are also consistent with the record, which shows the onset of symptoms in the right shoulder after trauma from injury in the 2007 motor vehicle accident. Regarding aggravation, there is no evidence to contradict the experts' finding that the right shoulder has not been worsened beyond the natural progression of arthritis and rotator cuff syndrome. Although the Board has considered the Veteran's assertion, he is not competent to determine the cause of arthritis or rotator cuff syndrome as this requires medical education and training to understand the complexities of the musculoskeletal system. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Therefore, the Board finds the weight of the competent evidence is against finding a relationship between the Veteran's right shoulder disabilities and his service-connected neck and back disabilities. The Board notes the Veteran's representative's assertion in the November 2021 appellate brief that the June 2021 examiner is not qualified to render an opinion because she is "merely" a nurse practitioner and the "[a]bsence of competence renders her assertions no more probative than the appellant's lay assertions...." First, the Board notes that a nurse practitioner is a medical professional with six years of education in the medical field, bachelor's and master's degrees in nursing, which clearly qualify the June 2021 examiner with medical expertise beyond that of a lay person. Indeed, the Court has held that nurse practitioners are qualified to render medical opinions for VA claims. Cox v. Nicholson, 20 Vet. App. 563, 568-69 (2007). Second, the representative suggests that a specialist in orthopedic medicine is needed to provide a competent opinion on the Veteran's disabilities. However, he fails to explain or justify this assertion. To the contrary, the Board finds that arthritis and rotator cuff tears are common ailments for which many medical professionals could have relevant education and experience. Next, the representative asserts that obtaining an opinion from the June 2021 examiner is a violation of the Board's prior remand instructions to obtain a medical opinion from an "expert." Again, the Court has found nurse practitioners are competent to provide diagnoses, statements, and opinions. The Board finds the June 2021 examiner has the requisite education to render a qualified medical opinion and is, therefore, considered a medical expert. The Board did not request an opinion from a specialist or orthopedist in the prior remand, and the Board continues to find the need for such a specialist is not demonstrated. The June 2021 examiner's opinion substantially complies with the Board's prior remand directive. Finally, the representative asserts that the June 2021 examiner's opinion is inadequate, because she did not provide a well-supported opinion. As discussed above, the Board finds the opinion adequate as the examiner reviewed the claims file and provided explanations that relied on a review of medical literature and an understanding of the arthritis disease process. Additionally, her opinion is consistent with those of the other experts of record. The representative further asserts the examiner failed to consider the Veteran's reports of continuity of symptomatology. The examiner noted the Veteran's reported medical history in the examination document. The Board has found the Veteran's reports are inconsistent and provide little probative value as to the onset of his disability; therefore, the examiner's opinion is not rendered inadequate by the lack of discussion of these reports. Lastly, the representative points out the language addressing right arm pain. The Board finds the Veteran is benefited by the examiner's explanation that the right arm pain could not be easily attributed to either the neck or shoulder diagnosis. By finding there was no pathology for radicular pain to cause or aggravate a shoulder disability but noting the inability to determine the exact cause of the pain symptom, the examiner allowed all of the pain symptoms in the Veteran's right arm to be attributed to his service-connected right upper extremity radiculopathy. See Mittleider v. West, 11 Vet. App. 181, 182 (1998). The Board notes that a September 2021 shoulder examination was associated with the claims file after the most recent adjudication by the Agency of Original Jurisdiction (AOJ). However, the examiner did not render an opinion on the etiology of the Veteran's right shoulder disability, and the diagnoses and lay statements are duplicative of other evidence previously of record and considered by the AOJ. The Board has not relied on any evidence from that new examination that could be prejudicial to the Veteran. The Board concludes that the examinations and medical opinions of record are adequate and that the competent, probative evidence weighs against the claim. See 38 U.S.C. § 5107(a). The Board is grateful for the Veteran's honorable service, and this decision is not meant to detract from that service. Unfortunately, the Board finds service connection for a right shoulder disability is not warranted at this time. A. S. CARACCIOLO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.P. Armstrong 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.