Citation Nr: 21071904 Decision Date: 12/01/21 Archive Date: 12/01/21 DOCKET NO. 15-27 112 DATE: December 1, 2021 ORDER Service connection for a left arm condition, shoulder to elbow is granted. Service connection for a left arm condition, elbow to wrist is denied. Service connection for a right arm condition, shoulder to elbow is granted. Service connection for a right arm condition, elbow to wrist is denied. REMANDED Entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. FINDINGS OF FACT 1. The Veteran's left arm condition, shoulder to elbow had its onset during his active duty service. 2. The Veteran's left arm condition, elbow to wrist symptoms are symptoms of the already service-connected bilateral elbow epicondylitis and left wrist disabilities, and are not manifestations of a separately diagnosable left arm, elbow to wrist disability. 3. The Veteran's right arm condition, shoulder to elbow had its onset during his active duty service. 4. The Veteran's right arm condition, elbow to wrist symptoms are symptoms of the already service-connected bilateral elbow epicondylitis and right wrist disabilities, and are not manifestations of a separately diagnosable right arm, elbow to wrist disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a left arm condition, shoulder to elbow are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for a left arm condition, elbow to wrist are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 4.14. 3. The criteria for service connection for a right arm condition, shoulder to elbow are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 4. The criteria for Service connection for a right arm condition, elbow to wrist are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 4.14. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1975 to July 1995. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a September 2012 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Petersburg, Florida. This matter has previously been before the Board, most recently in May 2021. At that time, the claims for service connection for bilateral upper and lower arm conditions were remanded to obtain adequate VA medical opinions. The claim for a TDIU was remanded as inextricably intertwined with the service connection claims. As the record reflects that adequate VA medical opinions were obtained, the Board finds that there has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection Generally, service connection will be granted if the evidence demonstrates that a current disability resulted from a disease or injury incurred in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection requires evidence of a current disability, an in-service incurrence, disease or injury and a causal relationship between the current disability and the in-service incurrence, disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Additionally, service connection can also be established through application of a statutory presumption for chronic diseases, like arthritis, when manifested to a compensable degree within a year of separation from service. 38 C.F.R. §§ 3.307, 3.309. If a chronic disease is not manifested to a compensable degree within a year of separation of service, then, generally, a showing of "continuity of symptoms" after service is required for service connection. 38 C.F.R. § 3.303(b). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518 (1996). Bilateral Arm Conditions, Shoulders to Elbows An August 2021 VA examination for the Veteran's shoulder and arm conditions confirm that the Veteran has been diagnosed with bilateral acromioclavicular (AC) joint osteoarthritis. The Veteran is thus able to meet the first element for service connection with respect to his bilateral upper extremities, shoulder to elbow. With respect to the second element, the Veteran reported to the August 2021 VA examiner that he experienced pain in his arms in service. According to the Veteran, his pain was attributable to the repetitive use and positioning of his arms as a dental hygienist in service. The Veteran reported constant pain from his shoulders to his elbows that worsened since its onset in service. The Board finds the Veteran's report of upper arm pain in service competent and credible. The Veteran's military personnel records confirm that he served as a dental hygienist during his 20 years of active duty service. The Veteran's service treatment records (STRs) also document complaints of arm pain in service, including an October 1988 complaint of bilateral arm pain for 2 weeks. The Veteran's complaints were assessed as bilateral arm discomfort and noted to probably be musculoskeletal in nature. The remaining question is whether there is a nexus between the Veteran's service and his current disability. The August 2021 VA examiner concluded that the Veteran's bilateral AC joint osteoarthritis was not related to service. According to the examiner, the condition is a normal age-related process that was diagnosed in 2009 and was unrelated to the service-connected right and left elbow epicondylitis disabilities. The Veteran is competent to report the details of his personal history, including his arm pain symptoms and their duration, and the Board finds him to be credible. The Veteran's reports of his experiences in service are confirmed by his military personnel records and STRs. The evidence supporting a finding that the Veteran's bilateral arm conditions, shoulders to elbows, began in service outweighs the opinion of the August 2021 VA examiner. The Board has no reason to question the credibility of the Veteran's reports regarding upper arm pain he experienced in service and ongoing since. Affording the benefit of the doubt to the Veteran, the Board finds that he has been experiencing chronic bilateral upper arm pain since service. Accordingly, service connection for bilateral arm conditions, shoulders to elbows, is granted. Bilateral Arm Conditions, Elbows to Wrists After a review of all the lay and medica evidence of record, the Board finds that the weight of the evidence demonstrates that the Veteran does not have bilateral arm, elbows to wrists disabilities that are not already service-connected. The August 2021 VA examiner concluded that the subjective and objective symptoms noted on examination were consistent with the Veteran's service-connected bilateral elbow epicondylitis and wrist disabilities. The examiner referenced medical literature in support of the conclusion that the symptoms experienced by the Veteran were consistent with his already service-connected disabilities. The Board finds this opinion entitled to probative weight. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (a medical opinion will be deemed adequate when it is based on consideration of the Veteran's medical history, describes the Veteran's condition and includes an explanatory rationale based on relevant medical literature). The Board notes that there is no contradictory medical opinion in the record. Although the Veteran is competent to describe his symptoms, there is no indication in the record that he has the qualifications to identify those symptoms as distinct from the already service-connected disabilities. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336-1337 (2006); Layno v. Brown, 6 Vet. App. 465, 469 (1994). Based on the foregoing, the Board finds that the weight of the evidence demonstrates that the Veteran is not currently diagnosed with a left arm, elbow to wrist, or a right arm, elbow to wrist disability for which compensation is not already provided. 38 C.F.R. § 4.14 precludes rating the same disability under different diagnoses. Therefore, the claims for service connection for bilateral arm conditions, elbows to wrists, must be denied. REASONS FOR REMAND TDIU In light of the above decision, the Veteran has additional service-connected disabilities for his bilateral upper extremities, shoulders to elbows. A decision on the initial ratings for the now-service-connected disabilities could impact a decision on the issue of entitlement to a TDIU. Accordingly, remand is warranted. The matter is REMANDED for the following action: Assign initial ratings for the service-connected bilateral arm conditions, shoulders to elbows. Thereafter, readjudicate the inextricably intertwined issue of entitlement to a TDIU. S.C. KREMBS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Snyder, 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.