Citation Nr: 21076628 Decision Date: 12/27/21 Archive Date: 12/27/21 DOCKET NO. 17-20 209 DATE: December 27, 2021 ORDER Service connection for a left shoulder disability, to include as secondary to a service-connected disability, is denied. FINDING OF FACT The Veteran's left shoulder disability is not shown to be due to any disease or injury during service, is not proximately due to, or aggravated by, a service-connected disability and left shoulder arthritis did not manifest to a degree of at least 10 percent within one year of separation from active duty. CONCLUSION OF LAW The criteria for service connection for left shoulder disability have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from September 1980 to September 1984. This case is before the Board of Veterans' Appeals (Board) on appeal from an April 2012 Department of Veterans Affairs (VA) Regional Office (RO) rating decision. In that rating decision, the RO denied service connection for left shoulder. The Veteran did not appeal that decision; however, the RO had the Veteran examined in July 2012 and that resulting report constituted new and material evidence within one year of that rating decision. 38 U.S.C. § 7105(c); 38C.F.R. §3.156(b). Accordingly, the April 2012 decision remained pending until the claim was readjudicated. In an April 2014 rating decision, the RO confirmed and continued its previous denial of service connection for left shoulder as secondary to essential tremor, (left (non-dominant) hand. The Veteran's notice of disagreement was received in September 2014. The RO issued a statement of the case in March 2017. The Veteran's VA Form 9, substantive appeal to the Board, was received in April 2017. In March 2019, December 2019, and June 2020 the Board remanded the case to the RO for further development and adjudicative action. Entitlement to service connection for left shoulder disability. The Veteran has contended throughout the pendency of the appeal that the onset of his left shoulder pain and current disability began during active duty, to include as a result of an in-service brachial plexus injury. Alternatively, he asserts that his left shoulder arthritis could have been aggravated by his service-connected tremors of the left hand. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (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. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In addition, certain chronic diseases, including arthritis, may also be established on a presumptive basis by showing that such a disease manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C. § 1112; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). In such cases, the disease is presumed under the law to have had its onset in service even though there is no evidence of such disease during the period of service. 38 C.F.R. § 3.307(a). To establish service connection under this provision, there must be evidence of a chronic disease shown as such in service (or within an applicable presumptive period under 38 C.F.R. § 3.307), and subsequent manifestations of the same chronic disease; or if the fact of chronicity in service is not adequately supported, by evidence of continuity of symptomatology after service. The provisions of 38 C.F.R. § 3.303(b) relating to continuity of symptomatology, however, can be applied only in cases involving those conditions explicitly enumerated under 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In pertinent part, service connection may be established on a secondary basis for a disability which is proximately due to or the result of 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) proximately caused by or (b) proximately aggravated by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Further, service connection may not be awarded on the basis of aggravation without establishing a pre-aggravation baseline level of disability and comparing it to the current level of disability. 38 C.F.R. § 3.310(b). Lay assertions may serve to support a claim for service connection by establishing the occurrence of observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1154(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As an initial matter, in a March 2019 decision, the Board denied the Veteran's claim of service connection for a neuropathic disability of the left upper extremity, which included the theory of direct service connection for a left upper extremity disability as a result of a brachial plexus injury. The Board determined that multiple medical studies conducted during the pendency of the appeal revealed that the Veteran did not have a neuropathic disability of the left upper extremity, to include a current diagnosis of brachial plexus injury. Accordingly, service connection for left shoulder disability due to a brachial plexus injury is not warranted. Although service treatment records show a ladder fall in which the Veteran fell on his buttocks and injured his left leg and left upper extremity pain due to possible nerve entrapment, the evidence of record does not document any diagnosis of a left shoulder disability during military service or within the first post-service year. Furthermore, the August 1984 separation examination was normal and noted no arthritis or bone/joint pain and the Veteran did not complain of any left shoulder issues at the time of his discharge; rather, the evidence does not demonstrate any complaints or treatment for many years after discharge from service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim, which weighs against the claim). Service connection on the basis of continuity of symptomatology in this case is therefore denied. 38 C.F.R. § 3.303(b). The Veteran was afforded several VA in-person examinations for his left shoulder, to include in July 2012, April 2014, July 2019, February 2020, November 2020, and an addendum medical opinion in December 2020. The most pertinent results are discussed below. The Veteran does not have an objective finding of a current diagnosis related to his reported left shoulder pain. The Board notes that 38 C.F.R. § 4.71a, Diagnostic Codes 5003 and 5010, require X-ray findings to establish a diagnosis of arthritis. During the July 2012 examination based on normal imaging results showing no arthritis, the examiner made no diagnosis regarding the Veteran's left shoulder. Despite normal imaging results again showing no arthritis, no objective signs of pain or weakness, but some limitation in motion in April 2014, the examiner diagnosed chronic left shoulder strain. The July 2019 examination performed no imaging; the examiner diagnosed chronic left shoulder strain and osteoarthritis based on a September 2003 MRI result showing severe arthritic changes. The February 2020 and November 2020 examinations included no current imaging and diagnosed only degenerative arthritis based on the 2003 MRI. Multiple x-rays since 2003 provide no evidence of arthritis or degenerative changes. The Board finds x-rays to be the most probative evidence whether arthritis exists and places greater weight on negative x-ray findings made after the 2003 MRI as it is a well-founded medical principle that degenerative changes do not reverse. Examinations that rely only on a single MRI, not an x-ray, are not probative because the most recent evidence does not support a finding of arthritis. Based on an extensive review of the entire record, in the December 2020 most recent medical opinion, the examiner finds the Veteran's reported shoulder pain was less likely than not incurred in or caused by the claimed in-service injury, event, or illness and provided the following rationale: Review of the service treatment records shows them to be silent for left shoulder injury. This includes the Veteran's physical examination at time of discharge, which is silent for any extremity condition. The Veteran has reported injury from his nerve conduction studies performed at Fort Hood in 1983. These would not be expected to cause any injury, and are a common test performed to test for nerve injuries. His study of his nerves in 1983 was completely normal. In addition, he was evaluated the day after the nerve testing and had a normal neurologic examination without evidence of injury or change in his condition. The Veteran has had numerous evaluations of his left shoulder with X-rays which are completely normal. There is no evidence on this imaging of any arthritis or other abnormality in the left shoulder. Although there is a reading of his left shoulder MRI from 2003 which indicates cartilage loss, this is inconsistent with the remainder of the evidence within the file and is not a formal read from a musculoskeletal radiologist but is from his neurologist (who are not typically trained in reading musculoskeletal MRIs). If there were complete cartilage loss in 2003, I would expect this to be readily apparent on X-rays taken a decade later (in 2014), but these are completely normal. Based on this, in my opinion, the [V]eteran does not have arthritis in his left shoulder. In summary, based on extensive chart review and my knowledge of musculoskeletal medicine, the Veteran has very minimal clinical findings that are supportive of any left upper extremity abnormality of any kind. He has no consistent objective evidence of structural abnormalities of his left shoulder, and there is no connection to his military service. The most probative evidence of record is the December 2020 VA addendum opinion by an orthopedic surgeon because she is an expert in joint injuries and provided an extensive medical rationale which is consistent with the evidence of record. The Veteran, as a lay person, is competent to report pain, but is not competent to diagnose a shoulder disability as this requires expert knowledge of internal medical processes and interpretation of clinical data, qualifications that the Veteran does not possess. Accordingly, his opinion as to any relationship between his reported shoulder pain and service is not afforded probative value. Further, while the Veteran sincerely believes his shoulder pain is secondary to his service-connected left-hand tremor, the preponderance of the evidence, including the medical evidence cited above, indicates otherwise. Specifically, there is no credible and competent evidence that his left shoulder pain is caused or aggravated by a service-connected disability to include his left-hand tremor. In summary, the most probative evidence of record does not support a relationship between the Veteran's shoulder pain and any in-service injury or disease. Accordingly, service connection for left shoulder disability is not warranted. Finally, although the June 2020 Board remand directed the most recent VA examiner to consider the Veteran's in-service fall from a ladder, the Board finds substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Upon extensive review of the Veteran's claims file, medical records, and service treatment records, it is reasonable to infer the December 2020 examiner read all of the Veteran's service treatment records. As the preponderance of the evidence is against the Veteran's claims for service connection, the benefit of the doubt doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). A. HODZIC Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board N. Ardalan, 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.