Citation Nr: 21077481 Decision Date: 12/29/21 Archive Date: 12/29/21 DOCKET NO. 13-35 898 DATE: December 29, 2021 ORDER Entitlement to service connection for peripheral neuropathy of the right upper extremity (RUE), claimed as RUE condition, to include elbows, hands, and fingers is denied. Entitlement to service connection for peripheral neuropathy of the left upper extremity (LUE), claimed as LUE condition, to include elbows, hands, and fingers is denied. FINDINGS OF FACT 1. The Veteran's RUE peripheral neuropathy was not present in service, did not manifest to a compensable degree within one year of service, and is not otherwise etiologically related to service or service-connected disability. 2. The Veteran's LUE peripheral neuropathy was not present in service, did not manifest to a compensable degree within one year of service, and is not otherwise etiologically related to service or service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for RUE peripheral neuropathy are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for LUE peripheral neuropathy are not met. 38 U.S.C. §§ 1110, 1112, 1113, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served active duty from May 1965 to August 1968. This matter is on appeal from a May 2010 rating decision. In May 2015, February 2018, November 2019, June 2020, and December 2020, the Board remanded it for additional development. The Board denied service connection for peripheral neuropathy of the RUE and for peripheral neuropathy of the LUE, considered together as bilateral upper extremity (BUE) peripheral neuropathy, in an April 28, 2021, decision. However, that decision was vacated by the Board in an August 2021 decision. In the introduction of the August 2021 vacatur decision, the Veteran and his representative were informed that the record would be held open for 90 days for the submission of additional evidence and argument. This period ended in November 2021. Yet to date, no additional evidence or argument has been submitted. Recent VA treatment records have been procured, but they are not relevant. This matter is in the same place it was in when the unfavorable April 28, 2021, decision was issued, in other words. That decision accordingly is reissued with only a few minor changes at this time. Service Connection The Veteran seeks entitlement to service connection for BUE peripheral neuropathy. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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 - the so-called "nexus" requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). Continuity of symptomatology may also provide a basis for a grant of service connection for those diseases defined as "chronic" by VA. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Certain chronic diseases are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Service connection may also be established on a secondary basis for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a); Allen v. Brown, 7 Vet. App. 439, 446 (1995) (en banc). In order to establish service connection for a claimed secondary disorder, there must be medical evidence of a current disability; evidence of a service-connected disability; and medical evidence of a nexus between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-7 (1995). The Veteran contends that a condition affecting his upper extremities, diagnosed as peripheral neuropathy, is related to his service-connected bilateral shoulder disabilities. Although he appears to have limited his argument to principles of secondary service connection, direct service connection was also considered during the course of the appeal. The record shows that VA providers submitted medical opinions in March 2017, September 2018, December 2019, and July 2020, in which each examiner rendered a negative nexus opinion as to whether the Veteran's peripheral neuropathy was etiologically related to service or his service-connected shoulder disabilities. However, the Board found the opinions inadequate due to insufficient rationale. See Board Remands dated in May 2015, February 2018, November 2019, and June 2020. The Board notes that although the September 2018 VA opinion was found inadequate, this was not due to a deficiency in the examiner's rationale, but because service connection for right shoulder arthritis had been granted since the opinion had been submitted. Therefore, the Board finds the opinion is still useful to review as it provides some context with respect to the etiology of the Veteran's peripheral neuropathy and is instructive for that purpose. That said, the 2018 VA examiner noted that examination findings showed the Veteran's peripheral neuropathy had a stocking-glove distribution with findings consistent with involvement of the distal end of the Veteran's arms. It was explained that shoulder conditions tend to cause neuropathy related to brachial plexus injury, not distal axon defects like those shown in earlier examination findings. For this reason, the Veteran's shoulder condition was less likely than not contributing to his peripheral neuropathy. Pursuant to the Board's most recent remand in December 2020, the Veteran's file was reviewed by a new VA examiner who confirmed the diagnosis of BUE peripheral neuropathy and concluded that it was not caused or aggravated beyond its natural progression by the Veteran's service-connected bilateral shoulder disabilities. The examiner cited extensively from the record, including relevant findings from outpatient treatment and the previous VA examination reports from throughout the file. It was noted that the etiology of the left and right upper extremity problems appeared to be a polyneuropathy possibly due to underlying thyroid issues or an undiagnosed connective tissue disorder. It was explained that the BUE symptoms of muscle weakness and other sensory symptoms experienced were not pathologically compatible with the service-connected left shoulder strain and right shoulder arthritis and that the pain and decreased range of shoulder motion from these disabilities did not aggravate the peripheral neuropathy beyond its natural progression. Based on the foregoing, the Board finds there is no probative and competent medical evidence of record to indicate that the Veteran's service-connected left shoulder strain or right shoulder arthritis play any role in the development of his current peripheral neuropathy of the bilateral upper extremities. The December 2020 VA opinion is both probative and persuasive medical evidence as it is based upon a review of the file and is supported by an adequate rationale. In providing the rationale, the VA examiner considered relevant medical and other history, the results of the previous clinical evaluations, and the Veteran's belief that his neuropathy problems are related to his service-connected shoulder disabilities. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (the probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion). There are no favorable competent opinions of record. To the extent the Veteran's statements attempt to provide a nexus opinion between his BUE peripheral neuropathy and service-connected shoulder disabilities, the Board notes determining such etiology (as distinguished from merely reporting the presence of symptoms) is not a simple question. Doing so requires knowledge of the complexities of the neurological system, the various causes of peripheral neuropathy, and the impact a musculoskeletal disability may have on such a diagnosis, and so is beyond the scope of knowledge of a lay person. In this case, the facts are complex enough that the Veteran's assertions are not sufficient to outweigh the remaining evidence of record. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (providing that although a veteran is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, a veteran is not competent to provide evidence as to more complex medical questions). In other words, any assertion by the Veteran that his BUE peripheral neuropathy is related to his bilateral shoulder disabilities treads into the realm of medical expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). The Board is also unable to attribute the post-service development of BUE peripheral neuropathy to military service on a direct basis. The Veteran did not experience chronic peripheral neuropathy symptoms in service and there is no evidence that peripheral neuropathy manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.303, 3.307, 3.309. Furthermore, there is no competent evidence linking the BUE peripheral neuropathy to service or any evidence that suggests such a relationship. Because the Veteran's BUE peripheral neuropathy was not present in service, and there is no competent medical evidence relating it to service or service-connected disability, the claims cannot be granted. 38 C.F.R. §§ 3.303, 3.310; Allen, supra; see also, Wallin, Reiber, supra. Accordingly, the preponderance of the evidence is against the claims, and there is no reasonable doubt to be resolved. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. Thomas H. O'Shay Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Becker 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.