Citation Nr: A21020163 Decision Date: 12/17/21 Archive Date: 12/17/21 DOCKET NO. 210309-141062 DATE: December 17, 2021 ORDER Entitlement to service connection for a right shoulder condition as secondary to a left foot condition is denied. FINDING OF FACT The Veteran's right shoulder condition is not proximately due to or the result of the Veteran's left foot condition. CONCLUSION OF LAW The criteria for entitlement to service connection for a right shoulder condition as secondary to a left foot condition have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. § 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1966 to April 1970. This case comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision of December 2020 issued by the Department of Veterans Affairs (VA) Regional Office (RO) under the Appeals Modernization Act (AMA). The Board briefly notes that this issue was also addressed in a prior rating decision of December 2019. See December 2019 Rating Decision at 2. The rating decision on appeal found that the Veteran had submitted new and relevant evidence sufficient to warrant readjudication of this claim. See December 2020 Rating Decision at 3; see also 38 C.F.R. § 3.156(d) (providing for reconsideration of supplemental claims under the AMA). Under the AMA, the Board is generally bound by favorable findings made by the RO, and the Board has not found clear and unmistakable evidence in the record to rebut this finding. See 38 C.F.R. § 3.104(c). Because the Veteran selected the direct review docket, no hearing before the undersigned Veterans Law Judge (VLJ) was scheduled. In claims adjudicated on the direct review docket, the Board's decision is based on the evidence of record at the time of the RO's decision. See 38 C.F.R. § 20.301. 1. Entitlement to service connection for a right shoulder condition as secondary to a left foot condition. Service connection requires the existence of a present disability, the in-service incurrence or aggravation of a disease or injury, and a causal relationship between the present disability and the disease or injury incurred or aggravated during service. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1167 (2004). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, disabilities which are "proximately due to or the result of a service-connected disease or injury" are also service connected. 38 C.F.R. § 3.310(a). "When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition." Id. The record reflects that the Veteran is service-connected for a left foot condition. See December 2020 Rating Codesheet at 1-2. The Veteran specifically asserts that he has developed bilateral shoulder conditions as a result of this left foot condition. See January 2020 VA Form 20-0995 (specifying "[right] shoulder condition secondary to [left] heel/foot condition"); see also id. (specifying same as to left shoulder condition). The Board briefly notes that the rating decision on appeal granted service connection for the Veteran's left shoulder condition, but not his right shoulder condition. See December 2020 Rating Decision at 1-2. The Board clarifies this point because a VA examiner reached differing conclusions as to the causes of the Veteran's shoulder conditions, and the evidence and reasoning supporting these differing conclusions is relevant to the adjudication of this claim. As an initial matter, the Board notes that the VA examiner diagnosed the Veteran with bilateral rotator cuff tears. See December 2020 VA Examination Report at 2. The Board therefore finds that the first Shedden factor has been met. As discussed above, the Veteran also has a service-connected left foot condition. The Board therefore finds that the second Shedden factor has been met as well. However, the VA examiner noted that the Veteran's right and left shoulder conditions did not have their onset simultaneously: [The Veteran] states that he started having shoulder pain in the [right] shoulder in 2005. There was no injury he could recall, it was just a gradual onset. He has pain with certain movements. Initial [treatment] was [physical therapy], no medication. About 5 [years] ago, he fell (related to the ongoing issues with his foot injury related to service-connected injury), and injured his [left] shoulder. This was also treated with [physical therapy]. He states his current treatment for the shoulders is "nothing" aside from Aleve [pro re nata]. He gets some sporadic [physical therapy treatment] as well. In terms of work, he states he can't lift anything heavy and has pain with certain movements. He states it does not affect his [activities of daily living]. MRIs done in 2018 and 2019 reveal rotator cuff tears in each shoulder, and on the [left] it was deemed inoperable. Was offered surgery on the [right] but [he] declined due to recovery time needed post-op. See December 2020 VA Examination Report at 3 (emphasis added). The VA examiner therefore opined in pertinent part as follows: [The Veteran] reports a gradual onset of [right] shoulder pain beginning in approximately 2005. There is no reported service connection, and there are no [service treatment records] for this issue. While he does have a well-documented injury to the left foot... incurred during [active-duty] service, there is no connection between this and the gradual onset of [right] shoulder pain approximately 35 years later. Therefore the claimed condition is less likely than not incurred in or caused by the claimed in-service injury. See December 2020 VA Medical Opinion (Right Shoulder) at 2; cf. December 2020 VA Medical Opinion (Left Shoulder) at 2 (providing that in the case of the Veteran's left shoulder, "[the Veteran] states that he injured the [left] shoulder around 2015 when he fell... onto the shoulder... it could be argued that the residuals from [his foot] injury caused the instability resulting in his fall around 2015 which injured the left shoulder"); see also id. (opining accordingly that it is at least as likely as not that the Veteran's left shoulder condition is secondary to his left foot condition). The Board notes that the Veteran has also provided a private medical opinion from his physical therapist in support of his claim: [The Veteran]... has been my patient since [September 2017] and is under my care for bilateral shoulder pain, low back pain[,] and thoracic pain. In addition to the aforementioned conditions, [the Veteran] also suffers from arthritis, plantar fasciitis[,] and calcaneal bone spurs in his left foot. These conditions have resulted in loss of balance and impaired gait and mobility. [The Veteran] has fallen several times in the past twelve months due to symptoms in his foot/ankle, resulting in injuries to his right and left shoulders. For this reason, it is my opinion, that it is at least as likely as not... that the injuries to his shoulders are partly the result of his left foot condition... See January 2020 Medical Treatment Record. "[Most] of the probative value of a medical opinion comes from its reasoning. Neither a VA medical examination report nor a private medical opinion is entitled to any weight... if it contains only data and conclusions." Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); see also id. at 302 (providing that "[the] first inquiry is whether the medical expert is informed of sufficient facts upon which to base an opinion relevant to the problem at hand") (internal citation omitted); see also Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (providing that "[an] opinion based upon an inaccurate factual premise has no probative value"). It is unclear from the physical therapist's opinion whether he was aware of the Veteran's prior history of gradual right shoulder pain developing from 2005. Because the VA examiner's reasoning more fully addresses the relevant facts of the Veteran's medical history, the Board assigns it greater probative weight than the physical therapist's opinion. The Board also notes that while the Veteran's medical treatment records reflect treatment for bilateral shoulder pain, and specifically identify left shoulder pain resulting from injuries sustained during falls, they are ambiguous as to whether or not the Veteran has also fallen onto his right shoulder. See November 2019 Medical Treatment Records at 307 (providing August 2018 treatment note observing "recent fall landing onto the left knee"); see also id. at 49 (providing August 2019 treatment note observing "fall in house... landed on left shoulder"); see also March 2020 Medical Treatment Records at 35 (providing January 2020 treatment note observing that "[the Veteran] fell today and re-injured his shoulder, knee, and ankle"); see also October 2020 Medical Treatment Records at 201 (providing February 2020 treatment note observing "bilateral shoulder pain" and that "[he] states that due to his current left foot pain he has had several [falls] landing with outstretched arm... [complains of] pain across the posterior/lateral shoulder"); see also id. 167 (providing March 2020 treatment note observing pain in "[left] ankle, left knee[,] and both shoulders due to falls"); see also id. at 46 (providing May 2020 treatment note observing that "[because] of the sharp pains [in lower extremities] he experiences a couple falls, one causing him to land on his left shoulder"). Instead, the Veteran's medical records support the VA examiner's finding that his right shoulder pain is of long-standing duration. See November 2019 Medical Treatment Records at 833 (providing September 2013 treatment note observing "[reported history] of [right] shoulder injury... about 1-2 years ago" and "[chronic history] of shoulder problems for years"); see also id. (noting Veteran's civilian employment as a truck driver and associated physical labor). Finally, the Board notes the Veteran's argument that "[the] rationale for both the left and right shoulder as being [service-connected] secondary to current [service-connected conditions] was the same" and that "a nexus opinion was provided to support the claims and the VA only awarded the one shoulder, though inexplicably." See March 2021 VA Form 21-4138. As discussed above, the physical therapist's opinion is inadequate to rebut the VA examiner's opinion because it does not address the Veteran's prior medical history of gradually-developing right shoulder pain. The VA examiner's differing conclusions as to the Veteran's right and left shoulder conditions are not inexplicable but are instead based on the separate medical histories of these conditions, including statements from the Veteran made during the examination itself. Because the Board has found no evidence in the record sufficient to rebut the VA examiner's opinion, it must conclude that the third Shedden factor has not been met. The assignment of service connection for the Veteran's right shoulder condition as secondary to his left foot condition is therefore not warranted. 38 C.F.R. § 3.310. The Board has considered the doctrine of reasonable doubt but finds that it is not applicable because the balance of the evidence is against the Veteran's claim. 38 U.S.C. § 5107. [SIGNATURE ON NEXT PAGE] JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Blore, 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.