Citation Nr: 21005559 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 11-33 845 DATE: February 2, 2021 ORDER Service connection for a left elbow disorder is denied. FINDING OF FACT A left elbow disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. CONCLUSION OF LAW The criteria for service connection for a left elbow disorder have not been met. 38 U.S.C. §§ 101(24), 1110, 5107; 38 C.F.R. §§ 3.1, 3.6, 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 2004 to December 2004 and from December 2005 to November 2006, with additional service in the U.S. Marine Corps Reserve with several periods of active duty for training (ACDUTRA) and inactive duty for training (INACDUTRA). This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2011 rating decision issued by a Department of Veterans Affairs (VA) Regional Office. In May 2015, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the record. In September 2015, May 2017, January 2020, and September 2020, the Board remanded the case for additional development and it now returns for further appellate review. Entitlement to service connection for a left elbow disorder. A Veteran is a person who served in the active military, naval, or air service and who was discharged or released under conditions other “than dishonorable.” 38 C.F.R. § 3.1(d). The term “active military, naval, or air service” includes: (1) active duty; (2) any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty; and (3) any period of INACDUTRA during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty. 38 U.S.C. § 101(24); 38 C.F.R. § 3.6(a). ACDUTRA includes full-time duty performed by members of the National Guard of any State or the Reserve. 38 C.F.R. § 3.6(c). INACDUTRA includes duty other than full-time duty performed by a member of the Reserve or the National of any State. 38 C.F.R. § 3.6(d). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. Id.; see also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff’d, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. At his May 2015 Board hearing and in documents of record, the Veteran contended that he has a left elbow disorder as the result of a fall during Marine boot camp or combat training in 2004. In this regard, he reported that he landed on his left elbow on a rock and, thereafter, his fingers became numb and remained so until he hit his elbow again approximately six months later. He indicated that, since the initial injury, his left elbow has been extremely sensitive to contact and he experiences numbness in his fingers. Thus, the Veteran claims that service connection for a left elbow disorder is warranted. As an initial matter, the Board finds that the evidence of record reflects a current diagnosis of a left elbow disorder, diagnosed as left medial epicondylitis with impingement at a July 2011 VA examination and left elbow compressive ulnar neuropathy at a June 2018 VA examination. Additionally, the Veteran’s service treatment records reflect that, in a January 2010 Report of Medical History, he reported pain in his elbows during strenuous activity. Thus, the remaining inquiry is whether the Veteran’s left elbow disorders diagnosed during the pendency of the claim are related to his military service, to include his reported in-service fall and/or his complaints of pain in his elbows during strenuous activity as noted in January 2010. In this regard, in July 2011, a VA examiner opined that the Veteran’s left elbow disorder was less likely than not caused by or a result of military service; however, as noted in the May 2017 Remand, the Board found such opinion to be inadequate as the examiner did not fully consider the evidence of record, to include the aforementioned January 2010 Report of Medical History that reflected complaints of elbow pain. Thus, the Board remanded the claim in order to obtain an addendum opinion addressing the etiology of the Veteran’s left elbow disorder. In November 2016, another VA examiner opined that the Veteran’s claimed left elbow disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness as he did not have a current diagnosis associated with the left elbow. However, as the Veteran had been diagnosed with a left elbow disorder during the pendency of the claim at the July 2011 VA examination, the Board again remanded the claim in order to obtain an addendum opinion addressing the etiology of such disorder. In August 2017, yet another VA examiner, Dr. JC, opined that the Veteran’s left medial epicondylitis was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include his reported injury during boot camp. Similarly, in May 2018, Dr. JC diagnosed bilateral compressive ulnar neuropathy at the elbow and opined that such disorder was less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include his reported injury during boot camp. In this regard, he indicated that, although the Veteran’s type of compressive neuropathy can be caused by trauma, such as the fall he reported from Marine boot camp, it is much more commonly associated with repetitive motion activities such as the use of a wrench consistent with his work as a mechanic. However, as Dr. JC did not address the January 2010 Report of Medical History reflecting the Veteran’s complaint of pain in the elbows during strenuous activity, the Board again remanded the claim to obtain another addendum opinion addressing the etiology of the Veteran’s left elbow disorders. In July 2020, Dr. JC again opined that it was less likely than not that the Veteran’s left medial epicondylitis with impingement was incurred in service. However, he did not consider the Veteran’s contention that his left elbow disorder was caused by a fall during service or the diagnosis of compressive ulnar neuropathy at the bilateral elbow. Thus, the Board again remanded the claim to obtain another addendum opinion addressing the etiology of the Veteran’s left elbow disorders. In October 2020, Dr. JC noted that the Veteran reported an injury to his left elbow while he was in Marine boot camp, which resulted in decreased or altered sensation in his left hand and arm that persisted until he reinjured it approximately six months later. After the second left elbow injury, the Veteran stated that the sensation returned to normal. Dr. JC opined that it is at least as likely as not that a blunt trauma injury to the medial aspect of the elbow can cause damage to the ulnar nerve, and this nerve injury can result in decreased or altered sensation into the forearm and hand, which is analogous to “hitting your funny bone.” However, Dr. JC explained that, while it is likely that this type of injury could occur as the Veteran has described it, it is unlikely that these symptoms would persist for six months, only to fully resolve after a second left elbow injury. He indicated that the Veteran’s history of two left elbow injuries that he has repeatedly presented is not consistent with the expected results of the types of injuries that he describes. In this regard, Dr. JC reported that the expected result would be a gradual resolution of the symptoms or a persistence or worsening of the symptoms. With a second injury to the same area, the expected result would be a worsening of the symptoms and not a sudden resolution of the symptoms. To explain this unexpected outcome as he has described would require to resorting to speculation. Dr. JC further explained that medial epicondylitis, of which the Veteran has a diagnosis, is commonly associated with repetitive motion type of injuries. He also noted that EMG and nerve conduction studies have shown that the Veteran has compressive ulnar neuropathy at the elbow bilaterally. In this regard, Dr. JC explained that, anatomically, the ulnar nerve passes around the elbow posterior to the medial epicondyle. Thus, the swelling that can occur with medial epicondylitis can cause impingement of the ulnar nerve. Episodic flares of medial epicondylitis, such as with repetitive motions, can result in compression of the ulnar nerve. Additionally, Dr. JC stated that, while the Veteran has reported injuries to his left elbow, he is currently diagnosed with compressive ulnar neuropathy in both elbows, and the characteristics of this compressive neuropathy are consistent with nerve compression associated with medial epicondylitis. (Emphasis added). Thus, Dr. JC found that, while the Veteran has reported that he had serial injuries to his left elbow, he had compressive ulnar neuropathy in both elbows, and, thus, it is less likely than not that the bilateral compressive ulnar neuropathy is due to a left elbow injury that occurred while on active duty service. Dr. JC also noted the January 2010 Report of Medical History in which the Veteran reported that he had experienced pain in his elbows during strenuous activity; however, he observed that there were no further details related to this entry in the record, there is no indication that this concern was evaluated further, and there is no diagnosis associated with this entry. Dr. JC further observed that the type, location, duration, and intensity of the elbow pain noted in the January 2010 report is unknown and the types of activities (besides strenuous) are unknown. He also indicated that it is unclear if these activities are repetitive activities or activities that involve strenuous lifting of large, bulky, or heavy objects. Consequently, he found that such entry provides minimal useful information due to its lack of specifics. Additionally, Dr. JC noted that this entry uses the pleural (elbows), meaning that both elbows were involved, yet the Veteran has reported that only his left elbow was injured in boot camp. Thus, Dr. JC determined that it is less likely than not that the Veteran’s current left medial epicondylitis and left ulnar nerve compressive neuropathy were incurred in or aggravated by his military service. The Board accords great probative weight to Dr. JC’s October 2020 opinion as such considered all of the pertinent evidence of record, to include the statements of the Veteran and relevant medical history, and provided a complete rationale, relying on and citing to the records reviewed. Moreover, he offered clear conclusions with supporting data as well as reasoned medical explanations connecting the two. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008) (it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (“[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions”). The Board also notes that, prior to rendering the unfavorable August 2017, May 2018, July 2020, and October 2020 opinions, Dr. JC offered a favorable opinion in January 2016. Specifically, at such time, he opined that the Veteran’s left elbow disorder is consistent with the mechanism of blunt trauma injury as he described. In support of such opinion, Dr. JC indicated that, as a compliant of pain is noted in the service treatment records as demonstrated by the January 2010 Report of Medical History and as the Veteran is considered competent to relate his symptoms and history, it was at least as likely as not that his current left elbow disorder was incurred in service. However, the Board affords minimal probative weight to such opinion as it was based on the Veteran’s reported symptoms without a sufficient discussion of the mechanism of injury or expected residuals thereof. In this regard, at such time, Dr. JC only noted that the Veteran’s left elbow disorder was consistent with the mechanism of blunt trauma and did not address the Veteran’s report that his symptoms improved/resolved with a second injury or the fact that he currently experienced symptoms in both of his elbows. Conversely, in his October 2020 opinion, Dr. JC reconsidered the facts of the case and provided a full discussion of the mechanism of injury, to include the expected residuals thereof, and the bilateral nature of the current disorder. Thus, due to the conclusory nature of Dr. JC’s January 2016 opinion, such is afforded minimal probative weight. Id. The Board also considered the Veteran’s assertions as to the etiology of his left elbow disorder; however, as a lay person, he does not have the requisite training and experience necessary to address such a complex medical matter. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis). In this regard, the etiology of such disorder involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship as it requires knowledge of the impact of trauma on the elbow and, thus, may not be competently addressed by lay statements. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (explaining that while the claimant is competent in certain situations to provide a diagnosis of a simple condition such as a broken leg or varicose veins, the claimant is not competent to provide evidence as to more complex medical questions). Accordingly, the Veteran’s opinion as to the etiology of his left elbow disorder is not competent evidence and, consequently, is afforded no probative weight. Therefore, based on the foregoing, the Board finds that the Veteran’s left elbow disorder is not shown to be causally or etiologically related to any disease, injury, or incident during service. As such, service connection for such disorder is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a left elbow disorder. As such, that 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. JAEGER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Dawn A. Leung, 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.