Citation Nr: 21006465 Decision Date: 02/04/21 Archive Date: 02/04/21 DOCKET NO. 13-28 183 DATE: February 4, 2021 ORDER Entitlement to service connection for a right elbow disorder, to include as secondary to service-connected shoulder disabilities, is denied. Entitlement to service connection for a right wrist disorder, to include as secondary to service-connected shoulder disabilities, is denied. Entitlement to service connection for a left ankle disorder, to include as secondary to service-connected left knee disability, is denied. FINDINGS OF FACT 1. The preponderance of the evidence does not demonstrate that a right elbow disability had its onset in service, has been chronic or continuous since service separation, manifested to a compensable degree within a year of service separation, is due to an in-service disease or injury, or is caused or aggravated by a service-connected disability. 2. The preponderance of the evidence does not demonstrate that a right wrist disability had its onset in service, has been chronic or continuous since service separation, manifested to a compensable degree within a year of service separation, is due to an in-service disease or injury, or is caused or aggravated by a service-connected disability. 3. The preponderance of the evidence does not demonstrate that a left ankle disability had its onset in service, has been chronic or continuous since service separation, manifested to a compensable degree within a year of service separation, is due to an in-service disease or injury, or is caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for a right elbow disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310, 3.317. 2. The criteria for entitlement to service connection for a right wrist disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310, 3.317. 3. The criteria for entitlement to service connection for a left ankle disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1987 to November 1987 and from November 1988 to August 1996. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a February 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These matters were previously before the Board in November 2017, January 2020 and July 2020 and were remanded for additional development. The case is once again before the Board. Service Connection In general, service connection requires the following: (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 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). Service connection may also be granted for a disability that is proximately due to, or the result of, a service-connected disability. 38 C.F.R. § 3.310(a). The controlling regulation has been interpreted to permit a grant of service connection not only for disability caused by a service-connected disability, but for the degree of disability resulting from aggravation of a non-service-connected disability by a service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). In other words, service connection may be granted for a disability found to be proximately due to, or aggravated by, a service-connected disease or injury. To prevail on the issue of secondary service connection, the record must show (1) evidence of a current disability, (2) evidence of a service-connected disability, and (3) evidence that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service connected disability. VA has established certain rules and presumptions for chronic diseases, such as arthritis. See 38 C.F.R. §§ 3.303(b), 3.307, 3.309(a); Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). With chronic diseases shown as such in service so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless attributable to intercurrent causes. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. § 3.303(b). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, chronic diseases are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Additionally, service connection may be awarded on a presumptive basis to a Persian Gulf veteran who exhibits objective indications of a chronic disability and served in the Southwest Asia theater as outlined in 38 C.F.R. § 3.317. In this case, the evidence does not demonstrate, and the Veteran has not contended as such in communication with VA regarding his appeal, that he served in the Southwest Asia theater of operations during the Persian Gulf War, which began for purposes of the application of this law on August 2, 1990. The evidence does reflect that the Veteran served on active duty during the requisite period, but he was not deployed in the Southwest Asia theater. VA obtained his military personnel records, and they do not show such service. Accordingly, 38 C.F.R. § 3.317 is not applicable in this instance. The Veteran asserts that he has joint pains in his right elbow, right wrist and left ankle related to vaccinations (to include anthrax) that he received in service. In the alternative, he has asserted that his joint pain is secondary to his service connected disabilities. Right elbow Regarding a current disability; the record demonstrates the Veteran has an olecranon spur on his right elbow with minimal degenerative changes. Therefore, a current disability has been established. Regarding an in-service incurrence, as noted above the Veteran maintains that he received an anthrax vaccination in his shoulder which caused his joint pain. The record does not demonstrate that he received an anthrax vaccination while in service. Additionally, the Veteran’s 1996 separation examination did not note any conditions related to the elbow. While the Veteran checked the trick “shoulder or elbow” box on the report, the examiner only noted problems related to his shoulder. With respect to evidence of a service-connected disability, the record reflects that the Veteran was granted service connection for his left shoulder, effective August 11, 1996, and his right shoulder, effective June 25, 2010. Therefore, a service-connected disability has been demonstrated. Post-service treatment records demonstrate left elbow pain (which resolved) in May 2005. The records do not demonstrate treatment for his right elbow disorder. This is consistent with the Veteran’s May 2019 statements that he did not discuss his joint disorders with his primary care physician. See May 2019 VA examination. In May 2019, the Veteran had a general joints examination. The Veteran stated his symptoms had been around for more than 15 years. The VA examiner found it less likely than not that the Veteran’s joint pain (to include elbow, ankle and wrist) was related to service. The examiner reasoned that the Veteran had degenerative arthritis in his joints. The examiner noted that the Veteran had chronic pain since he filed his claim; however, there was no mention of joint pain in the medical records to establish a chronic condition since service. The examiner stated there was no nexus event in the Veteran’s service treatment records and the current findings were consistent with his age and body habitus of morbid obesity, which is associated with degenerative changes in the joints due to excessive load bearing over time. The examiner reported that the Veteran was morbidly obese. The Veteran refused to be weighed, but the examiner estimated his weight to be over 300 pounds. Regarding the Veteran’s contention that his joint pain was related to an anthrax vaccination; the examiner noted that the Veteran’s service treatment records did not demonstrate that he received an anthrax vaccination and the vaccines he did receive are not known for causing degenerative arthritis. In March 2020 a VA examiner found it less likely than not that the Veteran’s right elbow disorder was proximately due to or the result of the Veteran’s shoulder disabilities. The examiner reasoned that the Veteran did not note right elbow problems upon separation. Diagnostic testing revealed an olecranon spur on the right elbow. The examiner stated that the spur is not part of the joint and therefore not affected by the shoulder disability. The examiner further determined the Veteran’s right elbow disorder was not aggravated by his left shoulder condition. The examiner reasoned that the olecranon spur in his right elbow was the natural progression of his elbow disorder. A July 2020 VA examiner concluded the Veteran’s right elbow was less likely than not due to or the result of the Veteran’s shoulder disabilities. The examiner reasoned olecranon spurs are indicative of degenerative changes due to repetitive use. The examiner stated there is no evidence in the medical literature that shows degenerative changes in the elbow are caused by problems in the upstream shoulder or opposing shoulder. The two joints are independent of each other; therefore, the Veteran’s shoulder disability and elbow disorder are unrelated. Similarly, the Veteran’s right elbow could not be aggravated by his shoulder disability because they are unrelated. In September 2020 the examiner offered an addendum opinion clarifying that the Veteran’s right elbow disorder is less likely than not related to the Veteran’s left shoulder. While the Veteran reported compensating for his left shoulder by shifting loads, the examiner reasoned that degenerative changes in the elbow are due to overuse of that joint and not the result of upstream arthritis on the shoulders, regardless of how loads are carried. The examiner found the anatomy and medical literature do not support a relationship between the shoulder and elbow in this case because the olecranon process is part of the ulna (a forearm bone) and is part of the elbow. The elbow joint functions independently of the shoulder joints and arthritis in the shoulders does not predispose arthritis in the elbows. The examiner further concluded that it was less likely than not that the Veteran’s right elbow was aggravated by his right or left shoulder disabilities. The examiner reasoned that the Veteran’s mild degenerative changes in his right elbow are consistent with his age and body habitus; that the Veteran’s obesity predisposes him to additional stresses on all joints and there is no evidence that either shoulder aggravated the Veteran’s elbow beyond any natural progression. In light of the foregoing, the Board must conclude service connection for a right elbow disability is not warranted. The Veteran did not experience onset of his right elbow disorder in service, and such a disability did not manifest until years after service. Moreover, no competent expert has suggested the Veteran’s right elbow pain had its onset in service or was related to an in-service disease or injury. In the absence of such evidence of in-service incurrence or relationship to a service-connected disability, service connection must be denied. Finally, there is no competent evidence suggesting the elbow condition has been caused or aggravated by a service-connected disability. The Veteran himself asserts his right elbow disability had its onset in service or is otherwise related to his service connected shoulder disabilities. However, as a layperson, the Veteran is not capable of making medical conclusions; thus, his statements regarding causation are not competent evidence. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Lay statements may be competent to support a claim for service connection by supporting the occurrence of lay observable events or the presence of disability or symptoms of disability subject to lay observation. Id. However, orthopedic disorders are complex disorders which require specialized training for a determination as to diagnosis and causation, and they are therefore not susceptible of lay opinions on etiology, and the Veteran's statements therein cannot be accepted as competent medical evidence. The Veteran is also not reporting an expert opinion as told to him, and his lay contentions have not subsequently been confirmed by a competent expert. The Board finds the medical evidence of record competent and highly probative. Notably, the May and September 2020 VA examiner conducted a thorough review of the claims file, provided a detailed explanation of the Veteran's medical history, and provided sufficient rationale for all opinions provided. To the extent that the Veteran asserts that his elbow pain is related to receiving vaccinations, to include an anthrax vaccination, he is competent to attest to his observations and the etiology of simple medical matters. As discussed above, he is not, however, competent to opine on complex medical matters such as the etiology of olecranon spurs with mild degenerative changes and their potential relationship to vaccines. The Veteran has submitted internet articles suggesting a possible nexus between various vaccines and medical symptoms, including joint pain. The U.S. Court of Appeals for Veterans Claims (Court) has held that “[g]enerally, an attempt to establish a medical nexus to a disease or injury solely by generic information in a medical journal or treatise 'is too general and inconclusive’.” Mattern v. West, 12 Vet. App. 222, 228 (1999). Medical treatise evidence may indicate enough of a basis of a generic relationship to establish “a plausible causality based on objective facts.” Mattern, 12 Vet. App. at 228 (citing Wallin v. West, 11 Vet. App. 509, 514 (1998)). In the present case, the Veteran has not submitted any competent evidence suggesting his joint pain is due to his in-service vaccinations (to allegedly include anthrax), and the submitted articles only generally suggest such a nexus could exist; they do not address the facts of his case to include his own medical history. Moreover, one of the articles submitted states, “There is no evidence that anthrax vaccine causes long-term health problems. Independent civilian committees have not found anthrax vaccination to be a factor in unexplained illnesses among Gulf War veterans.” See Vaccines & Immunizations. Basic and Common questions: Possible side-effects from Vaccines. Source: cdc.gov (received September 30, 2013). As the articles are speculative in nature, they are not considered probative by the Board. In the absence of any competent evidence suggesting such a nexus in the present case, service connection on this basis is not warranted. The submitted evidence, as found within the claims folder, was considered by a VA physician in 2019. To the extent that the Veteran’s statements are competent, the Board finds the specific reasoned opinions of the May 2019 VA examiner to be of greater probative weight than the Veteran’s more general lay assertions. The May 2019 examiner noted that the Veteran’s service treatment records did not demonstrate that he received an anthrax vaccination and the vaccines he did receive are not known for causing degenerative arthritis. In conclusion, the preponderance of the evidence is against the award of service connection for a right elbow disability, as such a disability was not incurred in service and is not related to an in-service disease or injury. Additionally, there is no evidence that his right elbow was manifested to a compensable degree within one year of the Veteran’s separation from service. Finally, there is no evidence the right elbow condition was caused or aggravated by a service-connected disability. Thus, service connection for a right elbow disorder is not warranted on a direct, secondary or presumptive basis. As a preponderance of the evidence is against the award of service connection, the benefit of the doubt doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1991). Right wrist With respect to a current disability, the Veteran has been diagnosed with degenerative joint disease. Therefore, a current disability has been demonstrated. With respect to an in service incurrence, the Veteran maintains that his joints were affected by in-service vaccinations. The Veteran’s service treatment records do not demonstrate any diagnosis or treatment for the wrist. Additionally, there is no evidence of an ongoing wrist disorder on the Veteran’s May 1996 separation examination. As discussed above, the Board has found the Veteran’s joint disorders are not related to vaccinations he received in service based on the medical opinion of record. As the evidence does not establish an in-service incurrence, service connection on a direct basis is not warranted. In the alternative, the Veteran has asserted that his right wrist disorder is secondary to his service-connected shoulder disabilities. With respect to evidence of a service-connected disability, the record reflects that the Veteran was granted service connection for his left shoulder, effective August 11, 1996 and right shoulder, effective June 25, 2010. Therefore, a service connected disability has been demonstrated. As discussed above, the May 2019 VA examiner found it less likely than not that the Veteran’s joint pain (to include elbow, ankle and wrist) was related to service. The May 2019 examination reflected the Veteran’s right wrist had normal range of motion and muscle strength. The Veteran stated that his wrist symptoms began approximately ten to twelve years prior. As noted above, the examiner found the Veteran’s weight to be the likely cause of his joint pain. In March 2020 a VA examiner determine it was less likely than not that the Veteran’s right wrist disorder was proximately due to or the result of the Veteran’s service connected shoulder disability. The examiner reasoned that the right wrist was too remote to have a direct impact or compensatory impact from the left shoulder. The examiner also concluded that the Veteran’s right wrist was less likely than not aggravated beyond its natural progression by the Veteran’s service connected shoulder disability. A July 2020 VA examiner concluded the Veteran’s right wrist disorder was less likely than not proximately due to or the result of the Veteran’s service-connected shoulder disability. The examiner explained there is no medical literature to support the contention that shoulder degenerative changes cause or aggravate degenerative changes in the corresponding wrist. The examiner concluded that the degenerative changes in the Veteran’s right wrist are due to repetitive use and are unrelated to his shoulder. In September 2020, the examiner provided an addendum opinion. The examiner stated the Veteran’s right wrist disorder was less likely than not due to or the result of the Veteran’s service connected shoulder disabilities. The examiner concluded that the wrists do not unload the work done by the shoulders. The Veteran’s age and body habitus predisposes arthritis in other joints. Additionally, the examiner found the Veteran’s right wrist disorder less likely than not aggravated beyond its natural progression by his shoulder disabilities. The examiner reasoned that there is no medical evidence to support the contention that the Veteran’s shoulder arthritis aggravated his wrist; rather, his wrist disorder is consistent with his age and body habitus. In light of the foregoing, the Board finds service connection for a right wrist disorder is not warranted. The Veteran did not experience onset of his right wrist disorder in service, and such a disability did not manifest until years after service. Moreover, no competent expert has suggested the Veteran’s right wrist pain had its onset in service or was related to an in-service disease or injury. In the absence of such evidence of in-service incurrence or relationship to a service connected disability, service connection must be denied. Matters of causation, in this case – degenerative changes in the wrist, involve questions that are beyond the competence of a layperson to provide an opinion as to etiology. Jandreau. The Board finds the July and September 2020 medical opinions highly probative and affords them great weight. The examiner considered the Veteran's medical history and supported the opinion with an articulated rationale that is consistent with the medical evidence of record. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value of a medical opinion). There is no medical opinion to the contrary. In conclusion, the preponderance of the evidence is against the award of service connection for a right wrist disability, as such a disability was not incurred in service and is not related to an in-service disease or injury. Additionally, there is no evidence that his right wrist condition was manifested to a compensable degree within one year of the Veteran’s separation from service. Finally, there is no evidence the right wrist condition was caused or aggravated by a service-connected disability. Thus, service connection for a right wrist disorder is not warranted on a direct, secondary or presumptive basis. Accordingly, the claim for service connection is denied. In reaching the above conclusion, the Board has considered the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine does not apply. See 38 U.S.C. § 5107(b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 55-57 (1990). Left ankle With respect to a current disability; the Veteran has been diagnosed with degenerative joint disease. Therefore, a current disability has been demonstrated. With respect to an in service incurrence, the Veteran maintains that his joints were affected by an anthrax vaccination. As noted above, the Board has found the Veteran’s joint disorders are not related to vaccinations he received in service. The Veteran’s service treatment records do not demonstrate any diagnosis or treatment for the left ankle. Additionally, there is no evidence of an ongoing left ankle disorder on the Veteran’s May 1996 separation examination. The record does contain a June 1997 ankle examination indicating an “old sprain,” however service treatment records do not demonstrate that it occurred in service. In the January 2020 remand, the Board accepted the Veteran’s report of an in-service left ankle injury. However, as discussed more below, there is no competent evidence linking the current condition to that alleged injury. In the alternative, the Veteran has asserted that his left ankle disorder is secondary to his service-connected knee disability. With respect to evidence of a service-connected disability, the record reflects that the Veteran was granted service connection for his left knee, effective June 25, 2010. Therefore, a service-connected disability has been demonstrated. In June 1997, a VA examiner reported that the Veteran’s ankles were normal; that they had no swelling and a normal range of motion. The clinical history reported an old sprain. A left ankle x-ray reflected a minuscule tilt of the ankle joint. The radiologist reported that his ankle was within the normal limits for his age. See June 1997 Radiologist report. As discussed above, the May 2019 VA examiner found it less likely than not that the Veteran’s joint pain (to include elbow, ankle and wrist) was related to service. In May 2019, the VA examiner diagnosed the Veteran with bilateral degenerative arthritis in the ankles. The examiner noted the Veteran’s weight as the likely cause of the Veteran’s ankle condition. A March 2020 VA examiner found the Veteran’s left ankle disorder less likely than not related to service. The examiner determined that there was no left ankle injury in service. The examiner noted the right ankle injury in service but found no left ankle injury in service. The examiner further concluded that the Veteran’s left ankle was less likely than not related to or aggravated by the Veteran’s service-connected knee disability. The examiner reasoned that the Veteran’s knee condition would not likely cause the degenerative changes diagnosed in the left ankle. The examiner stated the Veteran did not have degenerative arthritis when he separated from service, and the development of degenerative joints is a slow process that would not be made worse by his left knee soft tissue injury. As noted above, the Board accepted the Veteran’s report of an in-service left ankle injury, so, to the extent this opinion relied on a lack of documented injury during service, it was inadequate, and the Board remanded for a more reasoned opinion. In July 2020 a VA examiner concluded it was less likely than not that the Veteran’s left ankle was: (1) incurred in or caused by an event or injury in service (to include a left ankle sprain), (2) manifested within a year of separation from service, or (3) related to his service-connected left knee disability. He further concluded repetitive use and morbid obesity were the likely cause of the Veteran’s degenerative left ankle changes. The examiner reasoned that there was no injury to the left ankle in service or mention of ankle pains or other ankle issues on the Veteran’s separation examinations. The examiner noted the right ankle sprain in service and concluded that a right ankle sprain does not predispose the left ankle to injury. The examiner found that although the Veteran mentioned occasional ankle pain at a 1997 examination, it was attributed to inactivity and no arthritis was identified; moreover, the mild degenerative changes noted on the 2019 x-ray would be expected to be more advanced if they were present in 1997 given the progress and nature of arthritis. The examiner found mild and symmetric degenerative changes in the Veteran’s ankles which suggested the nature of his arthritis is natural joint degeneration with a contribution from his obesity. The examiner stated there was no medical literature to suggest upstream knee issues cause degenerative changes in the ankles, and the symmetry of the ankle changes do not support a mechanical imbalance. In September 2020, the VA examiner concluded that the Veteran’s left ankle condition was less likely than not incurred in or caused by service, to include a left ankle sprain that was noted in the 1997 post-service examination, but not noted in the service treatment records. The examiner reasoned that the Veteran’s current left ankle x-ray showed early degenerative changes. The examiner reiterated that the Veteran’s service treatment records only demonstrated a right ankle injury. The 2020 examiner noted that the 1997 examination did not provide a history to support the injury; however, the 1997 examiner found the left ankle was normal on examination and normal on the x-ray. The normal left ankle results in 1997 coupled with the Veteran’s obese body habitus suggest that the early degenerative arthritis findings in the left ankle are not traumatic in nature, but due to excessive load bearing and consistent with his age. In light of the foregoing, the Board finds the preponderance of the evidence weighs against finding that the Veteran’s left ankle disorder began during his active duty service or is otherwise related to an in-service injury, event, or disease. The Board has considered the Veteran’s contentions that his left ankle disorder is secondary to his knee disability. However, as noted above, as a lay person who is untrained in the field of medicine, he is not competent to provide a medical diagnosis. Consequently, the Board gives more probative weight to the VA medical opinion findings that his left ankle disorder is not related to service. The September 2020 opinion considered the contention that he had had an ankle sprain during service, but still provided a negative opinion, discussing the 1997 medical evidence and the progression of the Veteran’s ankle condition. Moreover, there is no evidence that his left ankle manifested to a compensable degree within one year of the Veteran’s separation from service. Finally, there is no evidence his left ankle condition was caused or aggravated by a service-connected disability. Thus, service connection for a left ankle disorder is not warranted on a direct, secondary or presumptive basis. MICHELLE KANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E.V. Palatt, 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.