Citation Nr: 21006934 Decision Date: 02/08/21 Archive Date: 02/08/21 DOCKET NO. 12-08 421 DATE: February 8, 2021 ORDER Service connection for rheumatoid arthritis, bilateral hands, ankles, thumbs and knuckles, is denied. Service connection for parathyroidism is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that rheumatoid arthritis, bilateral hands, ankles, thumbs, and knuckles began during active service or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that parathyroidism began during active service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for rheumatoid arthritis, bilateral hands, ankles, thumbs and knuckles have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 2. The criteria for service connection for parathyroidism have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1973 to November 1994. These matters came to the Board of Veterans’ Appeals (Board) from a July 2011 rating decision of a Department of Veterans Affairs (VA) Regional Office. In June 2012, the Veteran testified at a Board hearing before the undersigned; the transcript is of record. These issues were remanded in October 2014, November 2016, and June 2019. Service Connection The Veteran asserts that he has had continuous or recurrent symptoms of rheumatoid arthritis during service and following service. He asserts that the symptoms of parathyroidism (white knuckles, swollen joints) mimic rheumatoid arthritis symptoms, and that such condition is also due to service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has current disabilities of rheumatoid arthritis and parathyroidism that began during service or are at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has current diagnoses of rheumatoid arthritis and parathyroidism, the preponderance of the evidence weighs against finding that these disabilities began during service or are otherwise related to an in-service injury, event, or disease. Service treatment records reflect that the Veteran sought treatment in June 1975 for a lump in his right thumb. The impression was early trigger thumb. His thumb was injected with Depo Medrol and the condition resolved. 11/02/2014 STR-Medical at 27-30. At the Board hearing, the Veteran testified that he was injected with epomedrol (which was, according to the Veteran, is a generic version of methyl prednisone). He stated that he did not know for what he was being treated. He testified that he now knows that methyl prednisone is a common drug for treatment of rheumatoid arthritis. He cited a National Institute of Health (NIH) finding that there are no tests that can determine for certain whether someone has rheumatoid arthritis. Some such patients will have abnormal test results, and some will have normal test results. He also testified that although the RO has claimed that the right thumb lump had resolved in service, he continued to have other symptoms (including aching joints) in service and beyond service. He claimed that he was simply given ibuprofen for the symptoms. He also alleged that a doctor (from Hutchinson Clinic) suggested that he had rheumatoid arthritis well before he was specifically being treated for it. Correspondence dated in March 2011 from a rheumatologist at Hutchinson Clinic states that the Veteran has a history of rheumatoid arthritis and was first seen in November 2010. He was prescribed multiple medications. The physician stated that he had quite a bit of arthralgias, with shoulder and hand pain. He had a cortisone injection for tendinitis of the fingers of hands. The physician stated that it has been difficult for him to function and he is applying for disability through the military. 04/01/2011 Third Party Correspondence. Correspondence dated in June 2012 from the same rheumatologist states that the Veteran has had injections for painful fingers of the hands most likely related to tendinitis of the fingers of the hand while he was working as a jet engine aircraft mechanic in 1975. At that time, he received Depo Medrol injections (methylprednisolone acetate). The physician stated that Depo Medrol is still a very commonly used steroid for joint and tendon injections. 06/25/2012 Third Party Correspondence. While the Board has considered the March 2011 and June 2012 statements of the Veteran’s treating rheumatologist, the physician did not specifically opine that the in-service treatment in 1975 resulted in rheumatoid arthritis. Moreover, if the examiner was intending to suggest a positive relationship based on treatment with Depo Medrol injections in service, and such medicine being used as a steroid for joint and tendon injections, there is no indication that the physician had the benefit of review of the service treatment records nor the post-service medical records prior to treating the Veteran in November 2010. Thus, such statements do not constitute positive etiological evidence in support of the claim. In February 2015 a VA rheumatologist reviewed the claims folders and proffered negative etiological opinions with regard to his rheumatoid arthritis and parathyroidism. With regard to rheumatoid arthritis, the examiner explained that it is a disease which manifests with stiffness of joints of hands and feet. Patients normally complain of stiffness of the joints of hand and feet in the morning. This stiffness can last all day and can be associated with difficulty making a fist. Activity makes it better. The Veteran had a lump on the volar aspect of the thumb (the soft portion of the thumb), which was evaluated by an orthopedic surgeon and a hand Surgeon. The impression of the Hand Surgeon in June 1975 was early trigger thumb. This lump was injected with Depomedrol in July 1975. The VA examiner explained that although Depomedrol is a treatment for rheumatoid arthritis it is also used to inject joints, tendons, and nodules for conditions which are not due to rheumatoid arthritis. He was evaluated by a rheumatologist in September 1992, who indicated in his notes that the joint examination was normal and in his judgment the Veteran did not have any rheumatologic issue. The Veteran also did not have any joint issues in his September 1980 and August 1986 Medical Examination Reports. An x-ray of the hand done in June 1975 did not show any abnormality. The examiner opined that it is highly unlikely that the rheumatoid arthritis began or is causally related to service. With regard to parathyroidism, the examiner explained that he has primary hyperparathyroidism, which on laboratory studies is indicated by elevated Calcium levels. His calcium level was normal in March 1993 and September 1994. There was no calcium level data available in records between September 1994 and May 2006. The calcium level was high on May 1, 2006. Based on this, the Veteran might have developed primary hyperparathyroidism between September 1994 and May 2006. The examiner opined that it is highly unlikely that the primary hyperparathyroidism began or is causally related to service. In the November 2016 Board Remand, the February 2015 opinions were deemed insufficient as the Veteran was not afforded a physical examination nor was a clinical history taken from the Veteran. Moreover, the Board indicated that while the opinion of the rheumatologist was based on June 1975, September 1980, and August 1986 examinations that did not reveal any abnormalities, consideration was not given to the treatise materials from NIH, discussed by the Veteran in his hearing testimony, which indicated that there is no test that could determine with certainty whether he has rheumatoid arthritis; per the article, most patients with rheumatoid arthritis will have abnormal test results although some patients will have normal results. In March 2018, the Veteran underwent an examination with a nurse practitioner pertaining to his rheumatoid arthritis. The examiner opined that his rheumatoid arthritis was at least as likely as not incurred in or caused by the claimed in-service injury, event or illness. The examiner stated that there is documentation of a “lump” under the skin of the right thumb in 1975. He was injected with Depo Medrol and sent to the Ortho Clinic. The orthopedist diagnosed early trigger finger. According to the Journal of Rheumatology, September 2017, locked or catching joints (trigger finger) deformities or rheumatoid nodules due to thickening of the synovial lining can cause fingers to lock in unusual positions as the person tries to bend them. It is reported as occurring in early-stage rheumatoid arthritis. In March 2018, the Veteran underwent an examination with a nurse practitioner regarding his parathyroidism. Based on examination of the Veteran and review of the claims folder, the examiner opined that his parathyroidism is less likely than not due to rheumatoid arthritis. The examiner stated that there is no correlation between parathyroid disease and rheumatoid arthritis in view of no auto-antibody studies found in the records to suggest an auto-immune versus other cause of the hyperparathyroidism. There was no supportive literature found. The examiner found no service records to suggest a parathyroid condition. In May 2018, another VA nurse practitioner reviewed the claims folder and stated that there was an unmistakable error that is apparent when reviewing the evidence of rheumatoid arthritis. The examiner stated that the latest opinion regarding origins of rheumatoid arthritis is not etiologically correct. A lump on the right thumb (seen as early trigger finger) in 1975 would not be an early sign of rheumatoid arthritis that was diagnosed around the 2008-2010 time period. Also, there is a huge gap in complaints of the peripheral extremities, with complaints in 2001 with respect to the right wrist and then the fingers starting in 2001, which was not rheumatoid arthritis but related to his private employment at that time. The criteria for rheumatoid arthritis, according to the American College of Rheumatology, shows that when rheumatoid arthritis begins it is continuous and would not have a latent phase or no continuation of symptoms for multiple years. Basically, when the ‘process’ of rheumatoid arthritis begins it will not cease. To give service connection for a nodule of the right thumb in 1975 as the beginning of rheumatoid arthritis is at best wishful thinking/conjecture. 05/11/2018 C&P Exam. In June 2019, the Board noted that while the Veteran was afforded in-person examinations, such were conducted by a nurse practitioner, rather than a physician. While the May 2018 opinion pertaining to rheumatoid arthritis was proffered by a physician, such physician did not have the benefit of an in-person examination of the Veteran. Thus, further examinations and opinions were sought from a physician. In January 2020, the Veteran underwent C&P examinations with a VA physician with regard to rheumatoid arthritis and parathyroidism. With regard to rheumatoid arthritis, the examiner noted review of the VBMS and CPRS records and the Board’s prior remands. The examiner interviewed and examined the Veteran, took into account the Veteran’s statements as to his history and symptoms, and reviewed the appropriate current medical literature (text and electronic), and opined that the Veteran’s rheumatoid arthritis of the bilateral hands and ankles is less likely as not (less than 50% probability) incurred in or caused by the lump in the right thumb during service. The “lump” in the trigger finger, thumb, was an orthopedic condition with cystic qualities with etiology of overuse or local trauma. Its presence or surgical removal has no causal or temporal nexus to the onset of rheumatoid arthritis in 2010, a period of 35 years. The examiner stated that there is no credible medical evidence or documentation of interval complaints or care for rheumatoid arthritis or laboratory abnormality, as a manifestation of rheumatoid arthritis, during service or until November 2010. The medical truism of “proximity does not imply causality” holds true in the case. If the “lump” treated in service or within one year of separation/retirement was in any way related to the later development of rheumatoid arthritis the ethological agent would have laid dormant for the 35 year interval seen here which is also less likely as not (less than 50% probability). The usual clinical course of rheumatoid arthritis is one of progressive involvement without a resting, subclinical or latent phase, certainly not a latent period of over 30 years. With regard to parathyroidism, the examiner noted review of the VBMS and CPRS records, the Board’s prior remands, interviewed and examined the Veteran, took into account the Veteran’s statements as to his history and symptoms, and reviewed the appropriate current medical literature (text and electronic), and opined that hyperparathyroidism is less likely as not (less than 50% probability) have begun during service and is not causally related to service to include the lump in the Veteran’s right thumb in June 1975 or at any time in the 1970s. The examiner explained that the trigger finger, in this case trigger thumb, was an orthopedic condition with etiology of overuse or local trauma and has no causal or temporal nexus to the onset of hyperparathyroidism with a diagnosis in 2010, a period of 35 years. The examiner stated that there is no credible medical evidence or documentation of interval complaints or care for hyperparathyroidism or calcium abnormality, as a manifestation of excess parathyroid hormone production, during service. It also is less likely as not (less than 50% probability) that the Veteran’s hyperparathyroidism is due to or chronically worsened by his rheumatoid arthritis. Evidence reveals that the Veteran’s serum calcium levels were at most only slightly above normal, and were not high enough to cause deposition of calcium or new/abnormal bone formation, spurs, to have occurred as seen in the x-ray studies completed in January 2020. The examiner noted that after an in-depth explanation to the Veteran of the various different types of arthritis and the time lapse from the 1970s until 2010, he agreed that the “lump” removed from his right thumb would not have caused or adversely affected his hyperparathyroidism or rheumatoid arthritis. The Veteran stated the following: “I never had this explained to me and now I understand and see that there is no service connection.” The Board finds that the opinions of the January 2020 VA physician are highly probative as they were based on an examination of the Veteran, with consideration the medical and lay evidence, and were accompanied by explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). While acknowledging the positive opinion of the March 2018 nurse practitioner with regard to rheumatoid arthritis, such opinion had been requested from a rheumatologist, not a nurse practitioner. While the nurse practitioner determined that the 1975 “lump” under the skin of the right thumb and diagnosis of trigger finger was indicative of early-stage rheumatoid arthritis, the May 2018 nurse practitioner found error in such opinion as the nurse practitioner opined that a lump on the right thumb in 1975 would not be an early sign of rheumatoid arthritis diagnosed as early as 2008. Again, as the Board was seeking an opinion from a rheumatologist, the Board finds that the opinion of the January 2020 is the most probative evidence with regard to the etiology of the Veteran’s rheumatoid arthritis. While the Board acknowledges the Veteran’s lay assertions, as detailed above, rheumatoid arthritis and parathyroidism were diagnosed decades after separation from service. While the Veteran is competent to report his in-service experiences and while the service treatment records clearly support treatment to the thumb during service, the Veteran is not competent to provide a diagnosis in this case or determine that symptoms were manifestations of rheumatoid arthritis or parathyroidism. The issues are medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Id; see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Based on the Veteran’s lay assertions, opinions were sought from a rheumatologist which were negative. Consequently, the Board gives more probative weight to the January 2020 opinions of the trained physician. The Board acknowledges the treatise evidence cited by the Veteran pertaining to a relationship between the medication used on his thumb during service and such medicine being used for rheumatoid arthritis. As discussed, while the Veteran has submitted statements from his treating physician, such do not contain an opinion addressing the question of a relationship between his rheumatoid arthritis and in-service treatment. But based on the Veteran’s citations and assertions, this triggered the necessity of obtaining VA opinions. McLendon v. Nicholson, 20 Vet. App. 79, 81-83 (2006); see 38 U.S.C. § 5103A(d)(2), 38 C.F.R. § 3.159(c)(4)(i). As detailed above, the January 2020 VA opinions obtained were negative with regard to a relationship between his rheumatoid arthritis and parathyroidism and his in-service treatment for a trigger thumb. While medical treatise evidence can, in some circumstances, constitute competent medical evidence (see 38 C.F.R. § 3.159 (a)(1) (competent medical evidence may include statements contained in authoritative writings such as medical and scientific articles and research reports and analyses), both Federal regulation and case law preclude granting service connection predicated on a result of speculation or mere possibility. 38 C.F.R. § 3.102; see Utendahl v. Derwinski, 1 Vet. App. 530, 531 (1991) (stating that a medical treatise submitted by an appellant that only raises the possibility that there may be some relationship between sickle cell anemia and the veteran's fatal coronary artery disease does not show a direct causal relationship between the two disorders such as to entitle the appellant to service connection for the cause of the veteran's death). The Court has held that a medical article or treatise “can provide important support when combined with an opinion of a medical professional” if the medical article or treatise evidence discussed generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least “plausible causality” based upon objective facts rather than on an unsubstantiated medical opinion. See Sacks v. West, 11 Vet. App. 314, 316-17 (1998) (stating that medical article or treatise evidence, standing alone, may be sufficient if it discusses “generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based on objective facts rather than unsubstantiated lay medical opinion”). The Board notes that the treatise evidence here was not combined with or accompanied by competent medical evidence specific to the facts and medical history relevant to this Veteran. Thus, due to the lack of relevant medical history related to the Veteran, the Board places little to no weight on the treatise evidence as it related to the nexus element. As such, the Board finds that the general opinion is outweighed by the opinions of the January 2020 physician as they were based on facts pertinent to the matter at hand. In conclusion, the most probative evidence is against a link between the claimed rheumatoid arthritis and parathyroidism and active service. As the preponderance of the evidence is against the issues, reasonable doubt does not arise, and service connection is denied. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.W. Kreindler, 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.