Citation Nr: 21008717 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 13-11 040 DATE: February 17, 2021 ORDER Service connection for a rheumatoid factor disability is denied. Service connection for a heart disability is denied. FINDINGS OF FACT 1. The Veteran does not currently have a disability related to rheumatoid factor. 2. The Veteran does not currently have a heart disability. CONCLUSIONS OF LAW 1. A rheumatoid factor disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303, 3.317. 2. A heart disability was not incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1117, 1118, 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303, 3.317. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 1977 to November 1992. He had service in the Southwest Asia theater of operations in support of the Persian Gulf War. This appeal stems from a July 2011 rating decision that denied service connection for rheumatoid factor and heart aches claimed as a heart condition with arrhythmia. The Board of Veterans Appeals (Board) remanded these claims in March 2016 to obtain outstanding records from the Social Security Administration and from the VA vocational rehabilitation program. The requested records have been associated with the claims file. There has been substantial compliance with the Board’s prior remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). Service Connection Veterans are entitled to compensation from VA if they develop a disability “resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty.” 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed.Cir. 2004). In addition, service connection may also be warranted for a Persian Gulf Veteran who (1) exhibits objective indications; (2) of a qualifying chronic disability; (3) that became manifest during active military, naval or air service in the Southwest Asia Theater of operations during the Persian Gulf War, to a degree of 10 percent or more not later than December 31, 2021 and by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317; Gutierrez v. Principi, 19 Vet. App. 1 (2004). The term “qualifying chronic disability” means a chronic disability resulting from any of the following (or any combination of the following): (A) an undiagnosed illness; or (B) a medically unexplained chronic multi-symptom illness that is defined by a cluster of signs or symptoms, such as: (1) chronic fatigue syndrome; (2) fibromyalgia; (3) functional gastrointestinal disorders (excluding structural gastrointestinal disorders). 38 C.F.R. § 3.317 (a)(2)(i). Objective indications of a chronic disability include both signs, in the medical sense of objective evidence perceptible to an examining physician, and other, non-medical indicators that are capable of independent verification. Disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. Signs or symptoms which may be manifestations of an undiagnosed illness include, but are not limited to, fatigue, signs or symptoms involving the skin, headaches, muscle pain, joint pain, neurologic signs or symptoms, neuropsychological signs or symptoms, signs or symptoms involving the respiratory system, sleep disturbances, gastrointestinal signs or symptoms, cardiovascular signs or symptoms, abnormal weight loss, or menstrual disorders. 38 C.F.R. § 3.317 (b). In addition to certain chronic disabilities from undiagnosed illness, service connection may also be given for medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, and irritable bowel syndrome) that is defined by a cluster of signs and symptoms, as well as for any diagnosed illness that the VA Secretary determines by regulation warrants a presumption of service connection. 38 C.F.R. § 3.317 (a)(2)(i)(B). 1. Rheumatoid disability (claimed as rheumatoid factor). The Veteran seeks service connection for rheumatoid factor as due to exposures during his service in Southwest Asia during the Gulf War. See, e.g., September 2010 Statement in Support of Claim. Here, the Veteran made an informal claim for service connection for muscle and joint pains in October 2001, which was denied in a January 2003 rating decision. However, the Veteran has since been granted service connection for fibromyalgia. He now seeks service connection for a rheumatoid disorder separate from fibromyalgia and under the provisions applicable to Gulf War veterans. We also note that the Board remanded this claim for further development in June 2016 without considering the need for new and material evidence to reopen the claim. As such, we will consider the instant claim as a new claim without regard to whether new and material evidence has been received. After reviewing the evidence, the Board concludes that the preponderance of the evidence is against finding the Veteran has a disability manifest by rheumatoid factor. Service treatment records contain no findings, laboratory test results, or complaints relating specifically to rheumatoid factor. There are multiple reports of muscle and joint injuries. He struck his left knee on a Jeep in June 1979. He injured his right foot playing basketball in June 1982 and was assessed with a sprain. He injured his left knee during training in September 1983 and was assessed with a probable MCL ligament strain. In April 1985 the Veteran sprained his left ankle playing basketball and complained of low back pain and muscle spasms. In February 1988 he reported chronic low back pain that had begun two years prior after a fall. He was assessed with skeletal muscle pain. He complained of back pain again in April 1990 and was assessed with a back sprain. He jammed his left ring finger in May 1990 playing basketball. The November 1992 separation examination shows the upper and lower extremities, feet, spine, and musculoskeletal system were evaluated clinically normal. The Veteran reported a history of swollen or painful joints, recurrent back pain, and “trick” or locked knee in the November 1992 report of medical history. He reported that he injured his back in a fall and has back pains, that his left knee aches often, and that his right knee cannot bend past a 45-degree angle without pain. Post-service VA treatment records show the Veteran complained of chronic pain in his whole body during a March 2002 urgent care visit. Physical examination was unremarkable except for his knees, and he was assessed with polyarthralgias. Laboratory results completed two days later showed a positive rheumatoid factor result and he was referred to a VA rheumatology clinic. June 2002 rheumatology treatment notes show the Veteran had a low dilution rheumatoid factor of 1:2 that the treating physician stated was a true negative. The physician did note that the Veteran had osteoarthritis in his knees and that he had crepitus and pain in the knees and shoulders. The Veteran was provided VA joints examination in September 2002 in relation to a claim for service connection for muscle and joint pains. He reported that VA had diagnosed him with rheumatoid arthritis. The examiner noted a positive rheumatoid factor performed at VA that was only positive at a 1:2 dilution, a level not considered significant by most experts. Physical examination showed no swollen joints although he had tenderness on palpation of the knees, elbows, and shoulders. The examiner was unable to diagnose a specific rheumatic disease and determined he had a weakly positive rheumatoid factor that was of no significance. At a November 2010 VA rheumatology consultation, the Veteran reported pain all over his body, particularly his hands, wrists, elbows, shoulders, hips, knees, feet, and back. The pain had been present since 1995. He denied any swelling in his joints and reported morning stiffness. Lab results obtained in September 2010 showed a positive rheumatoid factor at 1:2 dilution. He was assessed with multiple joint pains and muscle aches with no evidence of inflammatory arthritis, likely fibromyalgia syndrome. The rheumatologist noted the low dilution rheumatoid factor at 1:2 and determined it was non-significant. He was also assessed with right shoulder pain likely secondary to supraspinatus and subscapularis tendinopathy, and bilateral knee osteoarthritis. In February 2011 the Veteran was provided a VA examination in connection with a separate claim for fibromyalgia. He complained of generalized pain, cramping, and paresthesias. He was assessed with fibromyalgia, bilateral shoulder rotator cuff tendonitis, degenerative joint disease in the cervical spine, bilateral knee osteoarthritis, and low titer (1:2) rheumatoid factor with no evidence of rheumatoid arthritis. The examining rheumatologist determined the Veteran’s fibromyalgia caused his chronic pain. There is little further medical evidence of record relating specifically to rheumatoid factor. SSA disability determination records dated March 2012 show the Veteran reported a diagnosis of rheumatoid arthritis based on the 2002 VA blood tests. More recent medical treatment records show no diagnosis of rheumatoid arthritis. We note that the Veteran continues to receive treatment for fibromyalgia, bilateral knee arthritis, and many other musculoskeletal disorders. He continues to have pain throughout his body. Here, the most probative evidence establishes that the Veteran does not have a disability relating to rheumatoid factor or any rheumatic disability. There is no indication that the Veteran’s in-service joint injuries and complaints are related to rheumatoid factor findings. The Veteran is service connected for fibromyalgia and bilateral knee osteoarthritis. He also has pending claims for service connection for a right shoulder disability and back and neck disabilities. There is no medical evidence suggesting they have any relation to rheumatoid factor. Despite the Veteran’s present musculoskeletal disabilities, there is remarkably little evidence that he has had any disease or disability caused by rheumatoid factor at any time. We acknowledge the rheumatoid factor test results obtained in 2002 and 2010. However, at the time of these test results, the Veteran’s rheumatologists determined the rheumatoid factor tests was clinically insignificant and that he had no disease process or symptoms attributable to the rheumatoid factor. There is no medical evidence of to the contrary; the available records suggest the Veteran’s rheumatoid factor was clinically insignificant and does not relate any disease or disability to the laboratory findings. The Board has considered the Veteran’s statements of record which indicate that he has rheumatoid arthritis, or some other disease or disability, caused by rheumatoid factor. The Veteran is competent to provide evidence of that which he experiences, including his symptomatology and medical history. Layno v. Brown, 6 Vet. App. 465, 469 (1994). In addition, lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or, (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007)); Kahana v. Shinseki, 24 Vet. App. 428, 433, n.4 (2011). The record is replete with the Veteran’s reports of and treatments for joint pain throughout his body. However, competence must be distinguished from probative weight. Although the Veteran is competent to relate what he experiences through the senses, the lay evidence is lacking in detail to support the conclusion that there is any current rheumatoid factor causing any symptoms. Any lay assertion that he currently has rheumatoid factor causing symptoms or disability are contrary to the medical evidence of record, which shows his 2002 rheumatoid factor laboratory results were not considered clinically significant. Although the Veteran has indicated he was diagnosed with rheumatoid arthritis, such a diagnosis is not reflected in the treatment records, and he is not competent to render such a diagnosis or to provide a nexus between the rheumatoid factor laboratory findings and a current disability. Such an opinion requires specific medical training in and is beyond the competency of the Veteran as a lay person. See 38 C.F.R. § 3.159 (a)(2); Jandreau, 492 F.3d at 1377. Accordingly, the statements offered by the Veteran in support of his own claim are not competent evidence of a nexus and are therefore afforded less probative weight and credibility than the medical evidence of record. The Board has considered sections 1110 and 1131, as well as the laws and regulations applicable to Gulf War veterans. Within the meaning of sections 1110 and 1131, we find that there is no disability relating to any laboratory rheumatoid factor findings and that there is no underlying disease or injury attributable to the 2002 rheumatoid factor test results. Regarding the Gulf War provisions, we also find that there is no disability relating to the laboratory rheumatoid factor findings. Since there is no disability (impairment) caused by the rheumatoid factor findings, the claims fail regardless of theory of entitlement. Stated differently, he does not have disability or impairment related to rheumatoid factor due to an undiagnosed illness or any other theory. The existence of a current disability is the cornerstone of a claim for VA disability benefits. See Degmetich v. Brown, 104 F.3d 1328 (Fed. Cir. 1997). Therefore, in the absence of current disability, there can be no valid claim. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In this case, there is no disability that resulted from a disease or injury. Under the circumstances, the Veteran has not met the regulatory requirements to establish service connection for a disability related to rheumatoid factor. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. Here, however, as the preponderance of the evidence is against the claims, that doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). In determining whether the duty to assist requires that a VA medical examination be provided or medical opinion obtained, there are four factors for consideration: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran's service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). Here, we are faced with a voluminous record and opinions from qualified professionals. The competent and credible evidence of record is clear that the Veteran does not have a current disability associated with laboratory findings of rheumatoid factor, nor is there any indication that such a disability could be associated with the Veteran’s service. Further examination is not warranted. 2. Heart disability. The Veteran seeks service connection for a heart disability. Specifically, he asserts that he has cardiac arrhythmia related to exposures during his service in Southwest Asia during the Gulf War. See, e.g., September 2010 Statement in Support of Claim. After reviewing the evidence, the Board concludes that the Veteran does not have a heart disability. Service treatment records show that the Veteran complained of chest pains in June and July 1979, and he was seen for low blood pressure in April 1982. He also complained of chest pains when coughing in May 1986 and was assessed with a chest cold. The service treatment records are otherwise absent any treatment, complaints, notations, or diagnoses of heart disorders. The Veteran denied any history of pain or pressure in the chest, palpitation or pounding heart, or heart trouble in the November 1992 report of medical history at separation. The November 1992 separation medical examination showed a clinically normal evaluation of the heart and chest. An April 1995 chest x-ray showed the heart was normal size and configuration. The Veteran complained of chest pain for approximately 4 months in June 1996. Chest x-rays were normal and unchanged from April 1995. A June 1996 electrocardiogram showed sinus bradycardia with occasional premature atrial complexes. The Veteran was hospitalized in January 2001 following a syncopal event. Sinus bradycardia was noted, although no history of heart palpitations or chest pain was noted. The discharge paperwork notes a diagnosis of cardiac dysrhythmias and that the Veteran had an abnormal EKG. He reported intermittent chest cramping in June 2008 and had a cardiology diagnostic in July 2008 where the baseline electrocardiogram showed sinus bradycardia. At a September 2009 VA primary care appointment, the Veteran complained of intermittent chest discomfort that could last 40 days. He was given a nuclear cardiology stress test in November 2009. The baseline electrocardiogram showed a normal sinus rhythm with a left axial deviation. Left ventricular ejection fraction was 50 percent. No symptoms or arrhythmias were noted. The test results were clinically and electrocardiographically negative for stress induced myocardial ischemia. In May 2011 the Veteran reported sharp chest pains for two years with no other symptoms. At a July 2011 VA cardiology appointment, he reported persistent irregular episodes of sharp left chest pain without any associated symptoms. He denied heart palpitations but reported some episodes of slow heartbeat not associated with dizziness. A cardiac catheterization was performed which showed normal coronaries and an ejection fraction of 65 percent. He was diagnosed with non-cardiac chest pain. More recently, a June 2019 electrocardiogram showed sinus bradycardia with a left axis deviation. Because the Veteran is a Persian Gulf Veteran, the Board must first consider whether the provisions of 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 are applicable. We note that cardiovascular signs and symptoms may be manifestations of for chronic disability that cannot be attributed to a known clinical diagnosis (undiagnosed illness). See 38 C.F.R. § 3.317 (b). Here, the Veteran is service connected for fibromyalgia, which is a qualifying chronic disability. However, there is no evidence of record suggesting any arrhythmia or bradycardia is related to his fibromyalgia. In addition, his arrythmia has been diagnosed as bradycardia, a slow heartbeat. This is a recognized diagnosis and, as it pertains to the instant claim for a heart disability, there is no disability due to undiagnosed illness. Additionally, 38 U.S.C. § 1117 and 38 C.F.R. § 3.317 still require a qualifying chronic disability that became manifest during service or to a degree of 10 percent or more not later than December 31, 2021. As explained above, there is no indication that the Veteran’s arrhythmia and bradycardia are part of a qualifying chronic disability, or alone result in disability. The probative medical evidence of record suggests he has non-cardiac chest pains and has routinely denied any symptoms that accompany his irregular heartbeat. The Veteran has not presented any medical opinion or medical literature that relates a heart disability, to include arrhythmia and sinus bradycardia, to his service or to any qualifying Gulf War disability. The Veteran is competent to report what he was told, which in this case at least includes that there are abnormal echocardiograms. However, to the extent he asserts that his arrhythmia and bradycardia are related to a qualifying Gulf War disability, the Board notes the etiology of a heart disability is a medical question that falls outside the realm of common knowledge of a layperson. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran is a layperson and has not alleged that he has any medical expertise; therefore, his own opinion in this matter is not competent evidence. The remaining issue for the Board is whether the Veteran has a disability that began during service or is at least as likely as not related to service pursuant to 38 U.S.C. sections 1110 and 1131. Here, the evidence shows bradycardia. We note that sinus bradycardia is the term for a low heart rate. However, a low heart rate by itself is not a disability. There is no evidence of record suggesting that his bradycardia is related to an underlying disease or injury. There is no evidence that bradycardia results in an impairment. Pertinently, the electrocardiograms and cardiac catheterizations of record have regularly been negative for any heart disorder other than sinus bradycardia. In addition, the first abnormal electrocardiogram of record dates from June 1996, over three years after the Veteran separated from service. No heart disorder besides arrhythmia and bradycardia has been identified. The Board has also considered the provisions of 38 C.F.R. § 3.303 (b). As noted in the regulation, the rule regarding chronicity and continuity does not mean that any abnormality of heart action or heart sound will permit service connection of disease of the heart first shown as a clear-cut clinical entity at some later date. Here, there is only abnormality of heart action which does not rise to the level of disability under any theory of entitlement. Based on the above, the preponderance of the evidence is against the claim for a heart disability under any theory of entitlement. The preponderance of the evidence is against the claim, and there is no doubt to be resolved. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). In reaching this conclusion, we recognize that the Veteran was not afforded a VA examination specifically for this claim. However, no examination or opinion is necessary. Here, the competent and credible evidence of record is clear that the Veteran does not have a current heart disability, nor is there any indication that such a disability could be associated with the Veteran’s service. McLendon, 20 Vet. App. at 79; 38 U.S.C. § 5103A (d); 38 C.F.R. § 3.159 (c)(4). The record is adequate. In sum, whether the issue is addressed under sections 1110, 1131 or 1117, the law requires the existence of disability. Here, there is no disability related to the heart and service connection is not warranted. H. N. SCHWARTZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Morse 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.