Citation Nr: 21013151 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 18-15 976 DATE: March 8, 2021 ORDER Service connection for a cervical spine disorder is denied. Service connection for a bilateral hip disorder is denied. Service connection for a bilateral ankle disorder is denied. Service connection for a bilateral foot disorder, aside from that involving the skin, is denied. Service connection for vertigo is denied. Service connection for urticaria is denied. Service connection for headaches is denied. Service connection for a jaw disorder manifested as bruxism is granted. FINDINGS OF FACT 1. Bruxism is shown in service and current symptomatology of such has been related to service by a medical clinician. 2. The most probative evidence of record weighs against a conclusion that the Veteran has a cervical spine, hip, ankle, or foot disorder; vertigo; urticaria; or headaches due to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a jaw disorder manifested as bruxism have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). 2. The criteria for service connection for a cervical spine, hip, ankle, or foot disorder; vertigo; urticaria; or headaches have not been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from May 1997 to May 2001. This case was remanded by the Board of Veterans’ Appeals (Board) in December 2018 and is now ready for appellate review. As service connection for a dermatologic condition of the feet was granted by a June 2020 rating decision pursuant to development requested by the Board remand, the appeal with respect to entitlement to service connection for a bilateral foot disability is now with respect to any such disability, such as the previously claimed plantar fasciitis and a disorder of the left fifth toe, that does not involve the skin of the feet. Based on evidence received since the December 2018 remand, the appeal with respect to temporomandibular joint [TMJ] dysfunction in the jaw has been recharacterized as a claim for service connection for a jaw disorder manifested as bruxism.   I. Legal Criteria It is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the Court of Appeals for Veterans Claims (Court) held that an appellant need only demonstrate that there is an “approximate balance of positive and negative evidence” in order to prevail. The Court has also stated, “It is clear that to deny a claim on its merits, the evidence must preponderate against the claim.” Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert. Service connection will be granted for disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. U.S.C. § 1110; 38 C.F.R. § 3.303. Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. §§ 3.303(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 inactive duty for training (INACDUTRA) during which the individual concerned was disabled or died from an injury incurred or aggravated in the line of duty, or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 U.S.C. § 101 (22), (24); 38 C.F.R. § 3.6(a) II. Analysis Setting forth the evidence and contentions in this case, first with respect to neck, the Veteran contends that she suffers from a “camel neck” as a result of work and military exercises while on active duty. She has reported that this condition had a gradual onset and that she still suffers from neck pain. With respect to the ankles, the Veterans assert that she injured her right ankle in basic training. [Service treatment records (STRs) from September 1997 do reflect that that she suffered a sprained right ankle.] She alleges that she continued to re-injure her right ankle while in service but did not seek further treatment. She has argued that due to favoring her injured right ankle, she began experiencing pain in the left ankle and her hips. She has reported that she continues to experience pain in her ankles and hips. Regarding her bilateral feet claims, the Veteran originally claimed that in addition to the dermatological condition contained therein, she developed bilateral plantar fasciitis and a left fight toe disorder due to service. Additionally, the Veteran contends that while on active duty, she experienced hives, edema in her lips and chin, and the sensation that her throat was closing after eating a meal ready to eat (MRE). She reported that the hives have been present intermittently since service as random periods of edema in her face, eyes, lips, hands, feet or toes. She indicated that she sought treatment from an allergist and was diagnosed with chronic idiopathic urticaria. Furthermore, the Veteran has contended that she began having headaches in service, and that they have continued since service. She has also contended that her headaches are caused by TMJ dysfunction [Reserve duty reports indicate that in March 2005, the Veteran was seen for jaw pain and given a provisional diagnosis of TMJ dysfunction.] She argues that her jaw pain has continued, and that she has current TMJ dysfunction which is worsening with time. The Veteran also reported that after suffering from severe vertigo on two occasions during service she started to experience headaches. Aside from the previously referenced treatment for a sprained right ankle in September 1997; dental records noting that the Veteran was fitted with a mouth guard for bruxism; and an isolated report of headaches after reading; the remaining STRs, to include the reports from the March 2001 separation examination, are silent for the disabilities for which service connection is claimed. Of note is that STRs from September 1997 characterized the sprained right ankle as having been “resolved.” In light of the contentions and evidence set forth above and post-service evidence reflecting evidence of relevant treatment, the December 2018 remand directed that the Veteran be afforded VA examinations that included opinions as whether the claimed disabilities were related to service. This remand also directed that development be undertaken to determine if the Veteran was serving on a period of INACTDUTRA or ACTDUTRA when she received her provisional diagnosis of TMJ in March 2005. The VA examinations requested in the December 2018 remand were accomplished in November and December 2019, with each examination reflecting consideration of the Veteran’s reported relevant in-service and post-service history. As for the opinions following these examinations, first with respect to the cervical spine, the December 2019 examiner found that it was less likely as not that the Veteran incurred a cervical spine disorder during her active military service. The rationale for this opinion was set forth as follows: After a review of the [V]eteran’s service treatment records, medical records, history[,] and physical examination, there is no documentation of any neck pain, treatment[,] or concern in the active duty service treatment records or in the medical records. On the interval assessments during her reserve status there are no complaints of pain or limitations. A negative opinion with regard to the ankles was also rendered in December 2019, with the rationale provided as follows: After a review of the [V]eteran’s service treatment records, medical records, history[,] and physical examination, there is no documentation showing a chronic recurring bilateral ankle problem that was incurred during her military service. There is one episode of a right ankle sprain in 1997 and the left ankle in 2019 that is recent. Since the initial injury in 1997 there is no documentation for 22 years that there was any chronic recurring problem. Documentation in 1997 reveals that the ankle sprain was resolved with no further complaints seen. No treatment or orders for braces, therapy[,] or documentation on the medical assessment forms that were completed during her reserve duty status . . . The [V]eteran was able to enlist in the Airforce reserves following her active duty [in] 2012 without any noted limitations in functioning or complaints of pain or treatment during her reserve status. With regard to a bilateral hip disability, the December 2019 VA examiner concluded that it was less likely as not that the Veteran incurred such a disability during service or had such a problem as secondary to an ankle disability. (As service connection for an ankle disability will be denied in the decision below, the matter of any relationship between an ankle disability and hip disability requires no further discussion.) The rationale for this opinion was as follows: After a review of the [V]eteran’s service treatment records, medical records, history[,] and physical examination, there is no documentation showing a complaint of bilateral hip pain. There has been no treatment, therapy, or documentation on the medical assessment forms that were completed during her reserve status. There is no documentation in the active duty records. . . The [V]eteran was able to enlist in the Airforce reserves following her active duty from around 2001-2002 to 2012 without any noted limitations in functioning or complaints of pain or treatment. There is no current documentation of any complaints for hip pain. The exam is positive for bursitis today but there is no history. As for a bilateral foot disability, the December 2019 VA examiner found that it was less likely as not that a bilateral foot disorder to include bilateral plantar fasciitis and a disorder of the left fifth toe was incurred in or caused by service. The rationale for this opinion was as follows: After a review of the [V]eteran’ service treatment records, medical records, history[,] and physical examination, there is no documentation showing a bilateral foot problem while in the active duty or in the reserves that would indicate a chronic recurring problem that was incurred during her military service. The physical examination is negative today for any pain in either foot. With respect to urticaria, the December 2019 VA examiner found that that it was less likely as not that that the Veteran incurred the claimed manifestations of such—namely, hives, edema in the lips and chin, and a sensation of the throat closing after eating MREs during service—during miliary service. The rationale of the opinion was follows: After a review of the [V]eteran’s service treatment records, medical records, history[,] and physical examination, there is no documentation/treatment or assessment of a chronic urticaria condition except for a one time exam with subjective complaints only. This condition requires almost daily hives. The findings that were given at the time of the diagnosis were limited to a subjective report once on 06/05/2008 post active duty. There is no other documentation of any other visits/treatment[,] reported pictures[,] or assessment of this condition in the military records. The [V]eteran brought in records from an allergist in Jacksonville, NC from 2017 who has diagnosed her with urticaria and shows treatment. The [V]eteran’s pictures she has shown me indicate[] a chronic urticaria but there is no documentation in the active service records. With respect to TMJ dysfunction, it is noted initially that military duty documents received in September 2019 after the December 2018 remand indicated the Veteran was not on a period of INACDUTRA or ACDUTRA when she received the provisional diagnosis of TMJ dysfunction in March 2005. See “Information Report” dated September 19, 2019. A November 2019 VA examination indicated the Veteran did not have TMJ dysfunction, and set forth a conclusion as follows: [The] Veteran was treated during active duty for bruxism with a hard night guard and she reports that she still grinds her teeth at night. It appears that her jaw pain is related to this rather than [TMJ] disorder as she has no mechanical limits to ROM [range of motion], no crepitus evidenced on this exam and no deviation in lateral excursions. With respect to headaches, the December 2019 examiner found it to be less likely than not that headaches were incurred in or caused by service, to include TMJ dysfunction suffered from therein. The rationale for the opinion was as follows: After a review of the [V]eteran’s service treatment records, medical records, history and physical examination, there is documentation in her active duty records of one headache that she reported following reading where her eyes were examined and she was provided with glasses but she reports that [this] did not totally resolve the headache until she received the contact lens. Since that time there is no documentation of any headache condition, symptoms[,] or treatment [] related to her dental problem or vision problem. The [V]eteran states she was prescribed a contact for the decreased vision in one of her eyes but she has not had a new prescription filled or wears the contact lens. The condition is most likely transitory and she was advised to seek another vision exam and obtain the necessary lens to correct the problem as she reported in the history that with use of the contact lens her headaches resolved. Applying the legal criteria to the facts set forth above, the Board notes that although TMJ dysfunction was not demonstrated at the time of the November 2019 VA examination, given the in-service evidence of bruxism and the November 2019 VA examiner’s linking of such to the Veteran’s current problems with bruxism, service connection for a jaw disorder manifested by bruxism may be granted. Such serves to satisfy the appeal with respect to the claim for service connection for a jaw disability. With respect service connection for a cervical spine, hip, ankle, or foot disorder; vertigo; urticaria; or headaches, the undersigned finds the above December 2019 opinions to be definitive as to the claims for service connection for these disabilities as they are documented to be based on thorough review of the clinical history and history provided by the Veteran and are supported by detailed rationale. With respect to vertigo, which the Veteran claims developed after in-service headaches, as service connection is denied for headaches herein, this denial necessarily precludes a grant of service connection for vertigo as secondary to headaches. There otherwise being no indication in the record that the Veteran suffers from vertigo as a result of service, further examination or medical opinion with respect to this condition is not necessary. The undersigned also notes that while the statement submitted in August 2020 from a service comrade of the Veteran who attested to witnessing her suffering from “breakouts” and difficulty breathing during service has been considered, the probative value of such has been outweighed by the December 2019 medical opinion finding no evidence of current disability resulting from these reported manifestations and the lack of any other objective evidence demonstrating a relationship between a current disability and these reported manifestations. To the extent the assertions of the Veteran and her representative are advanced in an attempt to establish that the Veteran has a cervical spine, hip, ankle, or foot disorder; vertigo; urticaria; or headaches as a result of service, such complex medical matters are within the province of trained medical professionals. See Jones v. Brown, 7 Vet. App. 134, 137-38 (1994). As neither the Veteran nor her representative are shown to have the appropriate training and expertise, neither are competent to render a persuasive opinion as to such matters. While the Veteran is competent to describe any lay observable symptoms associated with a cervical spine, hip, ankle, or foot disorder; vertigo; urticaria; and headaches since service, the undersigned finds the silent separation examination for these disorders; the negative opinions rendered in December 2019 set forth above; and the lack of any objective clinical evidence linking a cervical spine, hip, ankle, or foot disorder; vertigo; urticaria; or headaches to service to be more probative than any lay assertions made in connection with the claims for service connection for these disabilities, and that these facts weigh against a finding of continuity of relevant symptoms associated with these disorders since service. Given all of the above, the Board finds that the preponderance of the evidence is against the claims for service connection for a cervical spine, hip, ankle, and foot disorder; vertigo; urticaria; and headaches. As such, these claims must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. MARJORIE A. AUER Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Andrew Ahlberg, 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.