Citation Nr: 21013189 Decision Date: 03/08/21 Archive Date: 03/08/21 DOCKET NO. 16-21 341 DATE: March 8, 2021 ORDER Service connection for inflammatory polyarthropathy/ rheumatoid arthritis, to include as secondary to service-connected hypothyroidism, is denied. FINDING OF FACT The weight of the evidence is against a finding that the Veteran’s inflammatory polyarthropathy/ rheumatoid arthritis onset during service, was caused by service, manifested to a compensable degree within one year of separation from service, was caused by herbicide agent exposure or other chemical exposure, or was caused or aggravated by a service-connected disability. CONCLUSION OF LAW The criteria for service connection for inflammatory polyarthropathy/ rheumatoid arthritis are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2020).   REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1968 to August 1970. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a May 2014 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In July 2019, the Veteran testified at a video conference hearing before the undersigned Veterans Law Judge. A transcript of the hearing is associated with the claims file. In November 2019 and August 2020, the Board remanded the claim for further evidentiary development. Service connection for inflammatory polyarthropathy/ rheumatoid arthritis The Veteran contends that his rheumatoid arthritis warrants service connection, including as due to herbicide agent exposure and as secondary to his service-connected hypothyroidism. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Establishing entitlement to direct service connection generally requires: (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 - which is the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004).   Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic diseases (such as arthritis) may be presumptively service connected if they become manifest to a degree of 10 percent or more within one year of leaving qualifying military service. 38 C.F.R. §§ 3.307, 3.309. If a condition listed as a chronic disease in § 3.309(a) is noted during service but is either shown not to be chronic or the diagnosis could be legitimately questioned, then a showing of continuity of related symptomatology after discharge is required to support the claim. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). A Veteran who served in the Republic of Vietnam between January 9, 1962 and May 7, 1975 is presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence of non-exposure. 38 U.S.C. § 1116(f); 38 C.F.R. § 3.307. VA laws and regulations provide that, if a Veteran was exposed to an herbicide agent during service, certain listed diseases are presumptively service connected. 38 U.S.C. § 1116(a)(1); 38 C.F.R. § 3.309(e). Secondary service connection may be granted for a disability that is proximately due to, the result of, or aggravated by a service-connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence of (1) a current disability for which service connection is sought; (2) an already service-connected disability; and (3) that the disability for which service connection is sought was either (a) caused or (b) aggravated by the already service-connected disability. See Allen v. Brown, 7 Vet. App. 439 (1995). Turning to the evidence, the Veteran’s DD-214 shows that he served in the Republic of Vietnam from August 1, 1969, to August 1, 1970. The Veteran’s service treatment records show no reports of inflammatory polyarthropathy or rheumatoid arthritis. There are no complaints, diagnosis, or treatment for arthritis during service, and clinical examination on the Veteran’s July 1970 separation examination found that his upper and lower extremities, spine, and other musculoskeletal system were normal. The Veteran underwent a general VA examination in October 1970 for another claim for service connection. The examiner found no problems in the Veteran’s musculoskeletal system. In December 2010, the Veteran’s private Dr. P. diagnosed inflammatory polyarthropathy in the bilateral shoulders and the Veteran was treated. He initially reported symptoms of aching and stiffness in his shoulders, wrists, finger, and thumb joints. The doctor noted that symptoms onset six months previously, after vigorous activity in martial arts. In a May 2014 VA treatment note, the Veteran reported that rheumatoid arthritis with diffuse joint pains onset in 2002. He indicated that the disease occurred after service. In his July 2019 testimony before the Board, the Veteran stated that he served in the Republic of Vietnam. He testified that during his service he was exposed to diesel fumes and an unknown chemical in a spray used to clear the perimeter fence. He felt the spray contained DDT. The Veteran said that no doctor has told him that his arthritis is due to chemical exposure, and that doctors have been unwilling to say that his conditions are related to Agent Orange exposure or chemical exposure. He reported that his rheumatoid arthritis started about 12 years previously. The Veteran underwent a Compensation and Pension Examination in February 2020 and the examiner diagnosed atrophic rheumatoid arthritis, which he said was originally diagnosed in 2010. The clinician opined that it was less likely than not that rheumatoid arthritis was incurred in or caused by the Veteran’s service, including herbicide agent exposure. The clinician’s rationale was based on a discussion of medical literature that did not reveal consistent findings indicative of immunosuppression, increased risk of autoimmunity, or biomarkers of atopy or allergy with exposure to herbicide agents. The clinician also noted that the Veteran’s mother died from lupus, which is a similar autoimmune phenomenon to rheumatoid arthritis, so it was logical to assume that his rheumatoid arthritis was familial. On September 2020 VA examination, the examiner diagnosed rheumatoid arthritis of the bilateral knees, shoulders, and wrists, and of the right hip but not the left hip. The examiner checked the box that it was at least as likely as not that the Veteran’s rheumatoid arthritis was caused by his service, including exposure to herbicide agents. However, the rationale provided with the opinion was similar to that of the rationale provided in February 2020 and seemed to indicate that rheumatoid arthritis was not related to the Veteran’s service. Namely, the examiner based the opinion on studies that do not show that rheumatoid arthritis is caused by exposure to herbicide agents, and the fact that the Veteran’s mother had lupus, which the doctor said is a similar autoimmune phenomenon and indicates that the Veteran’s rheumatoid arthritis is familial and unrelated to service. The clinician also opined that the rheumatoid arthritis is less likely than not caused by the Veteran’s service-connected hypothyroidism. The doctor reached this conclusion based on a rationale that it is common knowledge in the medical community that there is no specific significant linkage of rheumatoid arthritis being caused by hypothyroidism, and that there is not a definition of one autoimmune disease causing another autoimmune disease. Finally, the clinician opined that the Veteran’s rheumatoid arthritis is less likely than not aggravated by the Veteran’s service-connected hypothyroidism. The clinician’s rationale was that there is no documentation in the records indicating that the Veteran’s condition was aggravated by his hypothyroidism, and the natural progression of rheumatoid arthritis is to worsen over the years, and that this would occur whether the Veteran had hypothyroidism or not. Finally, the clinician pointed out that none of the Veteran’s physicians have documented any worsening of rheumatoid arthritis linked to hypothyroidism. The clinician who prepared the September 2020 opinion also prepared an addendum in October 2020, clarifying that his September 2020 opinion was that it was less likely than not that the rheumatoid arthritis was caused by his service, to include herbicide exposure based on the rationale included in the September 2020 opinion.   Turning to the criteria for service connection, the Veteran has contended that the rheumatoid arthritis was caused by his exposure to herbicide agents during service. The Veteran’s DD-214 shows that he served in the Republic of Vietnam from August 1, 1969, to August 1, 1970. As such, he is presumed to have been exposed to herbicide agents therein. 38 C.F.R. § 3.307(a)(6)(iii). VA regulations do not provide arthritis, rheumatoid or otherwise, as a presumptive disability associated with herbicide agent exposure. Therefore, the Veteran’s rheumatoid arthritis is not presumed to be caused by his presumed exposure to herbicide agents. 38 C.F.R. § 3.309(e). The Veteran could still establish service connection for his rheumatoid arthritis on a direct basis, to include as due to herbicide agent exposure. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). As noted above, there are three requirements for direct service connection. Shedden, 381 F.3d at 1166-67. Here, the Veteran was first diagnosed with inflammatory polyarthropathy/ rheumatoid arthritis in December 2010. As the Veteran has a current rheumatoid arthritis disability, the first requirement of service connection has been met. Shedden, 381 F.3d at 1166-67. Turning to the second element of direct service connection, an in-service injury or event, the Board notes that the Veteran’s service treatment records do not indicate any complaint, diagnosis, or treatment for arthritis in service. However, as noted above, the Veteran is presumed to have been exposed to herbicide agents based on his service in Vietnam. 38 C.F.R. § 3.307(a)(6). The presumed herbicide agent exposure is an in-service event satisfying the second requirement of direct service connection. Shedden, 381 F.3d at 1166-67. However, the weight of the evidence is against a finding that the herbicide agent exposure or any other aspect of active service caused the Veteran’s rheumatoid arthritis. The February 2020 and September 2020 VA medical opinions stated that it was less likely than not that rheumatoid arthritis was caused by herbicide agent exposure because medical literature does not indicate that herbicide agent exposure has a relationship with arthritis, and because the Veteran’s mother’s history of lupus indicates that the Veteran’s rheumatoid arthritis is familial and unrelated to service. The Board places great weight of probative value on the September 2020 opinion as it considered the Veteran’s medical history, family medical history, and also pertinent medical literature. There is no medical evidence in the record indicating that the Veteran’s rheumatoid arthritis is related to his service, including herbicide agent exposure. In his July 2019 testimony before the Board, the Veteran contended that his condition was caused by herbicide agent exposure. The Board has considered the Veteran’s statement; as a lay person, he is competent to testify regarding observable symptomatology. See Layno v. Brown, 6 Vet. App. 465, 469 (1994). Although lay persons are competent to provide opinions on some medical issues, as to the specific issue in this case, the probable etiology of a disorder such as inflammatory polyarthropathy/ rheumatoid arthritis falls outside the realm of common knowledge of a lay person. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). The Veteran has not demonstrated or alleged expertise in determining a medical nexus, or offered any supporting medical opinion; therefore, his opinion in this matter has no probative value. The Board acknowledges that the Veteran has also indicated that rheumatoid arthritis could be due to other chemical exposures, including diesel fumes. However, he is not competent to relate his rheumatoid arthritis to such exposure and he has not presented any competent evidence indicating an association between rheumatoid arthritis and exposure to diesel fumes or other chemicals. The preponderance of the evidence is therefore against a finding that the Veteran’s rheumatoid arthritis was caused by or onset during his active duty service, to include herbicide agent exposure, and direct service connection cannot be established. Shedden, 381 F.3d at 1166-67. As noted above, arthritis is also a chronic disease under 38 C.F.R. § 3.309(a) and therefore service connection shall be granted if manifested to a compensable degree within one year of separation of service. In a May 2014 statement, the Veteran wrote that his knee bursitis onset during service. However, there are no records in service of any kind of arthritis or bursitis, and his separation medical examination was normal, and the 2010 private doctor who first diagnosed it stated that the Veteran’s symptoms onset six months after the Veteran was training in martial arts, and in his July 2019 testimony before the Board, the Veteran testified that it onset about 12 years earlier (in roughly 2007). Weighing the evidence, the Board finds that the preponderance of the evidence is against a finding that the Veteran’s rheumatoid arthritis manifested to a compensable degree within a year of his discharge from service. Thus, service connection cannot be established under 38 C.F.R. § 3.309(a). Additionally, there is no indication that a condition related to rheumatoid arthritis was noted in service and the same evidence is against a finding that the Veteran showed continuous symptoms of rheumatoid arthritis from the time of his discharge from service, and therefore service connection cannot be established by a showing of continuity of symptomatology. 38 C.F.R. § 3.303(b); see Walker, 708 F.3d at 1339. Moving to secondary service connection, the first element of secondary service connection is present because the Veteran has a current disability of inflammatory polyarthropathy/ rheumatoid arthritis. See 38 C.F.R. § 3.310(a). The second element, that of an already-service-connected disability, has also been met because the Veteran is currently service connected for hypothyroidism. However, the competent medical evidence from the September 2020 VA examiner indicates that the Veteran’s rheumatoid arthritis is not caused or aggravated by his service-connected hypothyroidism. This opinion holds great weight of probative value as it is based on a thorough review of the claims file, in-person examination of the Veteran, and consideration of the medical literature on the subject. The weight of the medical evidence is against a finding that there is causation or aggravation by a service-connected disability; hence, the benefit of the doubt does not apply, and secondary service connection cannot be established. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439 (1995). For the reasons set forth above, the preponderance of the evidence is against a finding that the Veteran’s inflammatory polyarthropathy/ rheumatoid arthritis is related to his service, to include presumed herbicide agent exposure, or onset within one year of separation from service, was noted in service with a continuity of symptomatology since separation from service, or was caused or aggravated by a service-connected disability. Accordingly, service connection for inflammatory polyarthropathy/ rheumatoid arthritis is denied. 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310. In reaching this conclusion, the Board has considered the   applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claim, that doctrine is not applicable. 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). M. SORISIO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board R. Dean 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.