Citation Nr: 21015919 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 17-31 260 DATE: March 18, 2021 ORDER Entitlement to service connection for a thoracic spine disability is denied. Entitlement to service connection for myositis is granted. FINDINGS OF FACT 1. The Veteran’s thoracic spine disability, diagnosed as degenerative disc/joint disease of the thoracic spine, is not etiologically related to an in-service injury or disease; thoracic spine arthritis did not manifest to a compensable degree within the applicable presumptive period; and the Veteran’s thoracic spine disability was not caused or aggravated by a service-connected disability. 2. The Veteran’s myositis is proximately due to a service-connected right shoulder disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a thoracic spine disability have not been met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2019). 2. The criteria for service connection for myositis have been met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.159, 3.310 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from October 2003 to November 2011, to include service in Southwest Asia. These matters come before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision issued by the VA Regional Office (RO). In connection with this appeal, the Veteran testified at hearing before the undersigned Veterans Law Judge in March 2020. In April 2020, the Board remanded the Veteran’s claim for additional development. The Veteran contends that his back and shoulder blade pain are related to his active service, or alternatively, secondary to his service-connected right shoulder labral tear and left shoulder dislocation (“bilateral shoulder disability”). Specifically, he reported that he was required to wear body armor and harnesses for prolonged periods during his deployment to Iraq. A review of the Veteran’s service treatment reports reveals that clinical evaluation of the spine was normal at the Veteran’s June 2003 entrance examination, and the Veteran denied back problems on a report of medical history form prepared in conjunction with the examination. The records do not include any complaints, findings, or treatment for the back. During an April 2014 VA examination, the Veteran reported that lifting and carrying equipment may have caused his back pain. The examiner diagnosed myositis of the right spinal muscles, T4 level. The examiner opined that the Veteran’s back disability was not the result of or due to an undiagnosed illness or medically unexplained chronic multi-system illness. Instead, he found that the Veteran’s back disability, diagnosed as myositis, is a mechanical problem with a clear and specific etiology. Post-service treatment reports dated from July 2012 to September 2020 reflect reports of low back pain beginning in 2018. A VA addendum opinion was obtained in May 2019. The examiner opined that the Veteran’s myositis, right paraspinal muscles, T4 level was less likely than not incurred in or caused by the Veteran’s military occupation specialty of wheel vehicle mechanic. The examiner’s rationale was that the Veteran’s service treatment reports did not reveal any back pain or complaints during service, no chronicity was demonstrated, and no nexus has been established. During a September 2020 VA examination, the examiner indicated that he was not treated for his back problems during service and initially presented for treatment at VA in 2012. The examiner diagnosed the Veteran with mild degenerative disc/joint disease of the thoracic spine and myositis of the interscapular muscles on the right side. The examiner opined that the Veteran’s back disabilities were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner’s rationale was that there was no treatment for the back during service and no treatment for the back until the 2014 VA examination. The examiner also indicated that arthritis of the thoracic spine was not diagnosed until mild changes were found at the current examination and a causal relationship could not be established between said changes and the Veteran’s service which included lifting and carrying equipment and wearing body armor for prolonged periods. The examiner also opined that the thoracic spine disability is less likely than not proximately due to or aggravated by the right shoulder disability. The examiner’s rationale was that the Veteran had a normal gait and the thoracic spine arthritis was not causally related to an altered gait and that degenerative joint/disc disease is known to be causally related to trauma or normal wear and tear (age-related) to the thoracic spine. The examiner concluded that the Veteran’s thoracic spine degenerative changes are more likely than not causally related to age or his current occupation as a mechanic. With regard to myositis noted at the right mid interscapular area at T4, the examiner indicated that such is a muscle condition and is not causally related to any thoracic condition or disability. The examiner opined that the Veteran’s myositis of the right interscapular muscle is at least as likely as not caused by the service-connected right shoulder disability. The examiner’s rationale was that the it is known that right shoulder conditions can cause interscapular muscle pain. Turning to the thoracic spine disability, the Board finds that service connection is not warranted. Although the Veteran has a current diagnosis of thoracic spine degenerative arthritis, which is a chronic disease under 38 C.F.R. § 3.309(a), it was not shown as chronic in service or within a presumptive period, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. Review of the claims file reveals that the Veteran was not diagnosed with thoracic spine degenerative arthritis until 2020, almost ten years after his separation from service. Given the above, the Board concludes that the Veteran does not have a thoracic spine disability related to his active service or secondary to a service-connected right shoulder disability. The VA opinions, when taken together, are probative evidence because they are based on an accurate history and are accompanied by well-reasoned rationale as well as supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). Moreover, there are no contrary medical opinions on file. To the extent that the Veteran believes his thoracic spine disability is either due to service or proximately due to or the result of/aggravated beyond its natural progression by his service-connected right or left shoulder disability, he is not competent to provide a nexus opinion in this case. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). In short, the Board gives more probative weight to the VA medical opinions of record. Accordingly, service connection for a thoracic spine disability is denied. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not applicable. See 38 U.S.C.§ 5107(b) (2018); 38 C.F.R. § 3.102 (2019); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Turning to the myositis, the Board finds that service connection is warranted. The Board finds that the April 2014 and May 2019 VA medical opinions have no probative value. Neither examiner specifically addressed secondary service connection. The evidence in favor of the claim includes the September 2020 VA opinion, as well as the Veteran’s lay statements. As noted, the clinician opined that the Veteran’s myositis is at least as likely as not proximately due to or the result of the Veteran’s service-connected right shoulder disability and he indicated it is known that right shoulder conditions can cause interscapular muscle pain. The clinician’s opinion is consistent with the Veteran’s testimony regarding his right shoulder disability aggravating his shoulder blade. Based on the foregoing, the Board finds that service connection for myositis as secondary to a service-connected right shoulder disability is warranted. As described above, the two negative opinions fail to opine as to secondary service connection. As the only adequate opinion is positive, and because it is consistent with the evidence of record, the Board will resolve any reasonable doubt in favor of the Veteran and grant service connection for myositis as secondary to a service-connected right shoulder disability. Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). Kristin Haddock Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Cryan, 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.