Citation Nr: 21015966 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 09-48 810 DATE: March 18, 2021 ORDER Entitlement to service connection for a respiratory disorder other than sarcoidosis and sleep apnea is denied. Entitlement to service connection for a right wrist disorder, claimed as an undiagnosed illness and as secondary to service-connected sarcoidosis, lumbar spine disability, radiculopathy of the left lower extremity, bilateral metatarsalgia, and bilateral knee disability, is denied. Entitlement to service connection for a right ankle condition, claimed as an undiagnosed illness and as secondary to service-connected sarcoidosis, is denied. Entitlement to service connection for a left ankle condition, claimed as an undiagnosed illness and as secondary to service-connected sarcoidosis, is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran has had a separately diagnosable respiratory condition other than his service-connected sarcoidosis and sleep apnea at any time during or approximate to the pendency of the claim. 2. The preponderance of the evidence of record is against finding that the Veteran’s right wrist tendonitis and ganglion cysts are secondary to service-connected sarcoidosis, lumbar spine disability, radiculopathy of the left lower extremity, bilateral metatarsalgia, and/or bilateral knee disability, or are otherwise related to an in-service injury or disease. 3. The preponderance of the evidence of record is against finding that the Veteran’s current right and left ankle conditions are related to an in-service injury or disease, or secondary to his service-connected sarcoidosis. CONCLUSIONS OF LAW 1. The criteria for service connection for a respiratory condition other than sarcoidosis and sleep apnea have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. The criteria for service connection for a right wrist disorder, to include as secondary to other service-connected disabilities have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). 3. The criteria for service connection for a right ankle condition, to include as secondary to service-connected sarcoidosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). 4. The criteria for service connection for a left ankle condition, to include as secondary to service-connected sarcoidosis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 1983 to September 1983 (active duty training), from June 1984 to August 1984, from April 1985 to November 1994 (with service in the Southwest Asia Theater of Operations from August 1990 to November 1994), from February 2002 to September 2002, and from February 2003 to September 2005. This case is before the Board of Veterans’ Appeals (Board) on appeal from July 2008 and June 2010 rating decisions by a Department of Veterans Affairs (VA) Regional Office. In May 2014, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge. A transcript of the hearing has been associated with the electronic claims file. The Board remanded the matters in August 2014, October 2015, and August 2020 for further development. Now the matters are returned to the Board. Service Connection A veteran is entitled to VA disability compensation if there is disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110, 1131 (2012). To establish an entitlement to service connection for a disability, a veteran must show: (1) a present disability; (2) an 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). Service connection may also be granted for a disability that is proximately due to or the result of an established service-connected disability. 38 C.F.R. § 3.310 (2019). This includes disability made chronically worse by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). Service connection also may be warranted for a Persian Gulf War veteran who exhibits objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than not later than December 31, 2021. 38 C.F.R. § 3.317(a)(1)(i) (2019). “Objective indications of 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. 38 C.F.R. § 3.317(a)(3) (2019). 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 is measured from the earliest date on which the pertinent evidence establishes the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317(a)(4) (2019). For purposes of 38 C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multisymptom illness that is defined by a cluster of signs and symptoms, such as chronic fatigue syndrome, fibromyalgia and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. If signs or symptoms have been medically attributed to a diagnosed (rather than undiagnosed) illness, the Persian Gulf War presumption of service connection does not apply. VAOPGCPREC 8-98. In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims stated that “a veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’ in order to prevail.” When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107(b) (2012). For VA to deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App., at 54. 1. Respiratory condition other than sarcoidosis and sleep apnea The Veteran is currently service-connected for sarcoidosis and sleep apnea, but has been pursuing a service connection claim for an additional respiratory condition other than those disabilities. As the evidence showed the Veteran’s symptoms including chest pain, a VA medical opinion for respiratory conditions was obtained in October 2020. After a review of all pertinent evidence, the October 2020 VA examiner found that there was worsening of the Veteran’s symptoms related to sarcoidosis, but there is no change to his current sarcoidosis diagnosis and no additional diagnosis has been rendered. The examiner also opined that the Veteran’s symptoms of chest pain, coughing, and shortness of breath are manifestations of his service-connected sarcoidosis as those are the typical symptoms of sarcoidosis. The Board also notes that the evidence of record does not contain any other diagnosis of a respiratory condition that is distinguishable from his service-connected sarcoidosis and sleep apnea. See e.g., August 2013 Pulmonary Outpatient Consult (the Veteran’s pulmonary sarcoidosis appears to be currently asymptomatic although differentiating respiratory symptoms from vague chronic pain symptoms is difficult); April 2015 Respiratory Disability Benefits Questionnaire (DBQ) (only diagnosis noted was sarcoidosis); April 2019 Dentistry Consult (only respiratory condition noted was sarcoidosis). Based on above, the Board finds that preponderance of the evidence of record is against finding that the Veteran has had a separately diagnosable respiratory condition other than his service-connected sarcoidosis and sleep apnea at any time during or approximate to the pendency of the claim. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply here. Consequently, the Board finds that the Veteran’s entitlement to a respiratory condition other than sarcoidosis and sleep apnea is not warranted. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 2. Right wrist disorder The Veteran is seeking service connection for his right wrist disorder and contends that it was caused by his exposure to environmental hazards during the Persian Gulf War, his use of a cane due to his service-connected lumbar spine disability, and/or other service-connected disabilities, including sarcoidosis, radiculopathy of the left lower extremity, bilateral metatarsalgia, and bilateral knee disability. Initially, the Board notes that the Veteran’s in-service complaints of bilateral wrist pain as well as polyarthralgia are of record, and he was granted service connection for chronic muscle pains as due to undiagnosed illness, effective September 27, 2005. As to the Veteran’s service connection claim for a right wrist disorder, the evidence shows the Veteran’s diagnoses of right wrist tendonitis and ganglion cysts. Thus, the Board will examine whether separate service connection is warranted for a right wrist disorder, to include tendonitis and/or ganglion cysts. The Veteran’s record confirms his service in the Southwest Asia Theater of Operations during the Persian Gulf War, so his exposure to environmental hazards during the war is conceded. However, the Board notes that right wrist tendonitis and ganglion cysts are not qualifying chronic disabilities for purposes of 38 C.F.R. § 3.317. Also, a VA examiner opined in May 2010 that it is less likely than not that the right wrist ganglion cysts are related to service, to include his service in the Southwest Asia Theater of Operations during the Persian Gulf War. The examiner reasoned that ganglion cysts have a clear and specific diagnosis and have no known relationship to toxic or environmental exposure that may have occurred in service in Southwest Asia during the war. The examiner concluded that there is no evidence of a causal relationship between exposures experienced by veterans and the development of ganglion cysts after a review of a medical literature published in 2016 entitled “Gulf War and Health: Volume 10: Update of Health Effects of Serving in the Gulf War.” See also April 2015 Compensation and Pension Examination Report; March 2019 BVA Medical Opinion DBQ (another examiner opined that the ganglion cysts condition is less likely than not caused by a toxic exposure in Southwest Asia Theater of Operations during the Persian Gulf War). Based on above, the Veteran’s claim of service connection for a right wrist disorder, claimed as an undiagnosed illness, as due to his service in the Southwest Asia Theater of Operations during the Persian Gulf War must be denied. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.317 (2019). The evidence does not show that the Veteran had any in-service diagnoses or treatments related to right wrist tendonitis or ganglion cysts. Also, the Veteran only contends that he is entitled to secondary service connection for the condition due to his other service-connected musculoskeletal disabilities. Thus, the Board will now examine whether the Veteran is warranted secondary service connection for right wrist tendonitis and/or ganglion cysts. As to right wrist tendonitis, the May 2010 VA examiner opined that the tendon condition is less likely caused by the Veteran’s use of a walking cane, and stated that there is insufficient evidence to find a causal link based on current literature review and clinical history and examination. The Board notes that the Veteran’s diagnosis of ganglion cysts was not given at the time of the May 2010 VA examination, and the examiner noted that a mass in the right wrist is being worked up for sarcoidosis at the time. The examiner further provided that the tendon condition is more likely than not caused by or a result of his right distal forearm mass. On April 2015 examination, the Veteran’s diagnosis of right wrist ganglion cysts was noted. However, the April 2015 VA examiner opined that the condition is less likely than not caused or aggravated by the service-connected pulmonary sarcoidosis. The examiner acknowledged that sarcoidosis may be associated with acute arthritis in up to 25 percent of individuals with sarcoidosis as an acute polyarthritis, but there was no clinically described overt synovitis during the multiple evaluations for the Veteran’s pulmonary sarcoidosis and no synovial fluid findings nor synovial tissue biopsy were obtained to establish the diagnosis sarcoid arthropathy since the onset of the Veteran’s sarcoidosis in May 2003. The examiner further provided that there is no known relationship of sarcoidosis with the development of a ganglion cyst. The examiner further opined in March 2019 that it is less likely than not that the right wrist ganglion cysts are caused or aggravated by the SC lumbar spine degenerative joint and degenerative disc disease, radiculopathy of left lower extremity, bilateral metatarsalgia, bilateral degenerative joint disease of the knees, degenerative change and arthralgias in the ankles, bilateral osteoarthritis of the first metatarsophalangeal joints, or are related to service. The examiner reasoned that a review of the literature indicates that there is insufficient medical or scientific evidence that ganglion cysts are caused by or related to the use of a cane, and there is no known medical evidence that the right wrist ganglion cysts would be caused or aggravated by the Veteran's service-connected musculoskeletal disabilities. The examiner provide that the pathogenesis of ganglion cyst remains unknown, although it has been suggested that they may represent mucoid degeneration of periarticular structures. Further, in December 2020, another VA examiner provided that the records do not show any residuals for right wrist tendonitis, which was identified during the May 2010 examination, and any previous right wrist tendonitis is completely resolved. The examiner stated that the records do not support causation of right wrist tendonitis due to any service-connected disabilities. The examiner concluded after a review of the Veteran’s records and the medical literature that the Veteran’s right wrist tendonitis was less likely caused or worsened by the service-connected sarcoidosis, lumbar spine degenerative disc disease, radiculopathy of the left lower extremity, bilateral metatarsalgia, and bilateral degenerative joint disease of the knees with a consideration of any use of a cane for the service-connected disabilities. The examiner also opined that the ganglion cyst of the right wrist is less than likely permanently aggravated by or a result of any in-service event, including exposure to environmental hazards in Southwest Asia, or service-connected sarcoidosis disability. The examiner provided that the opinion is confirmed by the medical literature which provides that there is no causal or aggravation association between sarcoidosis and a ganglion cyst and cited to a literature entitled “Ganglion Cysts of the Wrist and Hand.” Based on above, the Board finds that the preponderance of the evidence of record is against finding that the Veteran’s right wrist tendonitis and ganglion cysts are secondary to service-connected sarcoidosis, lumbar spine disability, radiculopathy of the left lower extremity, bilateral metatarsalgia, and bilateral knee disability, or are otherwise related to an in-service injury or disease. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply here. Consequently, the Board finds that the Veteran’s entitlement to service connection for a right wrist disorder, claimed as an undiagnosed illness and as secondary to service-connected sarcoidosis, lumbar spine disability, radiculopathy of the left lower extremity, bilateral metatarsalgia, and bilateral knee disability is not warranted. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). 3. Bilateral ankle condition Further, the Veteran is seeking service connection for bilateral ankle condition. The evidence of record shows the Veteran’s current diagnosis of osteoarthritis of right and left ankles. See e.g., April 2015 Ankle Conditions DBQ. Thus, first Shedden element for service connection is met. As to the in-service incurrence of the claimed bilateral ankle condition, treatment record while he was in service shows that there was speculation of acute sarcoidosis or Lofgren’s syndrome being the cause of the Veteran’s bilateral ankle arthritis, although the etiology of the arthralgia remained difficult to identify. See September 23, 2004 Clinic Note. Thus, the second Shedden element for service connection is also met. However, as to the causal link between the Veteran’s current bilateral ankle condition and his service or service-connected sarcoidosis, only negative medical opinions are of record. First, the April 2015 VA examiner opined that it is less likely than not that the bilateral degenerative joint disease of the ankles is caused by or a result of the Veteran’s active duty service, including a toxic exposure event in Southwest Asia theater of operations during the Persian Gulf War, or caused or aggravated by the service-connected pulmonary sarcoidosis. The examiner provided that the Veteran’s diagnosis of mild bilateral degenerative joint disease of the ankles was not established until a March 2008 VA examination, and the X-rays of the ankles obtained during military service and afterwards were normal, despite the Veteran’s complaint of bilateral ankle pain in service. The examiner stated that degenerative joint disease of the ankles is a biomechanical disorder and it would be less likely than not caused by or a result of a toxic exposure event in Southwest Asia. The examiner acknowledged that up to 25 percent of individuals with sarcoidosis may have acute arthritis. However, the examiner reasoned that no synovial fluid findings nor synovial tissue biopsy were obtained to establish the diagnosis of sarcoid arthropathy of the ankles since the onset of sarcoidosis in May 2003, and there was no erythema nodosum described at any time which would be required, along with hilar lymphadenopathy and acute polyarthritis, to suggest a diagnosis of Lofgren’s symptom. Also, the same VA examiner provided an addendum opinion in March 2019 and noted that the Veteran has had very little pain or discomfort in either ankles since the March 2008 VA examination, and he takes no specific medication for ankles. The examiner provided that chronic sarcoid arthritis is uncommon, which occurs in 1 to 2 percent of cases, and both acute and chronic sarcoid arthritis have a good prognosis. The examiner explained that the swelling usually occurs in the soft tissues around joints for the acute sarcoid arthritis (periarthritis) which is typically self-limiting, and the chronic sarcoid arthritis generally responds to usual treatments for sarcoidosis. The examiner also stated that joint damage is generally not seen in sarcoid arthropathy, and it is not known to result in or aggravate degenerative joint disease. Further, a December 2020 VA examiner concluded after a review of medical records and the medical literature that the osteoarthritis of the bilateral ankles is less likely permanently aggravated by the Veteran’s service-connected sarcoidosis. The examiner agreed with the previous VA examiner’s opinions and provided that the Veteran had transient arthralgias due to Lofgren’s Syndrome which was associated with the Veteran’s pulmonary sarcoidosis, but the condition is now in complete remission. The examiner explained that the finding of increased activity primarily in the feet shown on a 2005 bone scan is not a precursor of the more recent development of degenerative or osteoarthritis of the ankles found in 2008. The examiner noted that the Veteran’s inflammatory arthralgias in ankles were completely resolved with the treatment of his sarcoidosis, and there were no long-term sequelae of any ankle joint condition. The examiner opined that the Veteran’s current degenerative osteoarthritis was identified much later, and it is more likely than not due to normal aging, heredity, and weight-bearing of the ankle joints. Based on above, the Board finds that the preponderance of the evidence of record is against finding that the Veteran’s current right and left ankle conditions are related to an in-service injury or disease, or secondary to his service-connected sarcoidosis. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine does not apply here. Consequently, the Board finds that the Veteran’s entitlement to service connection for right and left ankle conditions claimed as an undiagnosed illness and as secondary to service-connected   sarcoidosis is not warranted. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.310, 3.317 (2019). MICHAEL LANE Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. E. Kim, Associate 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.