Citation Nr: 21016011 Decision Date: 03/19/21 Archive Date: 03/19/21 DOCKET NO. 16-37 981 DATE: March 19, 2021 ORDER Service connection for a right shoulder disability is denied. Service connection for a neck disability is denied. Service connection for a right leg disability, to include degenerative joint disease of the right hip, is denied. Service connection for a back disability is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against finding that a right shoulder disability began during active service or is otherwise related to an in-service injury or disease. 2. The preponderance of the evidence is against finding that a neck disability began during active service or is otherwise related to an in-service injury or disease. 3. The preponderance of the evidence is against finding that a right hip disability began during active service or is otherwise related to an in-service injury or disease. 4. The preponderance of the evidence is against finding that a back disability began during active service or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for a right shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 2. The criteria for service connection for a neck disability have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 3. The criteria for service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. 4. The criteria for service connection for a back disability have not been met. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1955 to January 1958. Service Connection The Veteran asserts that his disabilities of the back, neck, right shoulder, and right leg/hip are due to injuries sustained from athletics during service. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The question for the Board is whether the Veteran has current disabilities that began during service or are at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has a current diagnoses of degenerative joint disease, rotator cuff tear/repair, right shoulder; degenerative joint disease and degenerative disc disease of the cervical spine; degenerative joint disease of the right hip; and, degenerative disc disease of the lumbar spine and lumbar spondylosis, the preponderance of the evidence weighs against finding that the Veteran’s disabilities began during service or are otherwise related to an in-service injury, event, or disease. Service treatment records do not reflect any complaints, treatment or diagnoses related to the right shoulder, neck, right hip, and back. A January 1958 Report of Medical Examination reflects that his ‘spine, other musculoskeletal,’ ‘upper extremities,’ and ‘lower extremities’ were clinically evaluated as normal. 10/24/2014 STR-Medical at 6. A January 1958 Report of Medical History completed by the Veteran for separation purposes reflects that he checked the ‘No’ boxes for ‘painful or “trick” shoulder or elbow’ and ‘bone, joint, or other deformity.’ 10/24/2014 STR-Medical at 22. X-ray examinations of the cervical and lumbar spines conducted in July 1995 reflect right paracentral disc herniation at C4-C5 level with resultant some deformity of the right anterior thecal sac with no extension of the disc herniation into the right C4-C5 neural foramen, and at C5-C6 level right paracentral end plate spurs resulting in some deformity of the right anterior thecal sac without deformity of the spinal cord; and, minimal degenerative disc disease at L4-L5 and L5-S1 level without significant central spinal stenosis or neural foraminal stenosis present. 03/04/1998 Medical Treatment Record-Non-Government Facility at 61. Correspondence dated in July 1995 from a neurosurgeon reflects that the Veteran was evaluated in July 1995, wherein he reported that he had been disabled for the past 10-12 years after he had a car-bicycle accident. He was hit and continued to complain of severe lower back pain and neck pain. He worked as a truck driver until about 6 years prior when he had another car accident. It was a two-car head-on-collision and he was the driver. He hit the steering wheel, and this caused severe back, neck and chest pain and aggravated his old injuries. Since then he has had complaints of severe lower back, neck, shoulder and arm pain with shooting pain down to his left foot, right thigh and left arm/hand. Id. at 34. A May 1996 private treatment record reflects the Veteran’s report of right shoulder pain. He reported that he had a remote accident in 1982 when he landed on his right shoulder and the right side of his head and he has had difficulty since then. Thereafter, he underwent repair of the right rotator cuff. Id. at 17-23. In April 1998, the Veteran underwent a C&P examination for purposes of his nonservice-connected pension claim. He reported that in 1984 he was riding a bicycle for exercise and he was struck by a car and injured his neck, shoulder and low back. He recalled he was told he had a neck and back strain. He said he was told he had a bad sprain in his right shoulder that was diagnosed in 1995 as a rotator cuff tear. His back and neck hurt off and on and he took aspirin as needed. In 1986, he noticed his legs would get weak, numb and give out and he would fall. He sought medical care in 1990 for low back pain that was increasing. In 1989, he got a job as a truck driver and he noticed his neck was getting stiff and he was experiencing pain and weakness in his back and legs. In 1991 he was involved in a motor vehicle accident and sustained injuries to his neck, shoulders and low back. Upon physical examination, the examiner diagnosed degenerative joint disease of the cervical spine C5-C6 with diminished range of motion; degenerative changes lumbar spine L1, L2, L3 and retrolisthesis L1 to L4; degenerative joint disease right shoulder with diminished range of motion to abduction and rotation. 04/21/1998 VA Examination. In September 2011, the Veteran underwent a C&P examination wherein the examiner diagnosed degenerative joint disease of the right hip. The Veteran reported that he injured his right leg in service running or doing the pole vault and he landed on his right leg/thigh. He reported that he began to have pain in his right leg in the mid-1980s and he has pain in the right leg and thigh all the time. He initially sought treatment in 1994 wherein he was diagnosed with a lumbar spine condition. The examiner opined that the right hip condition is less likely as not due to service. The examiner stated that there is no indication of right hip degenerative joint disease greater than left hip degenerative joint disease to show residual of right leg pain. Minimal degenerative joint disease would be considered normal finding given age. 09/27/2011 VA Examination at 54, 68. Correspondence dated in June 2018 from a physician reflects that the Veteran sustained sports injuries, track and field and pole vault, with hip and back injuries. He was exposed to cleaning solvents and aromatic hydrocarbons and volatile aromatic solvents during his active duty. He was exposed to silica in the form of dust and sand. He was exposed to high molecular weight persistent organic pollutants through inhalation of smoke and diesel fumes through diesel engine exhaust. The Veteran has numbness and tingling in both hands and legs, and he has weakness in both legs and has problems with balance and loss of coordination. He has a history of upper extremity injury, neck injury and low back injury. The physician summarized the Veteran’s medical history. The physician stated that the Veteran has experienced onset of metabolic syndrome with hyperlipidemia, pre-diabetes with elevated blood sugar, insulin resistance, and peripheral neuropathy. Peripheral neuropathy is contributed to by EMG documented radiculopathy, particularly in the lower extremities. Chronic neck and arm pain, numbness and tingling and MRI’s documenting intervertebral disc herniation in the cervical spine further contribute to upper extremity numbness and tingling. He has residuals of 5th metacarpal fracture of the right hand. He has spinal degenerative disc disease, cervical and thoracolumbar, that were worsened by traumatic events detailed in review of medical records occurring after discharge. The examiner stated that his cervical and thoracolumbar condition are more likely than not due to service. The examiner stated that his metabolic syndrome with peripheral neuropathy, disordered capacity for concentration and mentation are causally related to exposure to both volatile organic pollutants and persistent organic pollutants. His conditions referencing pollutants to which he was exposed in the military environment have been causal to a primary neurological syndrome combined with and overlapping with spinal nerve root changes. 08/17/2018 Correspondence. In January 2020, the Veteran underwent C&P examinations wherein the examiner proffered negative etiological opinions. With regard to the back, the examiner stated that there was no chronic back pathology noted in service and that there was an obvious pathology, namely a motor vehicle accident noted several years after discharge. With regard to the neck, the examiner stated that current pathology was diagnosed several years after separation and no neck complaints were noted in service or several years after. With regard to the right shoulder, the examiner stated that no right shoulder complaints were noted in service or several years after separation. The current pathology since 1996 is therefore not related to service. With regard to the right hip, the examiner stated that an acute soft tissue strain had no evidence of chronicity and current pathology was noted several years after separation. In July 2020, the examiner proffered addendum opinions. The examiner stated that the Veteran has evidence of neck, back, and right shoulder conditions. However, for all of these condition areas and related diagnoses, it was found to be less likely than not that any of these conditions were incurred in or caused by a claimed in-service injury, event or illness. Specifically, for all diagnosed disorders of the neck/cervical spine, back/lumbar spine, and right shoulder, the examiner opined that it is less likely than not that the disorder manifested during active military service or is related to active military service. This medical opinion included consideration of the Veteran’s reports of athletic activities and reported exposure to pollutants mentioned within his case file. This medical opinion also includes consideration of the Veteran’s testimony of in-service and post-service symptomatology and the June 2018 private physician opinion within his case file. The examiner stated that the Veteran’s reports of his in-service athletic activities and reported exposure to pollutants mentioned, as well as the Veteran’s testimony of in-service and post-service symptomatology and the June 2018 private physician opinion, were all reviewed, but did not show objective, reliable evidence that his current neck, back or right shoulder conditions resulted from his active military service or within the 1 year after his active military service period or even within the immediate several years following his active military service. There was no reliable nexus to show that his current neck, back and right shoulder conditions were related to his active military service period of 1955–1958. This is because his initial diagnosis of a neck, back, and right shoulder conditions were not established until many years after his active military service period and this Veteran was known to have a mechanism of injury pathway of 2 motor vehicle accidents resulting in injury to these same areas. In this case, there was not a nexus between an in-service or service-related injury or disease and the current neck, back and right shoulder conditions based on the timing and occurrence of the documented diagnoses and symptomatology. With regard to the right leg/hip condition, the examiner opined that it is less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner stated that there was an acute soft tissue strain, but he had no evidence of chronicity and the right leg conditions were noted several years after active military service and unrelated to military service activities. This included any injuries sustained from athletic activities in-service or exposure to pollutants. The Veteran’s testimony regarding in-service and post-service symptomatology and the June 2018 private physician opinion was reviewed and considered for this medical opinion. In this case, there was not an objective reliable nexus between the in-service/service-related injury or disease and these current other right leg conditions based on the timing and occurrence of the documented diagnoses and symptomatology. As detailed above, based on the Veteran’s lay statements documented in medical records dated in the 1990s and thereafter, the Veteran was not diagnosed with disabilities of the cervical spine, lumbar spine, right shoulder, and right hip until decades after separation from service. While the Veteran is competent to report having experienced symptoms related to the neck, back, right shoulder and right hip due to injuries sustained while pursuing in-service athletic endeavors, he is not competent to provide diagnoses in this case nor determine that these symptoms were manifestations of chronic disabilities. The issues are medically complex, as such requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). It is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Id; see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Moreover, neither the clinical records nor the lay evidence in this case demonstrate symptomatology of the neck, back, right shoulder, and right hip dating back to service. Notwithstanding this, it is noted that despite the Veteran’s current assertions that he has disabilities of the neck, back, and right shoulder due to active service, when seeking private treatment in the 1990s and undergoing a C&P examination in April 1998, he reported sustaining injuries in two car accidents but did not report any in-service incidents or injuries. In fact, in July 1995 he reported that he had been disabled for the past 10-12 years, which would have been over a quarter century after separation from active service. It was not until 2011, over a half-century after separation from active service that the Veteran claimed that these disabilities were due to in-service incidents. While the Board finds the Veteran’s statements regarding his in-service athletic endeavors to be credible, the Board finds that the Veteran’s statements offered in the 1990’s pertaining to his medical history, which were negative for any report of in-service injuries or complaints, to be more credible and probative than assertions offered over a half century after separation from service in support of claims for compensation. With regard to the right hip, the Veteran reported problems since the 1980s, thus decades after separation from service. Based on the Veteran’s lay assertions, however, opinions were sought from C&P medical providers which were negative. As detailed, the September 2011 examiner proffered a negative etiological opinion with regard to right hip degenerative joint disease. The January 2020 examiner proffered negative etiological opinions with regard to the neck, back, right shoulder and right hip, which included July 2020 clarifying addendum opinions. These collective opinions are probative as they are based on examination of the Veteran, an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Consideration has been given to the opinion of the June 2018 physician however, but such opinion does not provide an adequate rationale on which to base a grant of service connection for any of the claimed disabilities. See Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (“[A] medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two.”). The physician acknowledged the Veteran’s reported in-service sports injuries and then detailed in-service exposures. The opinion of the physician appears to relate his neurological symptoms affecting the cervical and lumbar spine to in-service exposures, but the opinion does not detail a rationale for any finding that his musculoskeletal complaints affecting the neck, back and right shoulder are due to service. The physician makes a conclusory statement that his cervical and thoracolumbar conditions are due to service but does not provide an accompanying rationale. The physician asserts that he has spinal degenerative disc disease, cervical and thoracolumbar that were worsened by traumatic events occurring after discharge but does not detail the basis for any finding that he had these conditions prior to the post-service “traumatic event.” There is also no indication that the physician physically examined the Veteran. Based on a lack of rationale, the Board assigns less probative value to this opinion of record. As the C&P examiners’ opinions were based on examination of the Veteran and contain consideration of all of the lay and medical evidence of record and contains appropriate rationales such opinions are assigned more probative weight. Based on the Veteran’s lay assertions, opinions were sought, which were negative. Consequently, the Board gives more probative weight to the September 2011 and January and July 2020 opinions of trained medical professionals. In conclusion, the most probative, competent evidence is against a link between disabilities of the neck, right shoulder, back and right hip, and service. Because the preponderance of the evidence is against the issues, reasonable doubt does not arise, and service connection is denied. See 38 U.S.C. § 5107(b). Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board M.W. Kreindler, 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.