Citation Nr: 21023342 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 16-21 385 DATE: April 20, 2021 ORDER Service connection for a bone disorder (including any bone disorder of the shoulders), to include as secondary to a service-connected disability is granted. FINDING OF FACT The Veteran’s osteoporosis is caused and aggravated beyond its natural progress by medication used to treat his service-connected asthma with chronic obstructive pulmonary disease (COPD). CONCLUSION OF LAW Resolving doubt in the Veteran’s favor, the criteria for service connection for osteoporosis are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from March 1970 to February 1974. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). In November 2018 and September 2020, the Board remanded the claim for further development, to specifically include obtaining a VA opinion regarding the etiology of the Veteran’s bone disorders, specifically in light of his contentions that they were secondary to medication used to treat his service-connected respiratory condition. A review of the record shows that there has not been substantial compliance with the Board’s remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). However, as the Board is granting the full benefits sought on appeal, there is no prejudice in adjudicating the claim. See Scott v. McDonald, 789 F.3rd 1375 (Fed. Cir. 2015). The Veteran seeks service connection a bone disorder (including any bone disorder of the shoulders), to include as secondary to medication used to treat his service-connected asthma with COPD. Generally, the evidence must show: (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. 38 C.F.R. § 3.303(a); Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection is also warranted for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury. 38 C.F.R. § 3.310. Any additional impairment of earning capacity resulting from an already service-connected condition, regardless of whether or not the additional impairment is itself a separate disease or injury caused by the service-connected condition, should also be compensated. Allen v. Brown, 7 Vet. App. 439 (1995). When service connection is thus established for a secondary condition, the secondary condition shall be considered a part of the original condition. Id. Service connection may be established under the provisions of 38 C.F.R. § 3.303(b) when the evidence, regardless of its date, shows that a veteran had a chronic condition in service, such as arthritis, or during the applicable presumptive period. In addition, certain chronic diseases may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. The Federal Circuit has rejected the view that competent medical evidence is required when the determinative issue in a claim for benefits involves either medical etiology or a medical diagnosis. Under 38 U.S.C. § 1154(a), lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d. 1313 (Fed. Cir. 2009). Turning to the evidence, the Veteran’s service treatment records are absent of any complaint, treatment, or diagnosis of osteoporosis or any other bone disorder. The Veteran’s January 1970 enlistment examination and December 1973 do not indicate any findings for osteoporosis or any other bone disability. The post-service treatment records do, however, reveal the Veteran’s osteoporosis may be linked to steroids used to treat his service-connected asthma with COPD. A February 2009 VA respiratory examination notes that the Veteran took Prednisone (an oral steroid) for three years and was currently taking a Mometosone (steroid) inhaler once per day. Similarly, a March 2016 VA respiratory examination noted uses of corticosteroids for the Veteran’s asthma, albeit intermittently. In February 2015, the Veteran underwent a VA examination to determine the etiology of his bilateral shoulder disorder. The examiner diagnosed the Veteran with mild bilateral shoulder strain. The examiner also opined that it was less likely than not that the Veteran’s claimed condition was proximately due to, or the result of, his service-connected condition. The examiner explained that there was no diagnosis rendered for the arthritis joint condition, there was no established medical connection that exists between use of “inhaled albuterol medication” and the development of arthritis, and the most likely cause of the bilateral shoulder condition was normal aging. The Board notes that the VA examiner indicated that there was no evidence of arthritis; however, this statement appears to be contradicted by the VA treatment records which show multiple diagnoses for osteoarthritis of the bilateral shoulders and an October 2014 magnetic resonance imaging (MRI) test showing AC joint degenerative arthrosis. In August 2019, a VA examiner opined that the Veteran had mild degenerative joint disease (DJD) of the shoulders which is most likely indicative natural progression due to age. The examiner indicated that there is no evidence of osteoporosis on x-ray and that DJD is normally due to wear and tear to joint from use or trauma over time and determined that there was no correlation between DJD and COPD medication to demonstrate aggravation. As this VA examination only addressed the etiology of the bone disorder of the shoulders and not the other diagnosed bone disorders, the Board found the opinion inadequate and another was sought. In December 2020, after reviewing the Veteran’s file, a VA examiner opined that the Veteran’s bilateral shoulder disability was less likely than not due to, or the result of, his service-connected asthma. The examiner noted that the Veteran reported that he occasionally took Medrol and inhalation steroids, and although the examiner found no record of Medrol, he did find record of use of Symbicort as early as December 2015. Despite the evidence of use of a steroid treatment for asthma, the examiner stated that although steroid use has been associated with osteoporosis, inhalation steroids (Symbicort) would have to be used for a prolonged time to capture the same effect and “it’s not clear when his Symbicort was really started.” Upon review, the Board finds the December 2020 opinion inadequate because it neither addressed aggravation nor considered the February 2009 VA examination report which noted that at that time the Veteran had been taking Prednisone (an oral steroid) for three years and had been using a steroid inhaler (Mometosone) once a day. The Board considered remanding this case again; however, given that the evidence of record, namely the VA treatment records show that the Veteran’s service-connected asthma with COPD was treated with steroid medication as early as 2009 and the December 2020 VA examination which acknowledges that steroid use has been associated with osteoporosis, the Board finds that the evidence is in at least a state of equipoise as to whether the Veteran’s osteoporosis is secondary to a service-connected disability. 38 U.S.C. § 5107(b); 38 C.F.R. § § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49 (1990) (holding that “a veteran need only demonstrate that there is an ‘approximate balance of positive and negative evidence’ in order to prevail.”). In so deciding, the Board notes that despite the December 2020 VA opinion that steroid use would need to be long term for it to be associated with the Veteran’s osteoporosis, the Board notes that at that point the Veteran had been using steroids to treat his service-connected asthma with COPD for at least 11 years. As such, there is a reasonable basis to conclude that the Veteran’s disability was secondary to his prolonged steroid treatment. As such, service connection for osteoporosis is warranted. JOHN Z. JONES Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Hemphill 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.