Citation Nr: 21024057 Decision Date: 04/22/21 Archive Date: 04/22/21 DOCKET NO. 12-09 598 DATE: April 22, 2021 ORDER Entitlement to service connection for chest wall pain (claimed as residuals of chest wall injury) is denied. Entitlement to service connection for alopecia is denied. Entitlement to service connection for diabetic neuropathy is denied. FINDINGS OF FACT 1. The preponderance of the evidence is against a finding that the Veteran has a disability manifested by chest wall pain that began during active service or is otherwise etiologically related to service. 2. The preponderance of the evidence is against finding that alopecia began during active service or is otherwise etiologically related to service. 3. There is no service-connected diabetes mellitus disorder upon which secondary service connection for diabetic neuropathy disorder may be granted. CONCLUSIONS OF LAW 1. The criteria for service connection for chest wall pain (claimed as residuals of chest wall injury) have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309. 2. The criteria for service connection for alopecia have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.309. 3. The criteria for service connection for diabetic neuropathy have not been met. 38 U.S.C. §§ 1110, 1131, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served in the Army National Guard from February 1980 to May 1986. Her service included a period of active duty in the United States Army from June 1980 to October 1980. She also served on active duty for training (ACDUTRA) from June 13, 1981 to June 27, 1981. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2010 rating decision of the Department of Veterans’ Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania (Agency of Original Jurisdiction (AOJ)). The Veteran testified at a videoconference hearing before the undersigned in July 2016. A transcript of that proceeding is of record. This matter was most recently before the Board in June 2019, at which time it was remanded to afford the Veteran additional VA examinations for the issues on appeal. As will be discussed in more detail below, the Board finds that there has been substantial compliance with the remand directives from June 2019 regarding the claims for service connection. See Stegall v. West, 11 Vet. Appl 268, 271 (1998) (holding when a remand is issued, the Veteran is entitled, as a matter of law, the right to compliance with the remanded order). Service Connection The type of military service a claimant had governs his or her eligibility for service connection for a given disability. Relevant to this case, there is a difference between “active duty,” which includes full-time duty in the Armed Forces, other than active duty for training,” and “active duty for training” (ACDUTRA), which includes “full-time duty in the Armed Forces performed by Reserves for training purposes.” 38 U.S.C. § 101(21), (22). In this case, the Veteran had one period of active duty from June 1980 to October 1980, and one period of ACDUTRA, from June 13, 1981 to June 27, 1981, while she was in the National Guard. As set forth below, the distinction between active duty, ACDUTRA, and INACDUTRA governs the circumstances under which the Veteran may be eligible for service connection for the claims on appeal. Here, the evidence shows that the Veteran had D.C. National Guard service from February 1980 to May 1986. The Veteran is not eligible for VA disability benefits for her period of National Guard service based on being ordered into Federal service by the President of the United States under 10 U.S.C. § 12401, performing “full-time duty” under the provisions of 32 U.S.C. §§ 316, 502, 503, 504, or 505, or being ordered to ACDUTRA under 10 U.S.C. § 12301(d), as none of these scenarios occurred here. 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). Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Service connection may be granted on a secondary basis for a disability which is proximately due to or the result of an established service-connected disorder. 38 C.F.R. § 3.310. Similarly, any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, may be service connected on an aggravation basis. See 38 C.F.R. § 3.310(b); Allen v. Brown, 7 Vet. App. 439 (1995). Notably, active military service also includes any period of ACDUTRA during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty or period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C. § 101(21) and (24); 38 C.F.R. § 3.6(a) and (d). ACDUTRA is, inter alia, full-time duty in the Armed Forces performed by Reserves for training purposes. 38 C.F.R. § 3.6(c)(1). In other words, when a claim is based on a period of Reserve or National Guard service , it must be shown that the individual concerned became disabled (or died) as a result of a disease or injury incurred or aggravated in the line of duty on Reserve ACDUTRA/INACDUTRA or during Federalized National Guard service. In the absence of such evidence, the period of ACDUTRA would not qualify as “active military, naval, or air service” and the claimant would not achieve veteran status for purposes of that claim. See 38 U.S.C. § 101(2)-(24). Lay persons are competent to provide opinions on some medical issues falling within the realm of common knowledge. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). 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. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). It is the Board’s responsibility to evaluate the entire record on appeal. See 38 U.S.C. § 7104(a). When there is an approximate balance in the evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Chest Wall Pain The Veteran is seeking service connection for chest wall pain. Upon review of the evidence, the Board finds that service connection for chest wall pain is not warranted. The Veteran’s service treatment records from her period of active service are silent for any complaints, treatments, or manifestations of chest wall pain or shortness of breath. A November 1980 report of medical examination states the Veteran’s respiratory and cardiac systems were clinically normal. Subsequently, in December 1980, the Veteran experienced shortness of breath along with “occasional parasternal CP” which lasted a few seconds and occurred intermittently. Physical examination and pulmonary function studies yielded normal results and there was no evidence of any pulmonary disorder. In a March 1981 note, treating physicians noted the Veteran’s continued complaints of intermittent shortness of breath and chest pain. In August 1982, while serving in the National Guard, treatment records indicate that the Veteran was struck in the left chest with a rifle. She complained of discomfort, pain, and tenderness. Upon examination, the Veteran was assessed with soft tissue trauma. Shortly thereafter, the Veteran continued to report shortness of breath and chest wall pain. In October 1984, the Veteran reported that her chest pain began after undergoing a breathing test. She was assessed with chest wall pain and hay fever. Post-service, the Veteran first reported having muscular pain in the chest in October 2007. At that time, the Veteran reported that she was punched in chest at work repeatedly. Upon examination, there was no hematoma present. She was advised to apply warm compresses to the painful area. Subsequently, the Veteran reported chest discomfort and shortness of breath, secondary to sinus infections and respiratory infections. Her medical history included dyspnea, aggravated by diabetes and hypertension, and a lung nodule. The Veteran was first diagnosed with a lung nodule in August 2010; at that time, the nodule was noted as an “incidental finding” upon diagnostic testing for an unrelated disability. As the Veteran’s nodule was asymptomatic and presented low risk for cancer, treating physicians found that the Veteran did not need to follow up. At the April 2017 VA examination, the examiner noted the Veteran’s injury to the left breast in August 1982 but found that the soft tissue trauma did not result in any muscle injury. Further, there was no sequelae or chronicity related to the Veteran’s August 1982 soft tissue injury. The examiner also found that while the Veteran reported left chest pain and shortness of breath with exertion, the Veteran did not have a current muscle injury. In January 2019, based on the Veteran’s medical history the Board sought clarification as to whether the Veteran’s intermittent chest pain and shortness of breath represented the onset of a chronic cardiac and/or pulmonary disorder during service. In October 2020, the Veteran underwent VA respiratory and cardiac examinations. At that time, the Veteran was diagnosed with restrictive lung disease, coronary artery disease, and stable angina. At that time, the Veteran reported experiencing shortness of breath in 1981, while serving in the National Guard. She also noted that she started to experience intermittent chest pain in 2010. Upon review of the record, the examiner provided a negative nexus, finding that the Veteran’s conditions developed after the Veteran’s period of active service and there was no medical basis to attribute her current disabilities to her period of active service. Based on the above, the Board finds that service connection for chest wall pain is not warranted. Treatment records from the Veteran’s period of active duty are silent for any complaints, treatments, or manifestations of chest wall pain. Shortly after discharge, the Veteran’s relevant systems were clinically normal. See Report of Medical Examination dated November 1980. The most probative evidence preponderates against a finding that service connection is warranted. Here, the Veteran does not have a muscle injury, cardiac disability or pulmonary disability attributable to her period of active service. To that end, the most probative evidence on the issue of nexus consists of the April 2017 and October 2020 VA examinations of record. The examiners reviewed the Veteran’s claims file, to include her medical history, and found that based on the specific facts of the Veteran’s case, coupled with sound medical principles, the Veteran did not manifest a current residual muscle injury and her cardiac and pulmonary disabilities were not related to service. The Board finds that these opinions are highly probative as they are based on an accurate medical history and they provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The only evidence in favor of the Veteran’s claims consists of her own lay statements, in which she claims she has residual chest wall pain from the August 1982 injury. While the Veteran is competent to attest to any symptoms she experiences, the Board finds that the probative value of her statements is outweighed by that of objective evidence of record. The objective evidence establishes that the Veteran did not manifest a muscle injury during service and does not currently have a residual muscle injury. Moreover, the Veteran did not manifest any cardiac or pulmonary disabilities during her period of active service. As a lay witness, the Veteran is not competent to provide a diagnosis in this case or determine that any particular symptoms were manifestations of restrictive lung disease, coronary artery disease, or stable angina. This issue is medically complex, as it requires medical training and knowledge of the internal systems of the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). To the extent the Veteran manifests a disability secondary to the August 1982 rifle accident or any noted shortness of breath or chest pain noted during her service in the National Guard, the Board notes that service connection based on this period of service is prohibited for reasons stated above. See 38 U.S.C. § 101(2)-(24). In sum, the evidence fails to establish that the Veteran has a disability manifested by chest wall pain that is attributed to her period of active service. Accordingly, the claim is denied. Alopecia The Veteran is seeking service connection for alopecia, which she contends is related to an in-service head injury. For the reasons that follow, the Board finds that service connection for alopecia is not warranted on a direct basis. Service treatment records are silent for any complaints, treatments, or manifestations of alopecia. In July1980, the Veteran was accidently struck on the side of the head with a rifle. She complained of headaches and was assessed with minor trauma to the head. There was no broken skin and the treating physician did not prescribe any medications. Subsequently, the Veteran continued to seek treatment for headaches and related symptoms, to include dizziness and blurry vision. However, there were no complaints of hair loss or any autoimmune disease. Post-service, the Veteran first sought treatment for hair loss in June 2006. At that time, the Veteran reported experiencing hair loss for approximately seven to eight years. Upon examination, there was no tenderness, pain, or pruritus. The Veteran also denied stressors, blood loss, or trauma to the area. The physician diagnosed alopecia at the periphery of her scalp along with scarring hair loss on the central scalp. Subsequently, treating physicians listed scarring alopecia and hair loss in the Veteran’s medical history. While she was not prescribed any medication for her condition, she was advised to stop braiding her hair. In February 2017, the Veteran’s treating physician submitted a Disabilities Benefits Questionnaire (DBQ) related to her diabetic neuropathy. When evaluating the severity of the Veteran’s neuropathy, the examiner found that the Veteran’s hair loss was indicative of trophic changes attributable to the Veteran’s neuropathy. In April 2017, the Veteran underwent a VA skin examination to determine the nature and etiology of her alopecia. At that time, the Veteran reported experiencing hair loss on the scalp after being hit in the head with a rifle during service. She then indicated that her hair began to fall out after discharge from service; over time, she had complete hair loss. Upon examination, the examiner diagnosed scarring alopecia/diffuse hair loss and opined that the Veteran’s condition was less likely as not related to her period of service, to include the accidental trauma to her head. In so finding, the examiner noted that there was no documentation that the Veteran’s hair loss started during service. Rather, the examiner found that the type of hair loss the Veteran had was related to traction and hair treatments. See also, April 2017 VA peripheral nerves Examination. The Veteran underwent another VA skin examination in October 2020. At that time, the Veteran again reported experiencing hair loss during service. Upon consideration of the evidence, the examiner provided a negative nexus, opining that alopecia was not related to service. In so finding, the examiner reviewed the Veteran’s record and found that the Veteran did not manifest any autoimmune disorder, to include alopecia, during service or for many years after. Upon consideration of the record, the Board finds that service connection for alopecia is not warranted. On this record, the evidence does not establish or suggest that the Veteran’s alopecia developed during service. While the service treatment records establish that the Veteran sought treatment for a head injury, her residual symptoms included dizziness and blurred vision. Upon examination, there was no evidence of hair loss; rather, the Veteran’s scalp was normal upon physical examination; there was no evidence of broken skin or any abrasions or broken hair shafts. Thus, the Board finds that the evidence is against a finding that the Veteran developed alopecia during service. The issue of whether the current diagnosis of alopecia had its onset in service or are otherwise related to service presents an issue of medical diagnosis and causation beyond the competence of the lay claimant and the Board. 38 C.F.R. § 3.159(a)(1); Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). As to the issue of nexus, the Board finds that the most probative evidence of record consists of the objective medical evidence, to include the February 2017 DBQ and VA examinations dated April 2017 and October 2020. The clinicians reviewed the Veteran’s medical history, and upon consideration of the specific facts of the Veteran’s case, coupled with medical principles, found that the Veteran’s alopecia was not related to service. Rather, the clinicians provided specific etiologies of the Veteran’s alopecia/hair loss, namely, neuropathy and physical tension. These opinions also comport with the remaining objective medical evidence, to include her medical treatment records. The Board finds that these opinions are highly probative as they are based on an accurate medical history and they provide explanations that contain clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The only evidence in favor of the Veteran’s claim consists of her own lay statements. To the extent the Veteran reports she manifested symptoms of alopecia during service, as a lay person, she is competent to report having experienced symptoms. However, she is not competent to provide a diagnosis in this case or determine that any particular symptoms were manifestations of alopecia. This issue is medically complex, as it requires medical training and knowledge of the internal systems of the body. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). In any event, the Veteran’s current recollections are not consistent with her statements during service or in the earliest available treatment records. To the extent that the current recollections of the Veteran speak to the onset of alopecia in service, the Board places greater probative weight to the Veteran’s statements contemporaneous in time to service. During service, the Veteran reported several symptoms related to her head trauma, to include dizziness and blurred vision. However, she did not report, and the evidence does not reflect, any manifestations of alopecia or general hair loss. In addition, the earliest indication of the presence of alopecia of record is dated June 2006. At that time, the Veteran reported that her symptoms started approximately seven to eight years prior. The Board finds that these statements are more probative than her current statements as they bear indicia of reliability as being made in the context of obtaining appropriate medical treatment and/or diagnosis. See Lilly’s An Introduction to the Law of Evidence, 2nd Ed. (1987), pp. 245- 46 (many state jurisdictions, including the federal judiciary and Federal Rule 803(4), expand the hearsay exception for physical conditions to include statements of past physical condition on the rational that statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy since the declarant has a strong motive to tell the truth in order to receive proper care). Additionally, the current recollections are subject to the vagaries of memory due to the passage of time – here, several decades – and are not consistent with the Veteran’s own documented statements during service or the accompanying medical evidence which did not reflect treatment for alopecia contemporaneous in time to service discharge. See, e.g., Seng v. Holder, 584 F.3d 13, 19 (1st Cir.2009) (notwithstanding the declarant’s intent to speak the truth, statement may lack credibility because of faulty memory); State v. Spadafore, 220 S.E.2d 655, 661 (W. Va. 1975) (stating that the fact that a witness “has stated the matters differently on a previous occasion tends to demonstrate either a failure of memory, or a lack of integrity, and in either event it weakens and impairs the value of his testimony”). Consequently, the Board gives more probative weight to the objective medical evidence of record. In sum, the most probative evidence establishes that alopecia was not manifested during service, nor is it otherwise etiologically related to service. Accordingly, the claim for service connection for alopecia is denied. (continued on the next page) Diabetic Neuropathy Upon consideration of the evidence, the Board finds that service connection for diabetes neuropathy must be denied as a matter of law. The Veteran’s diabetes was caused by her non-service-connected diabetes. See April 2017 VA Examination. There is no primary service-connected disability upon which secondary service connection may be granted. As the Veteran has no service-connected diabetes mellitus disorder that may have caused or aggravated a diabetic neuropathy disorders, the benefit of the doubt doctrine does not apply, and service connection on a secondary basis must be denied at law. See 38 C.F.R. § 3.310(a); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). T. MAINELLI Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Orie, 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.