Citation Nr: 21026403 Decision Date: 05/03/21 Archive Date: 05/03/21 DOCKET NO. 13-21 371 DATE: May 3, 2021 ORDER Entitlement to service connection for a right wrist disability, claimed as secondary to service-connected left shoulder disability, is denied. Entitlement to a disability rating in excess of 20 percent for traumatic left joint sternoclavicular is denied. FINDINGS OF FACT 1. The Veteran's right wrist disability is not secondary to service-connected left shoulder disability, and is not otherwise related to an in-service injury or disease. 2. The Veteran's left shoulder disability is manifested by painful motion of the minor extremity. CONCLUSIONS OF LAW 1. The criteria for service connection for a right wrist disability are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for a rating in excess of 20 percent for a left shoulder disability have not been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.1, 4.3, 4.7, 4.71a, Diagnostic Code 5201. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from July 7, 2004 to July 22, 2004, and from June 2007 to April 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision issued in May 2011 by a Department of Veterans Affairs (VA) Regional Office (RO). This matter was previously remanded by the Board in February 2018 and again in August 2020 for additional development. It is now before the Board for further appellate review. Service Connection 1. Entitlement to service connection for a right wrist disability The Veteran asserts that he is entitled to service connection for a right wrist disability as secondary to his service-connected left shoulder disability. At the outset, the Board notes that the Veteran does not assert, nor does the record reflect, onset of right wrist disability in service. Service connection may be granted on a secondary basis for a disability which is aggravated by, proximately due to, or the result of a service-connected disease or injury under 38 C.F.R. § 3.310. Allen v. Brown, 7 Vet. App. 439 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). VA treatment records from December 2010 to October 2013 document complaints of right wrist pain. The Veteran appeared for a VA examination for his claimed right wrist disability in February 2011. During the examination, the Veteran reported that he has been noticing pain in his right wrist which he believes is due to him having to compensate with his right arm for perceived limitations of his left shoulder disability. There was no loss of range of motion and no objective evidence of pain upon evaluation. The examiner determined that there was no diagnosis warranted for the Veteran's wrist pain. The Veteran submitted a statement in support of his claim in July 2013. In his statement, the Veteran reported that he has pain in his right wrist due to overcompensating for the pain in his left arm. In the February 2018 Board remand, the Board found that the February 2011 examination was inadequate. Specifically, the February 2011 VA examiner failed to provide an etiological opinion for the Veteran's right wrist. Pursuant to the February 2018 Board remand, the Veteran appeared for another VA examination in January 2020. The examiner diagnosed the Veteran with a normal right wrist, and did not provide an opinion on the etiology of the pain reported by the Veteran. In August 2020, the Board found the January 2020 VA examination to be inadequate and remanded for another examination. The Veteran appeared for a third VA examination in January 2021. The examiner opined that the Veteran's right wrist disability was less likely than not related to his military service, to include his service-connected left shoulder. The examiner explained that there was no right hand weakness or numbness noted on the examination and that there was not enough evidence to make a diagnosis. Additionally, the examiner stated that while EMG testing was needed to determine the pathology of the Veteran's wrist condition, the decreased range of motion in the Veteran's left shoulder was not to the degree of functional loss that would warrant compensation from the contralateral arm. The examiner also opined that the Veteran's right wrist condition is not aggravated beyond its normal progression by the Veteran's service-connected left shoulder disability. The examiner explained that there was no noted treatment for his right wrist complaints. The Board finds that the January 2021 VA examiner's opinion is entitled to great probative weight as such considered all of the pertinent evidence of record, to include the statements of the Veteran, and provided a complete rationale, relying on and citing to the records reviewed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A]medical opinion... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). Further, there is no medical opinion to the contrary of record. Upon reviewing all of the pertinent evidence of record, the Board finds that entitlement to service connection for the Veteran's right wrist condition is not warranted. While the Veteran is competent to report symptoms of pain in his wrist, the January 2021 VA examiner found that the Veteran's left shoulder disability had not progressed to a degree that would require compensation from the Veteran's right upper extremity. Thus, the examiner determined that the Veteran's right wrist condition was not related to, and was not aggravated beyond its normal progression by, his service-connected left shoulder disability. While the Board acknowledges the Veteran's lay statements, the Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships. Therefore, 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. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the January 2021 VA medical examiner's opinion. Accordingly, the Board finds that entitlement to service connection for the Veteran's right wrist disability, as secondary to his left shoulder disability, is not warranted. In reaching such decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claims for service connection for his right wrist disability. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. Increased Rating 2. Entitlement to a disability rating in excess of 20 percent for traumatic left joint sternoclavicular sprain The Veteran asserts that he is entitled to a disability rating in excess of 20 percent for his service-connected left shoulder disability. Disability ratings are determined by the applications of the VA's Schedule for Rating Disabilities. 38 C.F.R. Part 4. The percentage ratings contained in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during service and their residual conditions in civil occupations. 38 U.S.C. § 1155; 38 C.F.R. §§ 3.321(a), 4.1. Pertinent regulations do not require that all cases show all findings specified by the Schedule, but that findings sufficient to identify the disease and the resulting disability and, above all, coordination of the rating with impairment of function will be expected in all cases. 38 C.F.R. § 4.21; Mauerhan v. Principi, 16 Vet. App. 436. When after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding the degree of disability such doubt will be resolved in favor of the claimant. 38 C.F.R. § 4.3. Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. Disabilities and injuries of the shoulder are evaluated under DCs 5200, 5201, 5202 and 5203. See 38 C.F.R. § 4.71a. During the pendency of the appeal, the rating criteria for evaluating musculoskeletal disabilities under 38 C.F.R. § 4.71a were amended effective February 7, 2021. 85 Fed. Reg. 230 (Nov. 30, 2020). These amendments revised select diagnostic codes "to ensure that this portion of the rating schedule uses current medical terminology and provides detailed and updated criteria for the evaluation of musculoskeletal disabilities." Id. If a law or regulation changes during the course of a claim or an appeal, the version more favorable to the Veteran will apply, to the extent permitted by any stated effective date in the amendment in question. 38 U.S.C. § 5110(g). If the revised version of the regulation is more favorable, the implementation of that regulation under 38 U.S.C. § 5110(g) can be no earlier than the effective date of that change. If the former version is more favorable, VA can apply the earlier version of the regulation for the period prior to, and from, the effective date of the change. 38 U.S.C. § 5110. Therefore, the Board will consider the Veteran's claim under the old criteria prior to February 7, 2021 and both the old and new rating criteria from February 7, 2021. The criteria that is more favorable to the Veteran will be applied. Normal range of motion in the shoulder is from 0 to 180 degrees of forward elevation (flexion); 0 to 180 degrees of shoulder abduction; 0 to 90 for external rotation; and 0 t 90 for internal rotation. See 38 C.F.R. § 4.71a, Plate I. Under DC 5201, for the nondominant extremity, a 20 percent rating is warranted for flexion and or abduction limited to 90 degrees at shoulder level or limited to 45 degrees midway between side and shoulder level; a 30 percent rating is warranted for flexion and or abduction limited to 25 degrees from side. The revised DC 5201 provides further clarification for the rating criteria but no changes to the actual ratings assigned for the nondominant extremity. A 20 percent rating is warranted for limitation of motion to shoulder level (flexion and/or abduction limited to 90 degrees); a 20 rating is always warranted for limitation of motion to midway between the side and shoulder level (flexion and/or abduction limited to 45 degrees); a 30 percent rating is assigned for flexion and/or abduction limited to 25 degrees from side. In addition, when assessing the severity of musculoskeletal disabilities that are at least partly rated on the basis of limitation of motion, VA must also consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination-assuming these factors are not already contemplated by the governing rating criteria. DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59. The Veteran appeared for a VA examination in June 2010. During the examination, the Veteran reported that his left arm was his nondominant arm. The Veteran also reported a pain and grinding sensation on the left side of his clavicle and stated that he has difficulty lifting things. The examiner noted crepitation and movement of the sternoclavicular joint. The Veteran had full range of motion of the shoulder, however, pain was noted in the sternoclavicular joint. The Veteran appeared for another VA examination in February 2011. Upon examination, the Veteran had objective evidence of pain with active motion on his left side. Additionally, the Veteran had full range of motion of his left shoulder. In February 2013, the Veteran underwent a third VA examination. The Veteran had full range of motion for shoulder flexion and abduction with objective evidence of pain with motion. The Veteran reported flare-ups manifesting as pain in the sternoclavicular joint on his left side. He was able to perform repetitive use testing with 3 repetitions without any additional loss of range of motion. VA treatment records from March 2014 document full range of motion for the Veteran's left shoulder with ongoing treatment for pain. In a December 2019 VA examination, the Veteran exhibited flexion from 0 to 180 degrees; abduction from 0 to 170 degrees; external rotation from 0 to 85 degrees; and internal rotation from 0 to 85 degrees. Pain was noted during range of motion testing and there was no additional loss of range of motion after repetitive use testing. The examiner noted that pain, fatigue, weakness, and lack of endurance significantly limited functional ability with repeated use over time. There was objective evidence of pain on passive range of motion testing, and with non-weight bearing. In a January 2021 VA examination, the Veteran exhibited flexion from 0 to 160 degrees; abduction from 0 to 160 degrees; external rotation from 0 to 90 degrees; and internal rotation from 0 to 90 degrees. Pain was exhibited on flexion and abduction and there was no additional loss of range of motion after repetitive use testing. It was also noted that pain contributed to functional loss during flare-ups and repetitive use over time; however, the examiner estimated no change in range of motion on flare-ups or repetitive use over time. Upon reviewing all of the pertinent evidence of record, the Board finds that entitlement to a disability rating in excess of 20 percent for the Veteran's left shoulder disability is not warranted. In this regard, the evidence of record does not show that the Veteran has had flexion or abduction limited to 25 degrees from side. In addition, as noted above, when assessing the severity of a musculoskeletal disability that is at least partly rated on the basis of limitation of motion, VA is generally required to consider the extent that the Veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent ("flare-ups") due to the extent of his pain, weakness, premature or excess fatigability, and incoordination. See DeLuca, 8 Vet. App. at 202; see also 38 C.F.R. §§ 4.40, 4.45, 4.59. However, additional limitation in degree more closely approximating a higher rating under Diagnostic Coe 5201 has not been demonstrated. Moreover, the Veteran is currently rated at 20 percent for his disability under 38 C.F.R. § 4.59 for painful motion. Consequently, a higher rating is not warranted on this basis. While the Board acknowledges the Veteran's lay statements concerning the symptoms associated with his disability, the requirements for a higher disability rating is based on objective test results. Certainly, as a lay person, he is competent to attest to physical symptoms that he experiences, such as pain. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). Generally, these statements are credible, however, neither the medical evidence nor the lay evidence of record suggests that an evaluation in excess of 20 percent is warranted at this time. The Board has considered whether the Veteran's disability warrants a higher rating under a different DC for his shoulder disability and finds that it is not warranted. The preponderance of the evidence is against a finding of ankylosis, or fibrous union or nonunion of the joint. Accordingly, entitlement to a disability rating in excess of 20 percent at any time during the appeal period for the Veteran's left shoulder disability is not warranted. G. E. Wilkerson Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board C. K. Hall, 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.