Citation Nr: 21028202 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 12-05 052A DATE: May 10, 2021 ORDER Service connection for the Veteran's bilateral ankle disability, as currently diagnosed, is granted. Service connection for the Veteran's bilateral shoulder disability, as currently diagnosed, is granted. FINDINGS OF FACT 1. The Veteran has a bilateral ankle disability that at least as likely as not was incurred in, or caused by, service. 2. The Veteran has a bilateral shoulder disability that at least as likely as not was incurred in, or caused by, service. CONCLUSIONS OF LAW 1. The criteria for service connection for the Veteran's bilateral ankle disability, as currently diagnosed, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for the Veteran's bilateral shoulder disability, as currently diagnosed, are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from December 1975 to December 1979. These matters come before the Board of Veterans' Appeals (Board) from a June 2009 rating decision. The Veteran testified at a Board hearing in August 2014. The Board remanded these matters in March 2016, December 2018, and September 2020. The Veteran's appeal previously included the issues of service connection for a bilateral knee, low back, and bilateral leg disabilities. Service connection for these disabilities has since been established and they are no longer on appeal. 1. Service connection for the Veteran's bilateral ankle disability, as currently diagnosed, is granted. The Veteran contends that he has a bilateral ankle disabilities that had its onset during his active duty service. The Veteran testified in May 2005 that he first had problems with his right leg and ankle in boot camp, including shin pain caused by marching. The Veteran testified in August 2014 that he had problems with his right and left knees in service due to basketball and marching as well as bilateral shin splints. He stated that at one point during service he required crutches due to his leg problems. He stated that he has also had bone spurs and shin splints in his bilateral legs. He testified that his ankles and feet are abnormal, and that this caused problems for him in service. The Veteran's service treatment records show a number of complaints related to the lower extremity. In January 1976, the Veteran was treated for a left leg "bump on rear end" and tender shins and given a profile for left leg muscle spasms. In September 1977, the Veteran complained of left leg soreness, was found to have possible lymph node inflammation, and was given a profile for inflammation of the left leg lymph nodes. The Veteran's August 1979 separation examination noted normal lower extremities and repeated the history of right knee pain noted above. On his August 1979 Report of Medical History, the Veteran noted having swollen or painful joints, cramps in his legs, and a "trick" or locked knee. The physician's summary stated that the Veteran had pain in his right knee since October 1978, etiology unknown, no treatment necessary, not incapacitating. A December 1993 private physical examination shows that the Veteran was diagnosed with a significant eversion deformity of the ankles. A December 2011 VA examination in December 2011 shows a diagnosis of ankle arthralgia and arthropathy. A June 2016 VA examination shows a diagnosis of bilateral ankle strain. An October 2019 VA examination shows a diagnosis of bilateral lateral collateral ligament sprain. More recently, a December 2020 VA examination shows a diagnosis of bilateral ankle tendonitis. The December 2020 VA examiner opined that the Veteran's bilateral ankle disability was at least as likely as not incurred in service or caused by it. This opinion was based on the Veteran's history of symptoms, both as documented in treatment records and as reported by the Veteran. Nevertheless, in January 2021, the same VA examiner issued an opinion stating the opposite, that the Veteran's Achilles' tendonitis is less likely than not related to service. The examiner's rationale was that there was no documentation in the service treatment records to support connection to service. The evidence establishes that the Veteran reported a history of painful joints on his report of medical history at separation. In fact, the Veteran is service-connected for multiple musculoskeletal disabilities based on in-service injuries. These service-connected disabilities suggest that the Veteran was involved in high-impact physical activity, which provide a plausible explanation for his reported history of ankle issues since service. In its March 2016 remand, the Board described as credible the Veteran's reports of ankle pain during, and continuously since, service. 03/21/2016, Remand BVA. The Board finds no reason to alter this finding of fact. As summarized above, the December 2020 VA examiner opined, based on the Veteran's credible history of symptoms, that the Veteran's bilateral ankle disability is at least as likely as not related to service. The examiner later changed opinion, based strictly on the absence of corroborating medical evidence. This rationale is not acceptable, as it unduly places a higher evidentiary threshold on the Veteran. So, the 2021 opinion is given little weight. The Veteran's report of continuous ankle symptoms since service is generally consistent with both the nature of his shoulder disability and his history of high-impact musculoskeletal injuries in service. The Board finds no reason to doubt the veracity of the Veteran's reported history of service connection since service. Based on this credible history, a VA examiner opined that the Veteran's current bilateral ankle disability is at least as likely as not incurred related to service. Based on this evidence, the Board finds that the Veteran has met the criteria for entitlement to service connection for his current bilateral ankle disability. 2. Service connection for the Veteran's bilateral shoulder disability, as currently diagnosed, is granted. The Veteran contends that he has a bilateral shoulder disability that had its onset during his active duty service. The Veteran testified in May 2005 that he never had problems with his shoulders until he joined the military, and that typing at a small desk all day caused stress on his shoulders, which led to his current problems. He stated that he began to get treatment for his shoulders soon after separation from service. In his August 2014 Board hearing, the Veteran discussed damaging his shoulder through typing and carrying a heavy flag and pole. He stated that he started having serious pain in his shoulder playing basketball in the early 1990s. On his August 1979 Report of Medical History, the Veteran noted having swollen or painful joints. There is, however, no indication of a specific shoulder issue. The Veteran has submitted private treatment records dating back to 1984. In September 1986 he reported pain in the posterior aspect of his right shoulder. He was diagnosed with bursitis. A December 1993 physical examination shows normal range of motion of the shoulders with provocative maneuvers positive suggestive of left subdeltoid bursitis. In September 1994 he was diagnosed with mild subdeltoid bursitis more prominent on the right than the left. The Veteran's VA treatment records show frequent complaints and treatment related to shoulder pain since 2001. In April 2002 he reported gradual onset of shoulder pain in right shoulder since a basketball game in 1987-1989. Veteran stated that months later he noted similar symptoms starting in the left shoulder, and that sometime later he started noticing "popping" in his shoulders with movement and pain and waxed and waned. In February 2004, the Veteran reported lower shoulder pain for the past 30 years. In April 2004 the Veteran reported pain all over, including his shoulders, which had been present for 15 years and had begun to get worse. The Veteran stated that he thought these problems happened while he was in the Army. In June 2004 the Veteran reported right shoulder pain for 1 to 2 years. He was found to have decreased range of motion in the right shoulder. In August 2004 the Veteran again reported shoulder pain. He described it as aching, throbbing pain that made it difficult to sleep. He stated that the symptoms had been worse since 1996, but began in the 1970s, and again in October 2004 he reported having shoulder pain since the 1970s and was diagnosed with rotator cuff impingement and osteoarthritis. A June 2016 VA examination shows a diagnosis of bilateral shoulder impingement syndrome. It also shows diagnoses of shoulder strain and rotator cuff tendonitis and tear for the right shoulder and acromioclavicular joint osteoarthritis for the left shoulder. A December 2019 VA examination shows a diagnosis of bilateral degenerative arthritis. It also shows diagnosis of rotator cuff tear and subacromial/subdeltoid bursitis for the right shoulder. More recently, a December 2020 VA examination shows diagnoses of bilateral shoulder strain and impingement syndrome. It also shows diagnoses of rotator cuff tendonitis and tear for the right shoulder and acromioclavicular joint osteoarthritis for the left shoulder. The December 2020 VA examiner opined that the Veteran's bilateral shoulder disabilities were at least as likely as not incurred in service or caused by it. This opinion was based on the Veteran's history of symptoms and treatment, both as documented in treatment records and as reported by the Veteran. The evidence establishes that the Veteran reported a history of painful joints on his report of medical history at separation. Treatment records indicate that he sought treatment for shoulder issues as early as 1986, around six years after service. Since then, the Veteran has continuously received treatment for progressively worsening shoulder issues. The Veteran has indicated that his shoulder issues began in service and have continued in service. As mentioned above, in his August 2014 Board hearing, the Veteran suggested that he damaged his shoulders through typing and carrying a heavy flag and pole. The Veteran's report of continuous shoulder symptoms since service is generally consistent with both the nature of his shoulder disability and the history of treatment documented in VA and private treatment records. The Board finds no reason to doubt the veracity of the Veteran's reported history. Based on this credible history, a VA examiner has concluded that the Veteran's current bilateral shoulder disability was at least as likely as not incurred in or caused by service. Based on this evidence, the Board finds that the Veteran has met the criteria for entitlement to service connection for his current bilateral shoulder disability. Paul Sorisio Veterans Law Judge Board of Veterans' Appeals Attorney for the Board P. López, 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.