Citation Nr: 21030783 Decision Date: 05/19/21 Archive Date: 05/19/21 DOCKET NO. 17-09 487 DATE: May 19, 2021 ORDER Service connection for a left shoulder condition is denied. Service connection for a lumbar spine condition is denied. Service connection for a cervical spine condition is denied. FINDINGS OF FACT 1. A preponderance of the evidence is against a finding that the left shoulder condition was shown to be related to or caused by his active service. 2. A preponderance of the evidence is against a finding that the lumbar spine condition was shown to be related to or caused by his active service. 3. A preponderance of the evidence is against a finding that the cervical spine condition was shown to be related to or caused by his active service. CONCLUSIONS OF LAW 1. The criteria have not been met for service connection for a left shoulder condition. 38 U.S.C. §§ 1101, 5107(b) (2018); 38 C.F.R. § §§ 3.102, 3.303, 3.307, 3.309 (2020). 2. The criteria have not been met for service connection for a lumbar spine condition. 38 U.S.C. §§ 1110, 1116, 1131, 5107(b) (2018); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2020). 3. The criteria have not been met for service connection for a cervical spine disability. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 5107(b) (2018); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the U.S. Army from June 1970 to June 1973. These matters come before the Board of Veterans' Appeals (Board) on appeal from a November 2015 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Boise, Idaho. In June 2018, the Board denied service connection for left shoulder, lumbar spine, cervical spine, and right knee disabilities. The Veteran appealed the Board's decision to the United States Court of Appeals for Veterans Claims. The parties filed a joint motion for partial remand (JMPR) and, in March 2019, the Veterans Court granted the JMPR, vacated the portion of the June 2018 Board decision that denied service connection for left shoulder, lumbar spine, cervical spine, and right knee disabilities, and remanded the matter to the Board for review. The Board remanded the case in July 2019 and again in July 2020 and January 2021 for additional development. The case has since been returned to the Board for further appellate review. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred or aggravated during active military service. 38 U.S.C. § 1101. Generally, service connection requires (1) the existence of a present disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). Certain disabilities, including arthritis, organic neurological disorders, and psychoses, are presumed to be serviced connected if they manifest to a compensable degree within one year following service. 38 C.F.R. § §§ 3.303, 3.307, 3.309. 1. Service connection for a left shoulder condition 2. Service connection for a lumbar spine condition 3. Service connection for a cervical spine condition The Veteran indicated he injured his shoulder, back, and neck while home on leave when he was in a motorcycle accident. See June 2015 statement. Factual Background Review of service treatment records (STRs) show the Veteran went to sick call in October 1971 reporting pain in his neck, back and legs that he attributed to an accident the prior July. No disability was diagnosed, and no follow up complaints are seen in the record. The examination conducted at the expiration of his term of service in January 1973 indicated the Veteran's spine, upper and lower extremities, were normal on clinical evaluation. A signed note at the bottom of the ETS exam indicated the Veteran was in good health to his knowledge. The Veteran was afforded a VA examination in October 2015. He reported intermittent, daily pain exacerbated by reaching above shoulder height. The examiner confirmed a diagnosis of acromioclavicular joint osteoarthritis in the left shoulder via x-rays also taken in 2014, also noting decreased range of motion. The Veteran indicated that he experienced back pain following the motorcycle accident during service and sought medical attention. He was unable to recall the specifics of the accident, although he reported that he did not lose consciousness. He reported dull, aching back pain since service that was occasionally severe and other times, barely noticeable. The examiner noted a diagnosis of degenerative arthritis of the spine. The Veteran reported intermittent pain since his motorcycle accident. He stated his neck symptoms improved modestly since the accident in service but have not resolved. He reported daily neck discomfort, and his symptoms worsened on some days. He did not seek medical attention for his neck prior to 2014, other than one visit with a chiropractor several years ago. June 2014 cervical spine x-rays showed moderate to severe narrowing of C5-6-disc space. The October 2015 examiner opined that none of the Veteran's conditions were related to service. The examiner explained there was insufficient evidence in the medical records to support the claim. The examiner noted that the physical exam performed after the 1971 accident was essentially normal and considered the Veteran's work in the timber/logging industry for many years following separation from service very likely played a role in the development of his current conditions. The Veteran underwent VA examination in January 2020. The examiner provided negative opinions. The examiner indicated the Veteran's left shoulder disability was more likely than not due to the 1974 motor vehicle accident. The examiner stated that there were no treatment records until 2019, and that the Veteran was a dish washer for decades. Regarding the lumbar spine disability, the examiner found that it was most likely due to the Veteran's two motor vehicle accidents after service and his decades long employment of washing dishes. Finally, with respect to the cervical spine the examiner opined that the one notation in the service treatment record did not indicate an injury that was not sufficient to cause mild degenerative changes decades after service and the disability was most likely age related. VA obtained an October 2020 addendum opinion regarding the left shoulder, lumbar spine, and cervical spine disabilities. However, the statements of the October 2020 examiner were essentially a reiteration of the earlier January 2020 opinion, which was found to be inadequate. In a January 2021 VA addendum opinion, the examiner opined that it was less likely than not that the claimed conditions were incurred in or caused by the in-service injury, event, or illness. Regarding the left shoulder the examiner explained that, after reviewing the claims file, the examiner determined the Veteran's left shoulder condition was not related to his 1971 motor vehicle accident. The examiner noted the STRs documented an October 1971 medical encounter, at which time the Veteran complained of total body pain following a motor vehicle accident three months earlier. The physical examination at that time was normal. The examiner also stated the 1973 separation examination is silent regarding shoulder pain. The examiner indicated medical records are subsequently silent regarding a left shoulder condition until 2014, at which time the Veteran reported left shoulder pain. Also, the examiner noted documentation of additional accidents after service (in 1974 and 2017). The examiner concluded that the factors associated with the additional accidents (with associated injury) and with overuse are at least as likely as not the cause of the Veteran's left shoulder condition, rather than the 1971 motor vehicle accident. Regarding a lumbar spine condition, the examiner noted the Veteran has well-documented diagnoses of chronic low back pain, IVDS, degenerative arthritis, and degenerative disc of the lumbar spine. The examiner also noted that an October 1971 STR documents the Veteran reported body pain, including vague lumbar pain, due to a motor vehicle accident that occurred prior to three months prior; however, his examination report was normal. The examiner further stated, the STRs and separation examination were silent regarding back pain. The examiner explained that there was a lack of evidence and clinical notes relating to lumbar spine condition until 2015, at which time the Veteran received an IPC steroid injection with improvement. The examiner further noted that subsequent VA records document ongoing chronic low back pain from 2018 through 2020. Therefore, the examiner concluded the Veteran's chronic low back condition with associated chronic low back pain was incurred in active service. Regarding the cervical spine condition the examiner STRs documented a medical encounter in October 1971 at which time the Veteran complained of body pain and vague cervical area pain following a motorcycle accident 3 months previously. The examiner stated the Veteran's examination was normal, and he received no further evaluation or treatment other than aspirin. The examiner noted the evidence of record documents the Veteran stated that his neck pain started following the 1971 accident. At the time of the October 2020 VA neck examination, the Veteran stated that he did not recall the accident well but that he believed the accident was the cause of his left shoulder and right knee injuries, although the history was silent regarding his neck condition. The examiner also noted that STRs, including the 1973 separation examination, are silent regarding his neck issues or neck condition. The examiner stated that there is a lack of evidence and VA treatment records prior to 2014, when VA records document medical treatment for neck pain. Analysis The Board has not overlooked the Veteran's statements about his left shoulder, cervical spine, and lumbar spine conditions. While the Veteran is competent to report observable shoulder symptoms, he does not have the training or credentials to provide a competent (qualified) opinion about the nature or cause of his left shoulder condition or whether it is related to active service, including the in-service motor vehicle accident. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Additionally, the Board finds that the January 2021 VA examination report to be probative. The Board finds that the January 2021 VA examination report to be the most probative evidence of record, because the examiner reviewed the claims file and provided a detailed rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). [CONTINUED ON NEXT PAGE] Because of this, the preponderance of the evidence is against the claim. The benefit-of-the-doubt rule does not apply, and this service connection claim must be denied. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. VICTORIA MOSHIASHWILI Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D. Braxton, 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.