Citation Nr: 21032299 Decision Date: 05/26/21 Archive Date: 05/26/21 DOCKET NO. 17-29 484 DATE: May 26, 2021 ORDER The claim of entitlement to service connection for residuals of a neck injury is denied. The claim of entitlement to service connection for residuals of a head injury is denied. FINDINGS OF FACT 1. The preponderance of the evidence of record is against finding that the Veteran suffered a neck injury or residuals thereof, to include cervical strain, that began during active service or is otherwise related to an in-service injury or disease, or to his service-connected left shoulder adhesive capsulitis with recurrent shoulder dislocations and rotator cuff tear. 2. The preponderance of the evidence of record is against finding that the Veteran suffered a head injury or residuals thereof, to include migraine headaches, that began during active service or is otherwise related to an in-service injury or disease, or to his service-connected left shoulder adhesive capsulitis with recurrent shoulder dislocations and rotator cuff tear. CONCLUSIONS OF LAW 1. The criteria for residuals of a neck injury, to include diagnosed cervical strain, denied have not been met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2020). 2. The criteria for residuals of a head injury, to include undiagnosed migraine headaches, have not been met. 38 U.S.C. §§ 1110, 5107 (2018); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from June 2001 to December 2002. The Veteran provided testimony at a video conference hearing in July 2020 before the undersigned Veterans Law Judge. A transcript of that hearing is of record. Service Connection The Board has reviewed all the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss every item of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (holding that VA must review the entire record but does not have to discuss each piece of evidence). The Board will summarize the relevant evidence and focus specifically on what the evidence shows or fails to show as to the claim. When there is an approximate balance of evidence regarding an issue material to the determination of a matter, the benefit of the doubt in resolving the issue shall be given to the claimant. 38 U.S.C. § 5107 (2012); 38 C.F.R. § 3.102 (2020); Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Service connection may be granted for a disability resulting from injury suffered or disease contracted in the line of duty or for aggravation of preexisting injury suffered or disease contracted in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303. In addition, service connection may be granted for any disease diagnosed after discharge, when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to prevail on the issue of entitlement to service connection, there must be (1) evidence of a current disability; (2) evidence of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. Hickson v. West, 12 Vet. App. 247 (1999). 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. To prevail on the issue of secondary service causation, the record must show (1) medical evidence of a current disability, (2) a service-connected disability, and (3) medical nexus evidence establishing a connection between the current disability and the service-connected disability. Wallin v. West, 11 Vet. App. 509, 512 (1998); Reiber v. Brown, 7 Vet. App. 513, 516-17 (1995). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). In weighing lay evidence, the Board must render a finding with regard to both competency and credibility. See Coburn v. Nicholson, 19 Vet. App. 427, 433 (2006). Competency must be distinguished from weight and credibility, which are factual determinations that support the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). 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; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Factual Background and Analysis Review of the service treatment records (STRs) reflects that the Veteran fell off of a truck in December 2001 suffering a left shoulder injury. The contemporaneous records reflect that the Veteran felt a pop and pain immediately at time of injury. Subsequently, he had left shoulder problems, to include recurrent dislocations. Post service private treatment records reflect continued left shoulder pain with dislocations. He underwent left shoulder surgery in March 2013. When examined by VA in March 2015, the Veteran reported that he dislocated the shoulder when he fell during service. It was relocated, and he was in a sling for 6 weeks. He had additional dislocations and subluxations. At the time of this evaluation, the diagnoses included left shoulder labral tear, including superior labral anterior-posterior lesion) (SLAP), adhesive capsulitis, and recurrent dislocations. The VA examiner opined that the condition claimed was likely as not incurred in or caused by the in-service injury. For rationale, it was noted that the recurrent dislocations might have been reset in the military, but the SLAP tear was never addressed in spite of its presence allowing for recurrences. Currently, the shoulder was dislocated with what appeared to be adhesive capsulitis. This was the typical picture of the natural course of the progression of untreated recurrent dislocations. In a March 2015 rating action, service connection was granted for adhesive capsulitis with recurrent shoulder dislocations. VA records include an October 2019 report wherein the Veteran was seen for left upper back/neck/shoulder pain related to a fall from 3 days earlier. He slipped and fell back on the ground. The pain radiated into the shoulder. His history of shoulder repair surgery was noted. Examination showed that the left shoulder was stable with good range of motion and strength. Ibuprofen and tramadol were prescribed for pain. At the July 2020 hearing, the Veteran testified that ever since he suffered the left shoulder injury during service, he had experienced neck problems as well as migraine headaches. His headaches included sensitivity to noise and light, as well as sleep disturbance, nausea, and body pains. He said that he had been treated for headaches at VA. The Board's July 2020 remand directives requested that VA examination(s) be conducted to provide medical opinions as to the nature and etiology of the Veteran's claimed neck disorder and migraine headaches. Upon VA in-person examination in January 2021, the claims file was reviewed by the examiner. The examiner provided opinions regarding the nature and etiology of any neck injury, to include any chronic neck disorder, and any head injury, to include migraine headaches. The examiner noted that it was less likely than not that the Veteran's diagnosed cervical strain, claimed as residuals of a neck injury, to include chronic neck disorder, was due to any in service illness, injury or event. It was noted that the Veteran stated on his interview and also noted on the Remand order of 7/19/2020 that he was contending that he hurt his neck while he fell off a truck on December 7, 2001. The VA examiner noted that there was no documentation of any cervical spine injury or complaints of neck pain at the time of this incident, and the note from 12/7/2001 was silent for any neck injury, complaints of neck pain or any cervical spine diagnosis. The claims file does include notation that the Veteran experienced neck pain after a fall on 10/10/2019, but this fell outside of the period of active duty. Hence, there was no connection established between the diagnosed cervical strain and any in service illness, injury or event. As for migraine headaches, the VA examiner opined that the claims file does not have documentation of the Veteran ever being diagnosed with a headache syndrome. While the Veteran stated that he had migraine headaches from a fall from a truck in 2001, the claims file did not include documentation of him complaining of or being diagnosed with migraine headaches, or any other headache syndrome, from the December 2001 event. The examiner noted that the claims file did have entries wherein the Veteran reported headaches in the context of using Tramadol and Clonazepam, but no diagnosis of a headache syndrome was rendered. Moreover, the Veteran was not reporting that he had been using or had been consistently using these medications. The examiner further noted that the diagnosis of migraine headaches required specific diagnostic criteria which were not met at the time of this evaluation. Additionally, it was noted by the examiner that the Veteran was contending that his headaches started after a head injury "that has not been diagnosed" and "for which the [V]eteran does not meet diagnostic criteria either." He further explained that headaches associated with traumatic brain injury also needed to meet specific, clear, diagnostic criteria that, again, absent documentation, the Veteran did not meet. He added that this was not to say that the Veteran was not credible, but rather that his claim lacked substantive medical evidence to render a diagnosis of a headache syndrome at this time. Hence, no service connection was established. The VA examiner also found that it was less likely than not that any claimed chronic neck disorder, to include diagnosed cervical strain, and any migraine headaches, (not diagnosed) was due to the service-connected left shoulder disorder. For rationale, the VA examiner noted that there was no anatomical basis to even begin to connect a reported left shoulder dislocation with cervical strain and "not much more c[ould] be said" other than the cervical strain was a muscular condition affecting the musculature of the cervical spine and having a (not evaluated) left shoulder diagnosis, based on medical facts, was not in any way related. There was "not much more to explain" since the question as sent lacked the anatomical foundation necessary to render a more "reasoned" explanation other than there was no relationship between the cervical spine muscular diagnosis of cervical strain and the Veteran having had a (not evaluated) shoulder diagnosis. There was no headache syndrome or migraine disorder to diagnose, hence, there was no rationale to render for a nonexistent diagnosis and the (not evaluated) left shoulder diagnosis. Thus, it was less likely than not that the Veteran's diagnosed cervical strain, claimed as neck injury was due to the Veteran's adhesive capsulitis with recurrent shoulder dislocations and rotator cuff tear. For rationale, it was noted that there was no anatomical basis to "even begin to consider" a causal relationship between the Veteran's cervical strain, a muscular disorder comprising the musculature of the cervical spine, and the left shoulder disorder. Moreover, the claims file was silent for any documentation to support a baseline worsening "to even begin to note" any aggravation as these two diagnoses were not in any way related. The examiner said that "[n]ot much more c[ould] be said" other than highlight that there was no medical foundation to even begin to consider how cervical strain could be aggravated by the left shoulder disorder. The VA examiner concluded his report by noting that it was less likely than not that the Veteran's claimed head injury was aggravated by the left shoulder disorder. For rationale, he noted that there was no diagnosis of traumatic brain injury to render at this time. Hence, "not much more c[ould] be said since there was no diagnosis of traumatic brain injury and no baseline to discuss any aggravation. Entitlement to service connection for residuals of a neck injury. The Veteran is seeking service connection for residuals of a neck injury. His primary contention is that he injured his neck/cervical spine at the same time that he incurred his service-connected left shoulder disorder during service. However, upon review of the evidence above, the Board finds that as there is no competent, probative evidence linking currently diagnosed cervical strain to the in-service injury, or as secondary to the left shoulder disorder itself, service connection is not warranted. As noted above, in the 2021 VA report, there was no documentation of any cervical spine injury or complaints of neck pain at the time of the in-service incident, or in December 2001. It was further noted that while there was notation of neck pain after a fall on 10/10/2019, this was many years after active duty. Hence, there was no connection established between the diagnosed cervical strain and any in service illness, injury, or event. Moreover, as to secondary service connection, the VA examiner noted that there was no anatomical basis to even begin to connect a reported left shoulder dislocation with cervical strain. The cervical strain was a muscular condition affecting the musculature of the cervical spine and a left shoulder disorder was not in any way related. Based on a longitudinal review of the record, the Board finds that the Veteran was not diagnosed with a residual neck or cervical spine disability resulting from his fall/left shoulder injury during service. The post service diagnosis of cervical strain was also unrelated to active service and was not caused or aggravated by the service-connected left shoulder disorder. While the Veteran can attest to subjective symptoms he experiences regarding his neck, cervical spine, he is not competent to provide an objective diagnosis or opinion regarding the etiology of his "residual" disability resulting from any in-service injury. The probative medical evidence of record reveals that the Veteran does not have a current residual disability resulting from his in-service head injury and possible concussion. As such, there can be no link between the in-service injury and a current disability. Accordingly, the Veteran's claim for service connection for residuals of a neck injury must be denied. The current diagnosis of cervical strain is unrelated to service and the service-connected left shoulder disorder. Service connection is not warranted. The doctrine of reasonable doubt is not for application. See 38 U.S.C. § 5107(b) (2012); Gilbert, supra. Entitlement to service connection for residuals of a head injury. The Veteran is also seeking entitlement to service connection for residuals of a head injury, to include migraine headaches, to include on a direct basis or as secondary to the left shoulder disorder. He asserts that he has suffered from migraine headaches since the in-service injury. However, there is no competent, probative evidence provided linking the Veteran's complaints of headaches to his military service. Headaches were first noted many years after service. Moreover, at the time recent examination in 2021, no chronic disorder resulting from alleged in-service head trauma was noted. This included chronic headaches which were specifically not found. In the absence of evidence of current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Therefore, his claim will be denied under both direct and secondary theories of entitlement. 38 C.F.R. § 3.102 (2020). Neither the lay evidence nor the medical evidence supports the Veteran's claim for service connection for residuals of head trauma, to include migraine headaches. Accordingly, given the record before it, the Board finds that the evidence against the claim for head trauma residuals is more probative than the Veteran's assertions. Thus, the Veteran's claim for service connection for residuals of head injury, to include claimed migraine headaches, must be denied and the doctrine of reasonable doubt is not for application. See 38 U.S.C. § 5107(b) (2012); Gilbert, supra. E. I. VELEZ Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Hal Smith, 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.