Citation Nr: 21037068 Decision Date: 06/16/21 Archive Date: 06/16/21 DOCKET NO. 13-17 196 DATE: June 16, 2021 ORDER Entitlement to service connection for a neck disorder, including as secondary to service-connected post-traumatic stress disorder (PTSD) is denied. FINDING OF FACT The most probative evidence of record shows the Veteran's neck disorder is not etiologically related to service or secondary to her service-connected PTSD. CONCLUSION OF LAW The criteria for entitlement to service connection for a neck disorder have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1116, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from October 1990 to June 1991, with additional service in the Navy Reserves. This case comes to the Board of Veterans' Appeals (Board) on appeal from a rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). This matter was remanded to the Agency of Original Jurisdiction (AOJ) in April 2015, June 2017, December 2017, September 2019, and most recently in January 2021. Specifically, the January 2021 remand directives required the AOJ to obtain any outstanding VA and private treatment records and to obtain an addendum opinion to address aggravation. Per the Board's remand directives, the AOJ scheduled and the Veteran attended a VA examination in March 2021. The Board finds that the examination is adequate and the records obtained, thus, there has been substantial compliance with the remand directives. Stegall v. West, 11 Vet. App. 289 (1998). Entitlement to service connection for a neck disorder, including as secondary to service-connected PTSD The Veteran contends that service connection is warranted for a neck disability as due to service, to include in-service injuries of being hit by a heavy metal door and being hit by a heavy box on the top of the head. Alternatively, the Veteran contends that her neck disability is secondary to her service-connected PTSD. The Veteran's service treatment records reveal a normal clinical evaluation of the spine, other musculoskeletal. See March 1989, January 1992, April 1994 Reports of Medical Examination. The Veteran also continuously denied having swollen or painful joints; bone, joint, or other deformity; or arthritis, rheumatism, or bursitis. See July 1986, March 1989, January 1992, April 1994 Reports of Medical History. The Veteran also denied having sustained any injury, illness, or disease in the past 12 months or having been under a physician's care during the last twelve months in Annual Certificates of Physical Condition, dated January 1995, January 1996, January 1997, and January 1998. An EMG performed in 2007 showed cervical radiculopathy. A December 2009 VA treatment record shows x-ray results of degenerative changes in the cervical spine c5-7 and some narrowing at the c5-6 on the left side. At the time of treatment, the Veteran reported that she had numbness and tingling radiating down her right arm. The Veteran stated that she had the problems on and off for years, and she related her disorder to an in-service injury. A May 2010 lay statement, authored by a fellow serviceperson (T.M.) reveals that the Veteran became intoxicated during service and was hit by a heavy metal door. In October 2012, the Veteran was asked what she believed was causing her pain. She answered that she was not sure, but "know part of it is physical and part mental." In a June 2013 Substantive Appeal (VA Form 9), the Veteran reported, in relevant part, that she is in pain every day from her neck injury and will never be right again. She further stated that during service, she was intoxicated as T.M. endorsed. She also noted that T.M. forgot to mention in his letter that the next day after being intoxicated, she complained that her neck hurt. A Social Security Administration Record, dated April 2015, reveals that the Veteran reported a box fell on her head when she was in the military. The Board notes, however, that such records do not include further complaints of or treatment for a neck disorder. These records also do not include an etiological opinion. The Veteran was afforded a VA examination in August 2015, at which time the examiner noted a diagnosis of degenerative joint disease of the cervical spine. At the time of examination, the Veteran reported that she sustained two head injuries while serving in the Navy. No medical care was sought following both injuries and no line of duty determinations were performed for either of the injuries. The Veteran endorsed neck pain and right-hand numbness. The Veteran also reported that she was an unemployed lab technician, noting that she did not want to work and felt that her neck pain would prevent her from working on a full-time basis. The examiner opined that the Veteran's cervical degenerative joint disease was less likely than not related to active duty service. The examiner reasoned that the Veteran's records were silent for a significant head or neck injury and that the degree of discomfort that she currently had was more likely than not related to her fibromyalgia and her radiographically mild cervical degenerative joint disease. In August 2017, a VA examiner opined that it was less likely than not that the Veteran complained of the signs/symptoms, was evaluated, diagnosed, or treated for any neck injury/pain while in service. The examiner also opined that it was less likely than not that the Veteran's subjective complaint of chronic neck pain/injury that initially appeared in her available treatment records in 2009 were secondary to an in-service neck injury. Additionally, the examiner opined that it was less likely than not that the Veteran's current subjective complaints of chronic neck pain secondary to an alleged in-service neck injury were aggravated, incurred, caused, or associated with her post-service diagnosis of PTSD. In January 2018, a VA examiner opined that it was less likely than not the Veteran's radiological, but not clinical, cervical spine degenerative joint disease was caused by or related to or had its onset during service or was otherwise causally related to service. The examiner reasoned that the Veteran never had medical care either in 1991 or in 1995 for any neck complaints and that she denied any injuries relating to the neck during military physical examinations. The examiner stated that the first indication of pertinent complaints was in December 2006, at which time the Veteran complained of right hand and wrist pain with neurological symptoms that had been present for six months and which was subsequently diagnosed as carpal tunnel syndrome. The examiner also noted that in September 2007, the Veteran did not complain of neck symptoms or a history of a neck condition or injury. The examiner further noted that it was not until two years later, in 2009, that the Veteran first recounted a history of an in-service injury and first complained of neck pain radiating to the right arm. A cervical spine x-ray done in late-2009 showed the presence of cervical spine degenerative joint disease with questionable findings of neural foraminal narrowing due to disc space narrowing. The examiner additionally reasoned that there was nothing in the evidence of record or recounted history that suggests that the Veteran's cervical spine disorder was not due to the normal aging process. Additionally, the examiner stated that the evidence of record did not support that the Veteran's described injuries during military service have led to any current neck condition that is chronic and disabling. Further, the examiner reported that the evidence of record does not support that the Veteran has a neck condition at all other than a radiological finding of degenerative joint disease. The examiner also opined that it was less likely than not that the Veteran's condition of radiological, but not clinical, cervical spine degenerative joint disease was caused by or related to or permanently aggravated beyond the normal progression of the condition by her service-connected PTSD. Here, the examiner reasoned that the weight of medical literature supports that PTSD is a behavioral health disorder manifested by hypervigilance and avoidance due to changes in the underlying central nervous system neurochemistry. The examiner also reasoned that the weight of the medical literature supports that neck conditions are of musculoskeletal etiology and does not support that changes in central nervous system neurochemistry can lead to the development of a musculoskeletal disorder in any location including the neck. In a December 2019, the Veteran presented to a VA chiropractic consultation with complaints of chronic neck pain. At the time of treatment, the Veteran reported that her symptoms had been ongoing for about fifteen years and began with training injuries in the military. The Veteran reported constant pain in the neck. In January 2020, an examiner opined that it was less likely than not that the Veteran's cervical spine degenerative disc disease was due to or the result of PTSD with alcohol use. Here, the examiner reasoned that the Veteran's cervical spine disorder was due to wear and tear of the spinal structure from overuse over time. The examiner also noted that the cervical spine disorder was not due to mood disorders such as PTSD, which affects neurotransmitters. The examiner also opined that it was less likely than not that the Veteran's cervical spine disorder was aggravated beyond the natural progression by PTSD. In providing the opinion, the examiner noted that a baseline of severity could not be determined. The examiner again reasoned that the Veteran's cervical spine disorder was due to wear and tear of the spinal structure from overuse over time. The examiner also noted that the cervical spine disorder was not due to mood disorders such as PTSD, which affects neurotransmitters Most recently, the Veteran was afforded a VA examination in March 2021. The examiner indicated that the Remand and entire claims file was reviewed, and the Veteran's statements were considered. The examiner opined that the Veteran's degenerative arthritis of the cervical spine was less likely than not aggravated beyond its natural progression by the service-connected PTSD with alcohol use disorder. The examiner acknowledged the Veteran's belief that her diagnosed cervical spine degenerative arthritis was aggravated beyond its natural progression by her service-connected PTSD. The examiner also acknowledged the October 2012 VA Pain Service consultation, which included the Veteran's lay statement relating her neck pain to physical and mental components. The examiner reasoned that degenerative arthritis of the cervical spine is medically known to result in limitation of range of motion of the neck as well as in pain, caused by repetitive wear and tear over time following occupational as well as leisure or sports activities involving repeated and forceful bowing/tilting of the head forward, backward, and from side to side, as well as turning of the head from side to side. The examiner noted that the Veteran was 41 years of age at the time of diagnosis in 2009 and cited to her age as a likely contributor to her neck condition. Here, the examiner identified that advancing age was a contributor to the arthritic and degenerative process, with individuals aged 40 and above at greater risk of developing cervical arthritis. Lastly, the examiner noted that there was a lack of evidence in medical literature that demonstrates the pathophysiological mechanism by which mental conditions, including PTSD cause pathologies affecting the articulating joints of the neck, hence less likely for it to aggravate the Veteran's neck condition beyond its natural progression. The Board also acknowledges the Veteran's lay statements of record. Here, however, the Board cannot afford probative weight to her assertions with respect to the etiology of her neck disorder in this case. While the Veteran is competent to report experiences and symptoms since service, she is not competent to provide a nexus opinion regarding the nature and etiology of this disability. Jandreau v. Nicholson, 492 F. 3d 1372 (2007); Buchanan v. Nicholson, 451 F. 3d 1331 (Fed. Cir. 2006). Here, the Veteran's reports of her neck symptoms are relevant and competent; however, the question of the etiology of this disability is a complex medical finding that is limited to the purview of someone with medical knowledge and training, such as the VA examiner in this case. Thus, the Veteran's assertions of the etiology of her neck disorder is not competent evidence. The Board finds that the weight of the evidence does not support a finding that the Veteran's neck disorder is related to her active duty service or to her service-connected PTSD. First, the Board notes that there was over a decade gap between the end of service and medical treatment for the claimed condition. While the absence of documented treatment or complaints in service or thereafter is not fatal to a service connection claim, a negative inference may be drawn from the absence of complaints for an extended period. See Ledford v. Derwinski, 3 Vet. App. 87, 89 (1992), Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Additionally, the Veteran's reports in the available medical evidence are contradictory as to the onset and continuity of her neck problems. She has reported problems since service, yet failed to identify any neck issues in post-service treatment records until 2009, and contrary to her statements of onset in service, in a 2019 treatment record she reported onset approximately 15 years prior, which would be around 2004, well after her periods of active service or reserve service. See December 2019 VA treatment record. Further, she stated onset was from being hit by a door, having a box fall on her, and/or from training exercises in service. Yet, service records are silent as to any complaints or treatment for a neck injury and in fact contain multiple denials of any neck problems in and during service. Even the lay statement submitted by T.B. does not assert that she complained of neck problems or suffered a neck injury after being intoxicated and being hit by a door. Thus, the Board finds her lay statements as to injuries in service and continuity after service to not be credible. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997); see also Pond v. West, 12 Vet. App. 341 (1999). Thus, the Board finds there is no competent or credible evidence of an inservice event or injury, nor is there any credible evidence of continuity of symptoms since service. Finally, the only competent medical evidence regarding a nexus shows that the Veteran's neck disorder was not caused her active service or caused or aggravated by her service-connected PTSD. Further, in viewing the VA examinations, in tandem, to specifically include the March 2021 VA opinion, as well as the additional evidence of record, the Board finds that the most probative evidence is against the claim. For the foregoing reasons, the Board finds that the preponderance of the evidence does not support the Veteran's claim for service connection for a neck disorder, and the claim must be denied. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; see also Fagan v. Shinseki, 573 F.3d 1282, 1287 (Fed. Cir. 2009). GAYLE STROMMEN Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Hanson, 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.