Citation Nr: 22015297 Decision Date: 03/17/22 Archive Date: 03/17/22 DOCKET NO. 17-17 205A DATE: March 17, 2022 ORDER Entitlement to service connection for a left shoulder disability is denied. FINDING OF FACT The weight of the competent and credible evidence is against finding that the Veteran's left shoulder disability manifested in service or within one year of service; and is not etiologically caused by an in-service injury, event, or disease. CONCLUSION OF LAW The criteria for service connection for a left shoulder disability have not been met. 38 U.S.C. §§ 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.309 (2021). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Navy from November 2005 to June 2006. This matter comes before the Board of Veterans' Appeals (Board) from a September 2013 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). Previously, the Veteran's claim was before the Board in August 2021, and was remanded for additional development. There has been substantial compliance with the prior remand directives, and the matters again are before the Board. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Service Connection A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in line of duty in active service. 38 U.S.C. §§ 1110, 1131. To establish a right to compensation for a present disability, a Veteran must show: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service" - the so-called "nexus" requirement. Shedden v. Principi, 381 F.3d 1163, 1167 Fed. Cir. (2004). For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Service connection for a recognized chronic disease can also be established through continuity of symptomatology. Walker v. Shinseki, 708 F.3d 1331 (2013); 38 C.F.R. §§ 3.303 (b), 3.309. Left Shoulder Strain The Veteran contends that service connection is warranted for a left shoulder disability. The Veteran reports that her left shoulder disability developed in-service while doing pullups. The Veteran contends that her current left shoulder disability is related to an in-service injury. The Veteran reported left shoulder symptoms have continued since service. The Veteran is competent to describe her current symptoms, in-service events, and the occurrence of ongoing symptoms. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The question for the Board is whether the Veteran has a left shoulder disability that began during service, manifested during the applicable presumptive period, or is at least as likely as not caused by an in-service injury or disease. The Veteran has a current diagnosis of a left shoulder strain. The Veteran's STRs have been associated with the claims file. In a December 2005 service treatment record, a radiologist examined the Veteran and found that the Veteran's left shoulder was normal. The radiologist stated that the Veteran did not have any fractures and no dislocation was seen in the Veteran's left shoulder. Her bony structures were intact. See April 2013 Medical Treatment Record-Government Facility, p. 12. In a January 2006 STR, the Veteran denied ever having arthritis, rheumatism or bursitis and an impaired use of her arms, hands, or feet. She also noted that she was in good health at that time. See April 2013 Medical Treatment Record-Government Facility, p. 10. In a May 2006 STR, the Veteran stated that she had at the time or in the past had a painful shoulder, elbow, or wrist. However, the Veteran also checked that she was in "currently in good health". The Veteran further stated that she hurt her shoulder in boot camp but had no problems since. See April 2013 Medical Treatment Record-Government Facility, p. 8,9. In a June 2013 VA treatment record, the Veteran had a normal MRI arthrogram of the left shoulder. See February 2017 Medical Treatment Record-Government Facility, p.404. In another June 2013 VA treatment record, a clinician noted that the Veteran had a seven-year history of left shoulder crepitus and the Veteran was diagnosed with joint pain, localized in the shoulder. See February 2017 Medical Treatment Record-Government Facility, p.441. In a June 2013 VA treatment record, the Veteran stated that she was not having any shoulder pain at the time. See February 2017 Medical Treatment Record-Government Facility, p.406. In another June 2013 VA treatment record, the Veteran complained of left shoulder crepitus since the injury in service. The Veteran also noted that she was running, swimming, and doing spinning classes at the time for exercise. The clinician indicated that there was no significant history of shoulder pain. The Veteran had a diagnosis of left shoulder pain and a labral tear. See February 2017 Medical Treatment Record-Government Facility, p.430-432. In a July 2013 radiology note, an examiner found that the Veteran's left shoulder showed that the soft tissue and bony structures were in normal limits. See July 2013 C&P Exam, p.2. In July 2013, the Veteran was afforded a shoulder and arms VA examination. The examiner reviewed the claims file; considered the subjective accounts and conducted an evaluation. The examiner noted that the Veteran had been diagnosed with a left shoulder strain in 2013. The Veteran reported onset as December 2005 when she injured her left shoulder while doing pullups and heard a pop. The Veteran reported that the condition was the same and pain was intermittent with weakness in the left arm. The Veteran's condition did not impact her ability to work. The examiner found that based on a medical record review it was less likely than not that the Veteran's left shoulder condition was associated with her injury in 2005. The examiner noted that the Veteran was injured in December 2005 during bootcamp but on three subsequent evaluations for periodic examinations in January 2006, March 2006 and on her separation examination in May 2006 the veteran stated that there were no sequelae to her shoulder condition. In addition, the examiner indicated that there were no records after 2006. Therefore, based on medical records review, it was less likely than not that her left shoulder pain was associated with her injury in 2005. In an April 2017 form 9, the Veteran stated that her shoulder issue was not a chronic issue, and it did not worsen until years after the injury. The Veteran also indicated that a specialist stated that her migraine and shoulder issue could have been related, since they were on her left side. See April 2017 Form 9, p.1. In December 2019, the Veteran was afforded another VA shoulder examination. The examiner reviewed the claims file; considered the subjective accounts and conducted an evaluation. The examiner noted that the Veteran was diagnosed with left shoulder strain in 2013. The Veteran reported that she injured her left shoulder while in bootcamp in 2005-2006; while doing pullups, she noted popping and snapping, and she fell down. The Veteran stated that she was in a sling for 2 weeks. The Veteran indicated that she had difficulty in those last 3-4 years (approximately 2015-2016). The Veteran described constant pain in the shoulder in the back of the scapula region and along the anterior shoulder musculature. In 2013, the Veteran underwent an arthrogram which was normal. The Veteran reported flare-ups when lifting any more than 5-10 pounds. But also noted functional loss or impairment since she could not lift more than 40 pounds. The Veteran did not use assistive devices and the condition impacted her ability to perform an occupational task because she had difficulty lifting overhead and lifting with weight due to pain. The examiner found that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner stated that the Veteran was evaluated for his left shoulder in-service but records from later years in-service showed that the Veteran's shoulder had no issues. The examiner further noted that imaging studies ruled out rotator cuff, arthritis, and bursitis. In addition, the examiner stated that there was normal range of motion, in the shoulder, in the 2013 examination. At the time of the examination, the examiner found that the Veteran had muscle strain in the trapezius and deltoid area of the musculature, which the examiner stated could be multifactorial. The examiner also indicated that the records did not demonstrate a pattern of a chronic disabling condition after the initial incident that could be attributed to the injury in service. In November 2021, the Veteran was afforded another VA shoulder and arms examination. The examiner reviewed the claims file; considered the subjective accounts and conducted an evaluation. The examiner noted that the Veteran was diagnosed with left shoulder strain in 2013 and with bilateral hypermobility syndrome with shoulder hyperlaxity and instability in 2021. The Veteran reported that while in-service she was doing pullups during PT in basic training and heard a snap followed by pain and could not use her left arm. The Veteran stated that she was placed in a sling for 2 weeks. The Veteran stated that she did not have issues after as she no longer had to do swimming and pull ups as part of PT. The Veteran noted that she never went to see medical for her shoulder after that incident. She does not recall having to take pain meds for her shoulder after the initial injury while in service. Then one day in 2007 she said she woke up and was unable to move her shoulder and neck on the left side and went on base to be seen. She was given ibuprofen, put in a sling again but did not remember being given a diagnosis or receiving any other treatment. She indicated that she has had recurrent episodes of shoulder and neck "freezing up" lasting a day or so then easing up. The Veteran indicated that she eventually had another bad episode of her left shoulder "freezing up" around 2012 and went to be evaluated again. She stated that she had imaging MRI/arthrogram and was told it was normal. The Veteran indicated that she was sent to physical therapy which she states did not help due to her pain level being too high to completes the exercises. The Veteran stated that in August 2021 she had another severe episode of left shoulder pain, but an x ray was negative. The Veteran described symptoms of her shoulder feeling "loose, like it hanging out if its socket." She described a constant dull pain in anterior and lateral shoulder as a well as describes sharp shooting pain along her trapezius muscle and up her neck. The Veteran reported tingling/ numbness in back of her arm from her shoulder down to her 4th and 5th digits. The Veteran stated her pain got sharper and more intense with raising her arm in any direction, reaching out away from her body, holding her arms out away from body, and lifting a grocery bag or anything heavy. The Veteran used a brace as an assistive device occasionally. The condition had a functional impact as to occupational tasks, she stated she would not be able to perform tasks requiring any lifting overhead activity, repetitive reaching away from her body and that she would have difficulty typing. The examiner found that it was less likely than not that the claimed condition was incurred in or caused by the in-service injury, event, or illness. The examiner stated that the enlistment exam was negative for shoulder issues. The examiner further indicated that the Veteran reported that she "strained my shoulder, left, doing pull-ups but had no problems after 2 days of leisure. The examiner further noted that the Veteran clearly indicated that there was no ongoing issues and an examiner noted no sequelae of her shoulder injury. The examiner indicated that the Veteran again checked "yes" to the question "Have you ever had, or do you now have painful shoulder, elbow or wrist" and stated that an absence of an ongoing shoulder problem: "I hurt my shoulder in boot camp, no problems since." And during the Veteran's separation examination she once again checked "yes" to the question "Have you ever had or do you now have painful shoulder, elbow or wrist" and again (for the third time since her injury) indicated that there were no ongoing issues with her shoulder: "I hurt my shoulder in boot camp, no problems since." The examiner found that the medical evidence of record did not support an ongoing shoulder issue in service. The examiner then addressed the 2019 Board remand by indicating that the Veteran checking "yes" to painful shoulder is consistent with answering the question regarding having ever had a painful shoulder (to which the answer would be "yes") after which she stated on 3 separate instances that the shoulder had not had a problem since the injury, meaning she has no shoulder issue at the time. In addition, the examiner noted that post-service records contained a left shoulder x ray report from November 2006, which was normal. The examiner also noted that the reason for the x ray was for recurrent shoulder dislocation with the first dislocation having occurred 6 weeks prior. The examiner further indicated that the left shoulder was not mentioned in a medical record until June 2013, seven years later. The examiner noted that the Veteran reported that she injured her shoulder in service and but then reported pain for those past 7 years, which contradicted her reporting during service and on her separation exam. At the June 2013 visit her shoulder was found to be not tender to palpation, with normal range of motion without pain. The examiner ultimately found that there was insufficient evidence to support the contention that the Veteran had an ongoing left shoulder condition during service. The examiner stated that the Veteran was diagnosed with a shoulder strain in 2013 (which was years after service). The examiner further stated that the Veteran's reports that she had the pain since her injury in service contradicted her multiple reports of no ongoing shoulder issues while she was still in service. The examiner also indicated that a muscle strain does not predispose one to have another muscle strain. In addition, the examiner stated that hypermobility spectrum disorder is not an acquired condition, but something one is born with and can predispose one to recurrent joint sprains and injuries due to hyperlaxity of the joints. After consideration of all the evidence of record the Board finds that the weight of the evidence is against finding that service connection for a left shoulder disability is warranted. The Board concludes that service connection for a left shoulder disability is not warranted on a direct basis as the Veteran's current left shoulder disability was not caused by service. While the Veteran's lay statements regarding her current symptoms and ongoing symptomology and in-service exposures are credible, the competent medical opinions of record and the treatment records are inconsistent with the Veteran's statements are considered to be of greater probative value in this instance. Specifically, as outlined by both VA examiners and as shown by the in-service and post-service treatment records, despite the Veteran's report of continuous shoulder pain in 2013, the records do not show any indication, even with repeated examination, of any residual to the left shoulder injury in service or for many years following service separation. The Veteran was repeatedly asked if she had shoulder pain, to which she replied that she did not. Moreover, she first obtained post-service treatment for her left shoulder almost seven years following service separation. Even then, there are contradicting reports of onset of her left shoulder problem at the time. While the Veteran's lay statements report that her current left shoulder strain is related to service, the record does not reflect that she has the requisite training or expertise to offer a medical opinion linking a current disability to service and as such the Veteran is not competent to provide a nexus opinion in this case. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). The Board finds that the medical evidence is more probative and credible than the lay opinions of record. The competent medical evidence including the November 2021 VA examination is entitled to significant probative weight. The November 2021 VA examiner found that it is less likely than not that the Veteran's left shoulder strain was caused by her military service. The examiner noted a review of the Veteran's STRs and a left shoulder injury in-service, but noted the Veteran stating on several occasions even on separation that she had no further problems after the in-service injury. The examiner also noted that a November 2006 record revealed a normal x-ray for the left shoulder and noted no further shoulder problems until her June 2013 left shoulder strain diagnosis. The examiner noted no evidence of chronicity of left shoulder problems. The examiner found that it is less likely than not that the Veteran's current left shoulder disability was related to service. The Board finds that direct service connection is not warranted as the Veteran's current left shoulder strain was not onset in or caused by service. The Board notes the Veteran was seen in-service in 2005, after an alleged left shoulder injury while doing pullups. However, a December 2005 radiology note indicated that the Veteran's shoulder was normal, with no fractures or dislocation. In addition, there after she reported having no further problems with her shoulder. The Board has considered the Veteran's lay statements however, the Board gives more probative weight to the competent medical evidence especially the November 2021 VA examination, for these reasons and those stated above. As such the Board finds the Veteran's current left shoulder strain is less likely than not related to active service In conclusion, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for a left shoulder strain. Since the preponderance of the evidence is against the claim, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107 (b); Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001); Gilbert v. Derwinski, 1 Vet. App. 49, 5557 (1990); 38 C.F.R. § 3.102. For these reasons, the claim is denied. R. Erdheim Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board E.Long-Ellis, 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.