Citation Nr: 22040144 Decision Date: 07/13/22 Archive Date: 07/13/22 DOCKET NO. 15-89 869A DATE: July 13, 2022 ORDER Entitlement to service connection for right epicondylitis is denied. Entitlement to service connection for left epicondylitis is denied. FINDING OF FACT The Veteran's right and left elbow disabilities did not have its onset during active duty and has not been shown to be related to military service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for right epicondylitis are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to service connection for left epicondylitis are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from March 1982 to March 1986. These matters come before the Board of Veterans' Appeals (Board) on appeal from a July 2015 rating decision by an Agency of Original Jurisdiction (AOJ) of the United States Department of Veterans Affairs (VA). The Veteran testified at an August 2019 hearing held before the undersigned Veterans Law Judge (VLJ). A transcript of the hearing is associated with the claims file. These issues were previously before the Board, most recently in February 2022, at which time they were remanded for additional development. With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his representative has advanced any procedural arguments in relation to VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all 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 establish service connection on a direct basis, the record requires competent evidence showing: (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, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Some chronic diseases may be presumed to have been incurred in service if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Arthritis and organic diseases of the nervous system, each with a presumptive period of one year following separation from service, are listed conditions. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence, the benefit of the doubt is afforded the claimant. The Veteran asserts he has right and left epicondylitis due to his time in service, more specifically as due to his in-service duties of steering a Gama Goat. The Veteran's service treatment records (STRs) are negative for complaints of arm and/or elbow pain in service. There is no record of an elbow or arm disability on the Veteran's separation examination. VA treatment records note treatment for complaints of left elbow pain in January 2005 at the Veteran's annual physical examination. He reported experiencing left elbow pain for the past 2 months, with no injury. He stated he is a mechanic and uses his hands a lot and is having increasing pain. The clinician noted no swelling and no pain with palpation. Pain primarily occurred after the Veteran works all day as a mechanic. Tendonitis was suspected. Physical therapy notes dated June 2011 reflect the Veteran reported experiencing bilateral forearm pain about three years earlier which he attributed to repetitive overuse; he denied trauma. Veteran was noted to be an auto mechanic with heavy use of his arms. X-rays from December 2013 indicate arthritic pain and chronic epicondylitis. January 2014 treatment notes indicate right elbow pain, suspected mostly degenerative joint disease; he received an epicondylar injection to left elbow. At his hearing, the Veteran testified that he experienced pain from steering the Gama Goats, a six wheel vehicle. He further testified that he did not seek treatment for this pain because he didn't want anyone to know that he might not be able to drive the truck. He testified that his arms hurt after service whenever he used them "hard." The Veteran testified that it was the struggle of turning the steering wheel without power steering which caused this pain. He did not seek treatment after service due to financial hardship. Private medical records include a June 2015 MRI report which documented severe radiocapitellar and moderate proximal radioulnar osteoarthritis, moderate joint effusion, and synovitis; and severe tendinopathy and 50 percent thickness partial tear of the common extensor tendon origin at the lateral humeral epicondyle. The issues were remanded by the Board in November 2019 to afford the Veteran a VA elbow and forearm examination to determine the nature and etiology of any current elbow and/or forearm disability. VA treatment records indicate the Veteran was seen in April 2019 for preoperative clearance for surgery on his cervical spine; he was wondering if he would be able to continue working as a mechanic, which he wants to do, and if he will be able to resume pickleball. A July 2019 note indicated the Veteran worked as a mechanic and plays pickleball. A December 2019 note reflects the Veteran wants to continue to work as a mechanic and to continue to play pickleball. The Veteran underwent a VA elbow examination in December 2019. The VA examiner noted the Veteran's diagnoses of bilateral lateral epicondylitis and degenerative arthritis. The Veteran reported his history of bilateral elbow pain, left greater than right, and that he has received left elbow steroid injections. He stated that he worked as an auto mechanic and uses wrenches and impact tools which caused vibration and pain in his bilateral elbows left greater than right. An MRI of the left elbow showed significant arthritis and tendinitis with a partial thickness tear of the common extensor tendon of the left elbow. The Veteran has full range of motion of elbows and pain on palpating over the lateral epicondyle and common extensor tendon of the left upper extremity, mild tenderness upon palpating over right lateral epicondyle. The VA examiner determined that it was less likely than not that the Veteran's bilateral elbow condition was incurred in or caused by the claimed in-service injury, event, or illness. The VA examiner noted that the Veteran's STRs were silent for any elbow condition or injury in service and that the Veteran did not complain of any elbow condition until approximately 2013. The VA examiner determined that it is more likely than not that the Veteran's bilateral elbow condition is related to his work as a mechanic after leaving the military. The Board found that this opinion was inadequate for adjudication purposes as it did not consider the Veteran's competent and credible reports of experiencing elbow pain in service resulting from the difficulty of steering the Gama Goat or reports of problems since. The issues were remanded in December 2020 for an addendum opinion. In December 2020, an addendum opinion was provided from the December 2019 VA examiner. The VA examiner stated that after reviewing the service medical records, current research and performing a physical examination and medical history, he stood by his December 2019 opinion. The VA examiner stated that he had a discussion with the Veteran and the Veteran told him the story of him driving a Gama Goat. The VA examiner stated, "I am very familiar with a Gama Goat is served over 20 years in the military myself. I took this into consideration when forming my opinion. I stated that I thought the Veteran's bilateral elbow condition as unrelated to his military service. It is more likely than not that the Veteran's bilateral elbow condition is related to his work as a mechanic after leaving the military." Unfortunately, this opinion did not comply with the Board's remand directives as it did not address the Veteran's accounts of his in-service experiences nor his statements regarding the continuity of his symptoms since service. The examiner's experience is simply not relevant. In February 2022, the Board remanded the matters again for an opinion that complies with its prior remand instructions. In February 2022, an addendum opinion was provided from a different VA examiner. The VA examiner determined it was less likely than not that the Veteran's left and/or right epicondylitis is caused or aggravated by the stresses of steering a Gama Goat in service. The VA examiner noted that the Gama Goat was difficult to steer, and that the Veteran's STRs were silent for complaints of elbow pain in service. The VA examiner noted that the Veteran worked as a mechanic for 35+ years after service. The VA examiner determined that the ability to perform the essential functions of the job as a mechanic for 30 + years after separating from service precludes the examiner from attributing military service as the putative element of cause or aggravation to his current elbow condition. The VA examiner noted that a September 2021 note from Peak Neurology documented "progressive loss of grip and strength in both hands, these symptoms presented prior to C-spine surgery in 2018 but had progressed. Worked in 2019 on and off still recovering from C-spine surgery. Since 2021 has been working in his own shop full time. He will be starting a job next week as a fabricator." The VA examiner noted that she provided special consideration to the lay statements. She noted that records show that the Veteran did not begin to complain of elbow condition until approximately 2013 and again in 2015. The VA examiner stated, "Per 'lay statements from claimant,' the elbow condition was due to his work as a mechanic working in confined spaces, repetitive twisting of screwdrivers, working with wrenches and other tools (left greater than right), because the claimant is left hand dominant. The VA examiner noted that the Veteran's medical records show he suffers from multiple co-existing neurological and musculoskeletal conditions (attributable to 35+ years working as a mechanic) affecting the bilateral upper extremities contributing to his symptoms and disabilities. The question in this case is whether a causal relationship or nexus exists between the Veteran's bilateral epicondylitis and his claimed in service elbow pain due to steering Gama Goats. After a careful review of the evidence of record, the Board finds that service connection for right and/or left epicondylitis is not warranted. There is no competent and credible evidence linking the current diagnosis to service. While the Veteran as expressed his belief in a connection, he lacks the knowledge and training required to render a nexus opinion on a cause and effect relationship unobservable to a lay person. Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). There is no medical evidence associated with the file that establishes a link between the Veteran's reported in-service elbow pain from steering Gama Goat vehicles and his currently diagnosed right and/or left epicondylitis, nor has a medical professional determined that his current disability is related to service. The Board finds there is no competent evidence of record which links the Veteran's bilateral epicondylitis to his active duty service. Accordingly, the Board concludes that the evidence is against the claim for service connection for bilateral epicondylitis, the benefit of the doubt rule is not applicable. 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Margaret M. Lunger, 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.