SHOULDER IMPAIRMENT OF

B. MULLINS · 2020 · Case ID: A20017862

DENIED

Summary

The Veteran, who served in the United States Army from April 1977 to July 1986, with an additional period in the Army National Guard, appeals the denial of service connection for several conditions. The Veteran claimed entitlement to service connection for a right shoulder strain and impingement syndrome, bilateral hip strain, radiculopathy of the bilateral hands (including carpal tunnel syndrome), and an acquired psychiatric disorder (major depression and PTSD). The Board denied all claims, finding that the preponderance of the evidence weighed against service connection for each condition. For the shoulder claim, the Board noted the lack of in-service complaints or treatment in service records, with post-service complaints emerging over a decade after separation. For the hip claim, service records were silent regarding hip complaints, and post-service records showed symptoms first noted around 2009, with no clear nexus to an in-service fall or subsequent diagnosis. For the hand radiculopathy, service records were silent, with post-service complaints of numbness and tingling in the hands first appearing around 2012, and a diagnosis of mild carpal tunnel syndrome noted in 2017, with no established link to service. For the psychiatric claim, service records were largely silent, with a positive depression screening in 2009 and a formal diagnosis of major depression in 2015, over a decade after separation, with no in-service treatment or nexus established. The Board found that lay evidence, while acknowledged, was outweighed by the lack of medical evidence supporting an in-service origin or nexus for any of the claimed conditions.

Rationale

Service treatment records silent for shoulder complaints/treatment; No in-service injury or diagnosis documented; Post-service complaints emerged over a decade after separation; VA exam found no causal linkage to service or lumbar spondylosis

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

190125-6804

Full Decision Text

Citation Nr: A20017862
Decision Date: 12/02/20 Archive Date: 12/02/20

DOCKET NO. 190125-6804
DATE: December 2, 2020

ORDER

Entitlement to service connection for right shoulder strain and impingement syndrome (claimed as chronic pain, right shoulder) is denied.

Entitlement to service connection for bilateral hip strain (claimed as hip pain) is denied.

Entitlement to service connection for radiculopathy, bilateral hands (to include carpal tunnel syndrome, left upper extremity) is denied.

Entitlement service connection for an acquired psychiatric disorder, to include major depression and posttraumatic stress disorder (PTSD) is denied.

FINDINGS OF FACT

1. The preponderance of the evidence weighs against finding that the Veteran’s right shoulder strain and impingement syndrome (claimed as chronic pain, right shoulder) was caused by or otherwise related to active service, to include as secondary to his service-connected secondary to lumbar spondylosis.

2. The preponderance of the evidence weighs against finding that the Veteran’s bilateral hip strain (claimed as hip pain) was caused by or otherwise related to active service, to include as secondary to his service-connected secondary to lumbar spondylosis.

3. The preponderance of the evidence weighs against finding that the Veteran’s radiculopathy, bilateral hands (to include carpal tunnel syndrome, left upper extremity) was caused by or otherwise related to active service, to include as secondary to his service-connected secondary to lumbar spondylosis.

4. The preponderance of the evidence weighs against finding that the Veteran’s acquired psychiatric disorder, to include major depression and PTSD, was caused by or otherwise related to active service, to include as due to an in-service event, injury, or disease.

CONCLUSIONS OF LAW

1. The criteria for establishing entitlement to service connection for a right shoulder strain and impingement syndrome (claimed as chronic pain, right shoulder) have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018).

2. The criteria for establishing entitlement to service connection for a bilateral hip strain (claimed as hip pain) have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018).

3. The criteria for establishing entitlement to service connection for radiculopathy, bilateral hands (to include carpal tunnel syndrome, left upper extremity) have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018).

4. The criteria for establishing entitlement to service connection for an acquired psychiatric disorder, to include major depression and PTSD have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2014); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2018).

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

On August 23, 2017, the President signed into law the Veterans Appeals Improvement and Modernization Act, Pub. L. No. 115-55 (to be codified as amended in scattered sections of 38 U.S.C.), 131 Stat. 1105 (2017), also known as the Appeals Modernization Act (AMA). This law creates a new framework for Veterans dissatisfied with VA’s decision on their claim to seek review. The Veteran chose to participate in VA’s test program RAMP, the Rapid Appeals Modernization Program. This decision has been written consistent with the new AMA framework.

The Veteran reports honorable active duty service with the United States Army from April 1977 to July 1986. An additional period of service included the United States Army National Guard.

The Veteran selected the higher-level review lane when he submitted the RAMP election form, dated July 2018. Accordingly, November 2018 rating decision considered the evidence of record as of the date VA received the RAMP election form. The Veteran timely appealed this November 2018 rating decision to the Board and requested evidence submission (within 90 days, no hearing request).

As a preliminary matter, the Board recognizes that the Veteran’s claim was originally filed as one of entitlement to service connection for major depression. However, in Clemons v. Shin
Veteran reports honorable active duty service with the United States Army from April 1977 to July 1986. An additional period of service included the United States Army National Guard.

As a preliminary matter, the Board recognizes that the Veteran’s claim was originally filed as one of entitlement to service connection for major depression. However, in Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009), the United States Court of Appeals for Veterans Claims (Court) held that the scope of a mental health disability claim includes any mental health disability that could reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and the other information of record. As such, as reflected on the first page of this decision, the Veteran’s claim has been rephrased as entitlement to service connection for an acquired psychiatric disorder, to include major depression and PTSD.

Duty to Assist and to Notify

VA is required to notify a claimant of what information or evidence is necessary to substantiate the claim; what subset of the necessary information or evidence, if any, the claimant is to provide; and what subset of the necessary information or evidence, if any, the VA will attempt to obtain. 38 C.F.R. § 3.159(b) (2018). Copies of compliant VCAA notices were located in the claim’s file.

VA’s duty to assist includes providing a thorough and contemporaneous medical examination, especially where it is necessary to determine the current level of a disability. Peters v. Brown, 6 Vet. App. 540, 542 (1994).

In this case, neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that “the Board’s obligation to read filings in a liberal manner does not require the Board... to search the record and address procedural arguments when the veteran fails to raise them before the Board.”); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument).

Thus, upon careful review of the file, the Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993).

Service connection, generally

Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C. § 1110, 1131 (2014); 38 C.F.R. §§ 3.303 (a), 3.304 (2018).

Entitlement to service connection benefits is established when the following elements are satisfied: (1) the existence of a current disability; (2) in-service incurrence or aggravation of a disease or injury; and, (3) a causal relationship between the current disability and the disease or injury incurred or aggravated during service (the medical ‘nexus’ requirement). See Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); 38 C.F.R. § 3.303 (a) (2018).

Service connection also is permissible on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b) (2018). See also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).

Furthermore, 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 a preponderance of the evidence is against the claim, in
, 7 Vet. App. 439, 448 (1995). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and, (3) nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998).

Furthermore, 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 a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107 (West 2014); 38 C.F.R. § 3.102 (2017); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of the matter, the benefit of the doubt will be given to the Veteran. Id.

The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on his behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board’s analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant).

Lay evidence, if competent and credible, may serve to establish a nexus in certain circumstances. See Davidson v. Shinseki, 581 F.3d 1313 (2009) (noting that lay evidence is not incompetent merely for lack of contemporaneous medical evidence). When considering whether lay evidence may be competent, the Board must determine, on a case by case basis, whether the Veteran’s particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007) (holding that “[w]hether lay evidence is competent and sufficient in a particular case is a factual issue

1. Entitlement to service connection for a right shoulder strain and impingement syndrome (claimed as chronic pain, right shoulder)

The Veteran contends that he suffers from a right shoulder strain and impingement syndrome as causally related to active service, to include as secondary to his service-connected lumbar spondylosis.

The threshold inquiry before the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that, while the Veteran has a current diagnosis of a right shoulder strain, and rotator cuff tendonitis, the preponderance of the evidence is against finding that either condition began during active service, or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d).

Service treatment records were largely silent for complaints of a right shoulder condition or any related treatment. In March 1977, a report of medical examination made no reference to a bilateral shoulder abnormality at enlistment. No reports of a shoulder, bone, joint, or other deformity were listed in a corresponding report of medical history. At separation, no physical abnormalities were identified in May 1986. The comments section indicates that a small growth or lesion was excised from the right hand. Thereafter, no residual conditions were reported. In a corresponding report of medical history, complaints of depression or excessive worry and leg cramps were listed. During a second period of service, a periodic report
(a), (d).

A private treatment record, dated April 1998, shows that the Veteran was evaluated for complaints of severe right shoulder and upper bicep pain, to include with raising the arm. Reportedly, he experienced pain while performing physical activities such as military calisthenics workouts and push-ups. A physical assessment suggested inflammation of the tendon supraspinatus muscle. Motrin was prescribed to treat pain. The Veteran was provided an excuse from physical training workouts for the National Guard for 2 weeks.

An individual sick call slip, dated July 1999, referenced an injury to the right hand and left ankle suffered during a fall while on a road march. No fractures or dislocations, or other abnormalities were indicated.

Post-service treatment records show sporadic complaints of shoulder pain and numbness. In February 2012, an outpatient nursing note referenced shoulder pain over a 1-month period. During a follow-up visit, two months later, the Veteran reported a history of chronic right shoulder pain dating back to 1996. Pain was rated as an 8 on a 10-point scale. The Veteran experienced difficulty reaching overhead, to include removing his shirt and sleeping on his right side.

An orthopedic clinical note, dated October 2012, indicated that the Veteran reported right shoulder and left knee pain dating back to active service in 1987. Reportedly, he fell off a cliff in 1986. Over time, the Veteran’s right shoulder pain worsened and included elevation limited to 120 degrees. No pain was observed with external rotation of the arm from the side. Magnetic resonance imaging of the right shoulder revealed supraspinatus tendinopathy and AC joint arthritis. Physical therapy was recommended.

In September 2013, x-rays of the right shoulder found no significant pathology. Prescribed treatments include acupuncture, a transcutaneous electrical nerve stimulation (TENS) unit, and Naproxen.

A primary care treatment record, dated April 2015, listed chronic back, knee and hip pain here for follow-up. Other symptoms include right arm numbness, that was particularly bothersome overnight. Magnetic resonance imaging of the cervical spine revealed a mild central broad-based disc osteophyte complex bulge at C3-C4, C4-C5 and C5-C6. Mild right neural foramen stenosis was also noted at C3-C4. One year earlier, a nerve conduction study of the upper extremities revealed normal findings. Electromyography (EMG) findings demonstrated features consistent with chronic neuropathic changes in the muscles supplied by the bilateral nerve roots at C5, C6 and C7. A physical examination of the right shoulder revealed normal muscle strength in the biceps and triceps. Sensation was grossly intact. The Veteran’s range of motion of the right arm was deemed very limited.

An X-ray series of the lumbar spine, dated February 2016, showed discogenic degenerative changes.

In May 2016, the Veteran underwent a neurological consultation. Therein, he complained of musculoskeletal pain in the neck, low back, shoulders, hips and knees. Neurological symptoms included numbness and pain in the bilateral upper extremities, neck, low back, shoulders, hips, and knees. Oral medications include Naproxen, Trazodone, Cyclobenzaprine, Duloxetine, and Gabapentin were prescribed to treat his symptoms. A peripheral nerve conduction study revealed normal findings in the upper and lower extremities. EMG features denoted chronic neuropathic changes in the muscles supplied by the bilateral C5-C6 nerve roots in the upper extremities and L5-S1 nerve roots on the bilateral lower extremities. The findings were deemed suggestive of cervical and lumbosacral radiculopathy.

Several months later, in November 2016, a follow-up neurological consultation referenced constant neck and back pain with numbness in the upper and lower extremities. The Veteran described his pain
Oral medications include Naproxen, Trazodone, Cyclobenzaprine, Duloxetine, and Gabapentin were prescribed to treat his symptoms. A peripheral nerve conduction study revealed normal findings in the upper and lower extremities. EMG features denoted chronic neuropathic changes in the muscles supplied by the bilateral C5-C6 nerve roots in the upper extremities and L5-S1 nerve roots on the bilateral lower extremities. The findings were deemed suggestive of cervical and lumbosacral radiculopathy.

Several months later, in November 2016, a follow-up neurological consultation referenced constant neck and back pain with numbness in the upper and lower extremities. The Veteran described his pain as sharp, stabbing, and it interferes with sleep. Neck pain radiates to the Veteran’s right shoulder. Tightness was also reported. Worsening symptoms were reported in the left upper extremity. In the upper extremities, pain was rated as a 7 without medication, and 5 with medication. Physical activity triggers weakness, pain and numbness in the upper and lower extremities, to include the hands and feet. Similar symptoms were reported upon rising in the morning. To treat pain, the Veteran endorsed use of Naproxen.

On physical examination, motor strength testing revealed normal findings. There was no evidence of muscle atrophy. Sensation to light tough and pinprick, was decreased in the upper and lower extremities, distally. The Veteran endorsed sensitivity to cold temperatures. Spurling testing yielded positive findings. Deep tendon reflexes in the bilateral triceps, biceps, brachioradialis, patellar, achilles, and plantar flexion were normal.

In February 2017, a primary care outpatient record noted chronic back, neck, and bilateral shoulder pain. The Veteran also reported chronic numbness in the left arm. Pain radiates from the low back down the right leg. Physical therapy treatments were unable to resolve his shoulder pain. X-rays of the bilateral shoulders found no evidence of acute fracture or dislocation. The soft tissues also appeared normal.

The Veteran was afforded a VA examination in July 2015. Current diagnoses included a right shoulder strain, and rotator cuff tendonitis. During the clinical interview, the Veteran reported pain in the bilateral shoulders with worsening symptoms on the right side. An onset of symptoms in the left shoulder occurred in 1998. Prescribed treatments included physical therapy, acupuncture and chiropractic treatments. Flare-ups of pain were described as difficulty lifting and carrying. Functional loss was described as decreased movement of the shoulders, arms, and difficulty with heavy lifting.

Range of motion of the right shoulder included flexion limited to 90 degrees, abduction limited to 100 degrees, internal and external rotation limited to 90 degrees. Abnormal range of motion contributes to functional loss in terms of an impaired ability to bend, twins, or turn. Pain was observed on examination and it causes functional loss as with all ranges of motion (flexion, abduction, internal rotation and external rotation). There was no evidence of pain with weight bearing. Localized tenderness or pain to palpation of the right shoulder was described as moderate over the anterior and posterior glenohumeral joint consistent with a shoulder strain. Objective evidence of crepitus was also noted. Pain, weakness, fatigue, lack of endurance, and incoordination impacted functional ability. With repetitive use testing, a reduction in range of motion of 5 degrees was observed in all directions. Other factors contributing to the Veteran’s disability included less movement than normal, weakened movement, and pain on movement. Muscle strength testing was slightly reduced. There was no evidence of muscle atrophy or ankylosis. Positive findings of a rotator cuff condition were observed, bilaterally. There was no evidence of instability, dislocation, AC joint, clavicle, or scapula condition. No loss of head, nonunion, fibrous union of the humerus, or malunion of the humerus with moderate or marked deformity. No other pertinent medical findings were indicated. The Veteran denied use of assistive devices.

Diagnostic imaging was silent for degenerative or traumatic arthritis. X-ray films of the left shoulder revealed trace enthesophyte formation along the greater tuberosity at the rotator cuff attachment. An approximately 6 millimeter (mm) sclerotic lesion was observed at the proximal humeral diaphysis. The findings were consistent with rotator cuff tendonitis. A functional impact was described as difficulty with prolonged heavy lifting, carrying, pushing, and pulling.

Following the clinical evaluation, the examiner opined that it is less likely than not that the Veteran’s right shoulder condition is proximately due to or the result
deformity. No other pertinent medical findings were indicated. The Veteran denied use of assistive devices.

Following the clinical evaluation, the examiner opined that it is less likely than not that the Veteran’s right shoulder condition is proximately due to or the result of his service-connected lumbar spondylosis. In support of he stated conclusion, the examiner indicated that there is insufficient evidence to relate the Veteran’s back condition with his right shoulder. Further, there is no concrete relationship between the two conditions.

On review of the record, the Board finds that service connection is not warranted for the Veteran’s right shoulder condition, to include as secondary to his service-connected lumbar spondylosis.

In the instant case, there is no evidence that the Veteran possesses the required training to diagnose a shoulder disability or opine as to its etiology. To the extent his statements may be competent, the Board ultimately assigns greater probative weight to the medical evidence of record, to include opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale.

It is further noted that the Board is not free to substitute its own judgment for that of a medical expert. See Colvin v. Derwinski, 1 Vet. App. 171, 175 (1991). Conversely, the Board is required to assess the credibility and weight of the evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997).

Review of service treatment records are silent for complaints of a right shoulder injury, treatment for pain, or a related diagnosis. While a line of duty injury to the low back has been confirmed, no complaints of a related shoulder injury has been documented. In fact, only an isolated complaint of right shoulder pain was reported with physical training. Post-service treatment records reference sporadic complaints of right shoulder pain. In February 2012, the Veteran complained of right shoulder pain dating back to 1987. MRI findings, dated October 2012, revealed supraspinatus tendinopathy and AC joint arthritis of the right shoulder. Thereafter, the Veteran received periodic treatment for right shoulder pain including physical therapy, oral pain medications, acupuncture, and TENS unit therapy. On examination in July 2015, the VA examiner rendered several bilateral shoulder diagnoses. However, no causal linkage to active service was established, to include as due to the Veteran’s service-connected lumbar spondylosis.

While the Board recognizes that the VA examiner’s etiological findings were brief, it nevertheless notes that the medical evidence is largely silent for any basis for linking the Veteran’s shoulder disability to active service. During his period of reserve service, the Veteran sought private treatment for shoulder pain. However, there is no evidence of in-service injury to either shoulder or related treatment. Post-service treatment records show complaints of pain beginning on or about 2012; more than a decade after separation from service.

Although the Board recognizes the Veteran’s subjective belief that he is entitled to service connection for a right shoulder condition, the evidence of record does not support his contention. Even if the Board were to assume the veracity of his complaints of symptoms in 1998, no additional complaints were reported until more than a decade later. Thus, no nexus could be reasonably established.

Based on the evidence cited above, the Board finds that the preponderance of the evidence is against the Veteran’s claim for service connection for a right shoulder disability. As the preponderance of the evidence is against the claim for service connection for a right shoulder disability, the benefit of the doubt rule does not apply. 38 C.F.R. § 5107 (2014); 38 C.F.R. § 3.102
connection for a right shoulder condition, the evidence of record does not support his contention. Even if the Board were to assume the veracity of his complaints of symptoms in 1998, no additional complaints were reported until more than a decade later. Thus, no nexus could be reasonably established.

2. Entitlement to service connection for bilateral hip strain (claimed as hip pain)

The Veteran contends that he suffers from bilateral hip strain (claimed as hip pain) that are causally related to active service, to include a secondary to his service-connected lumbar spondylosis.

The threshold inquiry before the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that, while the Veteran has a current diagnosis of a bilateral hip strain, the preponderance of the evidence weighs against finding that his bilateral hip strain began during or is otherwise causally related to active service, to include as secondary to his service-connected lumbar spondylosis. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d).

Service treatment records are largely silent for complaints of hip pain or any related condition or injury. At enlistment, no bilateral hip abnormalities were observed. No complaints of a bone, joint, or other deformity were listed in a corresponding report of medical history. In November 1983, a clinical record, referenced hip pain. No formal diagnosis was rendered. At separation, no physical abnormalities were identified, to include involving the bilateral hips.

Post-service treatment records show complaints of hip pain. A nursing outpatient note, dated April 2009, documented left lower back and left hip pain. Pain was described as shooting. Worsening symptoms were reported with prolonged walking. Reports of difficulty with ambulation and prolonged sitting were associated with bilateral hip pain in May 2011. Other symptoms included a periodic need to shift positions due to pain. The Veteran endorsed use of Motrin to treat pain.

A primary care treatment records between February 2012 and April 2015, referenced chronic back, hip and knee pain. Prescribed treatments included acupuncture, chiropractic treatment, a TENS unit, and oral medication, Naproxen.

In July 2015, the Veteran was afforded a VA examination. A current diagnosis of a bilateral hip strain was indicated. During the clinical interview, the Veteran reported symptoms dating back to a fall from a cliff-line during a training exercise in 1995. Overtime, he experienced worsening hip pain which interfered with his ability to walk or stand for prolonged periods. Periodic bouts with instability on his feet were also endorsed. Flare-ups of pain were reported with inclement weather. Functional loss was described as difficulty bearing weight, particularly with physical activities such as running, bowling, or playing volleyball.

Range of motion testing revealed flexion limited to 75 degrees, extension limited to 15 degrees, internal rotation limited to 30 degrees, external rotation limited to 40 degrees, hip abduction limited to 30 degrees, and left hip adduction limited to 10 degrees. The Veteran reported an inability to cross his legs. A loss of 10 degrees of motion was reported in all directions. Range of motion contributes to functional loss in terms of a limited ability to bend, twist, or turn. On examination, pain was observed with all ranges of motion, to include with weight-bearing. Mild localized tenderness or pain to palpation was reported along the anterior and lateral glenohumeral joint tenderness. There was no evidence of crepitus. Pain, weakness, fatigability and incoordination significantly limit functional ability over time.

Additional factors contributing to the Veteran’s disability includes less movement than normal, weakened movement, instability of station, disturbance of locomotion, interference with sitting and standing, and pain on movement, bilaterally. Muscle strength testing was slightly reduced. Muscle atrophy observes in the right lower extremity compared to the left. It was measured by change in width of 10 centimeters (cm). There was
observed with all ranges of motion, to include with weight-bearing. Mild localized tenderness or pain to palpation was reported along the anterior and lateral glenohumeral joint tenderness. There was no evidence of crepitus. Pain, weakness, fatigability and incoordination significantly limit functional ability over time.

Additional factors contributing to the Veteran’s disability includes less movement than normal, weakened movement, instability of station, disturbance of locomotion, interference with sitting and standing, and pain on movement, bilaterally. Muscle strength testing was slightly reduced. Muscle atrophy observes in the right lower extremity compared to the left. It was measured by change in width of 10 centimeters (cm). There was no evidence of ankylosis. The Veteran denied use of assistive devices. No diagnostic testing was indicated. The Veteran described a functional impact as difficulty with prolonged walking, sitting, standing or climbing.

Following the clinical evaluation, the examiner opined that it is less likely than not that the Veteran’s bilateral hip strain was proximately due to or the result of lumbar spondylosis. In support of the stated conclusion, the examiner found insufficient evidence to support an etiological linkage. While a treatment record, dated May 2012, suggested an onset of symptoms due to an in-service fall in 1995, no complaints of symptoms were reported at that time or within one year thereafter.

Post-service treatment records show a radiological finding which confirmed degenerative changes in the bilateral hips and discogenic degenerative changes of the lumbar spine on or about 2016. No acute fracture or aggressive osseous process was indicated. A current diagnosis of osteoarthritis of the bilateral hips was also rendered.

In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. While the Veteran is competent to report on the onset of his bilateral hip strain, the medical evidence fails to show a current diagnosis in service or within one year of separation. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006).

While the Board recognizes the Veteran’s subjective belief that his bilateral hip strain is causally related to active service, and notes a current diagnosis of osteoarthritis of the bilateral hips (rendered in March 2016) the medical evidence does not support a finding of nexus between his in-service fall with back injury and complaints of hip pain first noted on or about 2009. Moreover, the evidence of record fails to show that the Veteran has the requisite training or expertise to offer a medical opinion as complex as linking a current bilateral hip condition to active service, to include as secondary to his service-connected lumbar spondylosis condition.

Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to service connection for bilateral hip pain, to include as secondary to her service-connected lumbar spondylosis must be denied.

3. Entitlement to service connection for radiculopathy, bilateral hands (to include carpal tunnel syndrome, left upper extremity)

The Veteran contends that he suffers from radiculopathy, bilateral hands (to include carpal tunnel syndrome, left upper extremity) that are causally related to active service, to include as secondary to his lumbar spondylosis.

The threshold inquiry before the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that, while the Veteran has a current diagnosis of carpal tunnel syndrome of the bilateral hands, the preponderance of the evidence weighs against finding that the condition began during or is otherwise causally related to active service, to include as secondary to his service-connected lumbar spondylosis. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d).

Service treatment records are largely silent for complaints of radiculopathy of the bilateral hands or any related condition. At enlistment, no bilateral hand abnormalities were noted. No complaints of a bone, joint, or other deformity were referenced in a corresponding report of medical history. In April 1986, a lesion was excised from the Veteran’s right hand. Thereafter, he was granted a profile for 7-10 days with limited physical activity. No bilateral hand abnormalities were observed on physical examination at separation in May 1986. In July 1999, a statement of medical examination indicated that the Veteran suffered a left ankle and right-hand injury during fall while participating in a road march. Pain and swelling were reported. No reports of numbness, tingling, or radiculopathy impacting the bilateral hands were noted.

Post-service treatment records show periodic complaints of numbness, tingling, and pain in the bilateral hands. A nursing triage note, dated May 2012, referenced worsening right-hand pain. An onset of symptoms began 2 weeks earlier, with aggravation due to movement or application of pressure. Naproxen was used to treat pain. One year later, in March 2013, the Veteran was re-evaluated for complaints of chronic left shoulder pain and numbness that radiates to left arm and hand. Worsening symptoms were reported over the prior week. The Veteran denied any new injury or recent heavy lifting.

A patient-visit clinical record, dated April 2015, shows that the Veteran complained of numbness and tingling in both arms and hands. No pain to palpation was observed on physical examination. Full range of motion was observed against resistance. Radiculopathy in the bilateral shoulders with radiating symptoms to the 4th and 5th finger was suggested. The Veteran reported frequent bouts with symptoms over the prior 2-year period, to include while sleeping.

In November 2016, a neurological consultation referenced numbness and tightness in the upper and lower extremities. Specifically, the Veteran described difficulty gripping items with both hands. A musculoskeletal examination in March 2017, revealed mild subjectively decreased sensation in the left ulnar forearm, hand, and fingers.

A neurology clinic, in April 2017, referenced paresthesia in the upper extremities. A nerve conduction study yielded findings consistent with mild median motor and sensory neuropathy in the bilateral wrist with demyelinating features. A suggestion of mild carpal tunnel syndrome was also noted.

On examination in July 2015, current diagnoses included bilateral upper extremity peripheral neuropathy and carpal tunnel syndrome of the left hand. During the clinical interview, the Veteran reported moderate neuropathy (also described as constant pain) in the upper arms, with weakness, tingling, and numbness. Moderate paresthesias and/or dysesthesias impacted the bilateral upper extremities. Muscle strength was slightly reduced. The Veteran’s deep tendon reflexes were normal. Mild muscle atrophy in the right thigh was noted. Decreased sensation was noted in the bilateral shoulders, forearms, hands, and fingers. Tinel’s sign testing was positive in the left median nerve. Mild incomplete paralysis impacted the left median nerve. The Veteran denied use of assistive devices. A functional impact was described as difficulty with prolonged lifting and carrying.

Following the clinical evaluation, the examiner opined that it is less likely than not that the Veteran’s radiculopathy of the bilateral hands is proximately due to or the result of lumbar spondylosis claimed as back pain. In support of the stated conclusion, the examiner noted that a back condition only affects peripheral nerves of the lower extremities. Therefore, the Veteran’s current peripheral neuropathy in the bilateral upper extremities is not related to his back condition.

In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. While the Veteran is competent to report on his experience of radiculopathy of the bilateral hands and its onset, the medical evidence fails to show complaints of symptoms or a related diagnosis prior to 2012. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). At no time has the record revealed or suggested a causal linkage between the Veteran’s radiculopathy of the bilateral hands and active service, to include as secondary to her service-connected lumbar spine condition.

While the Board recognizes the
extremities is not related to his back condition.

While the Board recognizes the Veteran’s subjective belief that his bilateral hand condition is causally related to active service, the medical evidence does not support a finding of nexus between active service and symptoms first noted in 2012. Moreover, the evidence of record fails to show that the Veteran has the requisite training or expertise to offer a medical opinion as complex as linking his current diagnosis of bilateral hand radiculopathy to active service, to include the secondary to his service-connected lumbar spondylosis or an in-service fall.

Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to service connection for radiculopathy of the bilateral hands, to include as secondary to her service-connected lumbar spondylosis must be denied.

4. Entitlement service connection for an acquired psychiatric disorder, to include major depression and PTSD

The Veteran contends that his acquired psychiatric disorder, to include major depression and PTSD is causally related to active service. However, as outlined below, the preponderance of the evidence of record is against his claim.

In analyzing the Veteran’s claim, the threshold inquiry before the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease.

The Board concludes that, while the Veteran has a current diagnosis of major depression (and a possible diagnosis of PTSD), the preponderance of the evidence is against finding that his condition began during active service, or are otherwise related to an in-service injury, event, or disease. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); 38 C.F.R. § 3.303 (a), (d).

Service treatment records are largely silent for any complaints of depression, nervous trouble, excessive worry, or any related condition. In fact, only a single reference to depression and excessive worry were endorsed in a report of medical history dated May 1986. No treatment for psychiatric symptoms or any related condition was reported in-service or within one year of separation.

Post-service treatment records suggest a positive screening for depression in December 2010. Thereafter, formal complaints of depressive symptoms were first indicated on or about 2015. Specifically, in January 2015, a depression screening note indicated that the Veteran endorsed feeling depressed, hopeless, and low or reduced motivation with loss of interest, more than half the days of a given month.

In February 2015, the Veteran underwent an initial mental health evaluation. During the clinical interview, he reported recurring depression since 1986. He identified current symptoms including chronic fatigue, irritability, a decreased appetite, low motivation, and re-experiencing. The diagnostic impression listed major depression and a possible personality disorder. At the time, the Veteran denied any history of trauma that would meet the DSM criteria for PTSD. A score of 32 was reported for the Beck depression inventory study, which indicates severe depression.

In June 2015, a mental health physician note shows that the Veteran was observed as depressed. His mood was described as frustrated with a congruent affect. The Veteran’s memory was deemed intact, with good judgment and insight. He acknowledged that pain impairs his ability to sleep. Fluoxetine prescribed to treat his symptoms.

In November 2015, a psychotherapy treatment session listed current diagnoses including depression and PTSD. Prescribed medications included Paroxetine, Prazosin, and Trazodone.

A subsequent mental health treatment noted, dated November 2016, indicated that the Veteran presented with recurrent sleep problem and a negative mood. Reports of chronic pain impacted his neck, back, shoulders, and arms with numbness that radiates to hand and fingers. Pain, numbness and tingling interferes with sleep. Changes in position, triggers pain. Prescribed medication
The Veteran’s memory was deemed intact, with good judgment and insight. He acknowledged that pain impairs his ability to sleep. Fluoxetine prescribed to treat his symptoms.

In November 2015, a psychotherapy treatment session listed current diagnoses including depression and PTSD. Prescribed medications included Paroxetine, Prazosin, and Trazodone.

A subsequent mental health treatment noted, dated November 2016, indicated that the Veteran presented with recurrent sleep problem and a negative mood. Reports of chronic pain impacted his neck, back, shoulders, and arms with numbness that radiates to hand and fingers. Pain, numbness and tingling interferes with sleep. Changes in position, triggers pain. Prescribed medication includes Trazodone. It improves pain but causes daytime drowsiness. Due to chronically impaired sleep, the Veteran experiences irritability, frustration, anger, and a depressed mood. Other prescribed medications include Prazosin. It improves the Veteran’s experience of nightmares.

In the Veteran’s January 2019 Ramp Opt-in Election, he selected evidence submission. Attached thereto, was a lay statement from a fellow solider which asserted personal knowledge of the Veteran’s involvement in a search and rescue mission. Specifically, in August 1997, Korean Airlines Flight 801 approached A.B. Won Pat International Airport in Agana, Guam, while en route from Seoul, South Korea. The Boeing 747-300 aircraft crashed in a jungle section of Nimitz Hill. Following the accident, the Veteran was among 500 soldiers called to provide security, communication support, recovery and care for trauma victims, crowd control and accounting for casualties.

The Board acknowledges that noted lay assertions and the Veteran’s suggestion of a causal linkage between active service and his current diagnosis of depression.

In analyzing the Veteran’s claim, it is noted that the Veteran has not been afforded a VA examination for his acquired psychiatric disability.

In determining whether the duty to assist requires that a VA medical examination be provided, or medical opinion obtained with respect to a veteran’s claim for benefits, there are four factors for consideration.

These four factors are: (1) whether there is competent evidence of a current disability or persistent or recurrent symptoms of a disability; (2) whether there is evidence establishing that an event, injury, or disease occurred in service, or evidence establishing certain diseases manifesting during an applicable presumption period; (3) whether there is an indication that the disability or symptoms may be associated with the veteran’s service or with another service-connected disability; and (4) whether there otherwise is sufficient competent medical evidence of record to make a decision on the claim. See McLendon v. Nicholson, 20 Vet. App. 79 (2006); 38 U.S.C. § 5103A(d); 38 C.F.R. § 3.159(c)(4).

With respect to the third factor above, the Court of Appeals for Veterans Claims has stated that this element establishes a low threshold and requires only that the evidence “indicates” that there “may” be a nexus between the current disability or symptoms and the veteran’s service.

Therefore, a medical examination would serve no useful purpose in this case, since the requirement of an in-service disease or injury to establish a service connection claim cannot be met upon additional examination. The Veteran was not prejudiced by the lack of VA examination.

In making all determinations, the Board has fully considered all medical evidence and lay assertions of record. Generally, the Veteran is presumed competent to report on the onset of his current symptoms, their impact on his daily living and employment, and such reporting is deemed credible. However, as to the etiology of a particular claimed disability, the issue of causation of a medical condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In the instant case, there is no evidence that Veteran possesses the required training to diagnose a depressive disorder or opine as to its etiology. To the extent his statements may be competent, the Board ultimately assigns greater probative weight to the medical evidence of record, to include opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale.

In this case, the Board has fully considered all lay assertions of record, to include the fellow service-member’s account of the Veteran’s deployment to a search and rescue mission following a plane crash in 1997. Even assuming the veracity of the lay statements noted, the evidence of record fails to show any in-service treatment for nervous trouble, depression, or any related psychiatric condition. In fact, post-service treatment records show a favorable screening for depression in 2009 and an initial diagnosis of major depression noted on February 2015. At
competent, the Board ultimately assigns greater probative weight to the medical evidence of record, to include opinions rendered by trained medical professionals based on appropriate diagnostic testing and reasonably drawn conclusions with supportive rationale.

In this case, the Board has fully considered all lay assertions of record, to include the fellow service-member’s account of the Veteran’s deployment to a search and rescue mission following a plane crash in 1997. Even assuming the veracity of the lay statements noted, the evidence of record fails to show any in-service treatment for nervous trouble, depression, or any related psychiatric condition. In fact, post-service treatment records show a favorable screening for depression in 2009 and an initial diagnosis of major depression noted on February 2015. At that time, current symptoms included a depressive mood, irritability, loss of motivation/interest. During the clinical evaluation, the Veteran denied any prior history of trauma that would support a current diagnosis of PTSD. While lay contentions are acknowledged, as to the finding of “nexus,” the Board notes that record is largely silent for any basis upon which to conclude that the Veteran’s symptoms are causally related to active service. Moreover, a VA examination would service little benefit in establishing any such connection.

While the Board recognizes the Veteran’s subjective belief that his psychiatric symptoms are causally related to active service, the evidence of record does not support his assertion. In fact, a formal diagnosis of major depression was first rendered in February 2015 and a suggestion of PTSD nine months later, in November 2015. In light of the forgoing, the evidence fails to show any possible causally linkage between active service and depressive symptoms formally diagnosed more than a decade later in 2015.

Accordingly, as the preponderance of the evidence is against the claim, the provisions of 38 U.S.C. § 5107 (b) regarding reasonable doubt are not applicable. The Veteran’s claim of entitlement to service connection for an acquired psychiatric disorder, to include major depression and PTSD must be denied.

B. MULLINS

Veterans Law Judge

Board of Veterans’ Appeals

Attorney for the Board Whitaker, Nakiya

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.

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