HYPERTENSION

B. G. LEMOINE · 2022 · Case ID: 22026860

DENIED

Summary

The veteran, who served in the Navy from January 1973 to August 1973, appeals the denial of service connection for hypertension, diabetes mellitus type II, and right upper extremity myopathy, all claimed as secondary to service-connected disabilities. The Board denied all claims, finding the evidence did not support service connection. For hypertension, the Board noted the absence of in-service complaints or diagnosis, with the earliest evidence of hypertension appearing in 2004, over 30 years after service. Medical opinions consistently found no nexus to service or to the veteran's service-connected cystitis or prostatitis. Similarly, for diabetes mellitus type II, service treatment records were silent, with the earliest diagnosis occurring in 2001, nearly 30 years post-service. Medical opinions found no link to service or to the service-connected conditions, citing the lack of in-service evidence and the separate pathological nature of the conditions. For right upper extremity myopathy, service records were also silent, with the earliest diagnosis in 2010, over 30 years post-service. Medical opinions attributed the myopathy to severe right ulnar neuropathy, which was not service-connected, and found no nexus to service or to the service-connected cystitis or prostatitis. The Board found the VA examiners' opinions probative due to their review of the record and clear explanations, and gave them more weight than the veteran's lay assertions due to the medical complexity of the conditions.

Rationale

No in-service complaints or diagnosis of hypertension; Earliest diagnosis in 2004, over 30 years post-service; Medical opinions found no nexus to service or service-connected disabilities

Service Branch

NAVY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

14-42 204

Full Decision Text

Citation Nr: 22026860
Decision Date: 05/09/22 Archive Date: 05/09/22

DOCKET NO. 14-42 204
DATE: May 9, 2022

ORDER

Entitlement to service connection for hypertension, to include as secondary to a service-connected disability, is denied.

Entitlement to service connection for diabetes mellitus type II, to include as secondary to a service-connected disability, is denied.

Entitlement to service connection for right upper extremity myopathy, to include as secondary to a service-connected disability, is denied.

FINDINGS OF FACT

1. The evidence of record persuasively weighs against finding that the Veteran's hypertension began during active service or within one year of discharge, is related to an in-service injury or disease, or is otherwise secondary to a service-connected disability.

2. The evidence of record persuasively weighs against finding that the Veteran's diabetes mellitus type II began during active service or within one year of discharge, is related to an in-service injury or disease, or is otherwise secondary to a service-connected disability.

3. The evidence of record persuasively weighs against finding that the Veteran's right upper extremity myopathy began during active service, is related to an in-service injury or disease, or is otherwise secondary to a service-connected disability.

CONCLUSIONS OF LAW

1. The criteria for service connection for hypertension, to include as secondary to a service-connected disability, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

2. The criteria for service connection for diabetes mellitus type II, to include as secondary to a service-connected disability, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310.

3. The criteria for service connection for right upper extremity myopathy, to include as secondary to a service-connected disability, have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from January 1973 to August 1973. These matters are before the Board of Veterans' Appeals (Board) on appeal from a February 2014 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO).

The issues were previously remanded in July 2019, April 2020, March 2021, August 2021, and December 2021. There has been substantial compliance with the December 2021 remand directives. Stegall v. West, 11 Vet. App. 268, 271 (1998).

1. Entitlement to service connection for hypertension, to include as secondary to a service-connected disability, is denied.

The Veteran contends that his hypertension is due to his period of service, to include as secondary to his service-connected disabilities.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) 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 in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310.

Certain chronic diseases will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708
disease or injury. 38 C.F.R. § 3.310.

For VA purposes, "[h]ypertension or isolated systolic hypertension must be confirmed by readings taken two or more times on at least three different days," and "hypertension means that the diastolic blood pressure [the bottom number of the blood pressure ratio] is predominantly 90mm. or greater, and isolated systolic hypertension means that the systolic blood pressure [the top number of the blood pressure ratio] is predominantly 160mm. or greater with a diastolic of less than 90mm." 38 C.F.R. § 4.104, Diagnostic Code 7101, Note (1).

Turning to the records, the Veteran's service treatment records are silent for any complaints or a diagnosis of hypertension. His August 1973 separation examination shows a blood pressure reading of 110/60 and normal clinical evaluation of his heart and vascular systems.

After service, the first clinical documentation of hypertension was in 2004. A March 2001 private record shows no prior history of hypertension; the blood pressure reading was 114/79. An October 2002 private record noted that the Veteran's cardiac risk factors did not indicate hypertension; the blood pressure reading was 100/70. A November 2002 private record noted that the Veteran does not have history of hypertension; the blood pressure reading was 120/70. A May 2004 private record noted a blood pressure reading of 150/80, and the doctor prescribed medication for the Veteran's high blood pressure. A September 2004 VA record shows that the Veteran is diagnosed with hypertension. His VA records from 2004 continue to reflect a diagnosis of hypertension and blood pressure monitoring.

The Veteran underwent a VA examination for hypertension in September 2020. The examiner noted a diagnosis of hypertension as of 2004. The Veteran reported that the approximate date of onset was in 2003 when he went to an emergency room and was told that his blood pressure was high; he sought treatment at VA and was formally diagnosed with hypertension. The examiner opined that the Veteran's hypertension was less likely than not incurred in or caused by the claimed in-service injury event, or illness. The examiner noted that the Veteran served on active duty from January to August 1973, but that his service treatment records did not reveal a diagnosis of hypertension. She concluded that a nexus has not been established. The examiner also opined that the hypertension was less likely than not proximately due to or the result of the Veteran's service-connected cystis or prostatitis. She explained that after a thorough review of medical literature, she was not able to find any evidence for a causal relationship between hypertension and cystis or prostatitis. She stated that conditions of hypertension, and cystitis and prostatitis are not medically related, and that hypertension was an entirely separate entity from cystitis or prostatitis. She concluded that a nexus is not established.

In a May 2021 VA opinion, the examiner opined that the Veteran's hypertension was not at least as likely as not aggravated beyond its natural progression by his cystitis or prostatitis. The examiner noted that while all available medical records and remand documents were reviewed, there was no credible medical evidence that the Veteran's hypertension was subject to aggravation beyond natural progression by his cystitis or prostatitis. She stated that there is no pathological mechanism to allow for aggravation. She noted that while the Veteran may report that the symptoms are related, there was no scientific evidence demonstrating that the conditions are related or are subject to aggravation. She concluded that a nexus is not established.

In an August 2021 VA medical opinion, the examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected cystitis or prostatitis. She explained that the pathogenesis of primary hypertension, formerly called essential hypertension, is most likely the result of numerous genetic and environmental factors that have multiple compounding effects on
aggravation beyond natural progression by his cystitis or prostatitis. She stated that there is no pathological mechanism to allow for aggravation. She noted that while the Veteran may report that the symptoms are related, there was no scientific evidence demonstrating that the conditions are related or are subject to aggravation. She concluded that a nexus is not established.

In an August 2021 VA medical opinion, the examiner opined that the Veteran's hypertension was less likely than not proximately due to or the result of the Veteran's service-connected cystitis or prostatitis. She explained that the pathogenesis of primary hypertension, formerly called essential hypertension, is most likely the result of numerous genetic and environmental factors that have multiple compounding effects on cardiovascular and kidney structure and function. She stated that hypertension is a vascular condition caused by the restriction of arterial and venous flow, and therefore had no medical nexus to cystitis or prostatitis. The examiner also opined that the Veteran's hypertension is not aggravated by his cystitis or prostatitis. She explained that hypertension is a vascular condition caused by the restriction of arterial and venous flow, and that there was no pathological mechanism to allow aggravation beyond natural progression by cystitis or prostatitis. The examiner cited two medical sources for her opinion.

In a February 2022 VA opinion, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that a thorough review of the medical records did not reveal any objective evidence to support an onset, etiology, or pathophysiological basis for the Veteran's hypertension condition to have incurred in or caused by service. The examiner noted that while the absence of a diagnosis does not prove absence of hypertension, it conversely does not necessarily support that the hypertension was caused by service or an event in service. He stated that the absence of noted conditions, symptoms, or any prior diagnosed disease on entrance into or separation from service is considered to have established a presumption of soundness for a Veteran, and that the same principle applied when considering the likelihood that the hypertension condition began or had an etiological basis during service. He noted that, without any countervailing evidence or facts that show there was high blood pressure in service, the Veteran can be reasonably presumed sound during service. He added that where the determinative issue involves causation or medical diagnosis, competent medical evidence to the effect that the claim is possible or plausible is required, but that the Veteran did not meet this burden by merely presenting his lay opinion because such evidence does not constitute competent medical authority. The examiner further stated that there was no established medical nexus considering the following facts: the Veteran was on active duty for a short amount of time (Jan. - Aug. 1973) with no evidence of a condition in service which would cause a chronic high blood pressure; he had no treatment for hypertension after service for 32 years (1973-2005); he had a known significant risk factor that was unrelated to service (history of cigarette smoking since age 16 years old); and a questionable cardiac event that predated service (collapse at age 15 years old during wrestling where open heart surgery was reportedly recommended and declined). The examiner cited three medical sources to support his opinion.

After a cumulative review of the evidentiary record, the Board concludes that service connection for hypertension is not warranted.

The evidence does not show that the Veteran's hypertension manifested during service, or to a compensable degree within a year after discharge. His service treatment records are silent for any complaints or diagnosis of hypertension, and his separation exam shows normal clinical evaluation of heart and vascular systems. The earliest clinical evidence showing a diagnosis of hypertension was in 2004, which was more than 30 years after discharge from service. As there is no competent or credible evidence showing initial manifestations of hypertension in service, or to any degree within one year of separation from service, the one-year presumption under 38 C.F.R. §§ 3.307 and 3.309 is not an avenue for service connection, nor are the provisions of 38 C.F.R. § 3.303(b) pertaining to chronicity or continuity of symptomatology.

Furthermore, the evidence does not contain competent medical evidence linking the Veteran's hypertension to service. The probative medical evidence is not in favor of causal nexus. The September 2020 examiner opined that the Veteran's hypertension was less likely than not related to service because his service treatment records were silent for a diagnosis of hypertension. The February 2022 examiner further explained that a thorough review of the medical records did not reveal any objective evidence to support an onset, etiology, or pathophysiological basis for the Veteran's hypertension to have incurred in or caused by service. He also stated that considering no treatment for hypertension
38 C.F.R. § 3.303(b) pertaining to chronicity or continuity of symptomatology.

Furthermore, the evidence does not contain competent medical evidence linking the Veteran's hypertension to service. The probative medical evidence is not in favor of causal nexus. The September 2020 examiner opined that the Veteran's hypertension was less likely than not related to service because his service treatment records were silent for a diagnosis of hypertension. The February 2022 examiner further explained that a thorough review of the medical records did not reveal any objective evidence to support an onset, etiology, or pathophysiological basis for the Veteran's hypertension to have incurred in or caused by service. He also stated that considering no treatment for hypertension for 32 years since discharge from service, no evidence of a condition in service that would cause a chronic blood pressure condition, and having a known significant risk factor for hypertension that is unrelated to service, a nexus is not established.

Lastly, the evidence does not show that the Veteran's hypertension was caused or aggravated by his service-connected disabilities. The September 2020 examiner opined that the hypertension was less likely than not caused by his cystis or prostatitis because hypertension was an entirely separate entity from cystitis or prostatitis, and that a thorough review of medical literature did not reveal any causal relationship between hypertension and cystis or prostatitis. The August 2021 examiner also explained that hypertension is a vascular condition caused by the restriction of arterial and venous flow, and had no medical nexus to cystitis or prostatitis. Regarding aggravation, the May 2021 examiner opined that the Veteran's hypertension was not at least as likely as not aggravated by his cystitis or prostatitis because there was no credible medical evidence demonstrating that the Veteran's hypertension was subject to aggravation by his cystitis or prostatitis, and that there was no pathological mechanism to allow for aggravation. The August 2021 examiner added that hypertension is a vascular condition caused by the restriction of arterial and venous flow, and that there was no pathological mechanism to allow aggravation by cystitis or prostatitis.

The Board finds that the examiners' opinions on direct and secondary service connection are probative, as they are shown to have been based on a review of the Veteran's record and are accompanied by sufficient explanations. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). There is no competent medical opinion to the contrary.

The Veteran may believe that he had symptoms of hypertension in service, or that his hypertension is secondary to his service-connected disabilities. However, the issue is medically complex because it requires knowledge of internal physiological processes and knowledge of the interaction between anatomical relationships. The Veteran has not shown to have any relevant training or education, and thus he is not competent to determine that any symptoms during service were manifestations of hypertension, or that his hypertension was caused or aggravated by his service-connected disabilities. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiners' opinions.

In conclusion, the competent and probative evidence is not in favor of the claim. Service connection for hypertension is therefore denied.

2. Entitlement to service connection for diabetes mellitus type II, to include as secondary to a service-connected disability, is denied.

The Veteran contends that his diabetes is due to his period of service, to include as secondary to his service-connected disabilities.

The Veteran's service treatment records are silent for any complaints or a diagnosis of diabetes. His August 1973 separation examination was negative for sugar; all of the Veteran's systems were found normal except for birthmarks on his forehead.

After service, the first clinical documentation of diabetes was in 2001. A March 2001 private record shows that the Veteran was admitted for congestive heart failure; he denied any known history of diabetes but was diagnosed with type II diabetes mellitus at discharge. An October 2002 private record noted a diagnosis of non-insulin-dependent diabetes mellitus. An April 2004 VA record shows a diagnosis of diabetes mellitus type II and its prescription. His VA records thereafter continue to reflect the diagnosis of and medication for his diabetes.

The Veteran underwent a VA examination for diabetes mellitus in September 2020. The examiner noted a diagnosis of diabetes mellitus type II as of 2001. The examiner opined that the Veteran's diabetes was less likely than not incurred in or caused by the claimed in-service injury event, or illness. She explained that the Veteran served in the Navy from January to August 1973, and that there was no documentation or evidence of a diagnosis of or treatment for diabetes during active service. She concluded that a nexus was not established. The examiner also opined that the Veteran's diabetes was less likely than not proximately due to or the result of his service-connected disabilities. She explained that the conditions of diabetes mellitus type II, and cystitis and prostatitis are not medically related, and that diabetes mellitus type II is a separate entity entirely from the cystitis and prostatitis. She also noted that a thorough review of medical literature failed to demonstrate a causal relationship. She concluded that a nexus has not been established.

In a May 2021 VA opinion, the examiner opined that the Veteran's diabetes was not at least as likely as not aggravated beyond its natural progression by the service-connected cystitis or prostatitis. The examiner explained that there was no credible medical evidence showing that the Veteran's diabetes was aggravated by his service-connected disabilities, and that there was no pathological mechanism to allow for aggravation. The examiner acknowledged the Veteran's contentions, but pointed out that he was not qualified to ascribe symptoms to a diagnosis or etiology.

In an August 2021 VA opinion, the examiner opined that the Veteran's diabetes was less likely than not proximately due to or the result of the Veteran's service-connected disabilities. The examiner explained that diabetes is an endocrine disorder involving the bodys ability to produce insulin and/or metabolize glucose, and that there is no credible medical evidence of a causal link between cystitis or prostatitis and diabetes. The examiner also opined that that the Veteran's diabetes was not at least as likely as not aggravated beyond its natural progression by his cystitis or prostatitis. She similarly explained that diabetes is an endocrine disorder involving the bodys ability to produce insulin and/or metabolize glucose, and that there was no credible medical evidence of a possible mechanism to allow aggravation beyond the natural progression by cystitis or prostatitis. The examiner cited a medical article in support of her conclusion.

In a February 2022 VA opinion, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that a thorough review of the medical records did not reveal any objective evidence to support an onset, etiology, or pathophysiological basis for the Veteran's diabetes to have incurred in or caused by service. The examiner noted that while the absence of a diagnosis of diabetes during service does not prove evidence of diabetes, it conversely does not necessarily support that the diabetes was caused by or due to service or any event in service. He stated that the absence of noted conditions, symptoms, or any prior diagnosed disease on entrance into or separation from service is considered to have established a presumption of soundness for a Veteran, and that without any countervailing evidence that show there was high blood sugar during service, the Veteran is presumed sound during service. He noted that where the determinative issue involves causation or medical diagnosis, competent medical evidence to the effect the claim is possible or plausible is required, but that the Veteran did not meet this burden by merely presenting his lay opinion as such evidence does not constitute competent medical authority. The examiner further stated that considering the following facts, a nexus is not established: no evidence of a condition in service which would cause elevation of the blood sugar; no documented elevated serum glucose and no glucosuria in service; no diagnosis or treatment for diabetes until 28 years after service (from 1973-2001); and having risk factors for developing diabetes that are unrelated to service such as history of chronic tobacco use and alcohol use. The examiner concluded that, based on this history, there was no established medical nexus for the Veteran's diabetes mellitus type II to have incurred in or caused by service.

Upon review, service connection for diabetes mellitus type II is not warranted.

In this case, service connection for diabetes mellitus may not be presumed under the provisions of 38 C.F.R.
not established: no evidence of a condition in service which would cause elevation of the blood sugar; no documented elevated serum glucose and no glucosuria in service; no diagnosis or treatment for diabetes until 28 years after service (from 1973-2001); and having risk factors for developing diabetes that are unrelated to service such as history of chronic tobacco use and alcohol use. The examiner concluded that, based on this history, there was no established medical nexus for the Veteran's diabetes mellitus type II to have incurred in or caused by service.

Upon review, service connection for diabetes mellitus type II is not warranted.

In this case, service connection for diabetes mellitus may not be presumed under the provisions of 38 C.F.R. §§ 3.307, 3.309. As noted, service treatment records are silent for complaint, diagnosis, or treatment for diabetes mellitus. The competent evidence otherwise fails to show the presence of diabetes mellitus during service or within the first post-service year. His diabetes was diagnosed in 2001, which was close to 30 years after separation from service. While the Veteran is competent to report having experienced symptoms during active service, he is not competent to determine that these symptoms were manifestations of diabetes mellitus or relate diabetes mellitus to service-connected cystitis or prostatitis. Jandreau, 492 F.3d at 1377 n.4. As such, there is no showing that this disease manifested to a compensable degree within a year from separation from service and that presumption does not apply. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309.

Further, there is no competent evidence to show that his diabetes had onset in service or is otherwise attributable to active service. Service treatment records are silent for diagnosis or treatment of diabetes mellitus. Further, the September 2020 and February 2022 examiners opined that the Veteran's current diagnosis is less likely than not related to active service because his records did not reveal any evidence to support an onset, etiology, or pathophysiological basis for the diabetes to have incurred in or caused by his service. The examiners' opinions are probative as they are shown to have been based on a review of the Veteran's record and are accompanied by sufficient explanation. Nieves-Rodriguez, 22 Vet. App. at 304.

Moreover, there is no competent evidence that shows that his diabetes was caused or aggravated by his service-connected cystitis or prostatitis. The September 2020 examiner explained that diabetes mellitus type II, and cystitis and prostatitis are not medically related, and that a review of medical literature did not demonstrate a causal relationship. The May 2021 examiner explained that there was not credible medical evidence that the Veteran's diabetes was aggravated by his service-connected disabilities, and that there was no pathological mechanism to allow for aggravation. The examiners' opinions are probative as it was based on a review of the Veteran's clinical and service history, and was accompanied by thorough and cogent rationale. Id. There is no competent opinion to the contrary either on direct or secondary service connection.

While the Veteran may believe that he had symptoms of diabetes mellitus in service, or that his diabetes mellitus is secondary to his service-connected disabilities, the issue is medically complex because it requires knowledge of internal physiological processes and knowledge of the interaction between anatomical relationships. The Veteran has not shown to have any relevant training or education, and thus he is not competent to determine that any symptoms during active service were manifestations of diabetes or related to diabetes, or that his diabetes mellitus was caused or aggravated by his service-connected disabilities. Jandreau, 492 F.3d at 1377 n.4. Consequently, the Board gives more probative weight to the VA examiners' opinions.

Ultimately, the evidence persuasively weighs against finding that the Veteran's diabetes mellitus type II has onset during service or is otherwise related to service, to include as proximately caused or aggravated by the Veteran's cystitis or prostatitis. As such, there is no doubt to be resolved. Service connection for diabetes mellitus type II is denied.

3. Entitlement to service connection for right upper extremity myopathy, to include as secondary to a service-connected disability, is denied.

The Veteran contends that his myopathy in his right arm and hand was incurred in service, or alternatively, to his diabetes or his service-connected cystitis or prostatitis.

The Board initially notes that the Veteran is not service-connected for diabetes, and there is no legal basis upon which to award service connection for a secondary disability due to a primary disability that is not service-connected.

The Veteran's service treatment
as proximately caused or aggravated by the Veteran's cystitis or prostatitis. As such, there is no doubt to be resolved. Service connection for diabetes mellitus type II is denied.

3. Entitlement to service connection for right upper extremity myopathy, to include as secondary to a service-connected disability, is denied.

The Veteran contends that his myopathy in his right arm and hand was incurred in service, or alternatively, to his diabetes or his service-connected cystitis or prostatitis.

The Veteran's service treatment records are silent for any complaints or a diagnosis of right upper extremity myopathy. His August 1973 separation examination was normal except for birthmarks on his forehead.

After service, the first clinical record indicating right upper extremity myopathy was in 2010. An August 2010 VA electromyography (EMG) consultation noted a diagnosis of severe ulnar neuropathy with marked acute and chronic denervation. In a September 2010 VA record, physical examination revealed marked atrophy in the right hand with severe wasting of the first dorsal interosseus; the impression was severe right ulnar neuropathy. A February 2014 letter from a VA doctor noted that the Veteran has severe myopathy of right hand and arm. An October 2019 VA record noted that in 2010, the Veteran was diagnosed with myopathy that resulted in slow thenar atrophy that is present today; it further noted that the Veteran had a neurosurgical consult for his right hand but felt that it was not worth the risk of the surgery, and that he has lived with neural atrophy for the last nine years.

The Veteran underwent a VA examination for peripheral nerves conditions in September 2020. He was diagnosed with right upper extremity myopathy and right ulnar neuropathy as of 2010. He reported the date of onset was about 10 years ago; he started experiencing numbness on right hand fingertips, and pain, discomfort, and loss of muscle mass in the right hand. He stated he was seen by VA and was diagnosed with severe myopathy. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. She explained that there was no evidence that the Veteran had a right upper extremity myopathy during active service, nor any in-service diagnosis that contributed to muscle and nerve damage. The examiner further stated that his myopathy is likely caused by his right ulnar neuropathy, which is not a service-connected disability. She stated that myopathy is a muscle disease where a muscle in an area does not function properly. She noted that ulnar neuropathy in severe cases can cause atrophy in hand. She stated that the Veteran has severe muscle atrophy on his right hand, most likely caused by his ulnar neuropathy.

The examiner also opined that the claimed condition was less likely than not proximately due to or the result of Veteran's service-connected disabilities. The examiner explained that the conditions of right upper extremity, and cystitis and prostatitis are not medically related. She noted that the right upper extremity is an entirely separate entity from the cystitis and prostatitis, and that a thorough review of medical literature failed to demonstrate a causal relationship. The examiner also opined that the claimed condition was less likely than not aggravated beyond its natural progression by the Veteran's service-connected disabilities. The examiner did not provide an explanation as to how his myopathy is worsened by his cystitis or prostatitis; instead, she re-iterated that his myopathy is caused by his ulnar neuropathy, and provided instances where ulnar neuropathy is worsened. She noted that the following situations, where the elbow is bent, can make the sensations of ulnar nerve compression worse: holding a telephone, resting the head on the hand, crossing the arms over the chest, curling the arm under the body at night, holding the hand on top of a steering wheel and using the computer for long periods of time. She also noted that the problem usually worsens with activities or occupations that are practiced over an extended period of time.

In a May 2021 VA opinion, the examiner opined that the claimed condition was less likely than not aggravated beyond its natural progression by the Veteran's service-connected disabilities. The examiner noted there is no credible medical evidence that the Veteran's upper extremity myopathy is subject to aggravation beyond the natural progression by cystitis or prostatitis, and that there was no pathological mechanism to allow for aggravation. She noted that the Veteran may report
arms over the chest, curling the arm under the body at night, holding the hand on top of a steering wheel and using the computer for long periods of time. She also noted that the problem usually worsens with activities or occupations that are practiced over an extended period of time.

In a May 2021 VA opinion, the examiner opined that the claimed condition was less likely than not aggravated beyond its natural progression by the Veteran's service-connected disabilities. The examiner noted there is no credible medical evidence that the Veteran's upper extremity myopathy is subject to aggravation beyond the natural progression by cystitis or prostatitis, and that there was no pathological mechanism to allow for aggravation. She noted that the Veteran may report that symptoms are related, but that there is no scientific evidence that the conditions are related or are subject to aggravation. She added that the Veteran is not qualified to ascribe symptoms to a diagnosis or etiology.

In an August 2021 opinion, the examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness because the service treatment records were negative for diagnosis or symptoms consistent with right upper extremity myopathy. The examiner also opined that the claimed condition is less likely than not proximately due to or the result of Veteran's service-connected disabilities. The examiner noted that all available medical records were reviewed, but there was no credible medical evidence to support a causal link between upper extremity myopathy and cystitis or prostatitis that a nexus was not established. The examiner also opined that the claimed condition is less likely than not aggravated by the Veteran's service-connected disabilities. She noted that all available medical records were reviewed, but there was no credible medical evidence of a pathological mechanism to allow aggravation beyond natural progression of the upper extremity myopathy by cystitis or prostatitis.

Upon review, service connection for right upper extremity myopathy is not warranted.

There is no competent evidence to show that the Veteran's right upper extremity myopathy had onset in service or is otherwise attributable to active service. His service treatment records are silent for diagnosis or treatment of right upper extremity myopathy. He was diagnosed with the myopathy in 2010, which was more than 30 years after discharge from service. Further, the September 2020 and August 2021 examiners opined that the Veteran's current diagnosis is not related to active service. The opinions and rationales are probative, because they are based on an accurate medical history and both provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez, 22 Vet. App. at 304.

Moreover, there is no competent evidence that shows that his myopathy was caused or aggravated by his service-connected cystitis or prostatitis. The September 2020 examiner explained that his right upper extremity myopathy, and cystitis and prostatitis are not medically related, and that a review of medical literature did not demonstrate a causal relationship. The May 2021 examiner explained that there was not credible medical evidence that the Veteran's myopathy was aggravated by his service-connected disabilities, and that there was no pathological mechanism to allow for aggravation. The examiners' opinions are probative as they were based on a review of the Veteran's clinical and service history, and was accompanied by thorough and cogent rationale. Id. There is no competent medical opinion to the contrary.

While the Veteran may believe that his right upper extremity myopathy is related to service or secondary to his service-connected cystitis or prostatitis, the issue is medically complex because it requires knowledge of internal physiological processes and knowledge of the interaction between anatomical relationships. He has not shown to have any relevant training or education, and thus he is not competent to determine that his myopathy is related to service, or is secondary to his service-connected disabilities. Jandreau, 492 F.3d at 1377 n.4.

The evidence of record persuasively weighs against finding that the Veteran's right upper extremity myopathy had onset during service or is otherwise related to service, to include as caused or aggravated by his service-connected cystitis or prostatitis. There is no doubt to be resolved, and service connection for right upper extremity myopathy is denied.

B. G. LeMoine

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Jake Choi, 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.

extremity myopathy had onset during service or is otherwise related to service, to include as caused or aggravated by his service-connected cystitis or prostatitis. There is no doubt to be resolved, and service connection for right upper extremity myopathy is denied.

B. G. LeMoine

Acting Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board B. Jake Choi, Associate Counsel

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