SHOULDER IMPAIRMENT OF

RYAN T. KESSEL · 2026 · Case ID: 26000561

MIXED

Summary

The Veteran, who served from January 1976 to January 1994, appeals the denial of service connection for a left shoulder condition and a right elbow condition, and the denial of an increased rating for his right shoulder rotator cuff tendonitis. The Veteran also appeals the denial of Total Disability based on Individual Unemployability (TDIU) prior to July 15, 2010. The Veteran contends his shoulder and elbow conditions are related to an in-service motor vehicle accident, and alternatively, that his shoulder conditions are secondary to his service-connected lumbar spine and lower extremity conditions. The Board found that the Veteran's right shoulder rotator cuff tendonitis was aggravated by his service-connected lumbar spine and lower extremity conditions due to his use of a cane, and therefore granted service connection for the right shoulder condition. The Board denied service connection for the left shoulder and right elbow conditions, finding no relationship to service, no in-service onset, and no secondary connection to service-connected disabilities. The Board granted TDIU effective July 15, 2010, finding that the Veteran's service-connected disabilities precluded substantially gainful employment from that date forward. The Board noted that the Veteran's service treatment records were not provided, but this did not preclude granting service connection for the right shoulder due to aggravation.

Rationale

Aggravated by service-connected lumbar spine and lower extremity conditions; Use of a cane necessitated by service-connected conditions; Service connection granted

Special Benefit

TDIU

Docket No.

16-16 610

Full Decision Text

Citation Nr: 26000561
Decision Date: 01/15/26 Archive Date: 01/15/26

DOCKET NO. 16-16 610
DATE: January 15, 2026

ORDER

Service connection for right shoulder rotator cuff tendonitis, based on secondary aggravation, is granted.

Service connection for a left shoulder condition is denied.

Service connection for a right elbow condition is denied.

From July 15, 2010, a total disability rating based on individual unemployability (TDIU) is granted.

FINDINGS OF FACT

1. The Veteran's right shoulder rotator cuff tendonitis was aggravated by his service-connected lumbar spine condition and lower extremity conditions due to the use of a cane that began in 2021

2. The Veteran's left shoulder condition is not related to service, did not have its onset in service, and is not secondary to any of the Veteran's service-connected conditions.

3. The Veteran's right elbow condition is not related to service, did not have its onset in service, and is not secondary to any of the Veteran's service-connected conditions.

4. From July 15, 2010, the Veteran's service-connected disabilities precluded securing or following a substantially gainful occupation.

CONCLUSIONS OF LAW

1. The criteria for service connection for a right shoulder condition have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

2. The criteria for service connection for a left shoulder condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

3. The criteria for service connection for a right elbow condition have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310.

4. Effective July 15, 2010, the criteria for a TDIU have been met. 38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 3.102, 4.16.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from January 1976 to January 1994. He also had an additional 1 year, 11 months and 18 days active service.

The case is on appeal from September 2012 and April 2015 rating decisions.

In January 2020, the Veteran testified at a Board hearing.

Most recently, in a May 2025 decision, the Board remanded the claims for additional development.

While the case was in remand status, in a July 2025 rating decision, the RO granted service connection for a right elbow scar effective December 1, 2014.

The Veteran submitted additional evidence subsequent to the most recent supplemental statement of the case (SSOC) issued in July 2025. The Veteran provided a waiver of the RO's initial consideration of the evidence. See 38 C.F.R. § 20.1305(c). Other additional evidence is not pertinent to the claims on appeal.

The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008).

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

Service connection may also be
. §§ 1110, 1131; 38 C.F.R. § 3.303. A veteran seeking compensation under these provisions must establish three elements: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).

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

When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the Veteran. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; see Lynch v. McDonough, 999 F.3d 1391, 1395 (Fed. Cir. 2021) (holding that if the positive and negative evidence is in approximate balance, which includes but is not limited to equipoise, the claimant receives the benefit of the doubt).

1. Service connection for a right shoulder condition, to include a rotator cuff tear.

2. Service connection for a left shoulder condition, to include a rotator cuff tear and impingement syndrome.

The Veteran asserts he has left and right shoulder conditions that are related to an in-service motor vehicle accident (MVA). See May 2015 NOD. Alternatively, the Veteran contends his shoulder conditions secondary to his service-connected lumbar spine condition. See July 2010 Claim Form. During the pendency of the appeal, the Veteran, through his representative asserted that the Veteran has shoulder conditions that are related to playing softball during service (see Augus 2021 Correspondence) and that the Veteran has shoulder conditions that are secondary to his service-connected lower extremities conditions, to include to include bilateral pes planus, bilateral ankle degenerative joint disease, bilateral knee strain, and bilateral lower extremity radiculopathy, due to altered biomechanics. See April 2024 Correspondence.

Initially, Board finds the current disability requirement for the claims is established. A November 2015 VA treatment record reflects a diagnosis of left shoulder impingement syndrome, and a January 2021 VA examination report reflects a diagnosis of right and left rotator cuff tendonitis. Thus, the current disability element of the claims is satisfied.

Direct Service Connection

The Board will first address whether service connection is warranted under direct service connection theory of entitlement. That is, whether the Veteran's right and left shoulder conditions are related to service, specifically as due to the Veteran's involvement in an in-service MVA and participation in playing softball, or whether the conditions had their onset in service.

The Board finds that the evidence of record establishes the occurrence of an in-service event or injury. The Veteran's service treatment records (STRs) reflect that he was in an accident in which he became pinned under a jeep in August 1978. The STRs reflect further that the Veteran received a laceration to his right elbow for which he received wound care throughout September 1978, although there is no documentation that the Veteran injured either shoulder or complained of shoulder pain. However, his STRs show the Veteran was diagnosed with a right shoulder sprain in October 1988 and a left shoulder strain in May 1991. With regard to the Veteran's contentions regarding playing softball, a July 1984 STR reflects that the Veteran was hit in the leg playing softball. Thus, the evidence of record establishes that the Veteran was in a MVA in September 1978, injured his right in October 1988, injured his left shoulder in May 1991, and played softball in July 1984.

Concerning the direct service connection theory of entitlement, the question becomes whether there is a nexus between the Veteran's current right and left shoulder condition and the in-service MVA, his documented in-service right and left shoulder strains, and/or playing softball, or whether the Veteran's shoulder condition had its onset in service. Concerning this question, the evidence of record weighs against the claims. The evidence of record includes opinions obtained in February 2016, January 2021, October 2022, and August 2023. The opinions obtained in January 2021, November 2021, and October 2022 specifically address whether
his left shoulder in May 1991, and played softball in July 1984.

Concerning the direct service connection theory of entitlement, the question becomes whether there is a nexus between the Veteran's current right and left shoulder condition and the in-service MVA, his documented in-service right and left shoulder strains, and/or playing softball, or whether the Veteran's shoulder condition had its onset in service. Concerning this question, the evidence of record weighs against the claims. The evidence of record includes opinions obtained in February 2016, January 2021, October 2022, and August 2023. The opinions obtained in January 2021, November 2021, and October 2022 specifically address whether the right and left shoulder conditions are related to the in-service MVA and noted in-service shoulder strain diagnoses and the August 2023 addresses whether the Veteran's right and left shoulder conditions are related to the Veteran playing softball during service.

The February 2016 VA examiner did not provide an opinion concerning the etiology of the right shoulder condition but determined it is less likely than not that the Veteran's left shoulder impingement syndrome is related to the left shoulder strain noted in May 1991. The examiner explained that the Veteran's left shoulder impingement syndrome began after service in November 2015, as noted in a VA treatment record. The VA treatment record reflects that the Veteran reported that his left shoulder pain had its onset three weeks earlier. As a result, the examiner determined that the Veteran's left shoulder impingement syndrome was related to activities that occurred after service, unrelated and without continuity from service. He also explained that this is consistent with the Veteran's STRs which do not show a chronic left shoulder condition during service. The examiner acknowledged the May 1991 left shoulder strain diagnosis but stated that it was an acute and transitory injury that would be expected to resolve, and resolution of this condition is consistent with the Veteran's June 1993 separation examination which notes that the Veteran's upper extremities are normal.

The examiner who provided a VA examination in January 2021 determined it is less likely than not that the Veteran's diagnosed right and left rotator cuff tendonitis is related to the in-service MVA in 1978. She explained that an x-ray of the Veteran's shoulders in February 2012 was normal and that if the Veteran had a condition related to the in-service MVA in 1978, she would expect to see osteoarthritis on his x-ray. She explained further that a March 2012 examination noted a diagnosis of rotator cuff tendonitis, which was 30 years after service. The examiner noted that rotator cuff tendonitis is a common shoulder condition that develops with age. She also noted that the Veteran's medical records fail to document that the Veteran had a continuous and ongoing shoulder condition from the time of the MVA over 30 years later. In an addendum opinion obtained in March 2021, the examiner stated that left shoulder strain in May 1991 and the right shoulder strain in October 1998 were also not related to the Veteran's current right and left rotator cuff tendonitis and provided the same reasoning, relying on the March 2012 x-ray results which were normal, the absence of documentation concerning an ongoing right and left shoulder condition, and explaining aging as a more likely etiology.

The examiner who provided an examination in October 2022 determined it is less likely than not that the Veteran's right and left shoulder condition had its onset in service or is related to service. The examiner explained that the Veteran reported the onset of shoulder pain sometime around 2008 or 2009, which approximately 14 years after his separation from service. The examiner also specifically addressed whether the shoulder conditions are related to the 1978 MVA. She explained that an examination in August or September 1978 after the MVA reflects that all of the Veteran's extremities were essentially normal and the diagnoses associated with the MVA did not include any shoulder conditions. She also noted that at the time, the Veteran did not report that his shoulders were injured and did not complain of shoulder pain. She also explained that although it is conceded that the Veteran sustained shoulder strains during service, the medical records do not support a continuation of those symptoms. She noted that the Veteran's separation examination reflects that the Veteran did not report any shoulder pain and the physician summary does not indicate that there was shoulder pain or any other abnormality.

The examiner who provided an VA examination in August 2023 determined it is not at least as likely as not that the Veteran's right and left shoulder condition is related to playing softball during service. She explained that regardless of the Veteran's contention that his right and left shoulder condition is due to playing softball, and the information contained in the medical literature submitted by the Veteran's representative in August 2021 regarding injuries sustained by athletes who play softball, the Veteran did not receive treatment for a shoulder condition until many years after service. She explained further that if the Veteran's shoulder condition was due to the MVA or playing softball, it would likely be limited to one shoulder rather than both. She also noted that if the Veteran had any shoulder conditions related to service, she would expect x-rays to show early onset degenerative arthritis. However, the Veteran's 2012 x-rays fail to show early onset degenerative joint disease or evidence of trauma due to any activities during service, to include being involved in a MVA and playing softball. She explained further that the Veteran's right and left rotator cuff tendonitis is more likely due to aging and wear and tear.

The Board acknowledges the Veteran's contentions that his right and left shoulder conditions are related to service, or had their onset in service. However, these are complex medical questions outside the competence of a non-medical expert to determine whether such a cause-and-effect relationship exists in this particular case. Thus, this nexus question requires expert consideration and cannot be considered within the competence of a non-expert lay witness. As an individual without medical training, the Veteran has not established the competence needed to rebut the expert medical opinions of record. See Fountain v. McDonald, 27 Vet. App. 258, 274-75(2015); Monzingo v. Shinseki, 26 Vet. App. 97, 105-06 (2012). As such, his opinion is not adequate to rebut the examiners' opinions as to the etiology of the claimed conditions, nor is it otherwise sufficiently probative to be considered competent evidence tending to increase the likelihood of a positive nexus between service and a right and left shoulder condition, and an opinion by a qualified medical expert is required to decide the claim.

The Veteran's representative asserts that direct service connection is warranted as the Veteran stated that his shoulder pain began during service as a result of his MVA and that VA examiners impermissibly relied on the Veteran's denial of shoulder symptoms at the time of multiple in-service examinations. See August 2025 Appellate Brief. A veteran is competent to report the presence of symptoms and frequency of treatment. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). However, the Board does not find the report of continuous symptoms to
medical opinion of record weighing in favor of service connection based on the theory of direct service connection.

The Veteran's representative asserts that direct service connection is warranted as the Veteran stated that his shoulder pain began during service as a result of his MVA and that VA examiners impermissibly relied on the Veteran's denial of shoulder symptoms at the time of multiple in-service examinations. See August 2025 Appellate Brief. A veteran is competent to report the presence of symptoms and frequency of treatment. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). However, the Board does not find the report of continuous symptoms to be credible in this case, as there is a decades long gap between the Veteran's in-service MVA in 1978 and his reports of left or right shoulder pain. The Board notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).

In this case, the Veteran denied upper extremity issues at the time a November 1979 physical, and the associated physical examination reflects that his upper extremities were normal, his upper extremities were found to be normal at the time of a July 1992 physical, and he denied upper extremity issues at the time of his June 1993 separation physical, and the and his associated separation physical reflects that his upper extremities were "normal." VA treatment records in 2004 reflect that the Veteran did not report right or left shoulder pain until much later, although he reported other medical concerns including back pain. As the Veteran reported this condition, the Board finds it likely he would have similarly reported experiencing right and left shoulder pain. VA treatment records reflect that the Veteran initially began reporting right shoulder pain in 2020, and the Veteran did not report left shoulder pain until 2015 and reported its onset three weeks prior.

Concerning the left shoulder, the Veteran did not report any left shoulder pain until 2015 and reported its onset three weeks prior. In addition, the Veteran reported the onset of shoulder pain in 2008 or 2009 at the time of the October 2022 VA examination. See Horn v. Shinseki, 25 Vet. App. 231, 240 n.7 (2012). Thus, the absence of evidence is negative evidence in this case as the evidentiary foundation for finding such has been established. Accordingly, the Board finds that the evidence persuasively weighs against the claims based on a theory under 38 C.F.R. § 3.303(b).

As the evidence weighs persuasively against a finding that that the Veteran's right and left shoulder conditions began during active service, or are otherwise related to an in-service injury, event, or disease, it follows that the nexus element of the claim is not established. As such, service connection is not warranted for a right and left shoulder condition based on the theory of direct service connection.

Secondary Service Connection

The Board will also address whether service connection is warranted under the theory of secondary service connection, i.e., whether the Veteran's right and left shoulder conditions are caused or aggravated by a service-connected condition. The Veteran contends his shoulder conditions secondary to his service-connected lumbar spine condition. See July 2010 Claim Form. During the pendency of the appeal, the Veteran, through his representative asserted that the Veteran has shoulder conditions that are secondary to his service-connected lower extremities conditions, to include to include bilateral pes planus, bilateral ankle degenerative joint disease, bilateral knee strain, and bilateral lower extremity radiculopathy, due to altered biomechanics. See April 2024 Correspondence.

Concerning the question of whether the Veteran's right and left shoulder conditions were caused by his service-connected conditions, the evidence weighs against the claims. Weighing against the claims are opinions obtained in January 2021, November 2021, October 2022, January 2023, January 2025, and July 2025.

The examiner who provided a VA examination in January 2021 determined it is not likely that that the Veteran's lumbar strain is a cause of the Veteran's right and left shoulder problems. She explained there is no logical connection between lumbosacral strain and shoulder conditions. She also explained that she is similarly not aware of any explanation based on knowledge of anatomy and physiology, injury and disease, etc., that would logically attribute the Veteran's shoulder problems to his ankle problems.

The examiner who provided a VA examination in November 2021 determined it
claims are opinions obtained in January 2021, November 2021, October 2022, January 2023, January 2025, and July 2025.

The examiner who provided a VA examination in November 2021 determined it is less likely than not that the Veteran's diagnosed rotator cuff tendonitis is caused by his service-connected lumbar spine condition. She explained that the Veteran's right and left rotator cuff tear is an age-related disorder, and the Veteran's left shoulder osteoarthritis is also related to age. She noted that a bilateral shoulder series in February 2012 indicates that the Veteran's shoulders were normal, and the Veteran was diagnosed with right and left rotator cuff tear, which a common age-related condition 18 years after service. An addendum opinion was obtained in April 2022. The examiner explained further that there is no relation between the lumbar spine causing a rotator cuff tear in the shoulder as they are two completely independent non-associated conditions and there is not any medically possible means of a lumbar spine condition causing a rotator cuff injury as the musculature of the lumbar spine does not connect to the musculature of the shoulder joint.

The examiner who provided a VA examination in October 2022 determined it is less likely than not that the Veteran's right and left shoulder conditions are caused by his lumbar spine degenerative disc disease and lower extremity radiculopathy. She explained that physiologically and anatomically the shoulders and the lumbar spine, and lower extremity radiculopathy are unrelated as there is no connecting link, to include no muscular, neuro vasculature or other links.

The examiner who provided a VA examination in January 2023 determined it is less likely than not that the Veteran's left and right shoulder condition is caused his degenerative arthritis of the spine with bilateral lower extremity radiculopathy. The examiner explained there is no pathoanatomic correlation between the lumbar spine condition and the Veteran's right or left shoulder condition.

The examiner who provided a VA examination in January 2025 found it is less likely that not that the Veteran's shoulder conditions were caused by his service-connected lower extremity conditions. She considered articles provided by the Veteran's representative regarding the effect of altered biomechanics of the lower extremities on the shoulders submitted by the Veteran's representative in April 2024. The Veteran's representative asserts that the articles suggest difficulty using one's lower extremities may alter biomechanics, which can ultimately lead to gait disturbances and posture changes that put stress and strain on the shoulders.

The examiner explained the etiology of shoulder conditions in general, to include normal wear and tear, overuse or repetitive use, direct trauma to the joint which can cause muscle, nerve, vascular or joint damage, or due to a history of post injury arthritic changes. She explained further that physiologically and anatomically, the lower extremities are independent of the upper extremities and do not directly affect the upper extremities by way of muscle connection or innervation from the spine and have separate vascular beds. She noted that although it is acknowledged that there are interconnections of the musculoskeletal system and functional injury to a certain muscle will affect the musculoskeletal system as a whole, considerations of body mechanics dictate injuries to a particular area.

She also explained that when considering whether the Veteran's lower extremity conditions altered body mechanics and put stress and strain on the Veteran's shoulders, one way this could occur would be through repetitive syndrome, possibly through the use of ambulation devices such as crutches, canes, walkers. However, she stated further that medical records reflect that the Veteran used a cane only in 2021 and very rarely used crutches. She noted that there is no notice of strain on the shoulders other than playing softball, which is unrelated to lower body conditions. She also stated that the use of crutches or a cane does not directly cause the development of the shoulder conditions, as their use is more commonly associated with "axillobrachial arterial complications due to pressure from the axillary bar ... or compressive neuropathies due to pressure from the forearm cuff" in a forearm crutch and not rotator cuff tendonitis as was diagnosed in the Veteran.

An additional opinion concerning this contention was obtained in July 2025.
However, she stated further that medical records reflect that the Veteran used a cane only in 2021 and very rarely used crutches. She noted that there is no notice of strain on the shoulders other than playing softball, which is unrelated to lower body conditions. She also stated that the use of crutches or a cane does not directly cause the development of the shoulder conditions, as their use is more commonly associated with "axillobrachial arterial complications due to pressure from the axillary bar ... or compressive neuropathies due to pressure from the forearm cuff" in a forearm crutch and not rotator cuff tendonitis as was diagnosed in the Veteran.

An additional opinion concerning this contention was obtained in July 2025. The examiner determined it is less likely than not that the Veteran's right and left shoulder conditions were caused by his service-connected lower extremity conditions. The examiner provided additional clarification regarding the impact of the Veteran's use of a cane. She explained that the use of ambulation devices such as crutches, a cane, or walkers could put stress on the shoulders, but the Veteran denied using a cane regularly, and typically used one only when he had to walk longer distances during his past travels. She noted the use of crutches is even more rare (only used after healing from his feet surgeries). Concerning his right shoulder, she noted that the Veteran holds his single-point cane with his dominant right hand, but even at present, his cane use is limited to only two or three times per week, when the back or knee pains flared up. She explained further that although using a cane incorrectly or for the wrong reasons can aggravate shoulder or neck pains, the frequency for which it was utilized was not significant enough for an overuse syndrome to cause chronic shoulder conditions.

The examiner cited a study on mobility devices including wheelchairs, cane, or crutches as they affect shoulder pain as compared to using no device. The examiner noted that percentage of people that reported shoulder pain using a cane or crutches is only a small difference to those that did not (47.6% of participants using aids such as crutch(es) or canes, and 33.3% of participants walking without assistance). The examiner also stated that there is no notice of other strain on the shoulders other than playing softball, which is unrelated to the lower body conditions. She concluded that the cane or crutches use is unlikely to be cause the development of Veteran's shoulders issues, as cane or crutches use is more commonly associated with "axillobrachial arterial complications due to pressure from the axillary bar....or compressive neuropathies due to pressure from the forearm cuff" in a forearm crutch and not rotator cuff tendinopathy as was diagnosed in the Veteran.

The Board acknowledges the Veteran's contentions that his right and left shoulder conditions are caused by his service-connect lumbar spine condition, and lower extremity conditions. However, these are complex medical questions outside the competence of a non-medical expert to determine whether such a cause-and-effect relationship exists in this particular case. Thus, this nexus question requires expert consideration and cannot be considered within the competence of a non-expert lay witness. As an individual without medical training, the Veteran has not established the competence needed to rebut the expert medical opinions of record. See Fountain, 27 Vet. App. at 274-75; Monzingo, 26 Vet. App. at 105-06. As such, his opinion is not adequate to rebut the examiners' opinions as to the etiology of the claimed conditions, nor is it otherwise sufficiently probative to be considered competent evidence tending to increase the likelihood of a positive nexus between the Veteran's service connected conditions and a right and left shoulder condition, and an opinion by a qualified medical expert is required to decide the claim.

Consequently, the Board gives more probative weight to the VA examiners' opinions. The Board finds VA examiners' opinions clear and unequivocal and are based on the relevant information, including the Veteran's statements, post-service records, and relevant medical research. Moreover, the examiner's explanations are logical and follow from the facts and information given. See Monzingo, 26 Vet. App. at 105-06; Nieves-Rodriguez, 22 Vet. App. at 304. In finding that the Veteran's right and left shoulder conditions are not caused by his service-connected lumbar spine condition, and/or lower extremity conditions, the examiners explained that there is no relationship between the lumbar spine and shoulders that would create a causal link and consideration of body mechanics, to include the Veteran's intermittent use of a cane does not suggest a causal relationship. Therefore, the examiners' findings that it is less likely than not that the Veteran
medical research. Moreover, the examiner's explanations are logical and follow from the facts and information given. See Monzingo, 26 Vet. App. at 105-06; Nieves-Rodriguez, 22 Vet. App. at 304. In finding that the Veteran's right and left shoulder conditions are not caused by his service-connected lumbar spine condition, and/or lower extremity conditions, the examiners explained that there is no relationship between the lumbar spine and shoulders that would create a causal link and consideration of body mechanics, to include the Veteran's intermittent use of a cane does not suggest a causal relationship. Therefore, the examiners' findings that it is less likely than not that the Veteran's right and left shoulder conditions are caused by his service-connected lumbar spine condition and/or his lower extremity conditions is highly persuasive and probative evidence. Moreover, the January 2025 and July 2025 opinions considered the medical literature submitted by the Veteran's representative concerning the effects of altered biomechanics. In addition, there is no similar medical opinion of record weighing in favor of service connection based on the theory of secondary service connection, based on secondary causation.

As such, the evidence weighs persuasively against a finding that that the Veteran's right and left shoulder conditions were caused by his service-connected conditions. Accordingly, service connection is not warranted for a right and left shoulder condition based on the theory of secondary service connection based on secondary causation.

As service connection for a right and left shoulder condition is not warranted under the theory of secondary service connection based on secondary causation, the Board will address whether service connection is warranted under the theory of secondary service connection based on secondary aggravation.

The Board will initially address the claim for service connection for a right shoulder condition. The evidence weighs against and in favor of the claim. Weighing against the claim are VA opinions obtained in March 2021, November 2021, October 2022, January 2023, and March 2025. Weighing in favor of the claim for the right shoulder condition, are VA opinions obtained in January 2025 and July 2025. Concerning the claim for service connection for a left shoulder condition, the evidence weighs against the claim and in favor of the claim. Weighing against the claim are VA opinions obtained in March 2021, November 2021, October 2022, January 2023, and March 2025, and July 2025. Weighing in favor of the claim is a VA opinion obtained in January 2025.

As it concerns the right shoulder, the examiner who provided a March 2021 VA examination determined that it is less likely than not that the Veteran's right shoulder rotator cuff tendonitis aggravated by his service-connected degenerative arthritis of the spine.

The examiner who provided a VA examination in November 2021 determined it is less likely than not that the Veteran's diagnosed rotator cuff tendonitis is aggravated by his service-connected lumbar spine condition. She explained that the Veteran's right and rotator cuff tear is an age-related disorder, and the Veteran's left shoulder osteoarthritis is also related to age. She noted that a bilateral shoulder series in February 2012 indicates that the Veteran's shoulders were normal, and the Veteran was diagnosed with right and left rotator cuff tear, which a common age-related condition 18 years after service.

The examiner who provided a VA examination in October 2022 determined it is less likely than not that the Veteran's right shoulder condition is aggravated by his lumbar spine degenerative disc disease and lower extremity radiculopathy. She explained that physiologically and anatomically the shoulders and the lumbar spine with lower extremity radiculopathy are unrelated as there is no connecting link, to include no muscular, neurovasculature or other links.

The examiner who provided a VA examination in January 2023 determined it is less likely than not that the Veteran's right shoulder condition was aggravated by his degenerative arthritis of the spine with bilateral lower extremity radiculopathy. The examiner explained there is no pathoanatomic correlation between the lumbar spine condition and the Veteran's right or left shoulder condition.

The examiner who provided a March 2025 opinion determined it is less likely than not that the Veteran's right shoulder conditions was aggravated by the Veteran's service-connected degenerative arthritis of the spine, and service-connected conditions of the lower extremities including bilateral pes planus, bilateral ankle degenerative joint disease, bilateral knee strain, and bilateral lower extremity radiculopathy. The examiner explained rotator cuff tendonitis is aggravated by the Veteran's service-connected conditions because rotator cuff tendonitis is caused by inflammation or injury to the tendons of the rotator cuff. To address the medical literature provided by the Veteran's representative concerning alterations in biomechanics, the examiner noted that the medical literature is controversial regarding secondary causes of musculoskeletal biomechanical degenerative changes and is based on empirical evidence and not on randomly controlled double blind studies. He explained that the shoulder and the lumbar vertebrae do not have shared joints, ligaments or muscles in order to attribute the shoulder condition to the back, and to attribute the shoulder condition to the lower extremities is not possible without objective evidence. The examiner noted that the risk factors for rotator cuff tendonitis include age, smoking history, and obesity, as they contributors to tendon degeneration and impaired healing, independent of the Veteran's lower extremity and spinal conditions.

The examiner specifically addressed the study by Andrew C. Murphy's provided by the Veteran's representative. He stated that the structure, function, and control of the human musculoskeletal network emphasize the importance of network-based recovery models and the role of small-scale muscular organization in maintaining overall function. He stated further that his research suggests that when localized musculoskeletal structures are injured, recovery is influenced by both the affected muscle group and its interconnected network, but the study does not support the idea that lower extremity conditions or spinal arthritis would directly exacerbate rotator cuff tendonitis. While degenerative arthritis of the spine and lower extremity service-connected conditions may contribute to postural adjustments or compensatory movements, there is no direct biomechanical or physiological evidence that they aggravate rotator cuff tendonitis. The examiner clarified that the shoulder joint is primarily influenced by the scapular and upper thoracic musculature, not the lower extremities or lumbar spine and Murphy's findings further highlight that rehabilitation should be targeted at the primary site of injury which in this case is the rotator cuff, rather than assuming a secondary musculoskeletal condition is worsening the tendonitis. The examiner concluded therefore, the Veteran's rotator cuff tendonitis is more likely due to his individual risk factors rather than being aggravated by his SC lower extremity or spinal conditions.

Weighing in favor of the claim for service connection for a right shoulder condition are VA opinions obtained in January 2025 and July 2025. The examiner who provided a VA examination in January 2025 found it at least as likely that not that the Veteran's right shoulder condition was aggravated by his service-connected lower extremity conditions. The examiner explained that the Veteran's lower extremity conditions have altered biomechanics which have put stress and strain on his shoulders. The examiner stated that one could theorize that this could occur from repetitive use syndrome due to the use of ambulation devices such as crutches, canes, or walkers that put stress on the shoulders even though a review of the evidence reflects that the Veteran only used a cane regularly in 2021 and very occasionally used crutches. She noted that although the use of a cane or crutches is more commonly associated with "axillobrachial arterial complications due to pressure from the axillary bar... or compressive neuropathies due to pressure from the forearm cuff" in a forearm crutch, their use intermittently have put further strain on his shoulder conditions, making the conditions progressive faster than it naturally would have.

An additional opinion was obtained in July 2025 for the examiner to consider the Veteran's use of a cane. The examiner determined it is at least as likely as not that the Veteran's right rotator cuff tendonitis was aggravated by his service-connected lower extremity conditions. She explained that the condition was likely aggravated due to the intermittent use of assistive device of a cane for this lower extremity conditions. She stated that although the Veteran denied using a cane regularly, and typically only used one when he had to walk longer distances, and the use of crutches being even more rare, he held his single point cane with his dominant right hand which could lend to eventually and intermittent stresses on the right shoulder. The examiner noted that the Veteran was diagnosed with a right rotator cuff tendinopathy in Feb 2020, after the lower extremity conditions occur
determined it is at least as likely as not that the Veteran's right rotator cuff tendonitis was aggravated by his service-connected lower extremity conditions. She explained that the condition was likely aggravated due to the intermittent use of assistive device of a cane for this lower extremity conditions. She stated that although the Veteran denied using a cane regularly, and typically only used one when he had to walk longer distances, and the use of crutches being even more rare, he held his single point cane with his dominant right hand which could lend to eventually and intermittent stresses on the right shoulder. The examiner noted that the Veteran was diagnosed with a right rotator cuff tendinopathy in Feb 2020, after the lower extremity conditions occur. She stated that one can imagine that his intermittent use of the cane using his dominant right hand further stresses and irritates his right shoulder. The examiner noted that shoulder pain is a common complaint in people using mobility devices, although the Veteran only uses his cane two or three, when the back or knee pain flared up. She also stated that using a cane incorrectly or for the wrong reasons can aggravate shoulder or neck pains, even if intermittently, and can aggravate his already-present chronic right shoulder conditions.

In this case, the Board finds service connection is warranted for a right shoulder rotator cuff tendonitis based on secondary aggravation, when reasonable doubt is resolved in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. The Board has afforded the greatest probative weight to the January 2025 and July 2025 VA opinions. The Board finds VA examiners' opinions clear and unequivocal and are based on the relevant information, including the Veteran's statements, post-service records, and relevant medical research. Moreover, the examiner's explanations are logical and follow from the facts and information given. See Monzingo, 26 Vet. App. at 105-06; Nieves-Rodriguez, 22 Vet. App. at 304. The examiners who provided the January 2025 and July 2025 VA opinions explained that the Veteran's right shoulder rotator cuff tendonitis was at least as likely as not aggravated by the use of a cane, although intermittent, due to his service-connected lower extremity conditions, whereas the other opinions did not consider this aspect of the Veteran's medical history.

Thus, the evidence is at least in equipoise as to whether the Veteran's right shoulder rotator cuff tendonitis was aggravated by his service-connected lower extremity conditions, when resolving any reasonable doubt in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is warranted for right shoulder rotator cuff tendonitis, based on secondary aggravation.

Concerning the claim for service connection for a left shoulder condition, the evidence weighs against the claim and in favor of the claim. Weighing against the claim are VA opinions obtained in March 2021, November 2021, October 2022, January 2023, and March 2025, and July 2025. Weighing in favor of the claim is a VA opinion obtained in January 2025.

The examiners who provided VA opinions in March 2021, November 2021, October 2022, and January 2023 determined that the Veteran's left shoulder condition was less likely than not aggravated by his service-connected lumbar spine condition for the same reasons it did not aggravate his right shoulder condition, as previously described. The examiner who provided the March 2025 VA opinion determined the Veteran's left shoulder condition was less likely than not aggravated by his service-connected lumbar spine condition and lower extremity conditions, based on the Veteran's representative contention regarding altered biomechanics for the same reasons it did not aggravate his right shoulder condition, as also previously described.

The examiner who provided the July 2025 VA opinion determined it is less likely than not that the Veteran's left shoulder was aggravated by the Veteran's service-connected lower extremity conditions. In pertinent part, the examiner explained that the Veteran holds his single point cane with his dominant right hand, and even at present, he only uses his cane two or three times per week, when his back or his knees flare up. She stated that while improper cane use can aggravate shoulder or neck pain, the frequency with which the cane was utilized is not significant enough to aggravate a chronic left shoulder condition.

Weighing in favor of the claim is a VA opinion obtained in January 2025. The examiner who provided a VA examination in January 2025 determined it at least as likely that not that the Veteran's right shoulder condition
Veteran's left shoulder was aggravated by the Veteran's service-connected lower extremity conditions. In pertinent part, the examiner explained that the Veteran holds his single point cane with his dominant right hand, and even at present, he only uses his cane two or three times per week, when his back or his knees flare up. She stated that while improper cane use can aggravate shoulder or neck pain, the frequency with which the cane was utilized is not significant enough to aggravate a chronic left shoulder condition.

Weighing in favor of the claim is a VA opinion obtained in January 2025. The examiner who provided a VA examination in January 2025 determined it at least as likely that not that the Veteran's right shoulder condition was aggravated by his service-connected lower extremity conditions. The examiner provided the same rationale as it concerns right shoulder aggravation previously described.

In this case, the Board has afforded the most probative weight to the March 2025 VA opinion, in which the examiner found the it is not at least as likely as not that the Veteran's left shoulder condition was aggravated by his service-connected lumbar spine condition and lower extremity conditions, and the July 2025 VA opinion in which the examiner found it is not at least as likely as not that the Veteran's left shoulder condition was aggravated by his service-connected lumbar spine condition and lower extremity conditions when considering the use of an assistive device. The Board finds VA examiners' opinions clear and unequivocal and are based on the relevant information, including the Veteran's statements, post-service records, and relevant medical research. Moreover, the examiner's explanations are logical and follow from the facts and information given. See Monzingo, 26 Vet. App. at 105-06; Nieves-Rodriguez, 22 Vet. App. at 304. In finding that the Veteran's left shoulder condition was not aggravated by his service-connected lumbar spine condition, and/or lower extremity conditions, the examiner who provided the March 2025 opinion explained why the biomechanics involved would not aggravate the Veteran's shoulder conditions. The examiner who provided the July 2025 opinion explained that the Veteran's left shoulder conditions were not aggravated by his lumbar spine condition, and/or lower extremity conditions by the use of an assistive device because as the Veteran uses his right hand to hold his cane, he does not use his left arm with the requisite frequency to aggravate a left shoulder condition. Thus, the Board afforded less probative weight to the January 2025 opinion as the rationale does not distinguish between the differences between the right and left shoulder, as in the July 2025 opinion.

In sum, the evidence is at least in equipoise as to whether the Veteran's right shoulder rotator cuff tendonitis was aggravated by his service-connected lower extremity conditions, when resolving any reasonable doubt in the Veteran's favor. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. However, the evidence weighs persuasively against the claim for service connection for a left shoulder condition based on the theories of direct and secondary service connection. Thus, the benefit of the doubt doctrine is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is not warranted for a left shoulder condition.

3. Service connection for a right elbow condition.

The Veteran is seeking service connection for a right elbow condition. He asserts that he has a right elbow condition that is due to an in-service MVA. The Veteran specifically contends he scraped his right elbow on the pavement during the accident and that particles from the pavement still remain under his skin. The Veteran also asserted that he has a right elbow condition due to playing softball during service. The Board will also address whether service connection is warranted under the theory of secondary service connection, i.e., whether the Veteran's right elbow condition was caused or aggravated by a service-connected condition. The Veteran contends his right elbow condition is secondary to his service-connected lumbar spine condition. See July 2010 Claim Form. During the pendency of the appeal, the Veteran, through his representative asserted that the Veteran has a right elbow condition that is secondary to his service-connected lower extremities conditions, to include bilateral pes planus, bilateral ankle degenerative joint disease, bilateral knee strain, and bilateral lower extremity radiculopathy, due to altered biomechanics. See April 2024 Correspondence.

Initially, Board finds the current disability requirement for the claims are established. A January 2025 VA examination reflects diagnoses of right ulnar neuropathy status post nerve transposition and right cubital tunnel syndrome. Thus, the current disability element of the
secondary to his service-connected lumbar spine condition. See July 2010 Claim Form. During the pendency of the appeal, the Veteran, through his representative asserted that the Veteran has a right elbow condition that is secondary to his service-connected lower extremities conditions, to include bilateral pes planus, bilateral ankle degenerative joint disease, bilateral knee strain, and bilateral lower extremity radiculopathy, due to altered biomechanics. See April 2024 Correspondence.

Direct Service Connection

The Board will first address whether service connection is warranted under direct service connection theory of entitlement. That is, whether the Veteran's right elbow condition is related to service, specifically whether it is due to the Veteran's involvement in an in-service MVA and participation in playing softball, or whether the condition had its onset in service.

The Board finds that the evidence of record establishes the occurrence of an in-service event or injury. The Veteran's STRs reflect that he was in an accident in which he became pinned under a jeep in August 1978. The STRs reflect further that the Veteran received a laceration to his right elbow for which he received wound care throughout September 1978. With regard to the Veteran's contentions regarding playing softball, a July 1984 STR reflects that the Veteran was hit in the leg playing softball. Thus, the evidence of record establishes that the Veteran was in a MVA in September 1978 in which he received an abrasion to his right elbow and played softball in July 1984.

Concerning the direct service connection theory of entitlement, the question becomes whether there is a nexus between the Veteran's current right elbow condition and the in-service MVA and/or playing softball, or whether the Veteran's shoulder condition had its onset in service. Concerning this question, the evidence of record weighs against the claim. Weighing against the claim are VA opinions obtained in April 2015, January 2021, August 2023.

The examiner who provided a VA examination in April 2015 noted that the Veteran had ulnar neuropathy and concluded that it is less likely than not related to the right elbow laceration the Veteran received during service. The examiner explained that there are no supporting records to support that the Veteran has a chronic right elbow condition.

The examiner who provided a VA examination in January 2021 concluded that it is less likely than not that the Veteran has a right elbow condition that is related to service. Concerning the Veteran's contention that he has an elbow condition due to retained gravel fragments as a result of his in-service MVA, the examiner explained that a superficial abrasion and possible retained gravel fragments in the elbow would not result in nerve impingement. She explained further that if the Veteran had an elbow condition related to the 1978 MVA, she would expect to see osteoarthritis on x-ray due to trauma, however, the Veteran had a normal x-ray that did not identify any abnormalities in February 2012.

The examiner who provided a VA examination in August 2023 determined it is not at least as likely as not that the Veteran's right elbow condition is related to playing softball during service. She explained that the Veteran's STRs are silent for any care for a right elbow condition during service. She noted that the Veteran was treated for a left elbow abrasion after a MVA during service, which was a superficial skin abrasion. She explained that regardless of the Veteran's contention that his right elbow condition is due to playing softball, and the information contained in the medical literature submitted by the Veteran's representative in August 2021 regarding injuries sustained by athletes who play softball, the Veteran did not receive treatment for a right elbow condition until many years after service. She explained further that if the Veteran's right elbow condition was due to the MVA or playing softball, it would likely be limited to one elbow rather than both. She also noted that if the Veteran had any elbow conditions related to service, she would expect x-rays to show early onset degenerative arthritis. However, she noted that the Veteran's 2012 x-rays fail to show early onset degenerative joint disease or evidence of trauma due to any activities during service, to include being involved in a MVA and playing softball. She explained further that the Veteran
Veteran's representative in August 2021 regarding injuries sustained by athletes who play softball, the Veteran did not receive treatment for a right elbow condition until many years after service. She explained further that if the Veteran's right elbow condition was due to the MVA or playing softball, it would likely be limited to one elbow rather than both. She also noted that if the Veteran had any elbow conditions related to service, she would expect x-rays to show early onset degenerative arthritis. However, she noted that the Veteran's 2012 x-rays fail to show early onset degenerative joint disease or evidence of trauma due to any activities during service, to include being involved in a MVA and playing softball. She explained further that the Veteran's right elbow condition is not a condition caused by playing softball or a superficial abrasion to the elbow joint.

The examiner who provided an opinion in July 2025 determined it is not at least as likely as not that the Veteran's right elbow condition is related to service. She explained that the symptoms of neuropathy did not manifest in the right forearm until 2012, and an x-ray done that year noted no significant osseous or articular pathology, although there was a superficial five-millimeter calcification. She also noted that the Veteran did not report a right elbow condition at the time of separation, although noting a knee condition. The examiner concluded that it is unlikely that the neuropathy is due to an accident that occurred 34 years earlier.

The Board acknowledges the Veteran's contentions that his right elbow condition is related to his in-service MVA and/or due to playing softball. However, these are complex medical questions outside the competence of a non-medical expert to determine whether such a cause-and-effect relationship exists in this particular case. Thus, this nexus question requires expert consideration and cannot be considered within the competence of a non-expert lay witness. As an individual without medical training, the Veteran has not established the competence needed to rebut the expert medical opinions of record. See Fountain, 27 Vet. App. at 274-75; Monzingo, 26 Vet. App. at 105-06. As such, his opinion is not adequate to rebut the examiners' opinions as to the etiology of the claimed conditions, nor is it otherwise sufficiently probative to be considered competent evidence tending to increase the likelihood of a positive nexus between service and a right and left shoulder condition, and an opinion by a qualified medical expert is required to decide the claim.

Concerning the August 2023 opinion, the Board acknowledges that the examiner indicated that there was some inconsistency as to whether the Veteran received an abrasion to his left or right elbow as a result of the in-service MVA. However, the examiner explained that if the Veteran's right elbow condition was due to the in-service MVA or playing softball, the current condition would be limited to one elbow and not present in both. She also found significant the absence of an abnormality found in the 2012 x-rays, and the absence of a diagnosis of a right elbow condition until many years after service. Moreover, the opinion August 2023 opinion considered the medical literature submitted by the Veteran's representative concerning injuries associated with MVAs and playing softball, and found that based on the evidence, there is no relationship. In addition, there is no similar medical opinion of record weighing in favor of service connection based on the theory of direct service connection.

The Board acknowledges the Veteran reported that he experienced right elbow pain since the MVA. See March 2021 VA Examination Report. A veteran is competent to report the presence of symptoms and frequency of treatment. See Jandreau, 492 F.3d at 1377 n.4. However, the Board does not find the report of continuous symptoms to be credible in this case, as there is a decades long gap between the Veteran's in-service MVA in 1978
with MVAs and playing softball, and found that based on the evidence, there is no relationship. In addition, there is no similar medical opinion of record weighing in favor of service connection based on the theory of direct service connection.

The Board acknowledges the Veteran reported that he experienced right elbow pain since the MVA. See March 2021 VA Examination Report. A veteran is competent to report the presence of symptoms and frequency of treatment. See Jandreau, 492 F.3d at 1377 n.4. However, the Board does not find the report of continuous symptoms to be credible in this case, as there is a decades long gap between the Veteran's in-service MVA in 1978 and his reports of right elbow pain. The Board notes that evidence of a prolonged period without medical complaint, and the amount of time that elapsed since military service, can be considered as evidence against the claim. See Maxson, 230 F.3d at 1333.

In this case, the Veteran denied upper extremity issues at the time a November 1979 physical, and the associated physical examination reflects that his upper extremities were normal, his upper extremities were found to be normal at the time of a July 1992 physical, and he denied upper extremity issues at the time of his June 1993 separation physical, and the and his associated separation physical reflects that his upper extremities were "normal." VA treatment records in 2004 reflect that the Veteran did not report right elbow pain until much later, although he reported other medical concerns including back pain. As the Veteran reported this condition, the Board finds it likely he would have similarly reported experiencing right and left shoulder pain. VA treatment records reflect that the Veteran initially began reporting right elbow pain in 2014. See Horn, 25 Vet. App. at 240 n.7. Thus, the absence of evidence is negative evidence in this case as the evidentiary foundation for finding such has been established. Accordingly, the Board finds that the evidence persuasively weighs against the claims based on a theory under 38 C.F.R. § 3.303(b).

The Board acknowledges the Veteran's representative's contention that a January 2023 VA opinion concerning whether the Veteran's right elbow condition is aggravated by his service-connected conditions states that "[o]ther factors likely contributed likely contributed to the worsening of the neuropathy at the elbow such as ... the participation is softball" and that this indicates that service connection is warranted under a theory of direct service connection. However, as to the question of whether the Veteran's current right elbow condition is related to playing softball during service, the Board finds the January 2021 and August 2021 opinions are more probative as to this question as they discuss the Veteran's medical history and objective medical evidence, including the 2012 x-ray, which did not reflect a diagnosis consistent with playing softball. Concerning the January 2023 opinion, the Board has afforded it less probative weight concerning this contention as does not provide an adequate rationale as to why playing softball in service would be related to the current right elbow condition.

As the evidence weighs persuasively against a finding that that the Veteran's right elbow condition is related to an in-service injury, or event, and a finding that the condition had its onset in service, it follows that the nexus element of the claim is not established. As such, service connection is not warranted for a right elbow condition based on the theory of direct service connection.

Secondary Service Connection

The Board will also address whether service connection is warranted under the theory of secondary service connection, i.e., whether the Veteran's right elbow condition is caused or aggravated by a service-connected condition. The Veteran contends his shoulder conditions secondary to his service-connected lumbar spine condition. See July 2010 Claim Form. During the pendency of the appeal, the Veteran, through his representative asserted that the Veteran has shoulder conditions that are secondary to his service-connected lower extremities conditions, to include bilateral pes planus, bilateral ankle degenerative joint disease, bilateral knee strain, and bilateral lower extremity radiculopathy, due to altered biomechanics. See April 2024 Correspondence. As the RO granted service connection for a right elbow scar in a July 2025 rating decision, the Board will also address whether the Veteran has a right elbow condition that is secondary to service-connected right elbow scar.

Concerning the question of whether the Veteran's right elbow condition is caused by his service-connected lumbar spine condition, the evidence weighs against the claim. Weighing against the claims are VA opinions obtained in January 2021, November 2021, April 2022, January 2023, February 2024, and January 2025.

The examiner who
strain, and bilateral lower extremity radiculopathy, due to altered biomechanics. See April 2024 Correspondence. As the RO granted service connection for a right elbow scar in a July 2025 rating decision, the Board will also address whether the Veteran has a right elbow condition that is secondary to service-connected right elbow scar.

The examiner who provided a VA examination in January 2021 determined it is not likely that that the Veteran's lumbar strain is a cause of the Veteran's right elbow ulnar neuropathy. The examiner explained that the Veteran's medical records and research fail to support that his currently diagnosed ulnar neuropathy is due to or the result of service-connected degenerative arthritis of the spine. She explained that there is no research to support that degenerative arthritis of the spine causes ulnar neuropathy, and that it is medically impossible for the lumbar spine to cause upper extremity conditions.

The examiner who provided an examination in November 2021 determined it is less likely than not that the Veteran's diagnosed cubital tunnel syndrome is caused by his service-connected lumbar spine condition. She explained that there is no association of a lumbar spine condition causing an elbow condition, as the elbow and the spine are musculoskeletal joints that are not connected in any means or manner.

An additional opinion was obtained in April 2022. The examiner determined it is less likely than not that the Veteran's diagnosed right elbow condition is caused by his service-connected lumbar spine condition. She stated that to her knowledge, there is no logical connection between lumbosacral strain and any elbow condition.

The examiner who provided a VA examination in January 2023 determined it is less likely than not that the Veteran's diagnosed right elbow condition is caused by his service-connected lumbar spine condition. She explained that the lumbar spine condition could potentially affect the nerves of the Veteran's lower extremities but there is no correlation between the lumbar spine condition and the Veteran's right elbow.

The examiner who provided an opinion in February 2024 determined it is less likely than not that the Veteran's right elbow condition is caused by his service-connected lumbar spine condition. She explained there is no association between the lumbar spine and the right upper extremity.

The examiner who provided a VA examination in January 2025 found it is less likely that not that the Veteran's right elbow condition was caused by his service-connected lower extremity conditions. She considered articles provided by the Veteran's representative regarding the effect of altered biomechanics of the lower extremities on upper extremities submitted by the Veteran's representative in April 2024. The Veteran's representative asserts that the articles suggest difficulty using one's lower extremities may alter biomechanics, which can ultimately lead to gait disturbances and posture changes that put stress and strain on the elbow.

She also explained that when considering whether the Veteran's lower extremity conditions altered body mechanics and put stress and strain on the Veteran's right elbow, one way this could occur would be through repetitive syndrome, possibly through the use of ambulation devices such as crutches, canes, walkers. However, she stated further that medical records reflect that the Veteran used a cane only in 2021 and very rarely used crutches. She also explained that at the time of the Veteran's surgery for this elbow in 2014, the surgeon noted "the right ulnar nerve was entrapped and constricted at the right cubital tunnel from scarring." The examiner stated that Veteran's lower extremity condition did not lead to scarring or entrapment of the nerve issue at the elbow.

The examiner who provided an opinion August 2025 determined it is less likely than not that the Veteran's
could occur would be through repetitive syndrome, possibly through the use of ambulation devices such as crutches, canes, walkers. However, she stated further that medical records reflect that the Veteran used a cane only in 2021 and very rarely used crutches. She also explained that at the time of the Veteran's surgery for this elbow in 2014, the surgeon noted "the right ulnar nerve was entrapped and constricted at the right cubital tunnel from scarring." The examiner stated that Veteran's lower extremity condition did not lead to scarring or entrapment of the nerve issue at the elbow.

The examiner who provided an opinion August 2025 determined it is less likely than not that the Veteran's left elbow condition was caused by the use of assistive devices. The Board acknowledges that the opinion pertains to the left elbow rather than the right elbow, however, the Board finds the opinion rationale germane to the right elbow issue. The examiner explained that the Veteran's use of assistive devices could put stress on the elbow, but a review of the Veteran's records reflects that he only used a cane regularly in 2021, and very rarely used crutches. She explained further that improper use of a cane or crutches could potentially cause the compression of some nerves including the wrist, it would not result in compression at the elbow.

An opinion was obtained in July 2025 that addressed whether the Veteran's right elbow condition was caused by his service-connected right elbow scar. The examiner determined it is less likely than not that the Veteran's right elbow condition is caused by the right elbow scar. The examiner explained that the right elbow neuropathic symptoms would have become evident in the years following the complete healing of the scar. She explained further that complete wound healing can take up to two years, and the Veteran's symptom did not surface until about 2012, which was 34 years after the accident. As such, she concluded it is more likely that other factors led to the right elbow condition.

The Board acknowledges the Veteran's contentions that his right elbow condition is caused by his service-connected lumbar spine condition, lower extremity conditions, and/or a right elbow scar. However, these are complex medical questions outside the competence of a non-medical expert to determine whether such a cause-and-effect relationship exists in this particular case. Thus, this nexus question requires expert consideration and cannot be considered within the competence of a non-expert lay witness. As an individual without medical training, the Veteran has not established the competence needed to rebut the expert medical opinions of record. See Fountain, 27 Vet. App. at 274-75; Monzingo, 26 Vet. App. at 105-06. As such, his opinion is not adequate to rebut the examiners' opinions as to the etiology of the claimed conditions, nor is it otherwise sufficiently probative to be considered competent evidence tending to increase the likelihood of a positive nexus between the Veteran's service connected conditions and a right and left shoulder condition, and an opinion by a qualified medical expert is required to decide the claim.

As such, the evidence weighs persu
right elbow condition, based on the lengthy duration of time between the MVA and the appearance of right elbow symptoms. Therefore, the examiners' findings that it is less likely than not that the Veteran's right elbow condition is caused by his service-connected lumbar spine condition, his lower extremity conditions, and/or his right elbow scar is highly persuasive and probative evidence. Moreover, the January 2025 and July 2025 opinions considered the medical literature submitted by the Veteran's representative concerning the effects of altered biomechanics. In addition, there is no similar medical opinion of record weighing in favor of service connection based on the theory of secondary service connection, based on secondary causation.

As such, the evidence weighs persuasively against a finding that that the Veteran's right elbow condition was caused by his service-connected conditions. Accordingly, service connection is not warranted for a right elbow condition based on the theory of secondary service connection based on secondary causation.

The examiner who provided an examination in November 2021 determined it is less likely than not that the Veteran's diagnosed cubital tunnel syndrome or aggravated by his service-connected lumbar spine condition. There is no association of a lumbar spine condition causing an elbow condition, as the elbow and the spine are muscular skeletal joints that are not connected in any means or manner

The examiner who provided a VA examination in January 2023 determined it is less likely than not that the Veteran's diagnosed right elbow condition is aggravated by his service-connected lumbar spine condition. She explained that the lumbar spine condition could potentially affect the nerves of the Veteran's lower extremities but there is no correlation between the lumbar spine condition and the Veteran's right elbow.

The examiner who provided an opinion in February 2024 determined it is less likely than not that the Veteran's right elbow condition is aggravated by his service-connected lumbar spine condition. She explained it is not medically or anatomically possible for a lumbar spine condition to affect the upper right extremity.

A VA opinion was obtained in January 2025. The examiner found that it is less likely than not that the Veteran's right elbow condition was aggravated by his service-connected lower extremity conditions. She explained that there is no aggravation of the condition. The examiner acknowledged that although a change in biomechanics may have altered Veteran's gait or alternative use of muscles, this does not lead to an increase in weight-bearing of the elbow. She noted that his records reflect the irregular and rare use of crutches (3 times per year) for the lower back condition, which would not be enough of a frequency to contribute to an overuse syndrome. She explained further that other factors likely contributed to worsening of the neuropathy at the elbow, such as the scarring of the right elbow from his 1978 laceration or the participation in softball. The examiner cited an article regarding care concerning the ulnar nerve as it concerns athletes in competitive sports.

An addendum opinion was obtained in March 2025. A different examiner determined it is less likely than not that the Veteran's right elbow condition was aggravated by his service-connected degenerative arthritis of the spine and lower extremity conditions. He stated that the Veteran's risk factors for ulnar neuropathy include advanced age, as his age is 69 years, obesity as his body mass index is 38, and a diagnosis of diabetes mellitus, which contributes to the development of the elbow condition.

The examiner acknowledged that a network-based representation of the musculoskeletal system, as discussed by Andrew C. Murphy in one of the articles provided by the Veteran's representative, emphasizes the interconnectivity of muscles and neural pathways, suggesting that injuries or dysfunctions within the musculoskeletal network can have widespread effects. However, he explained that ulnar neuropathy is a localized peripheral nerve condition rather than a secondary consequence of spinal degenerative changes or lower extremity impairments. He noted the study highlights that disruptions in small-scale musculoskeletal organization can affect functional recovery, but this principle applies more to motor control rehabilitation rather than neuropathic compression syndromes. The examiner explained that the structure, function, and control of the musculoskeletal system emerge from finely tuned neuromuscular connections, whereas the ulnar nerve operates within a distinct anatomical pathway unrelated to the service- connected spine condition and lower extremity conditions. Thus, the examiner concluded that the development and progression of ulnar neuropathy is more likely attributed to mechanical compression and the Veteran's individual risk factors rather than any secondary effects from the spine or lower extremities. He also stated that there is
or lower extremity impairments. He noted the study highlights that disruptions in small-scale musculoskeletal organization can affect functional recovery, but this principle applies more to motor control rehabilitation rather than neuropathic compression syndromes. The examiner explained that the structure, function, and control of the musculoskeletal system emerge from finely tuned neuromuscular connections, whereas the ulnar nerve operates within a distinct anatomical pathway unrelated to the service- connected spine condition and lower extremity conditions. Thus, the examiner concluded that the development and progression of ulnar neuropathy is more likely attributed to mechanical compression and the Veteran's individual risk factors rather than any secondary effects from the spine or lower extremities. He also stated that there is no evidence in the that the Veteran's right elbow neuropathy was aggravated.

The examiner who provided an opinion August 2025 determined it is less likely than not that the Veteran's left elbow condition was aggravated by the use of assistive devices. The Board acknowledges that the opinion pertains to the left elbow rather than the right elbow, however, the Board finds the opinion rationale germane to the right elbow issue. The examiner explained that the Veteran's use of a cane or crutches was to infrequent to cause aggravation, as discussed, and that although the improper use of a cane or crutches could potentially cause the compression of some nerves including the wrist, it would not result in compression at the elbow.

An opinion was obtained in July 2025 that addressed whether the Veteran's right elbow condition was aggravated by his service-connected right elbow scar. The examiner determined it is less likely than not that the Veteran's right elbow condition is aggravated by the right elbow scar. The examiner explained that the scar healing completed in two to three years after the onset, which was in 1978, and if there was a worsening of the right elbow condition due to the scar, it would not have taken over 30 years to occur.

The Board acknowledges the Veteran's contentions that his right elbow condition is aggravated by his service-connected lumbar spine condition, lower extremity conditions, and/or a right elbow scar. However, these are complex medical questions outside the competence of a non-medical expert to determine whether such a cause-and-effect relationship exists in this particular case. Thus, this nexus question requires expert consideration and cannot be considered within the competence of a non-expert lay witness. As an individual without medical training, the Veteran has not established the competence needed to rebut the expert medical opinions of record. See Fountain, 27 Vet. App. at 274-75; Monzingo, 26 Vet. App. at 105-06. As such, his opinion is not adequate to rebut the examiners' opinions as to the etiology of the claimed conditions, nor is it otherwise sufficiently probative to be considered competent evidence tending to increase the likelihood of a positive nexus between the Veteran's service connected conditions and a right and left shoulder condition, and an opinion by a qualified medical expert is required to decide the claim.

Consequently, the Board gives more probative weight to the VA examiners' opinions. The Board finds VA examiners' opinions clear and unequivocal and are based on the relevant information, including the Veteran's statements, post-service records, and relevant medical research. Moreover, the examiner's explanations are logical and follow from the facts and information given. See Monzingo, 26 Vet. App. at 105-06; Nieves-Rodriguez, 22 Vet. App. at 304. In finding that the Veteran's right shoulder condition is not caused by his service-connected lumbar spine condition, and/or lower extremity conditions, the examiners explained that there is no relationship between the lumbar spine and the right elbow that could aggravate the condition and consideration of body mechanics, to include the Veteran's intermittent use of a cane does not suggest aggravation based on the Veteran's infrequent use and that the use of assistive devices is unlikely to cause compression of nerves associated with the elbow. The examiner also explained why it is not likely that the Veteran's right elbow scar aggravated his right elbow condition, based on the lengthy duration of time between the MVA and the healing of the scar and the appearance of right elbow symptoms. Therefore, the examiners' findings that it is less likely than not that the Veteran's right elbow condition is aggravated by his service-connected lumbar spine condition, his lower extremity conditions, and/or his right elbow scar is highly persuasive and probative evidence. Moreover, the January 2025 and July 2025 opinions considered the medical literature submitted by the Veteran's representative concerning the effects of altered biomechanics. In addition, there is no similar medical opinion of record weighing in favor of service connection based on the theory of secondary service connection,
the Veteran's right elbow scar aggravated his right elbow condition, based on the lengthy duration of time between the MVA and the healing of the scar and the appearance of right elbow symptoms. Therefore, the examiners' findings that it is less likely than not that the Veteran's right elbow condition is aggravated by his service-connected lumbar spine condition, his lower extremity conditions, and/or his right elbow scar is highly persuasive and probative evidence. Moreover, the January 2025 and July 2025 opinions considered the medical literature submitted by the Veteran's representative concerning the effects of altered biomechanics. In addition, there is no similar medical opinion of record weighing in favor of service connection based on the theory of secondary service connection, based on secondary aggravation.

As such, the evidence weighs persuasively against a finding that that the Veteran's right elbow condition was aggravated by his service-connected conditions. Accordingly, service connection is not warranted for a right elbow condition based on the theory of secondary service connection based on secondary aggravation.

In reaching the conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the evidence weighs persuasively against the claim, under the direct and secondary theories of service connection, that doctrine is not applicable in this case. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is not warranted for a right elbow condition.

4. A TDIU.

Legal Criteria

Total disability ratings for compensation may be assigned, where the schedular rating is less than total, when a veteran is unable to secure or follow a substantially gainful occupation as a result of service-connected disabilities, provided that if there is only one such disability, such disability shall be ratable as 60 percent or more, and if there are two or more disabilities, there shall be at least one disability ratable at 40 percent or more and sufficient additional disability to bring the combined rating to 70 percent or more. 38 C.F.R. § 4.16(a).

In determining whether a veteran can secure and follow a substantially gainful occupation, attention must be given to:

" The veteran's history, education, skill, and training;

" Whether the veteran has the physical ability (both exertional and nonexertional) to perform the type of activities (e.g., sedentary, light, medium, heavy, or very heavy) required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning lifting, bending, sitting, standing, walking, climbing, grasping, typing, and reaching, as well as auditory and visual limitations; and

" Whether the veteran has the mental ability to perform the activities required by the occupation at issue. Factors that may be relevant include, but are not limited to, the veteran's limitations, if any, concerning memory, concentration, ability to adapt to change, handle work place stress, get along with coworkers, and demonstrate reliability and productivity.

Ray v. Wilkie, 31 Vet. App. 58, 73 (2019).

For purposes of this decision, the Board uses the term "sedentary" to have the common meaning of a non-physical job, primarily involving sitting and usually performed in an indoor, office-type environment. See Withers v. Wilkie, 30 Vet. App. 139, 147-48 (2018).

Analysis

The Veteran contends he is unable to work due to his service-connected disabilities. The Veteran stated that he cannot work due to difficulties with lifting, bending, and standing. He also stated standing is also an issue due to the need for constantly shifting his weight to maintain comfort. See March 2016 Notice of Disagreement. The Veteran explained at the Board hearing that his job as a loss prevention manager required installing cameras and heavy cables. In a statement provided in May 2021 he also explained that as a loss prevention manager, his responsibilities included installing cameras, which were physically demanding.

Prior to May 31, 2019, when the Veteran was granted a combined 100 percent rating, his service-connected disabilities includes degenerative arthritis of the spine, rated at 60 percent from October 13, 1999; obstructive sleep apnea, rated at 50 percent from May 8, 2014; right ankle degenerative joint disease rated at 10 percent from May 27, 2009; left ankle degenerative joint disease, rated at 10 percent from May 27, 2009; right knee strain, rated at 10 percent from July 15, 2010; left knee strain, rated at 10 percent from July 15, 2010; right lower extremity radiculopathy, rated at 10 percent from October 16, 2012; left lower extremity radiculopathy, rated at 10 percent from June 14, 2014; hemorrhoids, rated as noncompensable from February 1, 1994; surgical scar, rated as noncompensable from February 1, 1994; and a right elbow scar, rated as noncompensable from December 1, 2014.

Regarding his history, education, skill, and training, the Veteran's TDIU applications reflect that he worked as a technician for a utility corporation from 1998 to 2007 and a loss prevention manager for a duty-free shop from 2007 to 2010. Concerning education, the Veteran reported that he completed an associate degree in general studies in 1989. As to the occupation at issue, the Board will consider the Veteran's service-connected disabilities as they concern employment as a technician and a loss prevention manager for a retail store. Concerning whether the Veteran has the physical ability to perform the type of activities required by the occupation at issue, the Board notes that the Veteran has physical limitations associated with his service-connected lumbar spine condition, right and left ankle degenerative arthritis, right and left knee strain, right and left lower extremity radiculopathy, and obstructive sleep apnea.

Concerning the Veteran's lumbar spine condition, the Veteran reported pain with prolonged standing and sitting. A March 2021 VA examiner stated that the Veteran's degenerative arthritis of the spine with radiculopathy affects his ability to be employed as he has difficulty with bending, twisting and turning side to side, prolonged walking, prolonged sitting or standing, stooping, squatting, and ambulating stairs due to back pain. The examiner stated that he is unable to perform any heavy lifting, pushing, or carrying due to back pain, and that he is unable to get in and out of a car easily, which would cause a transportation issue. With regard to the Veteran's right and left ankle condition, right and left knee condition, and right and left lower extremity radiculopathy, a March 2021 VA examination report reflects that the Veteran has difficulty with prolonged standing; ambulating ramps, hills, and stairs due to pain. The examiner stated that the Veteran's ankle pain impairs his ability to press on the gas and brake pedals, which impacts his ability to drive to and from work. With regard to the Veteran's sleep apnea, the March 2021 VA examination report reflects that if the Veteran does not use his CPAP, he experiences fatigue.

In regard to the question of whether the Veteran has the mental ability to perform the type of work activities required by the occupation at issue, the Board notes that the Veteran has limitations associated with the same noted disabilities. The Board finds that Veteran's multiple service-connected musculoskeletal conditions would cause at least some level of distraction due to pain. Concerning the Veteran's obstructive sleep apnea, the examiner who provided a March 2021 VA examination stated that if the Veteran does not use his CPAP, he is fatigued, which affects his daytime awareness, concentration, and alertness, which would affect his productivity at work.

Thus, due to the combined effects of the Veteran's physical and mental impairments caused by his lumbar spine condition, right and left ankle condition, right and left knee condition, right and left lower extremity radiculopathy, and obstructive sleep apnea, the Board finds it unlikely that the Veteran would be able to secure or follow more than marginal employment consistent with his background, training, and education at any job, whether sedentary or physical, which would require a degree of physical and mental functioning to carry out the job functions that has been outside the Veteran's capacity. The Veteran's work experience was in positions that included responsibilities that required manual labor and likely some responsibilities associated with sedentary employment. The limitations, both physical and mental, due lumbar spine condition, right and left
mental impairments caused by his lumbar spine condition, right and left ankle condition, right and left knee condition, right and left lower extremity radiculopathy, and obstructive sleep apnea, the Board finds it unlikely that the Veteran would be able to secure or follow more than marginal employment consistent with his background, training, and education at any job, whether sedentary or physical, which would require a degree of physical and mental functioning to carry out the job functions that has been outside the Veteran's capacity. The Veteran's work experience was in positions that included responsibilities that required manual labor and likely some responsibilities associated with sedentary employment. The limitations, both physical and mental, due lumbar spine condition, right and left ankle condition, right and left knee condition, right and left lower extremity radiculopathy, and obstructive sleep apnea make it unlikely that the Veteran would meet the requirements of substantially gainful employment. While the Veteran likely has experience with sedentary employment, the Board finds that limitations with prolonged sitting and obstructive sleep apnea symptoms would preclude him from performing gainful sedentary employment.

Therefore, particularly when reasonable doubt is resolved in favor of the Veteran, the Board finds the Veteran has been unable to obtain or follow gainful employment due to the limitations caused by his service-connected disabilities during this period. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. The Board concludes that a TDIU is warranted from the date of claim July 15, 2010.

As to the effective date for a TDIU, the claim is considered from July 15, 2010, as this is when the Veteran filed a claim for service connection for a left knee condition that was granted during the course of this appeal. The Board notes that Veteran meets the schedular requirements for a TDIU from that date as he is assigned a combined 80 percent rating. 38 C.F.R. §§ 4.16(a).

Accordingly, when reasonable doubt is resolved in favor of the Veteran, the Board finds that, as of July 15, 2010, the Veteran was not employed, and his service-connected disabilities prevented him from securing or following a substantially gainful occupation consistent with his educational and occupational background. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, a TDIU is warranted as of July 15, 2010.

RYAN T. KESSEL

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board Gray, Elissa A.

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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