POSTTRAUMATIC STRESS DISORDER (PTSD)

Summary

The veteran, who served in the Army Reserve from June 2014 to September 2014, with subsequent periods of active duty and inactive duty training, appeals the denial of service connection for several conditions, including PTSD, a right pinky finger injury, low back disability, bilateral radiculopathy, left wrist condition, and left and right hip conditions. The Board granted service connection for PTSD prior to May 23, 2025, finding that the Veteran's claimed military sexual trauma stressor was sufficiently corroborated by a VA examiner's opinion and subsequent favorable findings by the agency of original jurisdiction. Service connection for a right pinky finger injury prior to May 23, 2025, was also granted, based on a favorable VA examiner opinion and subsequent AOJ grant, despite initial denials due to lack of documented in-service treatment. The Board granted service connection for a low back disability, resolving reasonable doubt in the Veteran's favor, citing the timing of the diagnosis of degenerative disc disease within a year of an in-service motor vehicle accident and a favorable VA physician opinion, despite conflicting earlier VA examiner opinions. Radiculopathy of the left and right lower extremities was granted as secondary to the now service-connected low back disability, supported by post-service treatment records and a VA examination. Service connection for a left wrist condition was denied due to lack of evidence of a current disability and insufficient nexus to service. Similarly, claims for left and right hip disabilities were denied due to a lack of evidence of a current disability, with the Board affording greater weight to medical evidence over the Veteran's lay contentions and finding the evidence weighed against the claim, thus not applying the benefit of the doubt doctrine. The right shoulder disability was granted, resolving reasonable doubt in the Veteran's favor, based on a history of surgeries and a favorable VA physician opinion linking the condition to an in-service accident and subsequent aggravation during service.

Rationale

Favorable VA examiner opinion in June 2020; Subsequent AOJ grant in August 2025; Favorable finding by the Board resolving reasonable doubt

Full Decision Text

Citation Nr: A26038289
Decision Date: 04/23/26	Archive Date: 04/23/26

DOCKET NO. 200925-102919
DATE: April 23, 2026

ORDER

Service connection for posttraumatic stress disorder (PTSD) is granted prior to May 23, 2025. 

Service connection for right pinky finger injury is granted prior to May 23, 2025.

Service connection for a low back disability is granted. 

Service connection for radiculopathy of the left lower extremity is granted.

Service connection for radiculopathy of the right lower extremity is granted.

Service connection for a left wrist condition is denied. 

Service connection for a left hip condition is denied. 

Service connection for a right hip condition is denied.

Service connection for a right shoulder status post right shoulder open cartilage grafting of humeral head osteochondritis dissecans (OCD) is granted.

FINDINGS OF FACTS

1. Resolving reasonable doubt in favor of the Veteran, the record contains sufficient positive evidence to support the grant of service connection for PTSD from prior to May 23, 2025.  

2. The record contains sufficient positive evidence to support the grant of service connection for a right little finger condition prior to May 23, 2025. 

3. In resolving reasonable doubt in favor of the Veteran, the record suggests that his current low back disability is related to his military service. 

4. The evidence suggests that the Veteran's radiculopathy of the left lower extremity is related to his low back disability.

5. The evidence suggests that the Veteran's radiculopathy of the right lower extremity is related to his low back disability.

6. The medical evidence does not show a current disability of the left wrist. 

7. The weight of the evidence of record is against finding that the Veteran has a current left hip disability related to his miliary service.

8. The weight of the evidence of record is against finding that the Veteran has a current right hip disability related to his miliary service.

9. Resolving reasonable doubt in favor of the Veteran, the record suggests that his right shoulder disability had its onset during his period of service. 

CONCLUSIONS OF LAW

1. The criteria for entitlement to service connection for PTSD prior to May 23, 2025, have been met. 38 U.S.C. §§ 101(24), 1110, 1154(a), 5107(b); 38 C.F.R. §§ 3.6, 3.102, 3.303, 3.304(f), 3.309.

2. The criteria for entitlement to service connection for a right pinky finger injury prior to May 23, 2025, have been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303. 

3. The criteria for entitlement to service connection for a low back disability have been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303. 

4. The criteria for entitlement to service connection for radiculopathy of the left lower extremity have been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.310.

5. The criteria for entitlement to service connection for radiculopathy of the right lower extremity have been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303, 3.310.

6. The criteria for entitlement to service connection for a left wrist disability have not been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303.

7. The criteria for entitlement to service connection for a left hip disability have not been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303.

8. The criteria for entitlement to service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107;
 been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303.

7. The criteria for entitlement to service connection for a left hip disability have not been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303.

8. The criteria for entitlement to service connection for a right hip disability have not been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303.

9. The criteria for entitlement to service connection for a right shoulder disability have been met. 38 U.S.C. §§ 1110, 5103(a), 5103A, 5107; 38 C.F.R. §§ 3.159, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty from June 2014 to September 2014, November 2014 to November 2014, May 2016 to May 2016, and from July 2018 and July 2018. 

These matters are before the Board of Veterans' Appeals (Board) on appeal from an April 2020 and an August 2020 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). The April 2020 rating decision denied service connection for a left and right hip condition, a left wrist condition, and a right shoulder condition. The August 2020 rating decision denied service connection for PTSD, a low back disability, radiculopathy of the bilateral lower extremity sciatic nerves, and a right pinky finger injury. 

In the September 2020 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket.  A hearing before the undersigned Veterans Law Judge (VLJ) was held on October 8, 2024. 

Therefore, the Board may only consider the evidence of record at the time of the April 2020 rating decision on appeal (for the left and right hip condition, left wrist condition, and right shoulder condition) and at the time of the August 2020 rating decision on appeal (for PTSD, the low back disability, radiculopathy of the bilateral lower extremity sciatic nerves, and right pinky finger injury), as well as any evidence submitted by the Veteran or his representative at the hearing or within 90 days following the hearing. 38 C.F.R. § 20.302(a). If evidence was submitted either (1) during the period after the agency of original jurisdiction (AOJ) issued the decisions on appeal and prior to the Board hearing, or (2) more than 90 days following the hearing, the Board did not consider it in its decision. 38 C.F.R. §§ 20.300, 20.302(a), 20.801. 

If the Veteran would like VA to consider any evidence that was submitted that the Board could not consider, the Veteran may file a Supplemental Claim (VA Form 20-0995) and submit or identify this evidence. 38 C.F.R. § 3.2501. If the evidence is new and relevant, VA will issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. Id. Specific instructions for filing a Supplemental Claim are included with this decision.

Also, as an introductory matter, it is acknowledged that following the April 2020 and August 2020 rating decisions, the Veteran also sought review of the present issues on appeal by submitting a September 2020, VA Form 20-0995, Decision Review Request: Supplemental Claim. This was addressed in a September 2020 supplemental claim decision in which the AOJ declined to readjudicate the present issues on appeal by finding that new and relevant evidence had not been received. Although the September 2020 rating decision is the most recent rating decision to address the present issues on appeal, the Board notes that in his September 2020 VA Form 10182, the Veteran specifically requested to appeal the present issues from the April 2020 and August 2020 rating decisions rather than the September 2020 rating decision. 

In Terry v. McDonough, 37 Vet. App. 1 (2023), the U.S. Court of Appeals for Veterans Claims (Court) held that pursuant to 38 U.S.C. § 5104C(a), "a claimant is able to select a second administrative review option
 the present issues on appeal by finding that new and relevant evidence had not been received. Although the September 2020 rating decision is the most recent rating decision to address the present issues on appeal, the Board notes that in his September 2020 VA Form 10182, the Veteran specifically requested to appeal the present issues from the April 2020 and August 2020 rating decisions rather than the September 2020 rating decision. 

In Terry v. McDonough, 37 Vet. App. 1 (2023), the U.S. Court of Appeals for Veterans Claims (Court) held that pursuant to 38 U.S.C. § 5104C(a), "a claimant is able to select a second administrative review option with respect to a decision on the claim, so long as the 1-year period from that decision has not run and the second administrative review option does not run concurrently with the first administrative review option." Id. at 14. In this case, as the AOJ had completed its review of the September 2020 Supplemental Claim Application and the one 1-year period from the April 2020 and August 2020 rating decisions had not yet expired when the Veteran filed his September 2020 VA Form 10182, the matters are properly on appeal from the April 2020 and August 2020 rating decisions. 

Finally, regarding the characterization of the PTSD and right pinky finger injury issues on appeal, the Boards notes that while this appeal was pending, the Veteran submitted a VA Form 21-526EZ, Fully Developed Claim, on May 23, 2025, in which he requested service connection for depression, a generalized anxiety disorder, and an adjustment disorder, as well as degenerative arthritis in the bilateral hands or fingers. Although the Veteran had been previously denied service connection for PTSD and a right pinky little finger injury, claims for depression, a generalized anxiety disorder, adjustment disorder, and a general claim for degenerative arthritis in the bilateral hands or fingers had not been previously adjudicated by the AOJ. Accordingly, the AOJ addressed these as new claims and issued a rating decision in August 2025 that granted service connection for PTSD with adjustment disorder and generalized anxiety disorder and a right hand strain little finger, rated 70 percent and 0 percent, respectively, both effective May 23, 2025 (the date of new claim).

As the May 23, 2025 effective date for the Veteran's awards of service connection for PTSD with adjustment disorder and generalized anxiety disorder and a right hand strain little finger is after the date of the claim presently on appeal before the Board, the Board finds that the issues of entitlement to service connection for posttraumatic stress disorder (PTSD) and for a right pinky finger injury, prior to May 23, 2025, remain on appeal before the Board. See Concepcion-Maldonado v. Collins, 38 Vet. App. 294, 302 (2025) ("mootness if a case-specific inquiry requiring the Court to reckon with the individual circumstances of the appeal and the implications for appellant's ability to obtain full relief.").  

Service Connection

Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Disorders diagnosed after discharge will still be service connected if all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d).

Service connection may also be granted for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). When service connection is established for a secondary disability, the secondary disability shall be considered a part of the original disability. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability.

For certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service.  38 C.F.R. §§ 3.307(a)(3), 3.309(a).  When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.
 disability shall be considered a part of the original disability. Id. Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability.

For certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service.  38 C.F.R. §§ 3.307(a)(3), 3.309(a).  When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time.  When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a).  38 C.F.R. § 3.303(b); see also Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).

During the pendency of this appeal, the Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022 (PACT Act) created a statutory duty for VA to provide a Toxic Exposure Risk Assessment (TERA) examination to any Veteran determined to have been exposed to toxic substances, when there is not sufficient evidence to establish service connection without such an examination. 38 U.S.C. § 1168(a). When providing the Secretary with a TERA opinion, the health care provider must consider (1) the total potential exposure through all applicable military deployments of the veteran; and (2) the synergistic, combined effect of all toxic exposure risk activities of the veteran. 38 U.S.C. § 1168(a)(2)(A-B). This requirement shall not apply if the Secretary determines there is no indication of an association between the disability claimed by the veteran and the toxic exposure risk activity for which the veteran submitted evidence. 38 U.S.C. § 1168(b).

Reserve and National Guard service generally means ACUDTRA (active duty for training) and INACDUTRA (inactive duty for training). ACDUTRA is full time duty for training purposes performed by Reservists and National Guardsmen pursuant to 32 U.S.C. § 316, 502, 503, 504, or 505. 38 U.S.C. § 101(22); 38 C.F.R. § 3.6(c). That usually includes two weeks of annual training and/or an initial period of training. INACDUTRA includes duty, other than full-time duty, performed for training purposes by Reservists and National Guardsmen pursuant to 32 U.S.C. § 316, 502, 503, 504, or 505. 38 U.S.C. § 101(23); 38 C.F.R. § 3.6(d).  That usually indicates weekend drills or training.

The law applicable to active-duty service establishes "veteran" status without further requirements. Moreover, it permits a grant of service connection simply by evidence establishing an etiological relationship between an injury or disease in service and a post-service disability. The law pertaining to periods of ACUDTRA and INACDUTRA requires that the claimant have become disabled "during" the period of ACDUTRA or INACDUTRA in which the injury or disease occurred, and specifically requires that the disease and/or injury have been incurred in the line of duty.  Moreover, the claimant bears the burden of establishing that this sequence of events has occurred before "veteran" status is granted.  38 U.S.C. § 101(24).

The presumption of service connection for specific chronic diseases (38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309), can never apply to periods of ACDUTRA and INACDUTRA.  Smith v. Shinseki, 24 Vet. App. 40, 47 (2010). This is because 38 U.S.C. § 101(24) requires that the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty during ACDUTRA; or from an injury during INACDUTRA. However, the presumption of service connection for chronic disease applies only where there is
The presumption of service connection for specific chronic diseases (38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307, 3.309), can never apply to periods of ACDUTRA and INACDUTRA.  Smith v. Shinseki, 24 Vet. App. 40, 47 (2010). This is because 38 U.S.C. § 101(24) requires that the individual concerned was disabled or died from a disease or injury incurred or aggravated in the line of duty during ACDUTRA; or from an injury during INACDUTRA. However, the presumption of service connection for chronic disease applies only where there is no evidence that the disease occurred during service.

PTSD

The Veteran contends that he developed PTSD as a result of his military service, to include from an in-service sexual assault and harassment. See February 2020 VA Form 21-526EZ.

As noted in the Introduction, the Veteran is currently service-connected for PTSD with adjustment disorder and generalized anxiety disorder from May 23, 2025. Therefore, the question to be resolved in this appeal is whether entitlement to service connection for PTSD is warranted prior to that date.

At the October 2024 Board hearing, the Veteran described the events of his military sexual trauma by his military superior. He relayed that after a social gathering that involved eating and drinking with other people present, he was pressured to engage in sexual activity with a higher-ranking female service member and was too incapacitated to provide consent. After waking to find himself being sexually assaulted, his attempt to leave failed after she initiated threats against him. With her superior rank, she claimed to ruin his career if he did not engage in sexual activity with her that night. After the incident, the Veteran reported the assault and threat to his direct supervisor who dismissed his complaint. To cope with the stress and trauma, he began to drink heavily, which led to anxiety and chronic sleep problems. 

Claims of service connection for PTSD require a medical diagnosis conforming to the requirements of 38 C.F.R. § 4.125(a), an in-service stressor accompanied by credible supporting evidence that the stressor claimed to be the cause of the disorder occurred in service and established medical evidence connecting the current disability to the stressor. 38 C.F.R. § 3.304(f); see also 38 C.F.R.§ 4.125(a); Cohen v. Brown, 10 Vet. App. 128, 138 (1997). 

In claims with stressors based on personal assault, evidence from various sources may be used to corroborate the stressor, including evidence of behavioral changes following the claimed assault. 38 C.F.R. § 3.304(f)(5); see also Menegassi v. Shinseki, 638 F.3d 1379, 1382 (Fed. Cir. 2011) (stating that medical opinion evidence can be used to corroborate the claimed stressor in personal assault cases).

In the August 2020 rating decision on appeal, VA conceded that the Veteran had a diagnosis of PTSD, as such a diagnosis was confirmed during a June 2020 VA examination. Significantly, the June 2020 VA examiner opined that it was at least as likely as not that the claimed military sexual trauma stressor occurred and resulted in the Veteran's PTSD. The AOJ denied the claim, however, finding that the evidence of record did not contain credible supporting evidence that the claimed in-service stressor actually occurred. 

As noted above, following the Veteran's appeal of the August 2020 rating decision, in an August 2025 rating decision, the AOJ granted service connection for PTSD with adjustment disorder and generalized anxiety disorder, effective May 23, 2025. In reaching this decision, the AOJ made a favorable finding that the Veteran had a diagnosis of PTSD with adjustment disorder and generalized anxiety disorder that was directly related to his military service, as the evidence established that the claimed military sexual trauma occurred and was connected to his diagnosis of PTSD. Favorable findings made by the AOJ are generally binding on the Board, unless rebutted by evidence that identifies a clear and unmistakable error in the favorable finding. 38 U.S.C. § 5104A; 38 C.F.R. §§ 3.104(c); 20.801(a). Such evidence is not present in this case. Indeed, even at the time of the August 2020 rating decision, a VA examiner had opined in June 2020 that it was at least as likely as not that the Veteran's claimed military sexual trauma stressor had occurred and resulted in his PTSD. 

Moreover, subsequent to the October 2024 Board hearing, and within 90 days, the Veteran submitted a November 2024 letter from
 the AOJ are generally binding on the Board, unless rebutted by evidence that identifies a clear and unmistakable error in the favorable finding. 38 U.S.C. § 5104A; 38 C.F.R. §§ 3.104(c); 20.801(a). Such evidence is not present in this case. Indeed, even at the time of the August 2020 rating decision, a VA examiner had opined in June 2020 that it was at least as likely as not that the Veteran's claimed military sexual trauma stressor had occurred and resulted in his PTSD. 

Moreover, subsequent to the October 2024 Board hearing, and within 90 days, the Veteran submitted a November 2024 letter from his VA treating psychologist who documented that the Veteran had been treated through VA's primary care mental health integration for various psychiatric diagnoses, including PTSD stemming from a motor vehicle accident in 2014 and a military sexual trauma that occurred in 2018 (which more appropriately captured his anxiety and depression). 

Based on the foregoing, the Board finds that a nexus has been established and criteria for service connection for PTSD have been met.  Accordingly, the Veteran's claim of service connection for PTSD prior to May 23, 2025, is granted.

Right Pinky Finger Injury

The Veteran contends that he sustained and developed a right pinky injury as a result of a motor vehicle accident that occurred during service on a drill weekend. See February 2020 VA 21-526EZ. 

As noted in the Introduction, the Veteran is currently service-connected for a right hand strain little finger from May 23, 2025. Therefore, the question to be resolved in this appeal is whether entitlement to service connection for a right pinky injury is warranted prior to that date.

At the October 2024 Board hearing, the Veteran reiterated that his current right pinky finger condition was the direct result of his motor vehicle accident in service in November 2014. While he received surgical treatment for the left little finger, he was not treated for the right little finger, which did not heal properly. 

In the August 2020 rating decision on appeal, VA conceded that the Veteran had a current diagnosis for the claimed right pinky finger injury as a VA examination conducted in August 2020 confirmed a diagnosis of unspecified fracture of the fifth metacarpal bone, right hand. The AOJ also conceded that the Veteran was involved in a motor vehicle accident while in service. Significantly, the August 2020 VA examiner opined that it was at least as likely as not that the claimed right pinky finger injury was at least as likely as not related to the Veteran's service as the Veteran had a motor vehicle accident in November 2024. The AOJ denied the claim, however, finding that the Veteran did not report an injury to the right pinky finger after the accident or while receiving treatment.

As noted above, following the Veteran's appeal of the August 2020 rating decision, in an August 2025 rating decision, the AOJ granted service connection for right hand strain little finger, effective May 23, 2025. In reaching this decision, the AOJ made a favorable finding that the Veteran's right hand strain little finger was directly related to his military service (and specifically, the motor vehicle accident that occurred while in service, see July 2025 VA examination and medical opinion). Favorable findings made by the AOJ are generally binding on the Board, unless rebutted by evidence that identifies a clear and unmistakable error in the favorable finding. 38 U.S.C. § 5104A; 38 C.F.R. §§ 3.104(c); 20.801(a). Such evidence is not present in this case. Indeed, even at the time of the August 2020 rating decision, a VA examiner had opined in August 2020 that it was at least as likely as not that the Veteran's right pinky finger injury was related to his military service. 

Based on the foregoing, the Board finds that a nexus has been established and criteria for service connection for right pinky finger injury have been met.  Accordingly, the Veteran's claim of service connection for right pinky finger prior to May 23, 2025, is granted.

Low Back Disability

The Veteran contends that he developed a chronic low back disability as a result of his military service, particularly due to a motorcycle accident in November 2014, during a drill weekend. 

At the October 2014 Board hearing, the Veteran reiterated that he sustained a chronic low back disability as a result of his motor vehicle accident while he was on active duty. He described his low back condition as 'debilitating' and that his symptoms had resulted in chronic pain, leading to the development of radiculopathy in the lower legs. 

The Veteran's service treatment records are silent for complaints or
 Accordingly, the Veteran's claim of service connection for right pinky finger prior to May 23, 2025, is granted.

Low Back Disability

The Veteran contends that he developed a chronic low back disability as a result of his military service, particularly due to a motorcycle accident in November 2014, during a drill weekend. 

At the October 2014 Board hearing, the Veteran reiterated that he sustained a chronic low back disability as a result of his motor vehicle accident while he was on active duty. He described his low back condition as 'debilitating' and that his symptoms had resulted in chronic pain, leading to the development of radiculopathy in the lower legs. 

The Veteran's service treatment records are silent for complaints or treatment for a back condition or injury. 

While VA has conceded that the Veteran was involved in a motor vehicle accident in November 2014 while in the line of duty, his treatment records do not document any complaints, diagnosis, or treatment relating to a back injury sustained as a result of that accident. 

Nevertheless, the first complaint of a back disability was documented within a year of the November 2014 accident. Private treatment records from May 2015 note that the Veteran was seen for back pain with pain radiating down to his legs. A physical examination supported diagnoses of degenerative disc disease of the lumbar spine with lumbar spine radiculopathy and herniated nucleus pulposus. He was seen again in January 2016 for continued back pain and pain in the lower extremity. Subsequent records show that the Veteran continued to seek treatment for back pain and radicular symptoms. In April 2019, treatment records show a diagnosis of spondylosis with radiculopathy of the lumbosacral region. 

The Veteran was provided with a VA examination in March 2020. There, the Veteran indicated that he injured his back when he fell in July 2014 on active duty while running. He recalled having back pain and seeking medical attention. He had residual back pain in November 2014. After examining the Veteran and reviewing his claims file, the examiner found against a nexus between the Veteran's service and his current lumbar spine disability. As rationale, the examiner noted that the Veteran did not demonstrate evidence of an 'upper back condition,' and explained that his service treatment records were silent for any chronic back condition. The examiner stated that despite any injuries or other upper back conditions that the Veteran may have experienced during service, there was no evidence of a current chronic condition relating to his upper back. It was not until 2018 that the medical records documented a back condition. Therefore, it was less likely than not that the Veteran had a current upper back injury that was incurred in service. 

However, because the March 2020 VA examiner only noted a back condition in 2018, the AOJ requested a new VA medical opinion in May 2020 to consider later low back complaints due to the motorcycle accident in November 2014. The May 2020 VA examiner again found against a positive nexus between the Veteran's current low back condition and his active-duty service, even after considering the post active-duty back complaints in 2015, 2016, and 2019. 

Following the October 2024 Board hearing, and within 90 days, the Veteran submitted additional treatment records and a medical opinion to support his claim. These included the report from an August 2024 X-ray, which affirmed that the Veteran had a diagnosis of degenerative disc disease at L4-5 and L5-S1 with secondary spondylosis. The Veteran also submitted a November 2024 letter from his VA physician, indicating that the Veteran's current low back disability was related to his 2014 motor vehicle accident. In a separate statement, his physician noted that the Veteran had been struggling with physical therapy and experienced difficulties with engaging in regular activities due to his back pain. See December 2024 Medical Treatment Record-Government Facility. 

In review of the overall record, the Board resolves reasonable doubt in favor of the Veteran and finds that his current lumbar spine disability is related to the November 2014 motor vehicle accident that occurred in the line of duty. 

The record contains both positive and negative evidence as to the question pertaining to the etiology of the Veteran's current back disability. While the Veteran's service treatment records relating to the November 2014 motor vehicle accident show no indication of a back injury, post service records document that the Veteran was seen for back pain within a year after service. In May 2015, he was seen for a low back pain with radicular symptoms in his lower extremities, which had been present for at least a month. He was diagnosed with degenerative disc disease of the lumbar spine. 

While the March 2020 and May 2020 VA medical opinions found against a positive nexus,
4 motor vehicle accident that occurred in the line of duty. 

The record contains both positive and negative evidence as to the question pertaining to the etiology of the Veteran's current back disability. While the Veteran's service treatment records relating to the November 2014 motor vehicle accident show no indication of a back injury, post service records document that the Veteran was seen for back pain within a year after service. In May 2015, he was seen for a low back pain with radicular symptoms in his lower extremities, which had been present for at least a month. He was diagnosed with degenerative disc disease of the lumbar spine. 

While the March 2020 and May 2020 VA medical opinions found against a positive nexus, the examiners relied heavily on the lack of back complaints in service and failed to adequately consider the significance of a diagnosis of degenerative disc disease of the lumbar spine within a year of the Veteran's in-service motor vehicle accident in November 2014. 

In contrast, the Veteran's VA physician issued a November 2024 medical opinion, indicating that the Veteran's current lumbar spine disability stemmed from his November 2014 accident. 

Based on the Veteran's credible statements of symptoms during and since service, the medical history from service to the present documenting back issues, and the November 2024 positive medical opinion, the Board resolves all reasonable doubt in the Veteran's favor and finds that service connection for degenerative disc disease of the lumbar spine is warranted. See 38 C.F.R. § 3.303(a).

Radiculopathy of the Right and Left Lower Extremities

The Veteran contends that he has developed radiculopathy of the left and right lower extremities as a result of his lumbar spine disability. 

The Veteran's claim is supported by post service treatment records beginning in May 2015, which clearly document a diagnosis of radiculopathy secondary to the Veteran's now service-connected lumbar spine disability. Subsequent treatment records also show that the Veteran continues to complain of radicular symptoms associated with his lumbar spine disability, describing it as constant stabbing pain in both legs. Notably, when the Veteran was provided a VA examination in March 2020 for the claimed lumbar spine condition, the VA examiner also diagnosed lumbar radiculopathy of the right and left lower extremities.

Given the foregoing, the Board finds that the Veteran's radiculopathy of the left and right lower extremities is secondary to his now service-connected lumbar spine disorder. 38 C.F.R. § 3.310. Accordingly, the Veteran's service connection claims for radiculopathy of the left and right lower extremities are granted. 

Left Wrist Condition

The Veteran contends that he developed a left wrist condition as a result of his military service, specifically the November 2014 motor vehicle accident. See February 2020 VA 21-526EZ, Fully Developed Claim. 

At the October 2024 Board hearing, the Veteran testified that he sustained injuries to his left wrist and sought medical attention immediately after his November 2014 motor vehicle accident. 

However, in reviewing the overall record, the Board finds that the record fails to establish a current left wrist disability. 

The Veteran's service treatment records are silent for any complaints or treatment for a left wrist condition. While the Veteran sought medical attention pertaining to the injuries sustained as a result of the November 2014 accident, a left wrist condition was not among his documented injuries.

Private treatment records in February 2017 show that the Veteran was seen for pain in the left wrist, which he stated began months ago in December 2016. The physician noted that the Veteran was not planning to file a Workers Compensation claim with his employer related to the condition, possibly implying that the injury occurred during his employment. However, other than minimal tenderness noted upon examination, no diagnosis of a left wrist condition was rendered. See February 2020 Medical Treatment Record-Non-Government Facility. 

Post service, VA treatment records show that the Veteran has sought medical attention for various ailments. However, there are no complaints pertaining to a left wrist condition. His overall treatment records do not show any signs or symptoms indicative of a left wrist disability. 

Other than the Veteran's generalized claim that he developed a left wrist condition as a result of his military service, he has not submitted any medical evidence to support a current diagnosis or a nexus. There is also no persuasive evidence of symptoms that result in any functional impairment in earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a "disability" under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). 

The Board acknowledges that the Veteran was not provided a VA examination as to this issue. The language of the regulation is clear
 treatment records do not show any signs or symptoms indicative of a left wrist disability. 

Other than the Veteran's generalized claim that he developed a left wrist condition as a result of his military service, he has not submitted any medical evidence to support a current diagnosis or a nexus. There is also no persuasive evidence of symptoms that result in any functional impairment in earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a "disability" under 38 U.S.C. § 1110 refers to functional impairment of earning capacity). 

The Board acknowledges that the Veteran was not provided a VA examination as to this issue. The language of the regulation is clear that the evidence must, in fact, establish that an injury or event occurred in service in order to trigger VA's obligation to provide an examination or obtain a medical opinion. See 38 C.F.R. § 3.159(c)(4). For purposes of determining whether an examination or opinion is warranted, the threshold for finding a link between a current disability and service is low. Id. 

Here, the evidence fails to show an in-service event, injury, or disease related to a left wrist disability. There is no indication that the claimed disability may be related to service. For a VA medical examination or opinion to be warranted, all the McLendon criteria have to be met, which is not the case here. McLendon, 20 Vet. App. at 81; 38 U.S.C. § 5103A (d)(2); 38 C.F.R. § 3.159 (c)(4)(i). The only evidence of record relating the Veteran's claimed disability to service is his own general conclusory statement, which does not meet the low threshold of an indication that the claimed disability is due to service. See Waters v. Shinseki, 601 F.3d 1274, 1278-79 (Fed. Cir. 2010) Therefore, VA has no duty to provide a medical examination or medical opinion for this service connection claim at this time.

Under the PACT Act, VA is required to provide a disability examination and medical nexus opinion when a Veteran submits a compensation claim and has evidence of a disability and participation in a toxic exposure risk activity (TERA), but the evidence is not sufficient to establish service connection for the disability.  See 38 U.S.C. § 1168(a) (see PACT Act, Sec. 303).  However, in VA's sub-regulatory guidance, an exception to the above applies for claims based on physical trauma.  

"Congress specifically limits entitlement to service-connected disease or injury where such cases have resulted in a disability. In the absence of proof of a present disability there can be no claim." Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) (internal citation omitted). The requirement of a "current disability" is satisfied if a disorder is diagnosed at the time a claim is filed or at any time during the pendency of the appeal, even though the disability resolves prior to adjudication of the claim. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). The standard is whether a disability exists at the time the claim was filed or proximate thereto. Romanowsky v. Shinseki, 26 Vet. App. 289, 293 (2013). 

As discussed above, it is not shown that the Veteran has a current disability for the left wrist. Accordingly, service connection for a left wrist condition is denied. 

Left and Right Hip Disability 

The Veteran contends that he has developed a left and right hip disability as a result of his military service, specifically the November 2014 motor vehicle accident. See February 2020 VA 21-526EZ, Fully Developed Claim. 

However, the Board finds that the available records do not support a current diagnosis of a left or right hip disability. 

The Veteran's service treatment records noted joint hip pain in July 2014. The Veteran told his physician that he had twisted his right hip 3 days prior. A physical examination revealed normal sacroiliac joints. His bones were intact with no evidence of fracture or dislocation. There was no evidence of scintigraphic evidence of stress injury. He returned in August 2014 for right hip pain. However, no diagnosis was rendered other than the documentation of joint pain. 

At the October 2024 Board hearing, the Veteran testified that he was treated for a left and right hip injury immediately after the November 2014 motor vehicle accident. 

Pursuant to his November 2014 motor vehicle accident, the Veteran received treatment for physical injuries which did not include any hip pain. While the Veteran did, in fact,
 his physician that he had twisted his right hip 3 days prior. A physical examination revealed normal sacroiliac joints. His bones were intact with no evidence of fracture or dislocation. There was no evidence of scintigraphic evidence of stress injury. He returned in August 2014 for right hip pain. However, no diagnosis was rendered other than the documentation of joint pain. 

At the October 2024 Board hearing, the Veteran testified that he was treated for a left and right hip injury immediately after the November 2014 motor vehicle accident. 

Pursuant to his November 2014 motor vehicle accident, the Veteran received treatment for physical injuries which did not include any hip pain. While the Veteran did, in fact, have documented complaints of hip pain in service, subsequent service treatment records are silent for any continued complaints. Thus, the Board can reasonably infer that his hip pain resolved without any residuals. 

Post service, VA treatment records associated with the claims file at the time of the April 2020 rating decision showed that the Veteran had sought medical attention for various conditions. However, there were no complaints pertaining to any hip condition. His overall treatment records did not show any signs or symptoms indicative of a left or right hip disability. 

Following the October 2024 Board hearing, and within 90 days, the Veteran submitted additional treatment records to support his claim. These included X-rays of the bilateral hips dated October 2024; however, they showed no abnormalities pertaining to either hip. The joint spaces were maintained with normal articular surfaces and subchondral bone. 

To the extent that the Veteran believes that he has a hip disability related to his service, the Board notes that the Veteran is competent to provide testimony concerning factual matters of which he has first-hand knowledge and experiences through his senses. Barr v. Nicholson, 21 Vet. App. 303 (2007). However, as to the presence of a chronic hip disability, the issue of a clinical diagnosis of such a complex condition is a medical determination outside the realm of common knowledge of a lay person. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Thus, although the Board has carefully considered the lay contentions that the Veteran has a left and right hip condition related to his service, the Board ultimately affords the medical evidence greater probative weight. There is also no persuasive evidence of symptoms that result in any functional impairment in earning capacity. See Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018) (holding that a "disability" under 38 U.S.C. § 1110 refers to functional impairment of earning capacity).

As discussed above, Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Thus, in the absence of proof of a current disability at any time during the pendency of the claim or proximate to the filing of the claim, there can be no valid claim. Brammer, 3 Vet. App. at 225.

Similar to his service connection claim for a left wrist condition addressed above, there is no indication that the Veteran currently has a left or right hip condition related to service. Without meeting the McLendon criteria, VA's obligation to provide a VA examination or obtain a medical opinion has not been triggered. Furthermore, the Board also finds no basis under the PACT Act upon which or order a medical examination or opinion related to his claimed hip condition. 

For the above reasons, the evidence is neither evenly balanced nor approximately so with regard to whether entitlement to service connection for a left or right hip disability is warranted. Rather, the evidence persuasively weighs against the Veteran's claim for service connection for a bilateral hip disability. The benefit of the doubt doctrine is therefore not for application as to this claim. Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021).

Accordingly, service connection for a disability of the left and right hip disability is denied.

Right Shoulder Disability

The Veteran contends that he has a chronic right shoulder disability as a result of his military service, specifically due to a motor vehicle accident during a drill weekend. See February 2021 VA 21-526EZ, Fully Developed Claim.

At the outset, the Board notes that the Veteran has periods of active duty service along with periods of INACDUTRA. In December 2024 correspondence (submitted within 90 days of the Board hearing), the Veteran explained that he served in the 414th Military Police Company from February 2013 to February 2019. More specifically, the Veteran's service records showed that the Veteran served as an Army Reserve member from June 12, 2014
 hip disability is denied.

Right Shoulder Disability

The Veteran contends that he has a chronic right shoulder disability as a result of his military service, specifically due to a motor vehicle accident during a drill weekend. See February 2021 VA 21-526EZ, Fully Developed Claim.

At the outset, the Board notes that the Veteran has periods of active duty service along with periods of INACDUTRA. In December 2024 correspondence (submitted within 90 days of the Board hearing), the Veteran explained that he served in the 414th Military Police Company from February 2013 to February 2019. More specifically, the Veteran's service records showed that the Veteran served as an Army Reserve member from June 12, 2014 to September 3, 2014, November 1, 2014 to November 2, 2014, May 9, 2016 to May 13, 2016, and from June 16, 2017 to June 30, 2017. The Veteran had INACDUTRA service from October 1, 2016 to September 30, 2017 (48 days of drill day) and from October 1, 2017 to September 30, 2018 (34 days of drill day). As an Army Reserve member, he also had period of deployment from July 28, 2018 to May 29, 2019. 

At the October 2024 Board hearing, the Veteran reiterated that he was treated for a shoulder injury after his November 2014 motor vehicle accident. He ultimately underwent three surgeries over the next few years after the accident. 

While his medical treatment records do not show any complaints or treatments relating to a shoulder injury after the motor vehicle accident in 2014, his service treatment records from November 2017 note that the Veteran reported having 2 shoulder surgeries in June and July 2017, which is confirmed by his private treatment records. In his report of medical history dated June 2018, the Veteran reported having a painful shoulder. However, his accompanying report of medical examination did not reveal any clinical abnormalities pertaining to his upper extremities, including his shoulders. 

Concurrently, private treatment records from February 2017 show that the Veteran was seen for right shoulder pain that began months prior, citing an injury that occurred on December 7, 2016. There, he was diagnosed with a possible glenoid labral tear in the right shoulder. An MRI revealed a low-grade partial thickness supraspinatus and infraspinatus tendon tears with anterior and posterior labral tears. See February 2020 Medical Treatment Record-Non-Government Facility. 

Subsequently, while on active duty with the Army Reserves on June 22, 2017, the Veteran underwent a shoulder arthroscopy with cartilage grafting to treat a labral tear and osteochondral defect of the right central humeral head. In a follow up appointment, the Veteran's physician informed him of a second arthroscopy on the shoulder, which ultimately took place on July 20, 2017. He returned for a follow up visit in August 2017 and September 2017, wherein the Veteran continued to report pain and limited range of motion. 

Private treatment records from June 2018 show that the Veteran was diagnosed with post operative cartilage grafting of humeral head osteochondritis dissecans (OCD). 

Following the October 2024 Board hearing, and within 90 days, the Veteran submitted a November 2024 letter from his VA physician, who indicated that the Veteran suffered from right shoulder pain requiring cartilage grafting of the humeral head and osteochondritis dissecans (OCD) as a result of his November 2014 accident.

Resolving reasonable doubt in favor of the Veteran, the Board finds that the Veteran has a current disability of the right shoulder that can be traced back to his service. While the Veteran's service treatment records do not clearly document treatment for a shoulder injury immediately after the November 2014 motor vehicle accident, his subsequent treatment records strongly suggest that his right shoulder condition persisted and aggravated during his period of service, which ultimately required surgical intervention in June 2017. Despite surgery, the Veteran continued to experience symptoms, leading to another surgery in July 2017. While his injury was addressed by the surgical treatment, he continued to report residual symptoms such as pain and limited motion well beyond his period of service. 

Accordingly, the Board reasonable doubt in the Veteran's favor and finds that his right shoulder disability, diagnosed as shoulder strain, labral tear, acromioclavicular joint osteoarthritis, and tendinitis, began during his period of ACDUTRA (now considered active service) and has continued since. Therefore, service connection for right shoulder disability is granted. 

 

A. IS
 aggravated during his period of service, which ultimately required surgical intervention in June 2017. Despite surgery, the Veteran continued to experience symptoms, leading to another surgery in July 2017. While his injury was addressed by the surgical treatment, he continued to report residual symptoms such as pain and limited motion well beyond his period of service. 

Accordingly, the Board reasonable doubt in the Veteran's favor and finds that his right shoulder disability, diagnosed as shoulder strain, labral tear, acromioclavicular joint osteoarthritis, and tendinitis, began during his period of ACDUTRA (now considered active service) and has continued since. Therefore, service connection for right shoulder disability is granted. 

 

A. ISHIZAWAR

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board	Yeh, Nicole

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.