Case A26040863

J.P. NORMAN · 2026 · Case ID: A26040863

GRANTED

Summary

The Veteran, an Army Veteran who served on active duty from August 2001 to January 2002, with subsequent National Guard and Reserve service, appealed the denial of service connection for left and right leg conditions, left and right shoulder disabilities, low back disability, and left ankle disability. The Veteran withdrew the claims for left and right leg conditions at a hearing, and these were dismissed. The Board granted service connection for bilateral shoulder disabilities, finding that the Veteran's service treatment records (STRs) showed shoulder complaints during active duty in September 2001, and she had current bilateral shoulder strains diagnosed in March 2020. Although the Veteran had prior shoulder injuries and complaints, the Board found no pre-existing, ongoing disability prior to her July 2019 Active Duty Training (ADT) period, where she was diagnosed with overuse syndrome. The Board found the evidence in approximate balance, granting direct service connection for the bilateral shoulder disabilities. For the low back and left ankle claims, the Board acknowledged prior treatment but noted a lack of chronic symptoms or complaints in service records for over a year before her 2019 ADT. However, the Board found that the Veteran and her witnesses provided statements attesting to functional impairment due to low back pain and left ankle symptoms, which, when resolving doubt in the Veteran's favor, established current disabilities. The Board granted service connection for the low back and left ankle disabilities, finding the evidence in approximate balance and related to her 2019 ADT.

Service Branch

ARMY

Special Benefit

NO SPECIAL BENEFIT

Docket No.

210405-151263

Full Decision Text

Citation Nr: A26040863
Decision Date: 04/30/26 Archive Date: 04/30/26

DOCKET NO. 210405-151263
DATE: April 30, 2026

ORDER

Entitlement to service connection for a left leg disability has been withdrawn.

Entitlement to service connection for a right leg disability has been withdrawn.

Entitlement to service connection for a left shoulder disability is granted.

Entitlement to service connection for a right shoulder disability is granted.

Entitlement to service connection for a low back disability is granted.

Entitlement to service connection for a left ankle disability is granted.

FINDINGS OF FACT

1. At an evidentiary hearing on February 14, 2025, after discussion of the consequences of withdrawal and while represented by an attorney, the Veteran withdrew her service connection claims for left and right leg conditions.

2. The Veteran's bilateral shoulder, low back, and left ankle disabilities began with overuse injuries and strain in July 2019, when she was on active duty for training.

CONCLUSIONS OF LAW

1. The criteria for withdrawal/dismissal of the service connection claim for a left leg condition by the Veteran are met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205.

2. The criteria for withdrawal/dismissal of the service connection claim for a right leg condition by the Veteran are met. 38 U.S.C. § 7105; 38 C.F.R. § 20.205.

3. The criteria for service connection for a left shoulder disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

4. The criteria for service connection for a right shoulder disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

5. The criteria for service connection for a low back disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

6. The criteria for service connection for a left ankle disability are met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303.

REASONS AND BASES FOR FINDINGS AND CONCLUSIONS

The Veteran served on active duty in the United States Army from August 2001 to January 2002, with additional years of service in the National Guard and Army Reserve.

In the April 2021 VA Form 10182, Decision Review Request: Board Appeal (Notice of Disagreement), the Veteran elected the Hearing docket. A Board of Veterans' Appeals (Board) hearing was held on February 14, 2025. Therefore, the Board may only consider the evidence of record at the time of the January 2021 agency of original jurisdiction (AOJ) decision on appeal, as well as any evidence submitted by the Veteran [or 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 AOJ issued the decision 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.

1. Entitlement to service connection for a left leg condition is dismissed.

2. Entitlement to service connection for a right leg condition is dismissed.

At the February 2025 hearing, the Veteran withdrew her claims for left and right leg disabilities.

Generally, "withdrawal of a claim is only effective where the withdrawal is explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant." Deliso v. Shinseki, 25 Vet. App
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.

1. Entitlement to service connection for a left leg condition is dismissed.

2. Entitlement to service connection for a right leg condition is dismissed.

At the February 2025 hearing, the Veteran withdrew her claims for left and right leg disabilities.

Generally, "withdrawal of a claim is only effective where the withdrawal is explicit, unambiguous, and done with a full understanding of the consequences of such action on the part of the claimant." Deliso v. Shinseki, 25 Vet. App. 45, 57 (2011). Oral withdrawal at a Board hearing also requires the veteran or appellant understand the consequence of withdrawing a claim. Acree v. O'Rourke, 891 F.3d 1009 (Fed. Cir. 2018). Here, the Veteran withdrew her service connection claims at her Board hearing, while represented by an attorney, after discussing the procedural posture of her case and the consequences of withdrawing these three claims. The criteria for withdrawal of claims for entitlement to service connection for left and right leg conditions have been met. Deliso, 25 Vet. App. at 57; Acree, 891 F.3d 1009; 38 C.F.R. § 20.205. Accordingly, these claims are hereby DISMISSED. See 38 U.S.C. § 7105.

3. Entitlement to service connection for a left shoulder disability is granted.

4. Entitlement to service connection for a right shoulder disability is granted.

The Veteran asserts that her bilateral shoulder disabilities are due to military service. For the following reasons, the Board finds service connection warranted.

Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. Active military service includes active duty (AD), any period of active duty for training (ADT) during which the individual concerned was disabled or died from a disease or injury incurred or aggravated in line of duty, and any period of inactive duty for training (IDT) during which the individual concerned was disabled or died from an injury incurred or aggravated in line of duty or from an acute myocardial infarction, a cardiac arrest, or a cerebrovascular accident which occurred during such training. 38 C.F.R. § 3.6(a). ADT includes full-time duty in the Armed Forces performed by Reserves or National Guard members for training purposes, while IDT includes duty (other than full-time duty) prescribed for Reserves, as well as duty (other than full-time duty) performed by a member of the National Guard of any State. 38 C.F.R. § 3.6(c), (d).

The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004).

Certain chronic diseases are presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; if they manifested to a compensable degree within a presumptive period following separation from service; or if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309; Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). Presumptive periods for service connection do not apply to ADT or IDT. Biggins v. Derwinski, 1 Vet. App. 474 (1991).

A veteran is presumed sound on entry into active service except as to defects, infirmities, or disorders noted at the time of acceptance, examination, or enrollment, or where clear and unmistakable evidence demonstrates that the condition existed before enrollment and was not aggravated by service. 38 U.S.C. § 1111; 38 C.F.R. § 3.304(b). To be "noted" within the meaning of the statute and regulation, the condition must be recorded in the entrance examination report. Id. VA is not precluded from determining that the presumption of soundness is rebutted. See Kent v. Principi, 389 F.3d 1380, 1383 (Fed. Cir. 2004) ("The clear and unmistakable evidentiary standard...does not require the absence of conflicting evidence."). Finding condition onset prior to service may be based on concurrent evidence or recorded history in the record providing sufficient factual evidence to support a medical opinion (Miller v. West, 11 Vet. App. 345, 348 (1998)) or a later medical opinion based on statements made by a Veteran about the pre-service history of the condition (Harris v. West, 203 F.3d 1347 (Fed. Cir. 2000)).

The AOJ favorably found that service treatment records (STRs) show shoulder complaints during active duty in September 2001, and that the Veteran has current bilateral shoulder strains, diagnosed in March 2020. See January 2021 rating decision. These favorable findings are binding on the Board.

In May 2025 and within the permissive period to submit evidence, the Veteran added a series of military orders and STRs to the record. These included orders placing the Veteran on ADT from July 13 to August 2, 2019. STRs show July 23, 2019, notes diagnosing bilateral shoulder overuse syndrome and excusing the Veteran from physical training involving use of her shoulders during ADT. At separation, her August 5, 2019, STRs show continued reports of shoulder joint pain. The claims currently before the Board were filed in October 2019, shortly after ending that period of ADT. The March 2020 VA examination diagnosing bilateral shoulder strain was less than 8 months after the overuse syndrome diagnosis.

The record accordingly reflects that the claimed condition was incurred and diagnosed during ADT in July 2019. That said, the Board is cognizant that the AOJ found shoulder injuries during active duty in September 2001, and the Veteran endorsed symptoms since the outset of her service. See also March 2020 VA shoulder examination; February 2025 hearing testimony. STRs show she also injured her shoulder while on orders in April 2017. The record therefore raises the issue of a pre-existing shoulder condition.

STRs from 2019 do not indicate shoulder injuries reported at entry into ADT, and the medical record does not reflect a pre-existing shoulder condition in the year prior to ADT. The Veteran was treated for unspecified shoulder joint pain in March 2018. However, a June 2018 Periodic Health Assessment did not reflect any shoulder complaints, including reporting earlier injuries or pain. An August 2018 functional capacity report likewise denied shoulder pain or injuries. Rather, a functional capacity report completed that month shows that the Veteran was on a walk profile due to knee surgery at that time. She did not report, and the capacity report does not reflect, shoulder limitations such as push-up or lifting restrictions. Further, no shoulder complaints or restrictions appear on record until July 23, 2019, which is 10 days after the Veteran's ADT began.

As such, the Board does not find a pre-existing, ongoing shoulder disability prior to the Veteran's July and August 2019 ADT. 38 C.F.R. § 3.304(b); Harris, 203 F.3d 1347. The fact that the Veteran injured her shoulder prior to 2019 is not in dispute. However, the medical record does not associate earlier injuries with her overuse syndrome diagnosis during ADT. While the Board acknowledges the Veteran's competence to report her experiences and symptom onset, lay people are not competent to consider complex medical questions, including whether the overuse syndrome and strain diagnosed in July 2019 and March 2020 are associated with prior shoulder injuries.

In sum, the evidence shows the Veteran experienced shoulder pain during July 2019 ADT, leading to a bilateral shoulder overuse syndrome diagnosis during that duty period, for which she filed a compensation claim within several months of separating ADT. This is sufficient to award direct service connection. The Board is cognizant of the Veteran's claim for service connection on a chronic basis, considering shoulder pain from multiple duty periods. STRs of record indicate that she experienced shoulder pain at multiple points, as alluded. However, due to the same gaps in treatment and inconsistent contemporaneous symptom reports that prevented the Board from finding a pre-existing condition, the Board also does not find service connection for a chronic condition supported by the record. Further, a grant of direct service connection represents a complete grant of the claim on appeal.

The evidence of record is accordingly at least in approximate balance, if not more in favor of, finding that the Veteran's bilateral shoulder disability had its onset during and is related to the Veteran's July and August 2019 period of ADT. See Lynch v. McDonough, 999 F.3d 1391 (Fed. Cir. 2021). Thus, the Veteran's service connection claim for bilateral shoulder disabilities is hereby GRANTED.

5. Entitlement to service connection for a low back disability is granted.

6. Entitlement to service connection for a left ankle disability is granted.

The Veteran additionally asserts that she has low back and left ankle disabilities due to military service. The AOJ favorably found treatment for low back and left ankle symptoms in October 2001. See January 2021 rating decision.

March 2020 VA examinations did not find any current low back or left ankle disabilities. See March 2020 VA spine, ankle examinations. There, the Veteran reported low back pain that requires her to plan her movements, slowing motion, preventing bending, and causing her to lose sleep. During flare ups, her pain prevents sitting, bending, and carrying heavy items, requiring rest. At hearing, she additionally reported limitations driving and sitting for prolonged periods. The Veteran submitted four personal statements from friends and family who additionally witnessed the Veteran's reduced range of motion and visible symptoms of pain, including limping and inability to carry loads. See May 2025 VA Forms 21-10210. The Veteran, and her witnesses, are competent to report their own experiences, including experienced and observed symptoms. Jandreau, 492 F.3d 1372.

Regarding his left ankle, the Veteran reported left ankle pain and swelling with use. She reported symptom flare ups resulting in severe pain, requiring use of compression socks, hearing pads, and daily joint elevation to keep symptoms under control. She stated that her ankle pain interrupts sleep, requires her to be cautious with her activity, and determines what shoes she wears. At hearing, the Veteran attested to worsening symptoms with continued pain and swelling on use.

The first question for the Board is whether the Veteran's reported symptoms constitute a disability for VA compensation purposes. The term "disability," as used in 38 U.S.C. § 1110, "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and as such, "pain alone can serve as a functional impairment and therefore qualify as a disability." Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Said another way, pain that causes functional impairment, without an underlying diagnosis, is sufficient to establish a current disability.

In this case, the Veteran and her witnesses have offered statements attesting to functional impairment due to low back pain that prevents movement and requires her to rest for recovery. The same can be said of her left ankle symptoms, which
," as used in 38 U.S.C. § 1110, "refers to the functional impairment of earning capacity, not the underlying cause of said disability," and as such, "pain alone can serve as a functional impairment and therefore qualify as a disability." Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Said another way, pain that causes functional impairment, without an underlying diagnosis, is sufficient to establish a current disability.

In this case, the Veteran and her witnesses have offered statements attesting to functional impairment due to low back pain that prevents movement and requires her to rest for recovery. The same can be said of her left ankle symptoms, which require daily preventative measures to avoid reaching "9/10" pain severity, which causes the Veteran to modify her activities. Instead of remanding this claim for the AOJ to obtain a medical opinion as to whether the Veteran has a disability pursuant to Saunders, the Board will resolve all reasonable doubt in the Veteran's favor and conclude that she has current low back and left ankle disabilities during the pendency of her appeal. See cf. Mariano v. Principi, 17 Vet. App. 305, 312 (2003); Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991).

As above, the Board acknowledges that medical records show low back and left ankle pain-including acute injuries-at multiple points during the Veteran's military career, but STRs do not show chronic or ongoing symptoms. May 2025 statements generally reflect low back symptoms throughout service, and the statements from battle buddies C.B. and S.C. specifically witnessed the Veteran hurting her ankle while on "assignment" during 2016.

However, STRs do not show low back or left ankle complaints for more than a year prior to her 2019 period of ADT, including on the June 2018 periodic health assessment and the August 2018 functional capacity report. Notably, both of those June 2018 documents indicate limitations or symptom reports, so it is reasonable to expect that any other symptoms, including those related to the claimed conditions, would have been equally represented on those documents. On July 23, 2019, she was diagnosed with and treated for low back strain and overuse syndrome, with objectively observed left ankle swelling. She remained on profile, restricting physical activities, until separating from ADT. This claim was also one of those filed in October 2019, shortly after that period of duty.

Here again, the Veteran and the medical record both report low back and ankle pain prior to the appeal period. However, no lumbar or left ankle disability was reported at entry into ADT or otherwise reflected at the time of entry into ADT. The Board accordingly finds no pre-existing, ongoing shoulder disability prior to the Veteran's July and August 2019 ADT. 38 C.F.R. § 3.304(b); Harris, 203 F.3d 1347. The Board again acknowledges the Veteran's competence to report her experiences and symptom onset, but finds she is not competent to consider complex medical questions, including whether the overuse syndrome and strain diagnosed in July 2019 is associated with prior injuries. Layno, 6 Vet. App. at 470; Jandreau, 492 F.3d at 1377 n.4.

The evidence of record is accordingly at least in approximate balance, if not more in favor of, finding that the Veteran's low back and left ankle disabilities began during and are related to the Veteran's 2019 period of ADT. Lynch, 999 F.3d 1391. The Veteran's service connection claims for a low back disability and a left ankle disability are hereby GRANTED.

J.P. Norman

Veterans Law Judge

Board of Veterans' Appeals

Attorney for the Board W. Stearns, Counsel

The Board's decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.

Analyze in VA Law Explorer