Source: https://va-claim.com/2018/12/17/ptsd-left-shoulder-disorder-cervical-spine-disorder-left-radial-bone-healed-fracture-left-radial-bone-healed-fracture-with-impaired-flexion-of-the-forearm-denied-citation-nr-18124049/
Timestamp: 2019-04-19 08:45:19+00:00

Document:
The application to reopen the claim for service connection for an acquired psychiatric disorder is denied.
The application to reopen the claim for service connection for posttraumatic stress disorder (PTSD) is denied.
Entitlement to service connection for a left shoulder disorder, including as secondary to service-connected disabilities, is denied.
Entitlement to service connection for a cervical spine disorder, including as secondary to service-connected disabilities, is denied.
Entitlement to a rating greater than 20 percent for left radial bone healed fracture, with impaired supination and pronation, is denied.
Entitlement to a rating greater than 10 percent for left radial bone healed fracture, with impaired flexion of the forearm, is denied.
1.  In an unappealed October 1982 rating decision, the RO denied service connection for an acquired psychiatric disorder; an unappealed August 1991 rating denied the Veteran’s application to reopen the previously denied claim of entitlement to service connection for an acquired psychiatric disorder.
2.  In an unappealed November 2012 rating decision, the RO denied service connection for PTSD.
3.  The evidence received since the August 1991 and November 2012 rating decisions as to the issues of entitlement to service connection for an acquired psychiatric disorder and PTSD is cumulative in nature and repetitive of facts that were previously considered.
4.  A left shoulder disorder is not attributable to service; a left shoulder disorder is not related (causation or aggravation) to a service-connected disease or injury.
5.  A cervical spine disorder is not attributable to service; a cervical spine disorder is not related (causation or aggravation) to a service-connected disease or injury.
6.  Left radial bone healed fracture, with impaired supination and pronation, is productive of limitation of supination to 30 degrees and pronation limited beyond the last quarter of arc.
7.  Left radial bone healed fracture, with impaired flexion of the forearm, is productive of pain on motion; flexion is limited to 130 degrees.
1.  The August 1991 and November 2012 rating decisions denying claims for service connection for an acquired psychiatric disorder and PTSD are final.  38 U.S.C. § 7105; 38 C.F.R. § 20.1103 (2017).
2.  New and material evidence has not been received to reopen the claims for service connection for an acquired psychiatric disorder and PTSD.  38 U.S.C. § 5108; 38 C.F.R. § 3.156 (2017).
3.  The criteria for service connection for a left shoulder disorder have not been met.  38 U.S.C. §§ 1101, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017).
4. The criteria for service connection for a cervical spine disorder have not been met.  38 U.S.C. §§ 1101, 1131, 1137, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2017).
5.  The criteria for a disability rating in excess of 20 percent for left radial bone healed fracture, with impaired supination and pronation, have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Codes 5213 (2017).
6.  The criteria for a disability rating in excess of 10 percent for left radial bone healed fracture, with impaired flexion of the forearm, have not been met.  38 U.S.C. §§ 1155, 5107; 38 C.F.R. §§ 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code 5206 (2017).
The Veteran served on active duty in the U.S. Army from March 1977 to March 1980 and from November 1987 to March 1988.
This case came before the Board of Veterans’ Appeals (Board) on appeal of a July 2014 rating decision of Department of Veterans Affairs (VA) Regional Office (RO) in San Juan, Puerto Rico.
The Veterans Claims Assistance Act of 2000 (VCAA) imposes obligations on VA to provide claimants with notice and assistance.  38 U.S.C. §§ 5102, 5103, 5103A, 5107, 5126; Honoring America's Veterans and Caring for Camp Lejeune Families Act of 2012, Pub. L. No. 112-154, §§ 504, 505, 126 Stat. 1165, 1191-93; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017).  The VCAA requires VA to assist a claimant at the time that he or she files a claim for benefits.  As part of this assistance, VA is required to notify claimants of the evidence that is necessary in substantiating their claims, and provide notice that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded.  38 U.S.C. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio v. Principi, 16 Vet. App. 183, 187 (2002); Dingess v. Nicholson, 19 Vet. App. 473, 486 (2006).
In this case, the agency of original jurisdiction (AOJ) issued notice letters to the Veteran.  This letter explained the evidence necessary to substantiate the Veteran’s application to reopen the previously denied claims of entitlement to service connection, as well as the evidence necessary to substantiate the claims of entitlement to service connection and entitlement to increased disability ratings; the letters also explained the legal criteria for entitlement to such benefits.  The letters also informed him of his and VA’s respective duties for obtaining evidence.  The AOJ decision that is the basis of this appeal was decided after the issuance of an initial, appropriate VCAA notice.  As such, there was no defect with respect to timing of the VCAA notice.  See Pelegrini v. Principi, 18 Vet. App. 112 (2004).
VA also has a duty to assist a veteran with the development of facts pertinent to the appeal.  38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c).  This duty includes the obtaining of “relevant” records in the custody of a Federal department or agency under 38 C.F.R. § 3.159(c)(2), as well as records not in Federal custody (e.g., private medical records) under 38 C.F.R. § 3.159(c)(1).  VA will also provide a medical examination if such examination is determined to be “necessary” to decide the claim.  38 C.F.R. § 3.159(c)(4).
The claims file contains the Veteran’s available service treatment records, reports of post-service treatment, and the Veteran’s own statements in support of his claims.  The Veteran was afforded VA examinations responsive to the claims for service connection and his claims for increased disability ratings.  See McClendon v. Nicholson, 20 Vet. App. 79 (2006).  The opinions were conducted by a medical professional, following thorough examination of the Veteran, solicitation of history, and review of the claims file.  The examination reports contain all the findings needed to assess entitlement to service connection or rate the Veteran’s service-connected disabilities on appeal, including history and clinical evaluation.  See 38 C.F.R. § 3.327(a) (2017); Palczewski v. Nicholson, 21 Vet. App. 174, 182-83 (2007).
The Board has reviewed the Veteran’s statements and medical evidence of record and concludes that there is no outstanding evidence with respect to the Veteran’s claims.  For these reasons, the Board finds that the VCAA duties to notify and assist have been met.
Whether new and material evidence has been received to reopen the claim of entitlement to service connection for an acquired psychiatric disorder and/or posttraumatic stress disorder (PTSD).
In general, rating decisions and Board decisions that are not timely appealed are final.  See 38 U.S.C. §§ 7104, 7105; 38 C.F.R. § 20.1103.  If new and material evidence is presented or secured with respect to a claim that has been finally disallowed, the claim shall be reopened and reviewed.  See 38 U.S.C. § 5108; 38 C.F.R. § 3.156.
Under 38 C.F.R. § 3.156, a claimant may reopen a finally adjudicated claim by submitting new and material evidence.  “New” evidence is defined as evidence not previously submitted to agency decision makers.  “Material” evidence means existing evidence that, by itself or when considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim.  New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened, and must raise a reasonable possibility of substantiating the claim.  38 C.F.R. § 3.156(a).  The United States Court of Appeals for Veterans Claims (Court) has interpreted the language of 38 C.F.R. § 3.156(a) as creating a low threshold.  Shade v. Shinseki, 24 Vet. App 110 (2010).
New and material evidence received prior to the expiration of the appeal period, or prior to the appellate decision if a timely appeal has been filed (including evidence received prior to an appellate decision and referred to the AOJ by the Board without consideration in that decision in accordance with the provisions of 38 C.F.R. § 20.1304(b)(1)), will be considered as having been filed in connection with the claim which was pending at the beginning of the appeal period.  38 C.F.R. § 3.156(b).
If VA receives or associates with the claims file relevant official service department records that existed and had not been associated with the claims file when VA first decided the claim, VA will reconsider the claim as an original claim for benefits.  38 C.F.R. § 3.156(c).
If it is determined that new and material evidence has been submitted, the claim must be reopened.  The evidence is presumed credible for the purposes of reopening a claim, unless it is inherently false or untrue or, if it is in the nature of a statement or other assertion, it is beyond the competence of the person making the assertion.  Justus v. Principi, 3 Vet. App. 510 (1992).
The RO initially denied service connection for an acquired psychiatric disorder in October 1982; the initial claim for service connection of PTSD was denied in November 2012.  The Veteran did not appeal and the October 1982 and November 2012 decisions became final.  See 38 U.S.C. § 7105(c).
The October 1982 rating decision denied the Veteran’s claim for service connection of an acquired psychiatric disorder on the basis that there was no evidence indicating that an acquired psychiatric disorder was incurred in or caused by service or his service-connected left radial bone healed fracture; there was no record of complaints, treatment, or diagnoses related to an acquired psychiatric disorder during active service, and no evidence that the Veteran’s acquired psychiatric disorder was related to an injury or disease during service.  The Veteran filed an application to reopen, which was denied in an August 1991 rating decision.  The Veteran’s application to reopen was denied on the basis that the evidence was not new and material; although the medical evidence showed a current psychiatric diagnosis, there was still no medical evidence that the Veteran’s current psychiatric disorder was related to the Veteran’s service, including his service-connected left radial bone healed fracture.
Likewise, the November 2012 rating decision denied the Veteran’s claim for service connection of PTSD on the basis that there was no diagnosis of PTSD in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM), as published by the American Psychiatric Association and no verified stressor event.   The rating decision noted that the Veteran’s service treatment records and VA examination report were considered.
Evidence received since the August 1991 and November 2012 rating decisions includes private and VA treatment records, as well as a July 2014 VA examination report.  The July 2014 VA examination report found that the Veteran did not meet the diagnostic criteria for a diagnosis of PTSD and there was no link between the Veteran’s acquired psychiatric disorder and his service.  VA and private treatment records reflect that the Veteran has been diagnosed with depression and an anxiety disorder, but do not reflect that the Veteran’s acquired psychiatric disorder was related to service.  The Veteran re-iterated the same PTSD stressors that he had reported, and had been considered, in 2012, but did not provide any additional evidence with which to attempt to verify his statements.
The evidence submitted subsequent to the August 1991 and November 2012 rating decisions as to the issues of entitlement to service connection for an acquired psychiatric disorder and PTSD is not new and material.  Neither the VA nor private treatment records demonstrate that the Veteran’s acquired psychiatric disorder is related to his service.  These records also fail to demonstrate that the Veteran meets the diagnostic criteria for a diagnosis of PTSD.  At the time of the prior decisions, there was no medical evidence indicating that the Veteran’s acquired psychiatric disorder was causally or etiologically related to his service; the new medical evidence of record reflects that the Veteran has been treated for an acquired psychiatric disorder, variously diagnosed as depression, anxiety, and polysubstance abuse, but does not reflect that any acquired psychiatric is related to the Veteran’s service.  The new medical evidence of record also fails to show that the Veteran meets the diagnostic criteria for PTSD; likewise, the Veteran’s claimed stressors remain unconfirmed.  The evidence is cumulative of the evidence already of record at the time of the last denials. The Veteran has not provided any new and material evidence demonstrating that his acquired psychiatric disorder is due to a disease or injury during service, or that he has been diagnosed with PTSD related to his military service.
In sum, the evidence submitted as to the Veteran’s claims of service connection for an acquired psychiatric disorder and PTSD is cumulative rather than new and material.  Although the threshold for reopening a claim is low, the evidence presented in this case is insufficient to reopen the claims.
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; 38 C.F.R. § 3.303(a) (2017).  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—the so-called “nexus” requirement.  Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)).
Service connection may be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).
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.  For chronic diseases, if chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim.  38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013).
Disability which is proximately due to or the result of a service-connected disease or injury shall be service connected.  Any increase in severity of a nonservice-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the nonservice-connected disease, will be service connected.  However, VA will not concede that a nonservice-connected disease or injury was aggravated by a service-connected disease or injury unless the baseline level of severity of the nonservice-connected disease or injury is established by medical evidence created before the onset of aggravation or by the earliest medical evidence created at any time between the onset of aggravation and the receipt of medical evidence establishing the current level of severity of the nonservice-connected disease or injury.  38 C.F.R. § 3.310.
Entitlement to service connection for a left shoulder disorder and a cervical spine disorder, including as secondary to service-connected disabilities.
Based on the evidence of record, the Veteran’s claims of entitlement to service connection for a left shoulder disorder and a cervical spine disorder, including as secondary to service-connected left radial bone healed fracture must be denied.
The Veteran has a current disability related to his left shoulder and cervical spine, treatment records from 2011 show diagnoses of left shoulder tendonitis and cervical spine degenerative arthritis.
With regard to in service incurrence, no left shoulder or cervical spine disabilities were noted or identified during service or within one year of separation.  Additionally, there is nothing to suggest that there were characteristic manifestations sufficient to identify the claimed left shoulder tendonitis or degenerative arthritis of the cervical spine with spondylosis and disc herniation during service or within one year of separation.  38 C.F.R. § 3.303(b).  However, the Veteran contends that his symptoms began in service. Additionally, regarding secondary service connection, the Veteran is service-connected for residuals of a left radial fracture.
Nonetheless, there is no competent evidence of a relationship between the Veteran’s current left shoulder tendonitis or degenerative arthritis of the cervical spine with spondylosis and disc herniation and active service or his residuals of a left radial fracture.  See Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000) (a Veteran seeking disability benefits must establish the existence of a disability and a connection between such Veteran’s service and the disability).
Review of the record shows that neither the Veteran’s treating providers, nor the July 2014 VA examiner, have related the Veteran’s left shoulder tendonitis or degenerative arthritis of the cervical spine with spondylosis and disc herniation to his service or his service connected left radial bone healed fracture, or were aggravated thereby.  In this regard, the Board observes that the July 2014 VA examination reports and contemporaneous medical opinions clearly concluded that the Veteran’s left shoulder condition and cervical spine conditions are less likely than not related to the Veteran’s service or a service-connected disability.  The VA examiner noted that there was no biomechanical correlation between the Veteran’s left radial bone healed fracture and his left shoulder or cervical spine which could account for the etiology or aggravation of the Veteran’s cervical spine and left shoulder disorders.  Likewise, the VA shoulder examiner noted that the Veteran’s left shoulder tendonitis was secondary to degenerative joint disease of the shoulder, and that the Veteran’s left shoulder tendonitis could not be caused or aggravated by the Veteran’s service-connected left radial bone healed fracture because there was no mechanical relationship between the shoulder and elbow.   Additionally, the July 2014 VA medical opinions found no relationship between the Veteran’s left shoulder disability and cervical spine disability and his service.
In rendering a decision on appeal, the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive, and provide the reasons for its rejection of any material evidence favorable to the claimant.  See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994).
To the extent that there are lay statements, including those of the Veteran, asserting a connection between the Veteran’s current left shoulder problems and his cervical spine condition and either his active service or his service-connected residuals of a left radial fracture, the Board finds that the determining the etiology of the Veteran’s left shoulder tendonitis and degenerative arthritis of the cervical spine are beyond the competence of a lay person. While the Veteran, and other lay persons, are competent to report pain, and other observable symptoms, related to the left shoulder and cervical spine, the cause of those symptoms and whether those symptoms are aggravated by another disability, are medical questions that require medical training, knowledge and expertise. Thus, these opinions are not competent. Further, even if the statements were to be found competent, the Board finds that the probative value of the general lay assertions is outweighed by the specific, well-reasoned opinions of the July 2014 VA examination report and the clinical evidence of record. The VA examiners explained the reasons for the conclusions reached and based the findings on an accurate characterization of the evidence of record.
For the foregoing reasons, the preponderance of the evidence is against the claim for service connection for a left shoulder disability and a cervical spine disability, and the claims are denied.
Disability evaluations are determined by application of the criteria set forth in the VA’s Schedule for Rating Disabilities, which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4.  An evaluation of the level of disability present must also include consideration of the functional impairment of the Veteran's ability to engage in ordinary activities, including employment.  38 C.F.R. § 4.10.  After careful consideration of the evidence, any reasonable doubt remaining is resolved in favor of the Veteran.  38 C.F.R. § 4.3.
Separate evaluations may be assigned for separate periods of time based on the facts found. In other words, the evaluations may be staged.  Staged ratings are appropriate for any rating claim when the factual findings show distinct time periods during the appeal period where the service-connected disability exhibits symptoms that would warrant different ratings.  Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007).  Here, the service-connected disabilities on appeal have not materially changed and uniform evaluations are warranted for the rating period on appeal.
In addition, when assessing the severity of a musculoskeletal disability that is rated on the basis of limitation of motion, VA must also consider the extent that the veteran may have additional functional impairment above and beyond the limitation of motion objectively demonstrated, such as during times when his symptoms are most prevalent (“flare-ups”) due to the extent of his pain (and painful motion), weakness, premature or excess fatigability, and incoordination.  See DeLuca v. Brown, 8 Vet. App. 202, 204-7 (1995); see also 38 C.F.R. §§ 4.40, 4.45, 4.59.
In this case, documents of record establish that the Veteran is right handed; the Veteran reported that his dominant hand is his right hand at the November 2016 and April 2018 VA examinations.  See 38 C.F.R. § 4.69.
The Veteran’s left radial bone healed fracture, with impaired supination and pronation, is rated as 20 percent disabling pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Codes 5299-5213.  See 38 C.F.R. § 4.20.  Hyphenated diagnostic codes are used when a rating under one diagnostic code requires use of an additional diagnostic code to identify the basis for the evaluation assigned.  38 C.F.R. § 4.27 (2017).  See Tedeschi v. Brown, 7 Vet. App. 411, 414 (1995).
Diagnostic Code 5213 provides for a 20 percent rating, for either the major or minor wrist, where there is loss of pronation beyond the last quarter of arc or there is bone fusion with hand fixed near the middle of the arc or moderate pronation; a 20 percent disability evaluation is also available for the minor wrist where there is loss of pronation beyond the middle of arc or loss of pronation such that the hand is fixed in full pronation.  A 30 percent is available for the minor wrist where there is loss of pronation due to bone fusion with the hand fixed in supination or hyperpronation.
The Board finds that the Veteran’s disability picture more nearly approximates the criteria for the current, 20 percent disability rating for left radial bone healed fracture, with impairment of supination and pronation.  According to the July 2014 VA examination report, the Veteran had supination to 30 degrees with limitation of pronation with motion lost beyond the last quarter of the arc. At the November 2016 and April 2018 VA examinations, he had supination to 35 degrees and 30 degrees, respectively, and pronation to 30 degrees.  The Veteran reports experiencing pain on motion with limitation of motion during flare-ups, and the Board finds that these reports are credible and consistent with the physical findings.  However, his functional impairment is represented by the currently assigned, 20 percent disability rating; the Veteran neither manifests nor describes limitation of motion more nearly approximating loss of pronation due bone fusion with the hand fixed in supination or hyperpronation.  The fact that the Veteran has pain does not warrant a higher evaluation unless those symptoms actually limit motion or functional use; at both examinations, he retained functional motion of the left elbow and there was no evidence of ankylosis or muscle atrophy.  There was also no crepitus, and muscle strength testing was normal.  Similar findings were reported in the Veteran’s VA treatment records.
For the foregoing reasons, the preponderance of the evidence reflects that the Veteran’s symptoms have not more nearly approximated the criteria for a rating in excess of 20 percent for left radial bone healed fracture, with impairment of supination and pronation.
The appropriate diagnostic codes for evaluating limitation of motion of the elbow joint are Diagnostic Codes 5206 and 5207, applicable to limitation of flexion and extension of the elbow, respectively.  The Veteran’s left radial bone healed fracture, with impaired flexion, is rated as 10 percent disabling pursuant to the provisions of 38 C.F.R. § 4.71a, Diagnostic Code 5206.
Under Diagnostic Code 5206, a 10 percent rating is warranted for either the major or minor elbow where there is forearm limitation of flexion to 100 degrees.  Under Diagnostic Code 5207, a 10 percent rating is warranted for either the major or minor elbow where there is forearm limitation of extension to either 45 or 60 degrees.  For a 20 percent disability evaluation, there must be limitation of forearm flexion to 90 degrees (Diagnostic Code 5206), or limitation of forearm extension to 75 degrees (Diagnostic Code 5207).  For a 30 percent disability evaluation, there must be limitation of forearm flexion to 70 degrees (Diagnostic Code 5206), or limitation of forearm extension to 90 degrees (Diagnostic Code 5207).  For the next higher, 40 percent disability evaluation, there must be limitation of forearm flexion to 55 degrees (Diagnostic Code 5206), or limitation of forearm extension to 100 degrees (Diagnostic Code 5207).  For the highest, 50 percent disability evaluation, there must be limitation of forearm flexion to 45 degrees (Diagnostic Code 5206), or limitation of forearm extension to 110 degrees (Diagnostic Code 5207).  See 38 C.F.R. § 4.71a, Diagnostic Codes 5206-5207.
The Board finds that the Veteran’s disability picture more nearly approximates the criteria for the current, 10 percent disability rating for left radial bone healed fracture, with impairment of flexion.  According to the July 2014 VA examination report, the Veteran had range of motion to 130 degrees flexion on the right, with extension limited to 5 degrees.  At the November 2016 and April 2018 VA examinations, he had range of motion to 130 degrees flexion and extension to 15 degrees.  The Veteran reports experiencing pain on motion with limitation of motion during flare-ups, and the Board finds that these reports are credible and consistent with the physical findings.  However, his functional impairment is represented by the currently assigned, 10 percent disability rating; the Veteran neither manifests nor describes limitation of motion more nearly approximating limitation of flexion to 90 degrees or extension to 75 degrees.  As noted, the Veteran’s pain does not warrant a higher evaluation unless those symptoms actually limit motion or functional use; at both examinations, he retained functional motion of the left elbow and similar findings were reported in the Veteran’s VA treatment records.
For the foregoing reasons, the preponderance of the evidence reflects that the Veteran’s symptoms have not more nearly approximated the criteria for a rating in excess of 10 percent for left radial bone healed fracture, with impairment of flexion.

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