Citation Nr: 25010008 Decision Date: 08/01/25 Archive Date: 08/01/25 DOCKET NO. 18-44 928 DATE: August 1, 2025 ORDER Entitlement to service connection for joint disability manifested by pain (also claimed as arthritis), secondary to service-connected sarcoidosis, on a causation basis, is granted. FINDING OF FACT The evidence is approximately evenly balanced as to whether the Veteran experienced joint disability manifested by pain, other than degenerative disc disease of the lumbosacral spine, that was caused by his service-connected sarcoidosis. CONCLUSION OF LAW With reasonable doubt resolved in favor of the appellant, the criteria for service connection for joint disability manifested by pain, secondary to service-connected sarcoidosis, on a causation basis, are met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1983 to June 1986. He died and the appellant was substituted for the Veteran with respect to the issue of entitlement to service connection for arthritis/joint pain. This matter initially came before the Board of Veterans' Appeals (Board) from an October 2015 rating decision, in which the agency of original jurisdiction (AOJ) denied service connection for arthritis and joint pain (claimed as symptoms of sarcoidosis). The appellant testified before a Veterans Law Judge (VLJ) at an August 2020 hearing and a transcript of the hearing is associated with the claims file. The VLJ who held the hearing is a signatory to this decision. In January 2021, the Board remanded these matters for further development. The appellant testified at a second hearing before a VLJ at an April 2023 hearing and a transcript of the hearing is associated with the claims file. The VLJ who held the hearing is also a signatory to this decision. Under the legacy appeal system, a VLJ who conducts a hearing must participate in making the final determination of the claim involved. 38 U.S.C. § 7107(c); 38 C.F.R. § 20.707. Appeals can be assigned only to an individual VLJ or to a panel of not less than three members. See 38 U.S.C. § 7102(a). Therefore, when an appellant has had a personal hearing before two separate VLJs during the appeal and these hearings covered one or more common issues, as they have in this case, a third VLJ is assigned to the panel after the second Board hearing has been held. 38 C.F.R. § 20.707 requires that an appellant must be provided the opportunity for a hearing before all three VLJs involved in a panel decision. Arneson v. Shinseki, 24 Vet. App. 379 (2011). As noted above, the appellant testified at two hearings before two separate VLJs concerning the issue on appeal, and both VLJs are signatories to this decision. Thus, a third VLJ will be assigned to the panel deciding this appeal. During the April 2023 hearing, the appellant waived her right to a third hearing. Therefore, the Board may proceed to adjudicate her appeal. In June 2023, the Board again remanded this matter for further development. As a final preliminary matter, the Board notes that the issues of entitlement to service connection for diabetes mellitus and bilateral eye disability were also on appeal, and the Board most recently remanded these matters in June 2023 for further development. The AOJ awarded service connection for type II diabetes mellitus and bilateral cataracts in rating decisions dated in August 2024 and December 2024, respectively, and thereby resolved the appeal as to these issues. Entitlement to service connection for joint disability manifested by pain (also claimed as arthritis), secondary to service-connected sarcoidosis Service connection is warranted for disability that is caused by service-connected disease or injury. 38 C.F.R. § 3.310 (a). The Board finds, for the following reasons, that the evidence is approximately evenly balanced as to whether the Veteran experienced joint disability manifested by pain, other than degenerative disc disease of the lumbosacral spine, that was caused by his service-connected sarcoidosis. The Veteran reported on a June 2015 "Veteran's Application for Increased Compensation Based on Unemployability" form (VA Form 21-8940) and a June 2015 "Application for Disability Compensation and Related Compensation Benefits" form (VA Form 21-526EZ) that he experienced aching joints. The Board acknowledges that it already awarded service connection for degenerative disc disease of the lumbosacral spine, and that there is no evidence of any specifically diagnosed joint disability other than degenerative disc disease of the lumbosacral spine during the claim period (to include arthritis of any joint other than the lumbosacral spine). However, the Veteran separately claimed service connection for back disability and joint pain/arthritis, and evidence of joint pain alone is sufficient in some circumstances to show the existence of current disability. See Saunders v. Wilkie, 886 F.3d 1364-65 (Fed. Cir. 2018) (pain need not be diagnosed as connected to a current underlying condition to function as an impairment and pain alone can be considered a disability under 38 U.S.C. § 1110). In this case, the Veteran claimed joint pain (other than his claimed back disability) as a secondary complication of his service-connected sarcoidosis, which is rated under 38 C.F.R. § 4.97, Diagnostic Code (DC) 6846. A Note to DC 6846 says that extra-pulmonary involvement of sarcoidosis is to be rated under the specific body system involved. There is evidence that the Veteran's joint pain, which he essentially claimed as an extra-pulmonary involvement of his sarcoidosis, caused impairment in earning capacity during the claim period. See Wait v. Wilkie, 33 Vet. App. 8, 16 (2020) ("the rating schedule may serve as a proxy for determining whether certain manifestations may impair earning capacity"). Overall, the evidence is approximately evenly balanced as to whether the Veteran experienced joint disability manifested by pain, other than degenerative disc disease of the lumbosacral spine, during the claim period. As the reasonable doubt created by the approximate balance in the evidence must be resolved in favor of the appellant, the current disability requirement has been met with respect to the claimed joint disability manifested by pain. As for whether the Veteran's joint pain was caused by his service-connected sarcoidosis, there are conflicting medical opinions. 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 appellant. See Gabrielson v. Brown, 7 Vet. App. 36, 39-40 (1994). The Board may favor one medical opinion over another, provided an adequate statement of reasons or bases is provided. See Owens v. Brown, 7 Vet. App. 429, 433 (1995). In a March 2023 statement, C. Bash, M.D. noted a review of the Veteran's records and opined that considering every possible sound medical etiology/principle, it was to at least the 90 percent level of probability that the Veteran's joint pain was proximately due to his service-connected sarcoidosis. Dr. Bash reasoned, in pertinent part, that sarcoidosis is a likely known cause of joint pain. According to medical literature (i.e., Cecils textbook of medicine and rheumatology textbooks such as 2020 Firestein and Kelly textbook of Rheumatology), sarcoidosis is a system illness that affects multiple body organs at the same time, and is associated with arthritis/joint pain. In September 2024, a VA physician reviewed the Veteran's claims file and provided an opinion that his inflammatory arthritis of the lumbosacral spine was not likely proximately due to or the result of his service-connected sarcoidosis. The physician reasoned, in pertinent part, that sarcoidosis generally does not cause arthritis and joint pain in the lumbosacral spine because "it primarily affects the peripheral joints, such as the ankles, knees, and wrists, rather than the axial skeleton." While sarcoidosis is an inflammatory disease that can impact various organs and systems, "its musculoskeletal manifestations typically involve peripheral arthritis and not the spine." The VA physician provided a separate opinion in September 2024 that the claimed arthritis was not likely ("less likely than not"/"likelihood is less than approximately balanced or nearly equal") proximately due to or the result of the Veteran's service-connected sarcoidosis. The physician noted medical literature identified in March 2021 which addressed the relationship between sarcoidosis and inflammatory arthritis, and explained that arthritis refers to inflammation of the joints which causes pain, swelling, and stiffness. General risk factors of arthritis include advanced age, genetics, previous joint injuries, obesity, infection, smoking, autoimmune conditions like rheumatoid arthritis and lupus, and hormones. In this case, the Veteran's arthritis could have been due to his advanced age, obesity, and history of smoking. As people age, the wear and tear on joints over time can lead to osteoarthritis. Excess weight puts more stress on weight-bearing joints, such as the knees and hips. This increases the risk of osteoarthritis in these areas. Smoking is a major risk factor for rheumatoid arthritis, and it can worsen the severity of the disease and makes treatment less effective. The Veteran's risk factors had a strong influence in the development of his arthritis. Sarcoidosis, which affects the lungs, does not directly cause arthritis of the joints, and it did not have an etiological link or influence on the degree of severity of arthritis. In December 2024, the VA physician who provided the September 2024 opinions re-reviewed the Veteran's claims file and opined that his arthritis/joint pain was not likely ("less likely than not"/"likelihood is less than approximately balanced or nearly equal") proximately due to or the result of his service-connected sarcoidosis. The physician reasoned that sarcoidosis generally does not cause arthritis and joint pain. Rather, arthritis or joint pain can be due to advanced age, genetics, obesity, injury or overuse, infections, smoking, and jobs that involve repetitive motions and heavy lifting. In this case, the Veteran's advanced age had a strong influence in the development of his arthritis because of wear and tear. Although sarcoidosis is an inflammatory disease, its common affectations are vital organs, as opposed to peripheral joints. There is no medical literature to disprove that arthritis is not caused by sarcoidosis. The March 2023, September 2024, and December 2024 opinions are all based upon a review of the Veteran's records and/or medical literature and consideration of his reported history, and they are accompanied by specific rationales that are generally consistent with the evidence of record and the circumstances of his service. Therefore, these opinions are entitled to substantial probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Although the initial September 2024 opinion specifically pertains to the Veteran's back disability, the rationale that accompanies the opinion indicates that sarcoidosis affects the peripheral joints and that it can manifest as peripheral arthritis. (CONTINUED ON NEXT PAGE) ? Overall, in light of the above medical opinions, the Board finds that the evidence is approximately evenly balanced as to whether the Veteran's joint disability manifested by pain was caused by his service-connected sarcoidosis. As the reasonable doubt created by the approximate balance in the evidence must be resolved in favor of the appellant, service connection for joint disability manifested by pain, as secondary to service-connected sarcoidosis, on a causation basis, is warranted. 38 U.S.C. §§ 1131, 5107 (b); 38 C.F.R. §§ 3.102, 3.303. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals A. C. MACKENZIE Veterans Law Judge Board of Veterans' Appeals M. Donohue Veterans Law Judge Board of Veterans' Appeals Attorney for the Board B. Elwood, 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.