Citation Nr: 0007675 Decision Date: 03/22/00 Archive Date: 03/28/00 DOCKET NO. 97-13 169 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUE Entitlement to service connection for degenerative arthritis including as secondary to service-connected hepatitis. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESSES AT HEARING ON APPEAL Appellant and Spouse ATTORNEY FOR THE BOARD Carolyn Wiggins, Counsel INTRODUCTION The veteran served on active duty from January 1970 to September 1971. This appeal arises from rating decisions of the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle Washington, which denied entitlement to service connection for degenerative arthritis. Service connection is currently in effect for post-traumatic stress disorder, rated as 100 percent disabling; hepatitis- related arthralgias of multiple joints, rated as 40 percent disabling; and hepatitis, rated as 10 percent disabling. FINDINGS OF FACT The veteran has not presented competent medical evidence of a nexus between service or a service-connected disability and the development of degenerative arthritis. CONCLUSION OF LAW The claim for service connection for degenerative arthritis is not well grounded. 38 U.S.C.A. § 5107 (1999). REASONS AND BASES FOR FINDING AND CONCLUSION Initial Matters. A well-grounded service-connection claim generally requires medical evidence of a current disability; medical or, in certain circumstances, lay evidence of in- service incurrence or aggravation of a disease or injury; and medical evidence of nexus between an in-service injury or disease and a current disability. See Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table); see also Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) (expressly adopting definition of well-grounded claim set forth in Caluza, supra), petition for cert. filed, No. 97-7373 (Jan. 5, 1998). For purposes of determining whether a claim is well grounded, the evidence is generally presumed to be credible. See Robinette v. Brown, 8 Vet. App. 69, 75-76 (1995) (citing King v. Brown, 5 Vet. App. 19, 21 (1993)). Where the determinative issue involves either medical etiology (such as with respect to a nexus between a current condition and an in-service disease or injury) or a medical diagnosis (such as with respect to a current disability), competent medical evidence is generally required to fulfill the well-grounded-claim requirement of section 5107(a) that the claim be "possible" or "plausible". Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); see Caluza, supra. Where the determinative issue does not require medical expertise, lay testimony may suffice by itself (such as in the recounting of symptoms or, in certain circumstances, attesting to in-service incurrence or aggravation of a disease or injury). See Caluza, supra; Heuer v. Brown, 7 Vet. App. 379, 384 (1995) (citing Grottveit, supra). With regard to a claim for secondary service connection, a claimant must provide competent evidence that the secondary condition was caused by the service-connected condition. See Wallin v. West, 11 Vet. App. 509, 512 (1998). Relevant Laws and Regulations. In general, service connection may be granted for disability which is the result of disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131 (West 1991); 38 C.F.R. § 3.303 (1999). Service connection may also be granted on a presumptive basis for certain chronic disabilities, including arthritis, when they are manifested to a compensable degree within the initial post service year. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 1991 & Supp. 1996); 38 C.F.R. §§ 3.307, 3.309 (1999). Service connection may be granted for disease which is diagnosed after discharge from military service, when all of the evidence establishes that such disease was incurred in service. 38 C.F.R. § 3.303(d); see Cosman v. Principi, 3 Vet. App. 303, 305 (1992). Service connection may also be granted for disability which is due to service-connected disease or injury. 38 C.F.R. § 3.310(a). See Harder v. Brown, 5 Vet. App. 183, 187 (1993). Factual Background. On service enlistment examination in August 1969 the veteran's spine and musculoskeletal system were noted to be normal. Service medical records include an X-ray report of the lumbar spine from April 1970. X-rays revealed that the lumbosacral spine was normal. A February 1971 Narrative Summary from a period of hospitalization in service reveals that the veteran was diagnosed with hepatitis in December 1970. He was hospitalized for a period of two months. During his hospitalization an orthopedic consult was performed. The veteran had crepitus and subjective pain in the right knee. The discharge diagnoses were hepatitis, infectious, cleared, and chondromalacia, bilateral, right greater than left, mild. At the time of the veteran's separation from the service in September 1971 an orthopedic consult was conducted. The veteran reported low back pain and aching pain in the right knee. The examiner's impression was chronic low back strain and bilateral chondromalacia of the patella, right worse than left. On service separation examination in September 1971 the spine and lower extremities were noted to be abnormal. Diagnoses of chronic low back strain and chondromalacia were noted. On the bottom of the Report of Medical Examination a note states that the X-rays of the lumbosacral spine and both knees revealed no abnormality. A VA examination was performed in June 1972. X-rays of the lumbar spine revealed sclerotic changes involving the articulation between the 5th lumbar and sacrum. X-rays of the right knee revealed no bone or joint pathology. The diagnoses were possible fibromyositis of mild degree from L-3 to L-5 chiefly on the left side and history of hepatitis. In February 1984 a VA examination was performed. X-rays of the lumbosacral spine showed normal vertebral alignment. The disc spaces were well preserved. No osseous abnormality was seen. Views of the hands and knees were normal. The examiner's impression was that no musculoskeletal abnormalities were seen. The diagnoses were chronic lumbosacral strain, bilateral chondromalacia patellae and stress disorder. In April 1988 the veteran was evaluated by Objective Medical Assessments Corporation. The case index includes the veteran's previous medical history. It includes a record of injuries beginning with a July 1977 auto accident. The history first includes a diagnosis of degenerative disc disease in April 1982. A lumbar myelogram in July 1982 was normal. Degenerative disc disease secondary to facet arthritis was first diagnosed in January 1986. A January 1989 VA examination included an X-ray report of the lumbar spine. The impression on the X-ray report was prominent degenerative joint disease at L4, L5 and minimal L4, L5 disc narrowing. In May 1992 a VA medical record included a diagnosis of "degenerative arthritis of the right knee ?" A VA examination was performed in May 1994. The assessments were (1) history of infectious hepatitis in Vietnam in 1970; no known liver problems since then; no further symptomatology; no remarkable findings on examination today; (2) low back injury in Vietnam in 1970 by his history; ongoing low back problems, progressive over the years; all findings consistent with chronic low back strain and likely degenerative joint disease of the low back, progressive. X- rays of the lumbosacral spine revealed increasing degenerative osteoarthritis of the facet joints at L5-S1. The veteran and his spouse appeared and offered testimony at a hearing in March 1994. The veteran testified that he had hepatitis in service. (T-2). The veteran stated that he had back spasms. (T-5). He had chronic pain. His knees popped and snapped. His ankles hurt. (T-6). His wife said that she had not seen a man who had so much pain. (T-7). The veteran stated his current back problems were related in riding in an APC (armored personnel carrier) in service. (T- 9). In December 1995 the veteran went to the VA requesting treatment for stiff hands and painful ankles. The examiner's impression was that he had "arthralgias, stiffness in the hands and ankles, no arthritis was seen, could be secondary to hepatitis C or early rheumatoid arthritis." January 1996 VA records reveal that the veteran returned for follow up treatment for joint arthralgias. The assessment was that the veteran had arthritis that was hepatitis C related. Later in January it was noted that the veteran had both hepatitis C and Hepatitis B. VA records from February 1996 noted that the veteran had hepatitis C and arthritis with cryoglobulins. Two days later it was noted that the veteran had hepatitis C arthritis. March 1996 VA records again noted hepatitis C associated arthritis. VA records from April 1996 included a diagnosis of chronic hepatitis. A VA examination was performed in July 1996. In the history, the examiner wrote the following: "He subsequently developed some joint symptoms and further studies in 1995 showed that he had hepatitis C, and it was felt that his arthritic symptoms were secondary to the hepatitis." In June 1997 the RO granted service connection for hepatitis. A July 1997 VA examination report includes the following assessments: 1. Hepatitis A apparently in the 1970's; hepatitis B positivity established in 1995; hepatitis C antibody positivity established in the recent couple of years. He does have chronic hepatitis with mild activity per 4/96 liver biopsy. He currently has mild liver function test elevations and is followed here in the GI clinic. 2. He does have degenerative disc disease of the low back which first presented in the 1980's and which would have no relationship to the hepatitis. He does have cryoglobulin- positive arthralgias of the fingers, which have been attributed to the hepatitis per Dr. J. in the Arthritis Clinic here at the VA. His knee problems are found to be related to degenerative changes a meniscal injury for which he had a recent laparoscopic meniscal debridement, and current findings consistent with right medial meniscal injury. The veteran also has mild chronic medial epicondylitis of the elbow. The RO in a November 1997 rating decision granted service connection for cryoglobulin-positive arthralgias. In August 1998 a VA examination was performed to determine if there was hepatitis related joint disease of any other joints in addition to the hands. After examining the veteran and the conclusion of diagnostic testing the examiner addressed the issue in his impressions. He wrote in part as follows: 1) Multi-site degenerative joint disease with subjective significant impairment of abilities and activities of daily living: in respect to the patient's hepatitis and specific request for opinion of the relationship between his reported arthralgias and his hepatitis, it is more likely than not that his arthralgias are hepatitis-induced. The contribution of his documented multi-site degenerative joint disease is felt to be no more than 20%. * * * * 4) Specific questions posed to examiner via power of attorney: "Is there hepatitis related joint disease of any joint other than the hands?": As above, it is a well-documented phenomenon for patients with hepatitis to have ongoing, chronic arthralgias even in the presence of within normal limits liver function tests. In an October 1998 rating decision the RO granted a separate 40 percent rating for hepatitis-related arthralgias of multiple joints. Analysis. The Board must first address the issue of whether or not the veteran's claim for degenerative arthritis is well grounded. The evidence includes a current diagnosis of degenerative arthritis. There is no evidence of degenerative arthritis during service or during the initial post service year. The veteran has not presented any competent medical evidence of a nexus between his currently diagnosed degenerative arthritis and service. Epps v. Gober, 126 F.3d 1464, 1468 (Fed. Cir. 1997) The veteran has asserted in his testimony that riding in an armored personnel carrier in service contributed to the development of his current back problems. He has also reported and the service medical records note a back strain in service. There is no competent medical evidence of a nexus between the back strain in service and the current degenerative joint disease of the lumbosacral spine. A lay person is not competent to make a medical diagnosis or to relate a medical disorder to a specific cause. See Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). The veteran's claim for service connection on a direct and presumptive basis is not well grounded. The veteran has also asserted that his degenerative arthritis is caused by his service-connected hepatitis. A claim for secondary service connection, like all claims, must be well grounded. 38 U.S.C.A. § 5107(a); see Proscelle v. Derwinski, 2 Vet. App. 629, 633 (1992). Secondary service connection claims are well grounded when there is evidence of a current disability and evidence which demonstrates a causal relationship between the current disability and a service- connected disability. See Reiber v. Brown, 7 Vet. App. 513 (1995); Schroeder v. Brown, 6 Vet. App. 220 (1994). The RO granted service connection for hepatitis and hepatis- related arthralgias of multiple joints. The veteran is seeking service connection for degenerative arthritis. There is no question that the veteran is service-connected for hepatitis and that he currently has degenerative arthritis. The question in this case is whether or not there is competent evidence of a causal relationship between the service-connected hepatitis and the degenerative arthritis. VA examiner's have clearly stated that hepatitis is known to cause arthralgias. They have also noted that the veteran had arthritis related to hepatitis. None of the examiner's have attributed degenerative arthritis to the veteran's service- connected hepatitis. In reading the August 1998 examination report it is clear that the VA examiner differentiates between hepatitis related arthralgias and what he terms multi site degenerative joint disease. He treats them as two separate disabilities. As is noted above the veteran is not competent to provide such evidence. In the absence of competent medical evidence of a nexus between the degenerative arthritis and hepatitis, the claim for service connection on a secondary basis is not well grounded. See Wallin v. West, 11 Vet. App. 509, 512 (1998). ORDER Service connection for degenerative arthritis is denied. Gary L. Gick Member, Board of Veterans' Appeals