Citation Nr: 1126735 Decision Date: 07/18/11 Archive Date: 07/21/11 DOCKET NO. 07-27 198 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUES 1. Entitlement to service connection for frequent nosebleeds. 2. Entitlement to service connection for a headache disorder. 3. Entitlement to service connection for hemorrhoids. 4. Entitlement to service connection for residuals of a total right knee replacement. 5. Entitlement to service connection for a right shoulder disability. 6. Entitlement to service connection for a right wrist and hand disability. 7. Entitlement to service connection for right leg disability. 8. Entitlement to service connection for a left leg disability. 9. Entitlement to service connection for a bilateral foot disability. 10. Entitlement to service connection for plantar warts. 11. Entitlement to service connection for dermatitis of the hands and feet. 12. Entitlement to service connection for residuals of a nasal tumor, status post surgery, also claimed as a facial tumor. 13. Entitlement to service connection for cystitis. 14. Entitlement to service connection for bronchitis, to include as due to asbestos exposure. 15. Entitlement to service connection for right arm disability. 16. Entitlement to service connection for a visual disability, to include loss of vision and residuals of a left eye contusion. 17. Entitlement to service connection for a gastrointestinal disability, to include gastritis and gastroenteritis. 18. Entitlement to a certificate of eligibility for specially adapted housing or a special home adaptation grant (SAH/SHA). REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Jason A. Lyons, Counsel INTRODUCTION Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). 38 U.S.C.A. § 7107(a)(2) (West 2002 & Supp. 2010). The Veteran served on active duty from October 1944 to June 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2006 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina, denying the benefits sought. The Board first had the opportunity to consider this case in September 2009. At that time, claims on appeal were denied for service connection for a heart condition, hypertension, prostate disorder status-post surgery, positive tuberculosis (TB) test, and exposure to ionizing radiation. The remaining matters on appeal, comprised of those issues designated above on the title page, were remanded for further evidentiary development. Those claims have since been returned to the Board. Presently, the issues of service connection for cystitis, bronchitis, a right arm disability, visual disability, gastrointestinal disability, and of a certificate of eligibility for SAH/SHA are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. The RO/AMC will notify the Veteran if further action is required on his part. FINDINGS OF FACT 1. There is no competent evidence of a current disability involving frequent nosebleeds. 2. The Veteran does not currently have a headache disorder. 3. The Veteran does not currently have a hemorrhoid condition. 4. The Veteran's right knee pathology, and any residuals from right knee total replacement, were not incurred or aggravated during military service. 5. A right shoulder disorder was not incurred or aggravated during military service. 6. The Veteran does not currently have a right wrist or right hand disability. 7. A right leg disability was not incurred or aggravated during service. 8. A left leg disability was not incurred or aggravated during service. 9. The Veteran does not currently have a bilateral foot disability. Even assuming that there is evidence of neuropathy of the feet, this is not shown to have any causal connection to his military service. 10. The Veteran does not currently have plantar warts of the feet. 11. The Veteran does not currently have dermatitis of the hands and feet. 12. The condition of a nasal tumor, and any post-surgical residuals therefrom, are not causally related to the Veteran's military service. CONCLUSIONS OF LAW 1. The criteria are not met for service connection for frequent nosebleeds. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 2. The criteria are not met for service connection for a headache disorder. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 3. The criteria are not met for service connection for hemorrhoids. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 4. The criteria are not met for service connection for residuals of a total right knee replacement. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 5. The criteria are not met for service connection for a right shoulder disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 6. The criteria are not met for service connection for a right wrist and hand disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 7. The criteria are not met for service connection for a right leg disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 8. The criteria are not met for service connection for a left leg disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 9. The criteria are not met for service connection for a bilateral foot disability. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 10. The criteria are not met for service connection for plantar warts. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 11. The criteria are not met for service connection for dermatitis of the hands and feet. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). 12. The criteria are not met for service connection for residuals of a nasal tumor, status post surgery, also claimed as a facial tumor. 38 U.S.C.A. §§ 1110, 1131, 5103, 5103A, 5107(b) (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS VA's Duties to Notify and Assist the Claimant The Veterans Claims Assistance Act of 2000 (VCAA), codified at 38 U.S.C.A. §§ 5100, 5102, 5103A, 5107, 5126 (West 2002 & Supp. 2010), prescribes several requirements as to VA's duty to notify and assist a claimant with the evidentiary development of a pending claim for compensation or other benefits. Implementing regulations are codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326 (2010). VCAA notice consistent with 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) must inform the claimant of any information and evidence (1) that is necessary to substantiate the claim; (2) that the claimant is expected to provide; and (3) that VA will seek to provide on the claimant's behalf. A regulatory amendment effective for claims pending as of or filed after May 30, 2008 removed the requirement that VA specifically request the claimant to provide any evidence in his or her possession that pertains to the claim. 73 Fed. Reg. 23,353-56 (Apr. 30, 2008), later codified at 38 CFR 3.159(b)(1) (2010). The United States Court of Appeals for Veterans Claims (Court) has further held in Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006); aff'd sub nom. Hartman v. Nicholson, 483 F.3d 1311 (Fed. Cir. 2007), that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3/159(b) apply to all five elements of a "service connection" claim, including notice to the claimant that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. The RO has informed the Veteran of what evidence would substantiate the claims being decided herein through VCAA notice correspondence dated from December 2004 through October 2009. The VCAA notice further indicated the joint obligation between VA and the Veteran to obtain pertinent evidence and information, stating that VA would undertake reasonable measures to assist in obtaining further VA medical records, private treatment records and other Federal records. See Quartuccio v. Principi, 16 Vet. App. 183, 186-87 (2002). A March 2006 supplemental notice letter informed the Veteran regarding the downstream disability rating and effective date elements of his claims. The relevant notice information must have been timely sent. The Court in Pelegrini II prescribed as the definition of timely notice the sequence of events whereby VCAA notice is provided in advance of the initial adjudication of the claim. See also 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In this instance, the initial December 2004 VCAA notice correspondence was sent before issuance of the February 2005 rating decision adjudicating several of the claims now before the Board. A July 2005 VCAA letter likewise preceded the January 2006 rating decision on appeal addressing the remaining claims. These letters met the standard for timely notice. Meanwhile, the March 2006 VCAA notice and subsequent letters were sent after the rating decision on appeal, and thus technically were untimely. However, the Veteran has had an opportunity to respond to the subsequent issued VCAA notice letters in advance of the most recent March 2011 Supplemental Statement of the Case (SSOC) readjudicating his claims. There is no objective indication of any further relevant information or evidence that must be associated with the record. The Veteran has therefore had the full opportunity to participate in the adjudication of the claims. See Mayfield v. Nicholson, 19 Vet. App. 103, 128 (2005), affirmed, 499 F.3d 1317 (Fed. Cir. 2007). The RO has taken appropriate action to comply with the duty to assist the Veteran through obtaining service treatment records (STRs), records of VA outpatient treatment, and extensive records of private medical treatment. The Veteran has undergone several VA Compensation and Pension examinations. See McClendon v. Nicholson, 20 Vet. App. 79, 83 (2006); Charles v. Principi, 16 Vet. App. 370 (2002). See too, 38 C.F.R. § 3.159(c)(4). The Veteran has provided several personal statements in support of his claims. He declined the opportunity for a hearing. The record as it stands includes sufficient competent evidence to decide the claims. Under these circumstances, no further action is necessary to assist the Veteran. In sum, the record reflects that the facts pertinent to the claims have been properly developed and that no further development is required to comply with the provisions of the VCAA or the implementing regulations. That is to say, "the record has been fully developed," and it is "difficult to discern what additional guidance VA could [provide] to the appellant regarding what further evidence he should submit to substantiate his claim." Conway v. Principi, 353 F. 3d. 1369 (Fed. Cir. 2004). Accordingly, the Board will adjudicate the claims on the merits. Background and Analysis Service connection may be granted for any current disability that is the result of a disease contracted or an injury sustained while on active duty service. 38 U.S.C.A. §§ 1110, 1131 (West 2002 & Supp. 2010); 38 C.F.R. § 3.303(a) (2010). Service connection may also be granted for a disease diagnosed after discharge, where all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d) (2010). The elements of a valid claim for direct service connection are as follows: (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the current disability. Hickson v. West, 12 Vet. App. 247, 253 (1999). Certain disorders involving what are recognized as diseases of a chronic nature, such as arthritis, will be presumed to have been incurred in service if manifested to a compensable degree within one year after service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Provided however that the issue presented is still one of direct service connection, not presumptive, the foregoing applies. Where a chronic disease is shown during service, subsequent manifestations of the same chronic disease at any later date, however remote, are service-connected, unless clearly attributable to intercurrent causes. On the other hand, continuity of symptomatology is required where the condition noted during service is not, in fact, shown to be chronic, or where the diagnosis of chronicity may be legitimately questioned. Under the latter circumstances, a showing of continuity of symptomatology at the time of service discharge and continuing thereafter is required to support the claim. 38 C.F.R. § 3.303(b). Frequent Nosebleeds In the Veteran's service treatment history, a November 1952 entry refers to epistaxis (i.e., nosebleeds). A March 1953 entry indicates that while on liberty the Veteran had sustained a severe attack of epistaxis, and went to a naval hospital where bleeding was eventually controlled. It was noted that epistaxis had occurred frequently and an ENT consult was advised. The current record as it stands is absent further mention of nosebleeds during military service, or for that matter at any time since the Veteran's service. A comprehensive review of the extensive VA outpatient and private medical history has been completed, and there is no indication of reported or observed symptomatology of frequent nosebleeds. This follows thorough measures undertaken pursuant to the Board's remand order to obtain all remaining available records of private medical treatment for the Veteran. Moreover, the Veteran through his correspondence with VA has not identified any symptoms of or approximating frequent nosebleeds that would merit medical inquiry by VA examination. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007) (indicating competency of lay testimony to describe symptoms that support a later diagnosis by a qualified medical professional). Under these circumstances, without evidence indicating the existence of a current disability comprised of frequent nosebleeds, the Veteran's claim for service connection for that same condition must be denied. The first criterion to establish service connection is competent evidence of the disability claimed. VA law is clear in specifying that a current disability is the cornerstone of a valid claim for service connection. See Moore v. Nicholson, 21 Vet. App. 211, 215 (2007), citing Francisco v. Brown, 7 Vet. App. 55, 58 (1994) ("Compensation for service-connected injury is limited to those claims which show a present disability."); Hicks v. West, 12 Vet. App. 86, 89 (1998); Rabideau v. Derwinski, 2 Vet. App. 141, 144 (1992). See also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992) ("Congress specifically limits entitlement for service-connected disease or injury to cases where such incidents have resulted in a disability."). It follows that absent competent evidence of frequent nosebloods having transpired at any point post-service discharge, the Veteran's claim cannot be substantiated. Indeed, while there may have been relevant symptomatology as shown in STRs during the mid-1950s, without a current disability, there is no basis to inquire further into the etiology of the condition claimed. In view of the foregoing reasons and bases, service connection for frequent nosebleeds is being denied. The preponderance of the evidence is against this claim, and under these circumstances the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. See also Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Headache Disorder Upon similar grounds as the aforementioned claim, the Board also finds that the criteria have not been met for a headache disorder. There are intermittent references to the presence of headaches in the Veteran's STRs. This notwithstanding, the record is wholly absent for mention of a headache disorder since service discharge in June 1967, including with regard to both VA and private outpatient treatment, and on VA Compensation and Pension examinations. The Veteran also has not described in any detail having had chronic headaches post-service. Given the lack of findings indicating or suggesting a post-service disability since 1967 comprised of a headache disorder, there is again no competent evidence of the disability claimed. The absence of evidence of a current disability, a critical element of any claim for service connection, means that the claim cannot be substantiated. Rabideau, supra; Brammer, supra. Once again, the fact that the condition was noted in service is inapposite, since it must manifest post-service as well to warrant any potential adjudication of service connection. For these reasons, service connection for frequent nosebleeds is being denied. As the preponderance of the evidence is unfavorable, the benefit-of-the-doubt doctrine does not apply. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Hemorrhoids A November 1964 in-service treatment record indicates the presence of external hemorrhoids associated with pruritis and bleeding. While the Board recognizes the import of this in-service clinical record, it is equally significant that since then, there is no medical record anywhere substantiating a diagnosis of hemorrhoids following military service. Nor is there competent lay evidence substantiating the assertion that this claimed condition currently manifests. Once again, therefore, there is lack of competent evidence of a qualifying disability. The condition alleged essentially has not manifested in more than four decades since separation from service. It follows that the preponderance of the competent evidence is unfavorable to the Veteran's claim for service connection for hemorrhoids, and this claim must be denied. Residuals of a Total Right Knee Replacement STRs are absent for symptoms, findings, or complaints regarding any right knee problem. In March 2002, the Veteran was noted to have right knee degenerative joint disease. Later than month, the Veteran underwent a right total knee arthroplasty. The operative summary indicates that the Veteran presented with a progressive longstanding history of right knee pain, and previous treatment had failed. The procedure was undergone with no operative complications, and the Veteran had tolerated the procedure well. A May 2002 x-ray report for the right knee conducted at a private facility indicates a well-seated total knee arthroplasty seen. There was no fracture or dislocation. An October 2005 treatment record from a private physician indicates an assessment in part of chronic knee pain (right side) and foot pain. The Board's review of the competent and probative evidence does not establish a basis for the claim under consideration. Here, there is no question that the Veteran underwent a total right knee replacement procedure. So the initial element of a current disability is shown. That notwithstanding, any adjudication of service connection further requires the essential element of a causal nexus to service, or in other words, that the disability in question have been incurred or aggravated during military service. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service."); Hickson, supra. See, too, Duenas v. Principi, 18 Vet. App. 512, 516 (2004). In the claim now before the Board, there is no suggestion that right knee problems originated in connection with the Veteran's military service. There are no treatment records from military service demonstrating right knee pathology, nor does the Veteran allege that any such disability existed during service. Moreover, there is a treatment gap of more than three decades between service discharge, and when knee problems were first noted. This marked lack of continuity of symptomatology from military service to the time of initial diagnosis in 2002 weighs heavily against the claim. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The Board recognizes that the March 2002 operative report for the arthroplasty references a long history of right knee problems, nonetheless this is a nonspecific finding that does not in any manner help establish a causal link dating back to the Veteran's service. To ascertain a probable causal nexus in light of this factual finding thus would be no more than mere conjecture or speculation. For these reasons, the criteria for service connection for residuals of total right knee replacement have not been met. Since the preponderance of the evidence is unfavorable, VA's benefit-of-the-doubt doctrine does not apply and the claim must be denied. Right Shoulder Disability The service treatment history is absent documentation of any symptoms, findings or complaints pertaining to a right shoulder disorder. A September 2009 private treatment provider's x-ray of the right shoulder indicated no acute abnormality. On a February 2010 VA Compensation and Pension examination, the Veteran reported having had some pain in the right shoulder. Objective examination revealed that the right arm and shoulder appeared normal at rest. On range of motion testing, he could forward flex the right arm to about 140 degrees and then he grimaced with discomfort and could not go any further. Abduction was limited to around 90 to 100 degrees. There was good muscle strength in the right arm. The Veteran was able to do repetitive motion of the right arm and right shoulder up to the point of discomfort. The diagnosis was of bursitis, right shoulder with some restriction in movement. The VA examiner further commented after having reviewed the claims file that there did not appear to be any condition of the right shoulder that was related to military service. The examiner observed that the Veteran had no problem in the military service involving the shoulder that was chronic and that had been a continuous problem up until the instant examination. Also noted was that after the Veteran retired from the service, he worked for 20 years. This had required use of his right arm and right shoulder. It had been in the last few years that he had experienced most of his difficulty. Therefore, the examiner concluded, it was less likely than not that the right shoulder bursitis with restriction of motion was related to any problem that the Veteran may have had in the military service. On the basis of the preceding, the claim for service connection for a right shoulder cannot be established. Though the Veteran has the current medical condition of right shoulder bursitis, there is competent VA medical opinion evidence effectively ruling out any etiological connection between that diagnosed disorder, and his military service. Hence, the essential element of a causal nexus to service has not been proven. Looking more closely at the February 2010 VA examiner's opinion, the examiner articulated a clear and definitive rationale for finding that bursitis did not originate in service, and supported this conclusion with a medical history review. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000) (factors for assessing the probative value of a medical opinion include the medical expert's access to the claims file and the thoroughness and detail of the opinion); Boggs v. West, 11 Vet. App. 334, 340 (1998). The VA examiner cited as determinative the absence of any right shoulder problem in service, or for that matter more than two decades thereafter, as well as the Veteran's long history of employment with no apparent impact of right shoulder symptomatology. Given its plausible foundation in the medical history of the Veteran, the Board assigns probative weight to this opinion. Nor is there any contravening medical opinion on file. The Veteran's own assertions have also been afforded appropriate weight however, as he is a layperson, he cannot offer a competent opinion on the causation of a right shoulder disorder, given that the more than two decade interval between service and initial medical treatment renders this issue a matter not within the purview of lay observation. See Grottveit v. Brown, 5 Vet. App. 91, 93 (1993); Espiritu v. Derwinski, 2 Vet. App. 492, 494 (1992). For these reasons, service connection for a right shoulder disability is being denied. Right Wrist and Hand Disability STRs include a January 1955 right wrist x-ray which indicated no evidence of fracture or dislocation. There was a 1-mm area of decreased density of the cortex of the navicular bone, the significance of which was undetermined. When seen in April 1959, the Veteran stated that he had sprained his wrist the previous month, and had been in pain ever since. There was tenderness over the dorsum of the wrist and at the base of the thumb, with no mass or swelling, and with a negative x-ray. The treatment provider determined that in view of the persistence of the Veteran's problem he would apply a cast to the Veteran's wrist for a period of two weeks in order to obtain complete immobilization. A May 2003 private clinical record indicates numbness in the right hand, as well as in the feet persistently. The Veteran stated that the right hand had been numb since undergoing surgery. The impression was of neuropathy, possibly secondary to the diabetes but requiring further testing to confirm this. A November 2004 clinical record from another source indicates an assessment in part of neuropathy to the right hand, but does not elaborate whether this had any association with diabetes mellitus. In her December 2006 correspondence, a VA physician indicated that she had been treating the Veteran over the past year for right hand pain, amongst other conditions. The physician expressed the opinion that after reviewing the Veteran's service records, it was believed that his right hand problems were more likely than not related to his military service. The Veteran also underwent a February 2010 VA Compensation and Pension examination of the hand, thumb and fingers. He then reported having pain in the right hand, and some weakness of grip. It was reported that he had a tendency to drop plates and dishes. These symptoms had come on gradually over the past several years. There had been no history of hospitalizations or surgery involving the hand, no trauma to the hands or fingers, and no neoplasms. The current symptoms also increased loss of sensation in the hands, and some decreased strength and loss of dexterity. On physical exam, the Veteran had good grip strength. He could extend all fingers normally, and could bring the fingers together with good strength on adduction and abduction. He could bring all fingers to the mid palmar crease. He did have some osteoarthritis changes in the joints of the finger, however, the fingers extended normally. He could make a good tight grip. There was no limitation of motion of any digit. He had normal strength for pushing, pulling and twisting. The diagnosis was of a normal hand for the Veteran's age. The VA examiner elaborated that the Veteran did not have any current diagnosis of a hand disorder or disease. Therefore, there was no current diagnosis that could be attributed to the hand. Also indicated was that the Veteran did not have any condition involving the hand that could be related to his time in the military service. The present claim for service connection for a right wrist and hand disability must be denied, for lack of medical evidence of a current disability. This determination is heavily based upon the February 2010 VA medical examination findings, which essentially note the Veteran's right hand to have been in normal condition. By every indication, this VA examination investigated all dimensions of right hand functionality, down to the grip, strength, and individual movements of each of the fingers, and found no objective indication of any deficiency. Likewise, VA and private clinical records are largely absent showing of right wrist and hand pathology. There is the single November 2004 treatment record which alludes to possible neuropathy of the right hand, which may have been associated with diabetes mellitus. That notwithstanding, the Board ultimately finds the February 2010 VA medical examination to be more probative, since based upon a full and comprehensive medical inquiry into all reported symptomatology, and revealing entirely normal right hand grip and muscle strength. (Not without importance also is that the November 2004 report attributes neurological symptomatology to diabetes mellitus, which is a nonservice-connected disability itself.) Meanwhile, a December 2006 VA physician's letter observes that the Veteran experienced right hand pain. Still, the manifestation of pain alone does not comprise evidence of a current disability. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) ("pain alone, without a diagnosed or identifiable underlying malady or condition, does not in and of itself constitute a disability for which service connection may be granted."); dismissed in part and vacated in part on other grounds, Sanchez-Benitez v. Principi, 239 F.3d 1356 (Fed. Cir. 2001). In summary, the most probative medical evidence available effectively outrules the likelihood of any present cognizable right wrist/hand disability. In so finding, the Board recognizes that the December 2006 statement of a VA physician attributed right hand pain to the Veteran's military service. As stated however, right hand pain alone is not a recognized disability. Moreover, while the examiner did assert to have reviewed the Veteran's service records, it is worth noting that the Veteran never had sustained any documented right hand injury during service. The only relevant injury therein was a right wrist sprain. At no point does the VA physician in 2006 indicate that what he actually meant was that the Veteran experiences a current disability of the right wrist attributable to in-service injury. Rather, the proffered opinion appears to represent a generalized and factually unsupported reading of what service treatment records actually indicate. See Elkins v. Brown, 5 Vet. App. 474, 478 (1993) (the Board may consider and evaluate the underlying basis of an opinion on a medical question, and determine whether to accept such an opinion under the circumstances). In summary, given the lack of competent evidence of a current right wrist or hand disability, the claim under consideration must be denied. Right and Left Leg Disabilities STRs reflect that in January 1966, the Veteran complained of pain in the right leg over the previous three months. There was no further symptomatology observed, or similar condition otherwise noted on military separation. A December 2005 arterial lower extremities exam was performed with indications of peripheral vascular disease and bilateral leg pain, and showed no evidence for significant arterial disease in either lower extremity. More recently, a December 2010 private physical therapy evaluation indicates that the Veteran presented with significantly decreased strength in the bilateral lower extremities which limited stability with gait, and noted that he would benefit from acute physical therapy to begin addressing these deficits. An April 2011 clinical record indicates that the Veteran presented for evaluation of bilateral leg swelling and calf discomfort and also noted paresthesias of his lower legs over the previous few days. It was reported that gait was unsteady. The assessment was of imbalance and generalized weakness, and bilateral lower extremity edema and paresthesias and leg discomfort. Presently, service connection is already in effect for the conditions of right and left lower extremity venous varicosities. Based on the above, the preponderance of the competent and probative evidence regarding claimed service connection for a bilateral lower extremities disorder is unfavorable. The Board notes that in recent evaluative history, the Veteran had some symptomatology of bilateral leg weakness, paresthesias and discomfort, indicating the potential likelihood of a recognizable bilateral lower extremities disability apart from already service-connected venous varicosities. That having been acknowledged, there is no means to ascertain any causal relationship between the current disability noted, and the Veteran's military service. The only indication of possible relevant symptoms in service constituted a January 1966 reported instance of right leg pain for three months. By every apparent indication, this was an acute and transitory symptom that soon resolved. Of note, no recurrence was noted at the time of separation. Nor has the Veteran described any precipitating injury in connection with this 1966 complaint. Essentially, there are no plausible grounds upon which to associate a single episode of reported leg pain with a medical condition of the lower extremities manifesting some 40 years later. There is no theory advanced by the Veteran as to how the two very remote developments could be related, nor does not the record suggest any such theory. Consequently, the preponderance of the evidence on the subject of a causal nexus to service is clearly unfavorable, and the claim must be denied. Bilateral Foot Disability There are no STRs denoting treatment for a bilateral foot disability, apart from one or more dermatological conditions (which already are the subject of separate claims for service-connected disability compensation). A May 2003 private clinical record denotes the presence of numbness of the feet persistently. An impression was given in part of neuropathy, possibly secondary to diabetes mellitus. Also indicate was the presence of a lesion on the sole of the right foot. A follow-up was recommended to rule out melanoma. There is no record of follow-up evaluation. Having fully considered the record, there is no conclusive basis to establish a current bilateral foot disability. Even viewing the evidence in the most beneficial light, as meaning that there may exist neuropathy of the feet, there is no indication anywhere that said condition is service-related. There was no record of treatment for a foot disorder during service (again, apart from distinct dermatological impairment) or for several decades afterwards. If anything, neuropathy has been attributed in all likelihood to nonservice-connected diabetes mellitus. Thus, the critical element of a causal nexus to service had not been met. The claim for service connection for a bilateral foot disorder must be denied. Plantar Warts In May 1967 during military service, the Veteran was seen for a lump on the right foot, believed to be a plantar wart. The February 2010 VA dermatological examination reflects, in pertinent part, that the Veteran was not troubled with warts at that time. Since one occasion during military service, there is no indication whatsoever that the condition of plantar warts returned. The Veteran was not evaluated during service any further for plantar warts, nor has the condition been shown to manifest at any point since service. He also does not specifically contend that he currently experiences a medical condition of or similar to plantar warts. On this basis, there is no other conclusion to reach but that the Veteran does not have the condition claimed. As previously mentioned, without evidence of a current disability a claim for service connection must be denied. Hence, the claim for service connection for plantar warts cannot be substantiated. Dermatitis of the Hands and Feet A July 1952 clinical entry denotes contact dermatitis of the left hand. When seen in July 1957, the Veteran was complaining of peeling of the skin on his hands for the past month, and was advised to use rubber gloves while washing dishes in the pantry. For two weeks he had been complaining of small hard rash type dermatitis with itching sensation. The provisional diagnosis was dermatitis, both hands. On a subsequent dermatological consult, the Veteran was noted to have dermatitis on the palms of both hands which seemed to be aggravated by dish washing, possibly due to the soap. An ointment was prescribed, and the Veteran was advised to avoid duties involving dish washing. In February 1959, the Veteran again complained that both hands were dry, cracking and peeling. An ointment and powder were prescribed. In August 1963, the Veteran was noted to have had a fungus on both feet, and was given ointment and foot powder and returned to duty. In October 1965, the Veteran had what appeared to be an infected athlete's foot which had responded to some soaking treatments, but would not completely heal. Since the Veteran's having undergone separation from military service, there is no post-service record indicating the presence of dermatitis or other dermatological condition of the hands or feet. The Veteran underwent a VA Compensation and Pension examination for dermatological evaluation in February 2010. The Veteran's main complaint at that time was of breaking out and peeling and fissuring of the skin of the right hand. He stated that this had been going on since he was in the service. The VA examiner noted that it appeared this had been a chronic condition, however, there was very little in the record regarding a chronic hand skin condition. The Veteran further reported that his treatment for a right hand condition consisted of topical creams and keeping the hand covered with a glove to keep it warm. The left hand did not seem to be involved. He did not have any problems with the feet at that time. He stated that if he did not use moisturizing creams, that he would have peeling and fissuring of the skin of the hand. On objective physical exam, there was no evidence of any disease. The hands appeared normal. The skin appeared normal. Therefore, the percent of the exposed skin surface or entire body was 0 percent. There was no scarring or disfigurement. There was no acne or chloracne. There was no scarring alopecia, alopecia areata, or hyperhidrosis. In regard to a diagnosis, the VA examiner stated that there was no evidence of a hand skin disorder at that time. He further commented that the history as obtained from the Veteran, his wife and the record indicated that he had some problems with a chronic skin condition of the hands, that went back to military service, and this was documented in the medical record. The examiner expressed the opinion that it was at least as likely as not that any hand condition involving the skin that the Veteran had was a continuing process that started in military service. On thorough review of the proceeding, the complete criteria for service connection have not been met. The underlying basis upon which the Board makes this determination is lack of a current disability. The February 2010 VA examination was absent objective indication of a dermatological disorder of the hands or feet. Though this is not the only grounds to evaluate the potential for dermatological disability, it is telling that the extensive VA and private outpatient clinical records on file are demonstrably absent any finding of a skin condition of the hands and/or feet. As stated, without a present claimed disability, service connection cannot be established. The Board is mindful that the February 2010 VA examiner posited what on its face is a favorable opinion on the question of causal nexus -- notwithstanding this, the opinion that a dermatological disorder of the hands may have been service-related was wholly contingent on there being some other evidence of record of an actual disability. Such evidence has never materialized. There is simply no basis in the medical evidence to conclude that the Veteran has a current skin disorder. And while he is competent to report symptoms, and use of moisturizing creams, some objective medical finding would be necessary to confirm the presence of dermatitis. Therefore, the claim is being denied for lack of a current claimed disability. If however, at a future point medical evidence becomes available to substantiate a diagnosis of dermatitis of the hands, or similar dermatological condition of the hands, the Veteran is encouraged to submit such evidence in support of a petition to reopen his claim for service connection for the disability in question. Residuals of a Nasal Tumor In June 1997, a CT scan of the paranasal sinuses detected a large mass involving the nasal cavity, anterior ethmoid, and maxillary sinuses on the right extending into the nasopharynx. Presumably, this represented a large antral-choanal polyp, although a neoplasm could not be excluded, such as an inverted papilloma. A biopsy confirmed an inverted papilloma. The following month, the Veteran underwent a right medial maxillectomy via a mid-face degloving procedure. There were no operative complications immediately noted. Subsequently, in 1998 the Veteran was treated on more than one occasion for the symptoms of bleeding from constant tearing of the right eye following the right medial maxillectomy procedure. When seen again in March 2002, the assessment was of epiphora secondary to medial maxillectomy. The complete criteria for service connection have not been met in this instance. The Board does not take any issue with the fact that there is evidence to indicate a current disability. The Veteran had a right medial maxillectomy procedure in 1997, followed by the post-operative residual of epiphora roughly contemporaneous with when he filed his initial claim for service-connected compensation. See generally, McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (the existence of a current disability may be satisfied when a claimant has a disability at the time a claim for compensation is filed or during the pendency of that claim even though the disability resolves prior to the Secretary's adjudication of the claim). This having been established however, there is the additional requirement to establish service connection of a demonstrated causal nexus to military service. Here, the first manifestation of an inverted papilloma, within the paranasal sinuses, was not until 1997, nearly three decades after service discharge. There is no suggestion from the medical records, or competent assertion by the Veteran that the inverted papilloma of the sinuses was of service origin. Absent clear and competent indication that the claimed disability in question had a causal nexus to military service, the claim cannot be proven. Hence, the claim for service connection for residuals of a nasal tumor is being denied. ORDER Service connection for frequent nosebleeds is denied. Service connection for a headache disorder is denied. Service connection for hemorrhoids is denied. Service connection for residuals of a total right knee replacement is denied. Service connection for a right shoulder disability is denied. Service connection for a right wrist and hand disability is denied. Service connection for right leg disability is denied. Service connection for a left leg disability is denied. Service connection for a bilateral foot disability is denied. Service connection for plantar warts is denied. Service connection for dermatitis of the hands and feet is denied. Service connection for residuals of a nasal tumor, status post surgery, also claimed as a facial tumor, is denied. REMAND There are several claims which require still further evidentiary development before a decision may be issued upon them. The requested case development is outlined below. With regard to each claim for service connection being remanded, the Board is requesting either a new VA examination, or examiner's clarification of an existing medical opinion. See 38 U.S.C.A. § 5103A(d) (West 2002 & Supp. 2010); 38 C.F.R. § 3.159(c)(4) (2010) (VA will provide a medical examination or obtain a medical opinion based upon a review of the evidence of record if VA determines it is necessary to decide the claim). Cystitis In June 1966, the Veteran was evaluated as having a low grade fever, chills, general malaise, and severe burning on urination, as well as severe headache and low back pain. The impression was of cystitis. More recently, in February 2011 the Veteran had a urinary tract infection. Without any more documentation in the claims file, the Board cannot say at this point whether the more recent symptomatology has any connection to service. However, there is sufficient preliminary showing of that possibility, such that a VA medical examination is legally required. Thus, one will be requested on remand. Bronchitis In March 1965, the Veteran was evaluated in service for acute bronchitis superimposed on an upper respiratory infection. There are private clinical records of post-service bronchitis documented from June 2005 and October 2010. Here again, medical confirmation through a VA examination and opinion should be requested as to whether the Veteran has chronic bronchitis that is causally related to his active military service. Right Arm Disability An October 1967 document in connection with separation indicates that the Veteran had injured his right arm four months previously while straining to lift a heavy object. Since then, his right arm had been going numb and strength was decreased. The diagnosis given was of a contusion, right arm. Post-service, there are limited VA or private clinical records which refer to a distinctly identifiable right arm medical condition (and as distinguished from conditions involving specific joint groups of the lower extremities, i.e., the right shoulder, right wrist). The one relevant finding as to right arm disability is a December 2000 private clinical record indicating the diagnosis of median ulnar neuropathy, right wrist, and elbow. The Veteran then underwent surgical decompression of the median and ulnar nerve at the right wrist and elbow with epicondylectomy, and long arm splint and sling. A May 2003 private clinical record indicates numbness in the right hand, persistently. The Veteran stated that the right hand had been numb since undergoing surgery. The impression was of neuropathy, possibly secondary to the diabetes but requiring further testing to confirm this. Thereafter, the Veteran underwent a February 2010 VA Compensation and Pension examination of the joints regarding the right upper extremity, including a full physical exam. Based on review of the exam findings, the VA examiner did not offer any diagnosis pertaining to the right arm. Regardless of the February 2010 VA examination results, the preliminary evidentiary hurdle of a current disability is satisfied by the December 2000 diagnosis and treatment for median and ulnar neuropathy of the right upper extremity, and post-surgical numbness. The earlier showing of a neurological condition of the right upper extremity, with persistent residual right arm numbness, is sufficient to concretely demonstrate a present right arm disability. This does not end the Board's inquiry, however, since the disability in question must also be proven to be of service origin. In order to properly resolve this issue of causal nexus, the Board finds that a new VA examination should be scheduled, this time with a neurologist, to determine whether the Veteran still experiences residual right arm numbness following treatment for median ulnar neuropathy, and most significantly, whether said condition is objectively related to military service. Visual Disability When vision was measured in October 1947, it was uncorrected 15/20 in the right eye, and 13/20 in the left eye. In May 1949, it was measured at 10/20, right eye, and 15/20 left eye. In December 1950, there was vision of 26/20, right eye, and 67/20 left eye. In July 1951, it was 20/60 right eye, 20/40 left eye. In March 1957, it was 20/40 right eye, and 20/70 left eye. In November 1958, the Veteran sustained a contusion to the left eye. On exam five days later, he still had a marked superficial infection of the conjunctiva. The following day, the infection was subsiding, and vision was noted to be normal. On separation examination in June 1967, vision was 20/30 in both eyes, uncorrected (and correctable to 20/20 bilaterally). A December 2008 outpatient consult at a VA eye clinic indicated the presence of cataracts as the cause of reduced acuity in the left eye, with complaints of poor vision for near tasks. Contemporaneous private treatment records confirm the existence of cataracts with nuclear sclerosis. The Veteran underwent a February 2010 VA Compensation and Pension examination pertaining to his vision. His subjective complaint was of watery eyes. Ophthalmic treatments included bifocal lens spectacles and an eyedrop solution. It was observed that the claims file did document an October 1958 contusion to the left eye. There was a history of a cataract extraction and intraocular lens implantation for the left eye in 2006. The Veteran denied any personal history of eye injuries, infections, further disease or further surgeries. A full visual exam was completed. The assessment given was of no diabetic retinopathy or other retinal pathology for either eye; cataract, right eye, not caused by diabetes, primary cause being unknown; pseudophakia, left eye; hyperopia, both eyes; astigmatism, both eyes; dry eye, both eyes. The VA examiner further commented that there were no diagnoses related to the in-service left eye contusion. The foregoing VA medical examination report directly addresses the question of a causal nexus to military service, but simply stated, not in terms that are ultimately useful to the Board. The VA examiner found there were no diagnoses related to the in-service left eye contusion. Unfortunately, he never explained why this was the case, particularly given the post-service history of cataract surgery to the left eye. A medical opinion to be accepted as definitive, must have some underlying rationale and medical basis in fact. See e.g., Miller v. West, 11 Vet. App. 345, 348 (1998) (a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record). Therefore, the Board returns this case to the February 2010 VA examiner for vision to provide a more comprehensive medical opinion addressing what, if any, post-service residuals exist as the result of an in-service left eye contusion. Gastrointestinal Disability In September 1960, the diagnosis was established of acute gastroenteritis, cause undetermined, after an episode the previous month of cramping abdominal pain. It was noted that following the August 1960 episode, the Veteran had been completely asymptomatic. In January 1967, the Veteran reported having experienced epigastric distress. The assessment was rule out ulcer. A VA Compensation and Pension examination of the gastrointestinal system was completed in February 2010, during which the Veteran's reported symptoms and review of the record disclosed only two relevant medical conditions, those of chronic constipation and status-post inguinal hernia. The VA examiner further opined that there was no evidence to support that either of these conditions were related to military service, or were related to treatment in the military service for gastritis or gastroenteritis. Following the VA exam, additional private clinical records were associated with the claims file. These records reflect that in April 2008, the Veteran underwent an EGD study with the preliminary indications of gastroesophageal reflux disease (GERD), nausea, vomiting anemia and melena. The impression following the study was of gastritis, and duodenal polyp. That same month, a CT scan of the abdomen revealed no acute abnormality within the abdomen or pelvis, but possible small gallstones within the gallbladder. There was also diverticulosis coli without evidence of diverticulitis. Furthermore, that month an endoscopic biopsy from the stomach revealed a duodenal polyp and gastritis. Given the new evidence indicating additional gastrointestinal disability, and in particular a diagnosis of gastritis, the Board believes a supplemental opinion should be procured from the February 2010 VA examiner on whether any of these further diagnosed conditions have any objective relationship to military service. SAH/SHA Benefits On the remaining claim for entitlement to a certificate of eligibility for specially adapted housing or a special home adaptation grant, the disposition of this claim is directly premised upon the nature, extent and severity of the Veteran's service-connected disabilities. As yet, however, there are several outstanding claims for service-connected compensation that are being remanded -- for bronchitis, visual disability and gastrointestinal disability, amongst other conditions. The claim for SAH/SHA benefits is "inextricably intertwined" with the claims for service connection, and the disposition of the SAH/SHA claim must therefore be deferred pending resolving these preliminary matters. Harris v. Derwinski, 1 Vet. App. 180, 183 (1991) (two issues are "inextricably intertwined" when they are so closely tied together that a final decision on one issue cannot be rendered until a decision on the other issue has been rendered). See also Parker v. Brown, 7 Vet. App. 116 (1994). Accordingly, these claims are REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2010). Expedited handling is requested.) 1. The RO/AMC should schedule the Veteran for a VA genitourinary system examination to determine whether claimed cystitis is etiologically related to the Veteran's service. The claims folder must be provided to and reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be performed, and all findings should be set forth in detail. It is requested that the VA examiner determine whether the Veteran currently has the condition of chronic cystitis. The examiner must then opine whether any diagnosed disability is at least as likely as not (50 percent or greater probability) related to the Veteran's military service, based on the symptoms and complaints noted therein. The examiner should include in the examination report the rationale for any opinion expressed. However, if the examiner cannot respond to the inquiry without resort to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 2. Then schedule the Veteran for a VA respiratory system examination to determine whether claimed bronchitis is etiologically related to the Veteran's service. The claims folder must be provided to and reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be performed, and all findings should be set forth in detail. It is requested that the VA examiner determine whether the Veteran currently has the condition of chronic bronchitis. The examiner must then opine whether any diagnosed disability is at least as likely as not (50 percent or greater probability) related to the Veteran's military service, based on the symptoms and complaints noted therein. The examiner should include in the examination report the rationale for any opinion expressed. However, if the examiner cannot respond to the inquiry without resort to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 3. Then schedule the Veteran for a VA neurological examination to determine whether a claimed right arm disability is etiologically related to the Veteran's service. The claims folder must be provided to and reviewed by the examiner in conjunction with the examination. All indicated tests and studies should be performed, and all findings should be set forth in detail. It is requested that the VA examiner determine whether the Veteran currently has a right arm disability, particularly that of median ulnar neuropathy, or residual numbness from treatment for the same condition. The examiner must then opine whether any diagnosed disability is at least as likely as not (50 percent or greater probability) related to the Veteran's military service, based on the symptoms and complaints noted therein. The examiner should include in the examination report the rationale for any opinion expressed. However, if the examiner cannot respond to the inquiry without resort to speculation, he or she should so state, and further explain why it is not feasible to provide a medical opinion. 4. Then return the claims folder to the VA examiner who conducted the VA vision examination of February 2010, and request a supplemental opinion. All indicated tests and studies should be performed, and all findings should be set forth in detail. The VA examiner is requested to again opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed visual disabilities, particularly a cataract of the left eye, are etiologically related to service, taking into account all pertinent documented in-service medical history. The VA examiner is reminded of the need to provide a complete and thorough rationale for all conclusions reached, to include with regard to the significance, if any, of a left eye contusion as the likely cause of current pathology. Provided that the February 2010 examiner is not available, or is no longer employed by VA, schedule the Veteran for an examination by an examiner who has not seen him previously, and that addresses the inquiries set forth above regarding the disability claimed. 5. Then return the claims folder to the VA examiner who conducted the VA gastrointestinal examination of February 2010, and request a supplemental opinion. All indicated tests and studies should be performed, and all findings should be set forth in detail. The VA examiner is requested to again opine as to whether it is at least as likely as not (50 percent or greater probability) that the Veteran's diagnosed gastrointestinal disabilities, particularly recently diagnosed gastritis, are etiologically related to service, taking into account all pertinent documented in-service medical history. The VA examiner is reminded of the need to provide a complete and thorough rationale for all conclusions reached, including taking into account the recent private clinical records received substantiating current diagnoses of duodenal polyp and gastritis. Provided that the February 2010 examiner is not available, or is no longer employed by VA, schedule the Veteran for an examination by an examiner who has not seen him previously, and that addresses the inquiries set forth above regarding the disability claimed. 6. The RO/AMC should then review the claims file. If any of the directives specified in this remand have not been implemented, appropriate corrective action should be undertaken before readjudication. Stegall v. West, 11 Vet. App. 268 (1998). 7. Thereafter, the RO/AMC should readjudicate the claims for service connection for cystitis, bronchitis, a right arm disability, visual disability, and gastrointestinal disability, as well as a certificate of eligibility for SAH/SHA, based upon all additional evidence received. If any benefit sought on appeal is not granted, the Veteran and his representative should be furnished with a Supplemental Statement of the Case (SSOC) and afforded an opportunity to respond before the file is returned to the Board for further appellate consideration. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). No action is required of the Veteran until further notice. However, the Board takes this opportunity to advise the Veteran that the conduct of the efforts as directed in this remand, as well as any other development deemed necessary, is needed for a comprehensive and correct adjudication of his claims. His cooperation in VA's efforts to develop his claim, including reporting for any scheduled VA examination, is both critical and appreciated. The Veteran is also advised that failure to report for any scheduled examination may result in the denial of a claim. 38 C.F.R. § 3.655. These claims must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2010). ____________________________________________ DENNIS F. CHIAPPETTA Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs