Citation Nr: 1318278 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 09-06 918 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in North Little Rock, Arkansas THE ISSUES 1. Entitlement to an increased initial rating for right carpal tunnel syndrome, rated as 10 percent disabling prior to November 28, 2011 and 30 percent thereafter. 2. Entitlement to service connection for a left wrist disorder, claimed as left carpal tunnel syndrome, to include as secondary to service-connected right carpal tunnel syndrome. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and K. H. ATTORNEY FOR THE BOARD Kristy L. Zadora, Counsel INTRODUCTION The Veteran had active duty service from September 1978 to April 1985. These matters come before the Board of Veterans' Appeals (Board) on appeal from an October 2007 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri, which, in pertinent part, granted the Veteran's claim for service connection for right carpal tunnel syndrome and assigned an initial 10 percent rating. In addition, the Veteran's claim for service connection for left carpal tunnel syndrome was denied. Jurisdiction over these matters was transferred to the Little Rock, Arkansas RO in July 2008 at the Veteran's request. A review of the Virtual VA claims processing system reveals VA treatment records dated through December 2011; such were considered in the April 2012 supplemental statement of the case (SSOC). The Veteran testified before the undersigned at the RO in December 2009. A hearing transcript has been associated with the claims file. As a point of clarification, the Board observes that in May 2009, the RO issued a rating decision denying entitlement to a total disability rating based on individual unemployability due to service-connected disabilities (TDIU) and special monthly compensation based on the need for aid and attendance. In June 2009, the Veteran provided a statement titled "Notice of Disagreement" indicating that he wished to "reopen" his case in regard to issues concerning "non-service connected aid and unemployability." A note to the file dated thereafter in June 2009 reflects that the RO followed up with the Veteran and explained the difference between compensation and nonservice connected compensation. The Veteran indicated that he did not want to put a claim in for nonservice-connected compensation. In light of the foregoing, the Board finds no basis for any action on its part in regard to the June 2009 statement. In October 2011, the Board remanded the instant matters as well as a claim for service connection for a skin disorder for additional development and adjudication. As will be discussed herein, the Board finds that the agency of original jurisdiction (AOJ) substantially complied with the remand order with regard to the instant claims and no further action is necessary in this regard. See D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (2002). In an April 2012 rating decision, the Veteran's claim for an increased rating for right carpal tunnel syndrome was partially granted, as a 30 percent rating was assigned, effective November 28, 2011. In addition, the Veteran's claim for service connection for furunculosis (claimed as a skin condition) was granted and an initial rating was assigned. As this award of service connection represented a full grant of the benefits sought on appeal and a notice of disagreement objecting to the assigned rating or effective date has not been received, this issue is no longer before the Board for its consideration. See AB v. Brown, 6 Vet. App. 35, 39 (1993). FINDINGS OF FACT 1. The Veteran is right hand dominant. 2. Prior to November 28, 2011, the Veteran's right carpal tunnel syndrome manifested as episodic swelling with subjective complaints of weakness, numbness, parenthesis, dysesthesias and throbbing pain with no objective evidence of reduced muscle strength, loss of reflexes or reduced muscle tone. 3. Beginning on November 28, 2011, the Veteran's right carpal tunnel syndrome manifested as subjective complaints of severe intermittent weakness, dysethesias and pain with no objective evidence of reduced muscle strength, loss of reflexes or reduced muscle tone. 4. The Veteran is not diagnosed with left carpal tunnel syndrome, and pain associated with the left wrist has been clinically associated to post-service events. CONCLUSIONS OF LAW 1. The criteria for an increased rating for right carpal tunnel syndrome have not been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002); 38 C.F.R. §§ 3.102, 4.1-4.10, 4.20, 4.27, 4.120, 4.123, 4.124a, 8615 (2012). 2. Service connection for left wrist disorder, claimed as left carpal tunnel syndrome, is not established. 38 U.S.C.A. §§ 1112, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. VA's Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Proper VCAA notice must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). In Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held 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. Those five elements include: 1) Veteran status; 2) existence of a disability; 3) a connection between a Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. In Pelegrini v. Principi, 18 Vet. App. 112 (2004), the Court held that a VCAA notice, as required by 38 U.S.C.A. § 5103(a), must be provided to a claimant before the initial unfavorable AOJ decision on the claim for VA benefits. Relevant to the claim for service connection adjudicated herein, the Board finds that VA has satisfied its duty to notify under the VCAA. Specifically, a June 2007 letter, sent prior to the initial October 2007 rating decision, advised the Veteran of the evidence and information necessary to substantiate his claim for service connection on a direct basis, as well as his and VA's respective responsibilities in obtaining such evidence and information. He was also sent a November 2011 letter which advised him of the evidence and information necessary to substantiate his claim for service connection on a secondary basis. Additionally, the June 2007 letter advised him of the information and evidence necessary to establish a disability rating and an effective date in accordance with Dingess/Hartman. Following the issuance of the November 2011 letter, the Veteran's claim for service connection was readjudicated in an April 2012 SSOC. Such development "cures" the timing problem associated with inadequate notice or the lack of notice prior to the initial adjudication. Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006). In addition, the Veteran has neither alleged nor demonstrated any prejudice with regard to the content or timing of the notice provided and the record does not otherwise show such prejudice. Shinseki v. Sanders, 129 S. Ct. 1696 (2009) (reversing prior case law imposing a presumption of prejudice on any notice deficiency, and clarifying that the burden of showing that an error is harmful, or prejudicial, falls upon the party attacking the agency's determination). With regard to the Veteran's claim for an increased rating for right carpal tunnel syndrome, the Veteran is challenging the initial evaluation assigned following the grant of service connection. In Dingess, the Court held that, in cases in which service connection has been granted and an initial disability rating and effective date have been assigned, the typical service connection claim has been more than substantiated, it has been proven, thereby rendering section 5103(a) notice no longer required because the purpose that the notice is intended to serve has been fulfilled. Dingess, 19 Vet. App. at 490-91; see also 38 C.F.R. § 3.159(b)(3)(i). Thus, VA's duty to notify in this case has been satisfied. See generally Turk v. Peake, 21 Vet. App. 565 (2008) (providing that where a party appeals from an original assignment of a disability rating, the claim is classified as an original claim, rather than as one for an increased rating); see also Shipwash v. Brown, 8 Vet. App. 218, 225 (1995); see also Fenderson v. West, 12 Vet. App. 119 (1999) (establishing that initial appeals of a disability rating for a service-connected disability fall under the category of "original claims"). Accordingly, the Board finds that VA's duty to notify has been met with regard to this claim for an increased rating. Relevant to the duty to assist, the Veteran's service treatment records, VA outpatient treatment records and the VA examination reports have been obtained and considered. The Board notes the Veteran's reports during his November 2011 VA examination that he was in receipt of Social Security Supplemental Security Income (SSI) benefits due to a back disorder, which is not service-connected. As there is no evidence that the Veteran receives Social Security benefits due either to his service-connected right carpal tunnel syndrome or his claimed left wrist disorder, these records are not relevant to the instant claims. Golz v. Shinseki, 590 F.3d 1317, 1321 (Fed. Cir. 2010) (there is no duty to obtain SSA records when there is no evidence that they are relevant). The Veteran also has not identified any additional, outstanding records that have not been requested or obtained. The Veteran was afforded a VA examination in order to adjudicate his claim for service connection. In this regard, the Board notes that the November 2011 VA examiner offered an etiological opinion as to the claimed disorder and based his conclusions on interviews with the Veteran, a review of the record, and a full examination. The Board finds that the opinion is adequate. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Stefl v. Nicholson, 21 Vet. App. 120, 124-25 (2007); Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). With regard to his claim for an increased rating for right carpal tunnel syndrome, the Veteran has been provided with VA examinations in September 2007 and November 2011 in order to adjudicate his claim. Neither the Veteran nor his representative has argued that the examinations are inadequate for rating purposes. Moreover, the Board finds these examinations to be adequate in order to evaluate the Veteran's right carpal tunnel syndrome as they include an interview with the Veteran, a review of the record, and a full examination, addressing the relevant rating criteria. Therefore, the Board finds that the examinations of record are adequate to adjudicate the Veteran's initial rating claim and no further examination is necessary. Moreover, based on the foregoing, the Board determines that the AOJ has substantially complied with the November 2011 remand directives in affording the Veteran proper notice with regards to his claim for service connection on a secondary basis, securing all identified records, and affording the Veteran a VA examination, as applicable to the instant claims, and as such that no further action is necessary in this regard. See D'Aries, supra. Lastly, in Bryant v. Shinseki, the Court held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or Veterans Law Judge who chairs a hearing fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). The Board notes that the issues were addressed at the 2009 hearing and the development (medical examination and nexus opinion) necessary to substantiate the claims was ordered by the Board. Thus, if error found, the Veteran was not prejudiced. See Bryant, 23 Vet. App. at 498-99 ( "[A]lthough the Board hearing officer did not explicitly lay out the material issues of medical nexus and current disability, the record reflects that they were developed by the Secretary-to include medical examination reports on each of these disabilities and any nexus to service-and there was no indication that the represented appellant had any additional information to submit. Accordingly, the 'clarity and completeness of the hearing record' was intact with respect to these disabilities and the purpose of § 3.103(c)(2) was fulfilled."). Thus, the Board finds that VA has fully satisfied the duty to assist. In the circumstances of this case, additional efforts to assist or notify the Veteran in accordance with the VCAA would serve no useful purpose. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements of the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the Veteran are to be avoided). VA has satisfied its duty to inform and assist the Veteran at every stage in this case, at least insofar as any errors committed were not harmful to the essential fairness of the proceeding. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of his claims. II. Increased Rating A. Pertinent Statutes and Regulations Disability evaluations are determined by the application of the VA's Schedule for Rating Disabilities (Rating Schedule), 38 C.F.R. Part 4. The percentage ratings in the Rating Schedule represent, as far as can be practicably determined, the average impairment in earning capacity resulting from diseases and injuries incurred or aggravated during military service and their residual conditions in civil occupations. 38 U.S.C.A. § 1155; 38 C.F.R. § 4.1. When a question arises as to which of two ratings applies under a particular code, the higher rating is assigned if the disability more closely approximates the criteria for the higher rating. 38 C.F.R. § 4.7. At the time of an initial rating, separate ratings can be assigned for separate periods of time based on the facts found-a practice known as "staged" ratings. Fenderson v. West, 12 Vet. App. 119 (1999). Mild incomplete paralysis of the median nerve warrants a 10 percent for either extremity. Moderate incomplete paralysis warrants a 30 percent rating in the major extremity while severe incomplete paralysis warrants a 50 percent rating in the major extremity. 38 C.F.R. § 4.124a, 8515. Complete paralysis of the medial nerve warrants a 70 percent rating for the major extremity. Complete paralysis occurs where the hand was inclined to the ulnar side, the index and the middle fingers were more extended than normally, there was considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand), pronation was incomplete and defective, there was the absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, the index and middle fingers remained extended, cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb, at right angles to palm and flexion of wrist was weakened and there was pain with trophic disturbances. Id. In rating peripheral nerve injuries and their residuals, attention should be given to the site and character of the injury, the relative impairment and motor function, trophic changes, or sensory disturbances. 38 C.F.R. § 4.120. Under 38 C.F.R. § 4.124a, disability from neurological disorders is rated from 10 to 100 percent in proportion to the impairment of motor, sensory, or mental function. With partial loss of use of one or more extremities from neurological lesions, rating is to be by comparison with mild, moderate, severe, or complete paralysis of the peripheral nerves. The term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type of picture for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is only sensory, the rating should be for the mild, or at most, the moderate degree. In rating peripheral nerve disability, neuritis, characterized by loss of reflexes, muscle atrophy, sensory disturbances, and constant pain, at times excruciating, is to be rated on the scale provided for injury of the nerve involved, with a maximum equal to severe, incomplete paralysis. The maximum rating to be assigned for neuritis not characterized by organic changes referred to in this section will be that for moderate incomplete paralysis, or with sciatic nerve involvement, for moderately severe incomplete paralysis. 38 C.F.R. § 4.123. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, the Secretary shall give the benefit of the doubt to the claimant. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). B. Right Carpal Tunnel Syndrome The Veteran's right carpal tunnel syndrome is currently rated by analogy under the diagnostic codes for an unlisted peripheral nerve disability and impairment to the median nerve. 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; the additional code is shown after the hyphen. 38 C.F.R. § 4.27. When an unlisted disease, injury, or residual condition is encountered, requiring rating by analogy, the diagnostic code number will be "built-up" as follows: the first two digits will be selected from that part of the schedule most closely identifying the part, or system of the body involved, in this case, the neurological system, and the last two digits will be "99" for all unlisted conditions. Then, the disability is rated by analogy under a diagnostic code for a closely related disability that affects the same anatomical functions and has closely analogous symptomatology. 38 C.F.R. §§ 4.20, 4.27. A September 2007 VA nerves examination report reflects the Veteran's complaints of right wrist weakness, stiffness, numbness, paresthesias, dysesthesias, and throbbing pain. Physical examination found the Veteran's right wrist muscle strength to be "4" and noted that there was weakness with dorsiflexion only. Neurological examination found vibration, pain and light touch to be decreased while position sense was normal. Deep tendon reflexes were found to be 2+ in the biceps, triceps and brachioradialis with no muscle atrophy, abnormal muscle tone or abnormal muscle bulk. The examiner indicated that paralysis and neuritis were not present; rather, neuralgia was present. In regard to the effects of the problem on the Veteran's usual daily activities, the examiner entered "prevents" in all categories; however, this is clearly in error as it is inconsistent with the examination findings and the examiner concluded by noting the following: "[Veteran] able to dress and undress and get to [his] office-[the examiner] can't see how this prevents all care." The examiner also noted that electromyography (EMG) studies were attempted but not completed as the Veteran could not tolerate such testing. In a February 2009 substantive appeal, the Veteran wrote that his carpal tunnel prevented him from doing much with his hands. During a December 2009 hearing, the Veteran testified that he wore a brace to support his left wrist and that this brace had been issued by VA. The Veteran's girlfriend testified that the Veteran's grip strength had decreased and that he had recently dropped objects as a result. A November 2010 VA treatment note indicated that the Veteran's right wrist was swollen on examination. A November 28, 2011 VA nerves examination report reflects the Veteran's complaints of severe intermittent pain, paresthesias, dysesthesias and numbness on all surfaces of the hands, and that its onset occurred with course and fine motor activities. He also reported being right hand dominant. Physical examination was negative for muscle atrophy. Deep tendon reflexes were noted to be 2+ in the biceps, triceps, brachioradialis and finger jerk. Detailed motor examination was "5/5" in shoulder abduction, elbow flexion, elbow extension, wrist flexion, wrist extension, finger flexors, finger abduction and thumb opposition. Sensory examination found light touch and pinprick to be normal, vibration sense to be present and position sense to be intact. The radial nerve, median nerve, ulnar nerve, musculocutaneous nerve and circumflex nerve were found to be normal. After reviewing the evidence of record, the Board finds that the criteria for an initial rating in excess of 10 percent for right carpal tunnel syndrome for the period prior to November 28, 2011 are not met. There is no medical evidence to support that the Veteran's neurological symptoms are more than mild in nature. The objective findings of record indicate that the Veteran's impairment was wholly sensory in nature and only mild (4) weakness was demonstrated. Although his wrist was found to be swollen, there were no objective findings of motor impairment, muscle tone and bulk were found to be normal, and there were no findings of muscle atrophy. Moreover, the level of sensory disturbance has not been objectively shown to be more than mild in degree. The Veteran is competent to report on symptoms and credible in his belief that his symptoms are more severe than currently rated. The nature and degree of severity of his carpal tunnel syndrome, however, involves a medically complex matter so the medical evidence is more probative in assessing whether the Veteran's overall disability more closely approximates a higher rating. Absent probative evidence of more than mild impairment, an initial rating in excess of 10 percent for carpal tunnel syndrome for the period prior to November 28, 2011 is not warranted. For the period beginning on November 28, 2011, the Board finds that the criteria for an initial rating in excess of 30 percent for right carpal tunnel syndrome are not met. There is no medical evidence to support that the Veteran's neurological impairment is more than moderate in nature. The objective findings indicate that the nerves in the Veteran's upper extremity were normal and there were no objective findings of motor impairment or muscle atrophy and muscle strength was found to be normal. Deep tendon reflexes were also found to be normal on objective examination. Moreover, the Veteran subjectively reported that his pain was not constant but rather intermittent in nature. The Veteran does not have incomplete or complete paralysis of the nerve; rather, the September 2007 examiner described the Veteran as having neuralgia. Under 38 C.F.R. § 4.124, neuralgia is to be rated on the same scale, with a maximum equal to moderate incomplete paralysis, and under 38 C.F.R. § 4.123, the maximum rating that may be assigned for neuritis, not characterized by organic changes, will be that for moderate incomplete paralysis. Thus, while the Veteran experiences intermittent episodes of severe symptoms, the overall functional impairment is considered moderate. Indeed, it would be disproportionate to find that the physical findings were comparable to an individual with actual incomplete severe paralysis of the nerve. As previously discussed, while the Veteran is competent to report on symptoms and credible in his belief that his symptoms are more severe than currently rated, the nature and degree of severity of his disorder involves a medically complex matter. The medical evidence is more probative in assessing whether the Veteran's overall disability more closely approximates a higher rating. Absent probative evidence of more than moderate impairment, an initial rating in excess of 30 percent for carpal tunnel syndrome for the period beginning on November 28, 2011 is not warranted. C. Other Considerations In addition, the Board notes that there is no evidence of an exceptional or unusual disability picture with related factors, such as marked interference with employment or frequent periods of hospitalization, so as to warrant referral of the case to appropriate VA officials for consideration of an extra-schedular rating under 38 C.F.R. § 3.321(b)(1); see Shipwash v. Brown, 8 Vet. App. 218 (1995). In this case, the rating criteria reasonably describe the Veteran's disability level and symptomatology and provides for additional or more severe symptoms than currently shown by the evidence. The Board has considered the totality of the symptoms that form the Veteran's disability picture. The Veteran's symptoms (pain, tingling and numbness in the wrist, problems with detexerity, etc.) are not exceptional or unusual features of his disabilities. Thus, his disability picture for his right carpal tunnel syndrome is contemplated by the rating schedule, and the assigned schedular evaluation is, therefore, adequate and referral for extra-schedular consideration is not warranted. See Thun v. Peake, 22 Vet. App. 111 (2008) (the threshold factor for extra-schedular consideration is a finding that the evidence before VA presents such an exceptional disability picture that the schedular evaluation is inadequate). Finally, the Board is aware that a request for a total disability rating due to individual employability resulting from service-connected disability (TDIU), whether expressly raised by a veteran or reasonably raised by the record, is not a separate claim for benefits, but is rather part of the adjudication of a claim for increased compensation. Rice v. Shinseki, 22 Vet. App. 447 (2009). Thus, when entitlement to TDIU is raised during the appeal of a rating for a disability, it is part of the claim for benefits for the underlying disability. Id. at 454. In the present case, however, the Board finds that neither the Veteran's contentions nor the medical findings of record raise a TDIU claim. The Veteran has not specifically contended and the record does not otherwise suggest that he is unemployable solely due to his right carpal tunnel syndrome disability. As discussed above, the record establishes that the Veteran receives SSA benefits due to his nonservice-connected back disability. In addition, the Veteran reported during his November 2011 examination that it was his back disability that had rendered him completely disabled. In VA Form 21-8940 dated in March 2009, the Veteran indicated that he was unemployable due to service connected carpal tunnel syndrome and nonservice connected vascular disease and osteoporosis. As noted in the introduction, the Veteran later clarified that he meant he was seeking nonservice connected benefits but had since changed his mind and no longer desired such benefits. For these reasons, the Board finds that a claim for TDIU has neither been raised by the Veteran nor by the record in regard to the rating issue before the Board. In summary, the Board must conclude that the criteria for an initial rating in excess of 10 percent for carpal tunnel syndrome prior to November 28, 2011 and 30 percent thereafter have not been met at any point since the effective date of the grant of service connection for this disability. As such, there is no basis for further staged rating, pursuant to Fenderson, and each of the claims for a higher initial rating must be denied. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against assignment of any higher rating for the Veteran's right carpal tunnel syndrome, that doctrine is not applicable. See 38 U.S.C.A § 5107(b); 38 C.F.R. § 3.102; Gilbert, supra. II. Service Connection A. Pertinent Statutes and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303(a). Service connection may also be granted for any disease diagnosed after discharge, 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). Direct service connection may not be granted without evidence of a current disability; in-service incurrence or aggravation of a disease or injury; and a nexus between the claimed in-service disease or injury and the present disease or injury. 38 U.S.C.A. § 1112; 38 C.F.R. § 3.304. See also Caluza v. Brown, 7 Vet. App. 498, 506 (1995) aff'd, 78 F.3d 604 (Fed. Cir. 1996) [(table)]. A disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310. Secondary service connection is permitted based on aggravation. Compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between the disability and an injury or disease incurred in service. Establishing service connection on a secondary basis essentially requires evidence sufficient to show that a current disability exists, and that the current disability was either caused or aggravated by a service-connected disability. 38 C.F.R. §§ 3.303, 3.310. Alternatively, service connection may be established under 38 C.F.R. § 3.303(b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. Where a Veteran served for at least 90 days during a period of war or after December 31, 1946, and manifests certain chronic diseases, including arthritis, to a degree of 10 percent within one year and three years, respectively, from the date of termination of such service, such disease shall be presumed to have been incurred or aggravated in service, even though there is no evidence of such disease during the period of service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Lay testimony is competent to establish the presence of observable symptomatology and "may provide sufficient support for a claim of service connection." Layno v. Brown, 6 Vet. App. 465, 469 (1994). When a condition may be diagnosed by its unique and readily identifiable features, the presence of the disorder is not a determination "medical in nature" and is capable of lay observation. In such cases, the Board is within its province to weigh that testimony and to make a credibility determination as to whether that evidence supports a finding of service incurrence and continuity of symptomatology sufficient to establish service connection. See Barr v. Nicholson, 21 Vet. App. 303 (2007). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). B. Left Wrist Disorder The Veteran contends that his left wrist disorder was caused by his service-connected right carpal tunnel syndrome or his service. Service treatment records were negative for complaints, treatment or diagnoses related to any left wrist disorder. A May 1985 service discharge examination found the Veteran's upper extremities to be normal. In a July 2007 VA treatment note, the Veteran complained of left wrist and thumb pain that was not helped with naproxen. An assessment of left wrist pain, likely tenosynovitis, was made. A November 2011 VA nerves Disability Benefits Questionnaire (DBQ) noted the Veteran's complaints of the new onset left wrist symptoms in 2007. Following a physical examination and a review of the Veteran's claims file, a diagnosis of carpal tunnel syndrome, right side only, was made. The examiner opined that the Veteran's left wrist films were suggestive of residuals of a scaphoid fracture but his EMG showed no acute or chronic left chronic carpal tunnel syndrome. In addition, the examiner attributed the Veteran's complaints of left wrist pain to multiple non-service connected sources, including cervical radiculopathy and his history of methamphetamine use, and also cited to the results of a computed tomography (CT) scan which were suggestive of an old stroke or head trauma. Post-service treatment records document the Veteran's continued complaints of left wrist pain. Statements from the Veterans' friends submitted in April 2009 noted his hand and wrist pain. The Board finds that service connection for a left wrist disorder is not warranted. While the Veteran has subjectively complained of left wrist pain and numbness, the Veteran is not currently diagnosed with carpal tunnel syndrome and his symptoms have been attributed to post-service events. The Veteran has never contended and the evidence of record does not otherwise suggest that the Veteran sustained a scaphoid fracture of the left wrist, stroke, or head trauma during service. As the etiology of the Veteran's symptoms have been clinically attributed to post-service events other than right carpal tunnel syndrome, there can be no finding that the Veteran's left wrist disorder was incurred in service or caused by right carpal tunnel syndrome much less aggravated by right carpal tunnel syndrome. Right carpal tunnel syndrome is not responsible for any portion of the Veteran's left wrist symptoms. To the extent the Veteran's symptoms may be considered associated with a chronic disease under 38 C.F.R. § 3.309, a credible continuity of symptomatology is not established. At the 2011 examination, the Veteran reported the onset of symptoms in 2007 which is inconsistent with an assertion that the symptoms have been present continuously since service. Moreover, although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet.App. 428, 435 (2011), as to the specific issue in this case, whether the Veteran's symptoms are etiologically attributable to a service related event or secondary to service connected right carpal tunnel syndrome, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (providing that lay persons not competent to diagnose cancer). Indeed, the Veteran's contentions are not correct as the medical professional found that the Veteran's symptoms are likely attributable to other causes. For these reasons, the Board finds that service connection is not warranted. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for a left wrist disorder. As such, that doctrine is not applicable in the instant appeal, and his claim must be denied. 38 U.S.C.A. § 5107; 38 C.F.R. § 3.102; Gilbert, supra. ORDER An increased initial rating for right carpal tunnel syndrome, rated as 10 percent disabling prior to November 28, 2011 and 30 percent thereafter, is denied. Service connection for a left wrist disorder, claimed as left carpal tunnel syndrome, to include as secondary to service-connected right carpal tunnel syndrome, is denied. ____________________________________________ TANYA A. SMITH Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs