Citation Nr: 1320664 Decision Date: 06/26/13 Archive Date: 07/05/13 DOCKET NO. 05-32 411A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Seattle, Washington THE ISSUES 1. Entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to service-connected chronic lumbar strain and associated bilateral peripheral neuropathy of the lower extremities. 2. Entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to service-connected chronic lumbar strain and associated bilateral peripheral neuropathy of the lower extremities. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD Michael Wilson, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1973 to July 1975. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2004 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Seattle, Washington, which, in relevant part, denied entitlement to service connection for peripheral neuropathy of the Veteran's bilateral upper extremities. In his October 2005 VA Form 9, the Veteran indicated that he would like to be scheduled for a Board hearing before a Veteran's Law Judge at his local VA office. In October 2008, he withdrew his request for a Board hearing. See 38 C.F.R. § 20.704(e) (2012). These claims were previously remanded by the Board for additional evidentiary development in March 2009, January 2011, and June 2012. The issue of entitlement to service connection for a cervical spine disability was previously referred to the Agency of Original Jurisdiction (AOJ) in the Board's prior June 2012 remand. It appears, however, that this claim still had not been adjudicated. Therefore, the Board does not have jurisdiction over it, and it is again referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Service connection is in effect for a chronic lumbosacral strain and for associated peripheral neuropathy of the bilateral lower extremities. 2. The Veteran's current bilateral peripheral neuropathy of the upper extremities, identified as carpal tunnel syndrome, is not the result of a disease or injury during active service. 3. Bilateral peripheral neuropathy of the upper extremities is not proximately due to, or aggravated by, the service-connected lumbosacral strain or associated peripheral neuropathy of the bilateral lower extremities. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for peripheral neuropathy of the right upper extremity, to include as secondary to service-connected chronic lumbar strain and associated bilateral peripheral neuropathy of the lower extremities, have not been met. 38 U.S.C.A. § 1110, 1131, 5107(b) (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310 (2012). 2. The criteria for entitlement to service connection for peripheral neuropathy of the left upper extremity, to include as secondary to service-connected chronic lumbar strain and associated bilateral peripheral neuropathy of the lower extremities, have not been met. 38 U.S.C.A. § 1110, 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. 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, 5126 (West 2002 & Supp. 2013); 38 C.F.R §§ 3.102, 3.156(a), 3.159, 3.326(a) (2012). Upon receipt of a complete or substantially complete application for benefits, VA is required to notify the claimant and his representative, if any, of any information, and any medical or lay evidence, that is necessary to substantiate the claim. See 38 U.S.C.A. § 5103(a) (West 2002 & Supp. 2012); 38 C.F.R. § 3.159(b) (2012); Quartuccio v. Principi, 16 Vet. App. 183 (2002). Proper notice from VA 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. See 38 C.F.R. § 3.159(b) (2012). This notice must be provided prior to an initial unfavorable decision on the claim by the Agency of Original Jurisdiction. See Mayfield v. Nicholson, 444 F.3d 1328 (Fed. Cir. 2006); see also Pelegrini v. Principi, 18 Vet. App. 112 (2004). In Dingess v. Nicholson, 19 Vet. App. 473 (2006), the United States Court of Appeals for Veterans Claims (Court) held that the VCAA requires notice of what information and evidence not previously provided, if any, that is necessary to substantiate, each of the five elements of the claim, including notice of what is required to establish service connection and that a disability rating and an effective date for the award of benefits will be assigned if service connection is awarded. An August 2004 VCAA letter from the RO informed the Veteran of all elements required to substantiate his claims for peripheral neuropathy of the bilateral upper extremities in accordance with 38 C.F.R. § 3.159(b). A second, Dingess compliant notice was provided to the Veteran in September 2007, after which, his claims were readjudicated in a May 2010 supplemental statement of the case. See Mayfield v. Nicholson, 499 F.3d 1317, 1323 (Fed. Cir. 2007) (Mayfield IV); Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). Nonetheless, in light of the denial of his claims for service connection, no disability rating or effective date can be assigned, so there can be no possibility of prejudice to him under the holding in Dingess. Although the Veteran was not specifically advised of all the necessary elements to establish a claim of secondary service connection, he was not prejudiced by a lack of such notice, as the August 2004 and September 2007 VCAA letters did advise him that evidence of a nexus between a current disability and the claimed cause of such disability must be shown. This should have served to put him on notice that if he was claiming that a service connected disability had caused or aggravated a claimed disability, he would need evidence that the service connected disability had caused or aggravated the claimed disability. Regarding the duty to assist, treatment records, including pertinent VA and private medical records have been obtained to the extent possible. The Board notes that the record contains an October 2012 letter from the United States Office of Personnel Management (OPM), indicating that his application for disability retirement under the Federal Employees Retirement System had been approved. The letter further indicated, however, that before his annuity payments could be started, he was required to show that he had applied for disability benefits administered by the Social Security Administration (SSA). An additional October 2012 OPM letter noted that he claimed disability due to posttraumatic stress disorder (PTSD). A copy of the Veteran's SSA records has not been obtained. Additionally, review of the record reveals that records associated with an application for disability benefits administered through the Washington Department of Labor and Industries (DOLI) were requested in February 2008. It appears, however, that no response was received with respect to that request. There is no evidence to suggest that the Veteran sought disability benefits through the SSA or DOLI based on his claimed bilateral upper extremity peripheral neuropathy. Rather, his non-VA disability claims have been shown to be based only on his diagnosed PTSD. A February 2008 letter to his congresswoman specifically noted the effects of his PTSD on his employment and his request for a PTSD evaluation in association with his employment. Moreover, the October 2012 OPM letter specifically indicated that the Veteran claimed employment disability due to PTSD. Incidentally, service connection for PTSD was awarded in the January 2011 Board decision. Accordingly, there is no basis for finding that the Veteran's SSA or DOLI records would be relevant to the issues on appeal as there is no reason to believe that these records may give rise to pertinent information with respect to his service connection claims for peripheral neuropathy of the bilateral upper extremities; neither has the Veteran contended as much. See Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2009). Therefore, there is no duty for VA to obtain such SSA or DOLI records with respect to this appeal as they are irrelevant to the claims on appeal. In addition to obtaining relevant private and VA treatment records, the Veteran was afforded relevant VA examinations in March 2008, December 2009, July 2012, and addenda to those VA examination reports were obtained in March 2011 and March 2013. Collectively, these examination reports are responsive to the determinative questions regarding the etiology of the Veteran's claimed disabilities. Accordingly, VA's duty to provide an adequate VA examination has been met. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (rev'd on other grounds by Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013)). The RO/AMC substantially complied with the Board's June 2012 remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999); Stegall v. West, 11 Vet. App. 268 (1998). The Board remanded the Veteran's claims in an effort to obtain an adequate medical opinion regarding the etiology of his claimed upper extremity peripheral neuropathy, specifically with respect to the claimed secondary relationship with his service-connected lumbosacral sprain and associated peripheral neuropathy of the lower extremities. He was afforded a requested VA examination in July 2012, and an additional independent medical opinion was obtained in March 2013. Collectively, the VA examination report and independent medical report adequately addressed the queries put forth in the Board's remand directives. The duty to assist has, therefore, been satisfied and there is no reasonable possibility that any further notice or assistance would be reasonably likely to assist the Veteran in substantiating these claims. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); see also Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). Further notice or assistance is; therefore not required. II. Service Connection A. Governing Law and Regulations Service connection will be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303 (2012). Establishing service connection requires evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Walker, 701 F.3d 133; Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F. 3d 604 (Fed. Cir. 1996) (table). Service connection may be granted for a disease first diagnosed after discharge when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. See 38 C.F.R. § 3.303(d) (2012). Additionally, service connection may be granted on a secondary basis for a disability that is proximately due to or the result of an established service-connected disorder. See 38 C.F.R. § 3.310(a) (2012). Similarly, any increase in severity of a non-service-connected disease or injury that is proximately due to or the result of a service-connected disease or injury, and not due to the natural progress of the non-service-connected disease, will be service connected. 38 C.F.R. § 3.310(b) (2012); see Allen v. Brown, 7 Vet. App. 439 (1995). In the latter instance, the non-service-connected disease or injury is said to have been aggravated by the service-connected disease or injury. See 38 C.F.R. § 3.310(b) (2012). In cases of aggravation of a non-service-connected disability by a service-connected disability, a claimant shall be compensated for the degree of disability over and above the degree of disability existing prior to the aggravation. See 38 C.F.R. § 3.322 (2012). VA will not concede aggravation unless there is medical evidence created prior to the aggravation or current level of disability that show a baseline of the disease prior to the aggravation. 38 C.F.R. § 3.310(b). In making all determinations, the Board must fully consider the lay evidence of record. Davidson v. Shinseki, 581 F.3d 1313 (Fed.Cir.2009). A layperson is competent to report on the onset and continuity of current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the 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. Davidson, 581 F.3d at 1316; Jandreau v. Nicholson, 492 F.3d 1372, 1376-1377 (Fed. Cir. 2007). When considering whether lay evidence is competent the Board must determine, on a case by case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v, 492 F.3d at 1376-77. The Board is charged with the duty to assess the credibility and weight given to evidence. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997), cert. denied, 523 U.S. 1046 (1998); Wensch v. Principi, 15 Vet. App. 362, 367 (2001). Indeed, in Jefferson v. Principi, 271 F.3d 1072 (Fed. Cir. 2001), the United States Court of Appeals for the Federal Circuit, citing its decision in Madden, recognized that the Board had inherent fact-finding ability. Id. at 1076; see also 38 U.S.C.A. § 7104(a) (West 2002). The Court has declared that in adjudicating a claim, the Board has the responsibility to weigh and assess the evidence. Bryan v. West, 13 Vet. App. 482, 488-89 (2000); Wilson, 2 Vet. App. at 618. As a finder of fact, when considering whether lay evidence is satisfactory, the Board may also properly consider internal inconsistency of the statements, facial plausibility, consistency with other evidence submitted on behalf of the Veteran, and the Veteran's demeanor when testifying at a hearing. See Dalton v. Nicholson, 21 Vet. App. 23, 38 (2007); Caluza, 7 Vet. App. at 511. In determining the probative value to be assigned to a medical opinion, the Board must consider three factors. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). The initial inquiry in determining probative value is to assess whether a medical expert was fully informed of the pertinent factual premises (i.e., medical history) of the case. A review of the claims file is not required, since a medical professional can also become aware of the relevant medical history by having treated a Veteran for a long period of time or through a factually accurate medical history reported by a Veteran. See id. at 303-04. The second inquiry involves consideration of whether the medical expert provided a fully articulated opinion. See Id. A medical opinion that is equivocal in nature or expressed in speculative language does not provide the degree of certainty required for medical nexus evidence. See McLendon v. Nicholson, 20 Vet. App. 79 (2006). The third and final factor in determining the probative value of an opinion involves consideration of whether the opinion is supported by a reasoned analysis. The most probative value of a medical opinion comes from its reasoning. Therefore, a medical opinion containing only data and conclusions is not entitled to any weight. In fact, a review of the claims file does not substitute for a lack of a reasoned analysis. See Nieves-Rodriguez, 22 Vet. App. at 304; see also Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) ("[A] medical opinion ... must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions."). 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. See 38 U.S.C.A. § 5107 (West 2002); see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). B. Analysis The Veteran has advanced two theories for service connection for his claimed peripheral neuropathy of the bilateral upper extremities. He initially raised the contention that the upper extremity neuropathy was incurred directly as a result of an in-service motor vehicle accident. In the alternative, he has contended that the upper extremity neuropathy developed as secondary to his service-connected lumbosacral spine strain with associated peripheral neuropathy of the lower extremities, due to overuse of his upper extremities to compensate for disability in his spine and lower extremities. Service connection has been in effect for a chronic lumbosacral strain since October 1975. Additionally, the November 2004 rating decision granted service connection for associated peripheral neuropathy of the lower extremities, and assigned an effective date of August 6, 2004. Considering first the current disability requirement for service connection for his claimed upper extremity neuropathy, the Veteran's recent July 2012 VA examination diagnosed mild bilateral carpal tunnel syndrome. Accordingly, based on this diagnosis, the current disability requirement has clearly been met. See Walker, supra. With respect to the second required element for service connection on a direct basis, an in-service incurrence of a disease or injury, a review of the Veteran's service treatment records (STRs) reveals that he was involved in a motor vehicle accident in June 1974, during service. A June 1974 clinical report noted that he complained of pain in his neck, though he denied trauma to his head or experiencing a loss of consciousness. He was noted to have a slight decreased in range of motion of the upper limbs in all senses. A cervical spine X-ray showed results within normal limits. The impression was whiplash. A July 1974 clinical report noted the Veteran's history of a whiplash injury, and restricted range of motion of the neck. A January 1975, clinical record noted that the Veteran complained of back pain since the time of his in-service accident. He reported that the pain did not radiate into his legs. On examination, no atrophy was noted in the upper extremities, and strength was good in the upper extremities. Pulses were noted to be one to two plus in the upper and lower extremities. A May 1975 health record noted that the Veteran had low back syndrome with a secondary diagnosis of spina bifida occulta S-1 vertebra. A July 1975 clinical report also noted that the Veteran had a history of spina bifida. Based on the evidence showing that the Veteran suffered an in-service motor vehicle accident, the Board finds that the second required element for service connection on a direct basis has been met. See Walker, supra. Accordingly, the Board is left to consider whether there is a nexus between the Veteran's current bilateral carpal tunnel syndrome and his active service; or in the alternative, whether there is a nexus between his current disability and his service-connected lumbosacral strain and associated peripheral neuropathy of the bilateral lower extremities. Post-service VA treatment records reveal that during an April 1991 VA clinical consultation, the Veteran complained of having neck stiffness and headaches brought on by work. The report noted a low back injury during the motor vehicle accident in 1974. He additionally reported having a resulting numbness in his right leg that had recurred. The assessment was a chronic and recurrent lumbar back strain. The report did not specifically note complaints of peripheral neuropathy of the upper extremities at that time. In an October 1991 VA clinical report, the Veteran was assessed with chronic low back pain with intermittent flare-ups since 1974. He was additionally assessed as having a weak left hand, noted to be secondary to a work injury, since July 1991. The Veteran was afforded a VA spine examination in September 1998. The tentative diagnosis was low back pain. The examination report did not, however, mention peripheral neuropathy of the upper extremities. The Veteran was afforded a VA general medical examination in July 2004. At that time, he was noted to have been suffering with low back pain for 30 years. The pain reportedly traveled to his legs, arms, and neck. He was noted to have most likely suffered a sprain/strain injury to his back and neck as a result of his 1974 motor vehicle accident. He reported waking up two to three times per week during the nights and feeling numbness in the arms, especially if he had fallen asleep compressing his arms. On examination, muscle spasms were present in both arms. While the VA examiner noted that the Veteran most likely suffered a sprain/strain to his back and neck during his in-service motor vehicle accident, and noted that his symptoms, including especially peripheral neuropathy symptoms of the lower extremities, were more likely than not due to his in-service injury, the examiner unfortunately did not diagnose or clearly describe the Veteran's complaints pertaining to peripheral neuropathy of the upper extremities. Similarly, the examiner did not provide reasons for his opinion that the Veteran's current symptoms were related to his in-service accident. During the Veteran's later March 2008 VA examination, he was found to have neuralgia of the ulnar nerve. Sensory dysfunction was demonstrated by decreased sensation to the hands and fingers of both upper extremities. No motor dysfunction was noted. Unfortunately, the examiner did not provide an opinion regarding the etiology of the Veteran's neuralgia. The Veteran was afforded a VA peripheral neuropathy examination in December 2009. He reported symptoms of weakness and numbness below the elbow, affecting the fingers of both hands, with the thumb less affected. After examining the Veteran, the examiner diagnosed bilateral mild carpal tunnel syndrome. The examiner then opined that the Veteran's carpal tunnel syndrome was not caused by or a result of his in-service motor vehicle accident. The examiner explained that the Veteran's in-service accident involved a whiplash injury to the neck, and that the little neuropathy found on his current examination was related to very mild carpal tunnel syndrome and not his neck or back. The examiner additionally opined that the Veteran's upper extremity peripheral neuropathy was not caused by his lower back disability. The examiner explained that neurologically speaking, the upper extremities were above and hence not affected by problems arising in the lower back. Additionally, the examiner noted that while conditions of the cervical spine could affect the upper extremities, this was not the case for the Veteran, per his testing results. The examiner additionally noted that the low back disability would not be expected to aggravate the upper extremity peripheral neuropathy. Thus, the examiner concluded that upon review of his records, there was nothing that would support any relationship between the Veteran's carpal tunnel syndrome and his active service. In a June 2010 statement, the Veteran specifically noted his belief that his peripheral neuropathy of the upper extremities may have been aggravated by chronic lumbosacral strain and associated peripheral neuropathy of the lower extremities. He wrote that the aggravation was due to over using his upper extremities as a result of a weakened lumbar spine and legs. He specifically reported using his arms more to get out of chairs, and to achieve other positions where his legs and back prevented him from proper body stabilization. In a March 2011 addendum to the December 2009 VA examination report, another VA examiner reviewed the record and noted that there was no indication that the Veteran had any disease of the bilateral upper extremities other than a normal progression of use caused by mild bilateral carpal tunnel syndrome. The examiner noted that his electromyography (EMG) report revealed essentially normal results. Following the Board's June 2012 remand, the Veteran was afforded a new VA peripheral nerves examination in July 2012. The Veteran reported that since the time of his motor vehicle accident in 1974, he had experienced intermittent numbness in his upper extremities, and that the numbness had become increasingly more severe over the last ten years. He complained of decreased sensitivity in the upper arms, and an occasional warm feeling in his upper arms. After conducting testing, the VA examiner diagnosed bilateral, mild, incomplete paralysis of the upper extremities. The examiner provided the opinion that the Veteran's bilateral carpal tunnel syndrome was less likely than not incurred in or caused by any claimed in-service injury, event, or illness. The examiner noted that the evidence in the Veteran's STRs showed resolution of his neck pain and no evidence of a chronic neck condition or decreased sensation/neuropathy. The examiner additionally noted that there was no evidence of any correlation between the Veteran's current arm numbness and his military service. The examiner further commented that he did not feel in any way that the Veteran's upper extremity numbness was caused by overuse due to his other service-connected disabilities. Where the July 2012 VA examiner did not comment on the possibility that the Veteran's upper extremity peripheral neuropathy was aggravated by his service-connected disabilities, an additional independent medical opinion was obtained in March 2013. In that opinion, the reviewing physician thoroughly reviewed the Veteran's claims file and prior medical examinations of record and also provided the opinion that the Veteran's diagnosed bilateral carpal tunnel syndrome was less likely than not incurred in or caused by any claimed in-service injury, event, or illness, to include his in-service motor vehicle accident. The physician additionally opined that the Veteran's diagnosed bilateral carpal tunnel syndrome was not aggravated, that is permanently worsened beyond the normal progression of the disease, by his service-connected lumbar disability or his bilateral peripheral neuropathy of the lower extremities. In rationalizing the opinion, the physician cited the December 2009 examination report wherein the prior VA examiner noted that neurologically speaking, the upper extremities are above and hence not affected by problems arising in the lower back. The physician further explained that an injury to the spine leading to degenerative disc disease or degenerative joint disease would result in nerve impingement in proximity to the spine, in other words, a radiculopathy. Peripheral impingement of nerves, as occurred with median nerve entrapment, as in carpal tunnel syndrome, occurred in the periphery, in this case, at the wrist. Thus, the physician concluded that the Veteran's in-service motor vehicle accident had no relationship to his diagnosed bilateral mild carpal tunnel syndrome. Moreover, the physician noted that the Veteran's medial nerve neuropathy was only mild, as evinced by the record, thus there was no evidence of permanent worsening beyond its normal progression. The foregoing medical opinions, especially the July 2012 and March 2013 medical opinions, regarding the etiology of the Veteran's claimed bilateral peripheral neuropathy of the upper extremities are fully informed, fully articulated, and well-reasoned. See Nieves-Rodriguez, 22 Vet. App. at 304. The examination reports are based on thorough review of the record as well as current examination of the Veteran. Collectively, these medical opinions have thoroughly considered the Veteran's contentions and concluded that his current upper extremity peripheral neuropathy was not incurred during or as a result of his active service, to include is in-service motor vehicle accident, and was not caused or aggravated by his service-connected lumbosacral spine sprain or associated peripheral neuropathy of the bilateral lower extremities. Accordingly, based on the evidence of record, the Board cannot make a finding that a nexus exists between the Veteran's current upper extremity peripheral neuropathy and his service or any service-connected disability. See Walker, supra; see also Wallin, supra. The Veteran has expressed his opinion that upper extremity peripheral neuropathy was related to his service-connected lumbosacral strain and associated lower extremity peripheral neuropathy as a result of overuse due to decreased back and lower limb function. As the Veteran lacks the requisite medical expertise, however, his opinions do not constitute competent evidence regarding the etiology of his diagnosed peripheral neuropathy of the upper extremities. See Jandreau v, 492 F.3d at 1376-77. Additionally, while the Veteran has reported that he experienced intermittent numbness of the upper extremities since his in-service accident; medical opinions of record have considered this contention and nonetheless concluded that there was simply no evidence to suggest that his mild carpal tunnel syndrome could be related to his in-service accident. Further, peripheral neuropathy is not among the listed chronic diseases. 38 U.S.C.A. §§ 1101, 1112(a); 38 C.F.R. § 3.309(a). Continuity of symptomatology could not serve to establish a nexus between the current claimed disabilities and service. Walker; cf. 38 C.F.R. § 3.303(b). Accordingly, there is no other competent evidence linking the Veteran's current bilateral carpal tunnel syndrome to his in-service injury or to service-connected lumbosacral strain and associated peripheral neuropathy of the lower extremities. Absent such competent evidence, the Board finds that the preponderance of the evidence is against these service connection claims. Reasonable doubt does not arise and the claims for service connection for peripheral neuropathy of the upper extremities must be denied. 38 U.S.C.A. § 5107(b) (West 2002). ORDER Entitlement to service connection for peripheral neuropathy of the right upper extremity is denied. Entitlement to service connection for peripheral neuropathy of the left upper extremity is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs