Citation Nr: 1336022 Decision Date: 11/06/13 Archive Date: 11/13/13 DOCKET NO. 10-04 585 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Detroit, Michigan THE ISSUES 1. Entitlement to service connection for left upper extremity carpal tunnel syndrome (CTS), including as due to herbicide exposure. 2. Entitlement to service connection for right upper extremity CTS, including as due to herbicide exposure. 3. Entitlement to service connection for left ulnar nerve damage, including as due to herbicide exposure. 4. Entitlement to service connection for right ulnar nerve damage, including as due to herbicide exposure. 5. Entitlement to service connection for a left knee disability, claimed as arthritis. 6. Entitlement to service connection for right knee condition, status post-total replacement, including arthritis, including as due to herbicide exposure. 7. Entitlement to service connection for right foot disability, including arthritis. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD W.T. Snyder, Counsel INTRODUCTION The Veteran served on active duty from February 1966 to January 1968. This appeal to the Board of Veterans' Appeals (Board) arose from a January 2009 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA) in Detroit, Michigan, which, in pertinent part, denied entitlement to service connection for bilateral carpal tunnel syndrome, bilateral ulnar nerve damage with tremors, a heart condition, arthritis, a right food condition and a right foot condition. The Veteran's formal claim (VA Form 21-526), his written submissions, and statements from his wife and daughter all note his description of joint pains, joint fatigue, and arthritis. The Board notes that the scope of a disability claim includes any disability that may reasonably be encompassed by a claimant's description of the claim, reported symptoms, and the other information of record. Clemons v. Shinseki, 23 Vet. App. 1 (2009). As explained below, the Board has characterized the issues of the case as shown above. The November 2008 VA joints examination report reflects the examiner asked the Veteran to clarify what joints his arthritis claim pertained, and the Veteran stated his claim pertained to his left knee. Thus, in light of the evidence of record, the Board has styled the issues of arthritis and CTS as shown above on the cover sheet. See Boggs v. Peake, 520 F.3d 1330 (Fed. Cir. 2008). Further, the Board refers the left knee claim below. In a July 2011 rating decision, an RO Decision Review Officer (DRO) awarded service connection for coronary artery disease as due to herbicide exposure and assigned an initial 100 percent rating, effective in September 2007. A September 2012 rating decision assigned a 30 percent rating, effective in October 2007. This was a full grant of the benefits sought on appeal. See 38 C.F.R. § 20.200 (2012). The Veteran indicated on his January 2010 Substantive Appeal (VA Form 9) that he desired a Board hearing. In June 2010, however, he informed the RO he desired a hearing before a DRO in lieu of a Board hearing. An October 2011 RO letter informed him his hearing was scheduled for November 30, 2011. He failed without explanation to appear for the hearing. The Veteran has a Virtual claims file, which is a highly secured paperless repository, associated with his appeal. The Board has considered the documents in both files while reviewing this appeal. The issues of entitlement to service connection for peripheral neuropathy of the upper and lower extremities have been raised by the record, but have not been adjudicated by the Agency of Original Jurisdiction (AOJ). Therefore, the Board does not have jurisdiction over them, and they are referred to the AOJ for appropriate action. FINDINGS OF FACT 1. Neither CTS nor ulnar nerve damage of the upper extremities had their onset in active service and neither are they causally connected to a disease or injury in active service. 2. A right knee disability, including arthritis, did not have its onset in active service, and neither is it causally connected to active service. 3. A current left knee disability has not been demonstrated. 4. A current right foot disability has not been demonstrated. CONCLUSIONS OF LAW 1. CTS, bilateral upper extremities, was not incurred in active service, nor may it be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307(a)(3), (6), 3.309(a), (e) (2013). 2. Ulnar nerve damage, bilateral upper extremities, was not incurred in active service, nor may it be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.159, 3.303, 3.307(a)(3), (6), 3.309(a), (e). 3. A right knee disability, including arthritis, was not incurred in active service, nor may it be presumed to have been incurred in active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.159, 3.303, 3.307(a)(3), (6), 3.309(a), (e). 4. A left knee disability, including arthritis, did not have its onset in active service, and neither is it causally connected to active service. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 1154 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.303, 3.307(a)(3), (6), 3.309(a), (e). 5. The criteria for entitlement to service connection for a right foot disability are not met. 38 U.S.C.A. § 1110; 38 C.F.R. §§ 3.159, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSION Veterans Claims Assistance Act of 2000 (VCAA) The provisions of the VCAA, codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a), and as interpreted by the Court, have been fulfilled. In this case, the Veteran filed his service connection claims in September 2007. Prior to issuance of the January 2009 rating decision, the Veteran was given the notice required by the VCAA a letter dated in January 2008. The letter notified the Veteran of VA's responsibilities in obtaining information to assist the Veteran in completing his claim, identified the Veteran's duties in obtaining information and evidence to substantiate his claim, and provided other pertinent information regarding VCAA, to include how disability evaluations and effective dates are determined and assigned. The January 2008 notice letter was fully time- and content-compliant. See 38 C.F.R. § 3.159(b); see also Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006). Thus, VA has complied with the VCAA notice requirements. VA also has a duty to assist the Veteran in the development of the claim. This duty includes obtaining relevant records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159(c). Upon receipt of the Veteran's claim, the RO obtained the service treatment records, VA outpatient records, the existing private records identified by the Veteran. During the appeal process, the RO also obtained records from the Social Security Administration associated with that agency's award of benefits to the Veteran. An examination is adequate "where it is based upon consideration of the veteran's prior medical history and examinations and also describes the disability, if any, in sufficient detail so that the Board's 'evaluation of the claimed disability will be a fully informed one.' " Stefl, 21 Vet. App. at 123 (quoting Ardison v. Brown, 6 Vet. App. 405, 407-08 (1994)). It is a medical examiner's responsibility to provide a well-supported opinion so that the Board may carry out its duty to weigh the evidence of record. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (concluding that medical opinion is not entitled to any weight "if it contains only data and conclusions"); Stefl, 21 Vet. App. at 124 (stating VA medical opinion "must support its conclusion with an analysis that the Board can consider and weigh against contrary opinions"). The Court Of Appeals For Veterans Claims (Court) has also held that an examination is inadequate if the examiner ignores a veteran's assertions of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (finding error where "the VA examiner did not indicate whether he considered a veteran's reports of continuity of symptomatology"). In this case the VA examiner provided detailed reasons for his opinions and took into account the entire medical history, including the Veteran's reports. It does not appear that the reports of physical findings were inaccurate, inasmuch as they are consistent with the other medical evidence of record. Thus, the examination was adequate for appellate review purposes. Neither the Veteran nor his representative asserts there are additional records to be obtained, or that VA has failed to assist the Veteran. In light of the above, VA has adequately assisted the Veteran with his claim. Hence, the Board finds the merits of the Veteran's appeal may be addressed without prejudice to him. See Bernard v. Brown, 4 Vet. App. 384 (1993). 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; 38 C.F.R. § 3.303. Establishing service connection generally requires medical or, in certain circumstances, lay 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 Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see also 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). Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element in a claim involving a listed chronic disease, is through a demonstration of continuity of symptomatology. 38 U.S.C.A. § 1101; Walker v. Shinseki, 708 F.3d 1131 (Fed. Cir. 2013); see also Barr v. Nicholson, 21 Vet. App. 303 (2007), if the condition is a chronic disease. Continuity of symptomatology may be established if a claimant can demonstrate (1) that a chronic disease was "noted" during service or within the applicable presumptive period; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Walker, supra; see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). If a chronic disease is adequately demonstrated during service and at any time thereafter, service connection will be conceded. 38 C.F.R. § 3.303(b). Certain listed chronic diseases such as arthritis and organic diseases of the central nervous system are presumed to have been incurred in service if such manifested to a compensable degree within one year of separation from service. This presumption applies to veterans who have served 90 days or more of active service during a war period or after December 31, 1946. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307(a), 3.309(a). In addition to the above, a veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975, shall be presumed to have been exposed during such service to an herbicide agent, unless there is affirmative evidence to establish that the veteran was not exposed to any such agent during that service. VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 67 Fed. Reg. 42600-42608 (2002). When a claimed disorder is not among the listed presumptive disorders, direct service connection may nevertheless be established by evidence demonstrating that the disease was in fact "incurred" during the service. See Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). In relevant part, 38 U.S.C.A. § 1154(a) requires that VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim for disability or death benefits. Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009). The Federal Circuit has held that "[l]ay 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 profession." See Jandreau v. Nicholson, 492 F. 3d 1372, 1377 (Fed. Cir. 2007); see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed. Cir. 2006) ("[T]he Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence." "Symptoms, not treatment, are the essence of any evidence of continuity of symptomatology." Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); (citing Wilson v. Derwinski, 2 Vet. App. 16, 19 (1991). Once evidence is determined to be competent, the Board must determine whether such evidence is also credible. See Layno v. Brown, 6 Vet. App. 465, 469-70 (1994) (distinguishing between competency ("a legal concept determining whether testimony may be heard and considered") and credibility ("a factual determination going to the probative value of the evidence to be made after the evidence has been admitted"). Service connection may be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Presumptive periods are not intended to limit service connection to diseases so diagnosed when the evidence warrants direct service connection. The presumptive provisions of the statute and VA regulations implementing them are intended as liberalizations applicable when the evidence would not warrant service connection without their aid. 38 C.F.R. §§ 3.307, 3.309. The Board must fully consider the lay evidence of record. Davidson, 581 F.3d 1313. A layperson is competent to report on the onset of disability and, when applicable, continuity of his or her 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; see Jandreau v. Nicholson, 492 F. 3d 1372, 1376-77 (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 for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau, supra. 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, aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). The bottom line is that lay testimony, where probative on the issue, still must be assessed for credibility and accuracy. 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; 38 C.F.R. § 3.102; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). Analysis The Veteran asserts his upper extremity, right knee, and claimed right foot disabilities had their onset in active service, or they are causally related to his active service, including his service in Vietnam where he was exposed to Agent Orange (AO). The service treatment records do not contain any entries related to complaints of or treatment for nerve-related symptoms, a right knee or right foot disorder. The November 2008 examination report, however, notes the Veteran reported he injured his knee during the North Vietnamese Army/Viet Cong Tet Offensive when he fell into a hole while running. He reported further that he did not seek medical attention. The Veteran's January 1968 Report of Medical History at separation reflects he denied any history related to disability of his arms, knees, or foot. The January 2008 Report of Medical Examination For Separation reflects his upper extremities, neurological system, and lower extremities were assessed as normal. He was deemed physically fit for separation from active service. Upper Extremities Private records note the Veteran sustained a work-related injury to his right hand in December 1998. He had surgery and subsequently returned to work with restrictions. An April 2003 report from Met Life notes the Veteran had four surgeries on the right hand between 1998 and 2003. An April 2003 report of the Evaluation Group note confirms that the Veteran underwent carpal tunnel release surgery of the right hand in February 2001, open carpal tunnel release in July 2001, and that after a September 2002 EMG revealed a slowing of the ulnar nerve at the right elbow; the Veteran underwent right ulnar nerve transposition at the right elbow in January 2003. The examiner noted the Veteran was a tool and die maker, and he had ongoing symptoms associated with right median neuropathy at the wrist and right ulnar neuropathy at the elbow. A history of fused first carpometacarpal joint of the right hand was also noted. The examiner opined that all the noted conditions were work-related by history, as the Veteran had been employed at the same company for 371/2 years doing repetitive and heavy physical labor with his hands. The report contains no report of a history of in-service symptoms or continuous symptoms afterwards. The November 2008 VA examination report reflects the examiner conducted a review of the claims file as part of the examination. The report notes the Veteran reported the date of the onset of his ulnar nerve symptoms as 1998, and that his symptoms were confined to his right hand, which was his dominant hand. He reported further that he worked on an assembly line at General Motors both before and after service, the post-service work ending in 2004. The Veteran related his right hand nerve damage to firing a gun in Vietnam. He also asserted it was due to AO exposure. The Veteran reported the onset date for CTS was in 1995, and he reported he had surgery in 1997. Based on the history received from the Veteran, the examiner noted a repetitive work damage. The Veteran's primary symptoms were noted as numbness and paresthesias of the 4th and 5th fingers of the right hand. The examiner opined that neither the Veteran's ulnar nerve pathology nor CTS was associated with AO exposure. In addition to the fact that neither was disorder was deemed by VA to be associated with AO exposure; the examiner noted the Veteran's work in the manufacturing industry placed him at risk for development of CTS. As concerned the ulnar nerve, the examiner noted the fact the Veteran's ulnar nerve damage was an occupational injury for which the records in the claims file showed the Veteran received Workmen Compensation coverage. The examiner noted the Veteran worked for a significant amount of time in the manufacturing industry with equipment that placed the Veteran at considerable risk for that type of injury. Contrarily, there was no indication of ulnar nerve damage in service. Right and Left Knee The November 2008 VA examination report reflects the Veteran reported it was actually his right knee that was involved, and that it had hurt since after his discharge from active service; but, he had just become aware of VA services. The Veteran attributed his right knee replacement to his AO exposure in Vietnam. He reported his right knee cracked and ground whenever he got up and moved. The Veteran also recalled an event during Tet when he was running at night and fell into a hole and hurt both knees. Although he had knee pain, he deemed it minor compared to the injuries of fellow soldiers, and he never followed up on it. He asserted his knee had bothered him ever since. Physical examination revealed painful limitation of motion (LOM) in each knee of 0 to 110 degrees. See 38 C.F.R. § 4.71a, Plate II. The Veteran told the examiner he had X-rays that showed degenerative joint disease of both knees, but he did not have them with him. The examiner limited his diagnosis of the right knee to right knee replacement, as there was insufficient evidence for additional diagnoses. The examiner noted that disabilities that lead to joint replacement later in life were not deemed associated with AO exposure. The Examiner also noted the Veteran failed to complete ordered diagnostic testing. The examiner noted further the combat-related injury the Veteran reported may have injured the knee, thereby setting up pathology; but, that prospect was speculative, especially since the Veteran did not complete the diagnostic testing which was ordered. The examiner also observed that the prospect of an old injury from the Vietnam era had to be weighed against the aging process, which was a strong risk factor for the development of disability in the joint. As concerns the Veteran's CTS and ulnar nerve disorders, the Board finds the Veteran is competent to report any symptoms he experienced, such as numbness, tingling, etc. 38 C.F.R. § 3.159(a)(2). Beyond that, however, the Board finds that specifically identifying or diagnosing CTS or ulnar nerve pathology, and any related etiology, is beyond the training and experience of a lay person. There is no evidence the Veteran has medical training, or that a medical professional told him the disorders are related to AO exposure. Hence, his personal opinion that his CTS and ulnar nerve damage are due to AO exposure, or any other etiology, is not probative on the issue. In any event, there are a plethora of private records in the claims file that the Veteran's upper extremity symptoms had their onset after his work-related injury in 1998. Hence, as no neurological disorder was diagnosed at the time the Veteran was discharged from active service, or within one year afterwards, there is no factual basis for allowing the claim on the basis of continuous symptomatology. 38 C.F.R. § 3.303(b). The extensive records contain no reported history of in-service symptoms or other relationship to active service. Indeed, as noted earlier, the Veteran's private physicians who treated him opined that all of his symptoms were due to a 30 plus year history of work that involved repetitive actions. The VA examiner's opinion is consistent with the evidence of record. Thus, the Board is constrained to find the preponderance of the evidence is against the CTS and ulnar claims on both a presumptive and direct basis. 38 C.F.R. §§ 3.303, 3.307(a)(3) and (6), 3.309(a), (e). As concerns the right knee, the Veteran can attest to factual matters of which he had first-hand knowledge, e.g., experiencing pain in service, reporting to sick call, being placed on limited duty, and undergoing physical therapy. See Washington v. Nicholson, 19 Vet. App. 362, 368 (2005). The Veteran's lay evidence is especially relevant, as he related he sustained right knee trauma during the Tet Offensive. Satisfactory lay or other evidence that an injury or disease was incurred or aggravated in combat will be accepted as sufficient proof of service connection, if the evidence is consistent with the circumstances, conditions, or hardship of such service even if there is no official record of such incurrence or aggravation. 38 U.S.C.A. § 1154(b); 38 C.F.R. § 3.304(d). The combat presumption, however, does not obviate the need for evidence of a medical nexus between a current disability and military service. Reeves v. Shinseki, 682 F.3d 988, 988-1000 (Fed. Cir. 2012); Collette v. Brown, 82 F.3d 389, 392-93 (Fed. Cir. 1996); Arms v. West, 12 Vet. App. 188, 194-95 (1999). The Board further notes that under Collette v. Brown, 82 F.3d. 389 (Fed. Cir. 1996) and Caluza v. Brown, 7 Vet. App. 498 (1995) the correct application of 38 U.S.C.A. § 1154(b) requires a three-step, sequential analysis: (1) Has the claimant produced "satisfactory lay or other evidence of such injury or disease." "Satisfactory evidence" is defined as "credible evidence that would allow a reasonable fact finder to conclude that the alleged injury or disease was incurred in or aggravated by the veteran's combat service." (2) Is the proffered evidence "consistent with the circumstances, conditions, or hardships of such service." (3) Once the first two steps are met, the Secretary "shall accept" the veteran's evidence as "sufficient proof of service connection," even if no official record of such incurrence exists, unless the Government can meet the burden of showing "clear and convincing evidence to the contrary." Id. A determination that a veteran engaged in combat with the enemy may be supported by any evidence which is probative of that fact, and there is no specific limitation of the type or form of evidence that may be used to support such a finding. VAOPGCPREC 12-99 (1999). Evidence submitted to support a claim that a veteran engaged in combat may include the veteran's own statements and an "almost unlimited" variety of other types of evidence. Gaines v. West, 11 Vet. App. 353, 359 (1998). The Board takes official notice of the fact that the Tet Offensive began on January 30, 1968, while the Veteran was discharged from active service on January 22, 1968. See Sykes v. Apfel, 228 F.3d 259, 272 (3d Cir.2000) (explaining that official notice is the proper method for agency decisionmakers to apply knowledge not included in the record. It is the administrative law counterpart of judicial notice. Both doctrines allow adjudicators to take notice of commonly acknowledged facts, but official notice is broader than judicial notice insofar as it also allows an administrative agency to take notice of technical or scientific facts that are within the agency's area of expertise."). The Veteran has not presented credible evidence that the knee injury was incurred in combat during the Tet offensive, because he was not on active duty at that time of that offensive. Records of one of the Veteran's private physicians, Dr. M, date back to the 1970s. In an entry dated in August 1978, Dr. M noted the Veteran reported a five-year history of right knee pain and a two- to-three-year history of left knee pain. The Veteran denied any prior injury but reported he played football as a teenager. Dr. M's records note an eventual right knee menisectomy in November 1978. There is no indication in Dr. M's records of a reported in-service knee injury. Dr. M's records skip from December 1979 to March 1990 without explanation. A December 1990 entry notes the Veteran's complaints of bilateral knee pain. Dr. M noted x-rays did not show a lot of evidence of collapse, and he opined the Veteran's symptoms could be the beginning of mild arthritis. A July 1995 X-ray showed medial narrowing and degenerative changes. Dr. M's records note the Veteran had subsequent repeat arthroscopies. Other records note the right knee replacement in 2006. The Veteran's earliest contemporaneous reports place the onset of his right knee symptoms at 1973, and 1975 for the left knee, both several years after his discharge from active service. Hence, the Board finds any current report of ongoing symptomatology since service to be incredible. The earliest indication of the manifestation of arthritis is 1990, per Dr. M's records, which was confirmed by a 1995 X-ray. Thus, the Board finds no factual basis for entitlement to service connection for arthritis on a presumptive basis as a chronic disease. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). The Board notes a February 2008 private report which the RO received in May 2008. The report was prepared by Dr. S.K., and it provided his neurological findings related to the Veteran's reported tremors. In one isolated sentence of the report, Dr. K noted the Veteran "is a Viet Nam veteran and was exposed to Agent Orange, which may contribute to arthritis pain." Dr. K did not include any other comment related to the quoted sentence, nor did he set forth a rationale for the notation. Hence, the Board accords it little weight. See Nieves-Rodriguez, 22 Vet. App. 295. In light the above, the Board is also constrained to find the preponderance of the evidence of record is also against the right knee claim on a direct basis as well. 38 C.F.R. § 3.303. Right Foot The November 2008 examination report reflects the Veteran reported the right foot got sore; and, when it did, he had a hard time walking on it. He then walked with a limp as a result. He attributed his right foot symptoms to a lot of walking and standing, and being in uncomfortable positions. The Veteran also related that he believed his symptoms were caused by in-service forced marches and exposure to monsoons. He explained that the forced marches were in basic and advanced infantry training. He denied any prior surgery on the right foot. The Veteran reported occasional pain, most often when the weather was rainy or cold, or on excess walking. The Veteran denied any history of a right foot injury. The Veteran denied any history of swelling, heat, redness, weakness, or other symptoms. He related that his foot pain was located at the arch of the foot and around by the ball of the foot. The Veteran reported flare-ups occurred two to three times a month that lasted at least two but less than seven days. During the flare-ups, he walked with a limp, but he did not use a cane or other assistive device. Physical examination revealed no evidence of painful motion, swelling, tenderness, weakness, or abnormal weight bearing. The examination report notes the Veteran failed to report for X-rays of the foot. The examiner noted there was insufficient evidence to warrant a diagnosis of an acute or chronic right foot disorder. When a claimant fails to report for an examination scheduled in conjunction with any original claim, the claim shall be rated on the evidence of record. 38 C.F.R. § 3.655(b). The examination report notes the examiner ordered the X-rays as part of the examination. The examiner would have used the X-rays results to render a diagnosis. The evidence of record shows only right foot pain. Pain alone, without a diagnosed underlying disorder associated with the pain, is not subject to service connection. See Sanchez-Benitez v. West, 13 Vet. App. 282, 285 (1999) ("[P]ain 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 the absence of a currently diagnosed right foot disorder, there is no factual basis for an allowance of service connection. In light of the above, the Board is constrained to find the preponderance of the evidence of record is against the right foot claim. 38 C.F.R. § 3.303. In reaching this decision the Board considered the doctrine of reasonable doubt. As the preponderance of the evidence is against the Veteran's claims, however, the doctrine is not for application. Schoolman v. West, 12 Vet. App. 307, 311 (1999). ORDER Entitlement to service connection for left upper extremity CTS is denied. Entitlement to service connection for right upper extremity CTS is denied. Entitlement to service connection for left ulnar nerve damage is denied. Entitlement to service connection for right ulnar nerve damage is denied. Entitlement to service connection for right knee disability, status post-total replacement, including arthritis, is denied. Entitlement to service connection for right foot disorder, including arthritis, is denied. ____________________________________________ Mark D. Hindin Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs