Citation Nr: 1339165 Decision Date: 11/27/13 Archive Date: 12/13/13 DOCKET NO. 07-29 201 ) DATE ) ) Received from the Department of Veterans Affairs (VA) Regional Office (RO) in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for a right wrist disability. 2. Entitlement to service connection for a heart disorder, to include as secondary to service-connected post traumatic stress disorder (PTSD). REPRESENTATION Appellant represented by: Disabled American Veterans WITNESSES AT HEARING ON APPEAL Veteran and spouse ATTORNEY FOR THE BOARD Christopher Maynard, Counsel INTRODUCTION The Veteran had active service from August 1973 to August 1975. This matter initially came before the Board of Veterans' Appeals (Board) on appeal from a May 2005 decision by the RO which denied the benefits sought on appeal. A hearing before at the RO before the undersigned was held in April 2010. The Board remanded the issues currently on appeal for additional development in October 2010. By rating action in January 2012, the RO granted service connection for PTSD, subsequently rated 100 percent disabling; effective from the date of original claim. 38 C.F.R. § 3.400(b)(2) (2013). The Veteran and his representative were notified of this decision and have not expressed dissatisfaction with that decision. Accordingly, this issue is no longer in appellate status and will not be addressed in this decision. FINDINGS OF FACT 1. The most probative evidence of record shows that the Veteran's current right wrist disability was caused or aggravated by service and arthritis of the right wrist did not manifest itself to a compensable degree in the first post-service year. 2. The most probative evidence of record shows that the Veteran's current heart disorder was not caused or aggravated by service and it was not caused or aggravated by his service connected PTSD. CONCLUSIONS OF LAW 1. A right wrist disability was not incurred in or aggravated by military service and may not be presumed to have been incurred in service. 38 U.S.C.A. §§ 1110, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2013). 2. A heart disorder was not incurred in or aggravated by military service and it is not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1110, 5100, 5102, 5103, 5103A, 5107 (West 2002 & Supp. 2012); 38 C.F.R. § 3.310 (2006); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2013). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Before addressing the merits of the Veteran's claim, the Board is required to ensure that the VA's "duty to notify" and "duty to assist" obligations have been satisfied. See 38 U.S.C.A. §§ 5103, 5103A (West 2002); 38 C.F.R. § 3.159 (2013). Under the Veterans Claims Assistance Act (VCAA), when VA receives a complete or substantially complete application for benefits, it must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 C.F.R. § 3.159. Such notice must indicate that a disability rating and an effective date for the award of benefits will be assigned if there is a favorable disposition of the claim. Id; 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.159, 3.326; see also Pelegrini v. Principi, 18 Vet. App. 112, 120-21 (2004) (Pelegrini II). In this regard, the Board finds that letters dated in October 2004 and January 2005, prior to the May 2005 rating decision, along with a letter dated in August 2011 provided the Veteran with notice that fulfills the provisions of 38 U.S.C.A. § 5103(a). The Board also finds that even if VA had an obligation to provide the Veteran with additional 38 U.S.C.A. § 5103(a) notice, such as notice of the laws and regulations governing disability ratings and effective dates as required by the United States Court of Appeals for Veterans Claims (Court) in Dingess v. Nicholson, 19 Vet. App. 473 (2006), and failed to do so this notice problem does not constitute prejudicial error in this case because the record reflects that a reasonable person could be expected to understand what was needed to substantiate the claims after reading the above letters as well as the rating decision, the statement of the case, the supplemental statements of the case, and the Board remand. See Shinseki v. Sanders, 129 S.Ct. 1696 (2009). As to VA's duty to assist, the Board finds that all necessary development has been accomplished and that appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The Veteran's service treatment records (STRs) and all available and identified post-service VA and private medical records have been obtained and associated with the claims file. The Board also reviewed the Veteran's Virtual VA electronic medical records. The Veteran also testified at a hearing at the RO before the undersigned in April 2010. The record also shows that the Veteran was provided with post-remand VA examinations in December 2010, May 2011, July 2011, and March 2012. Moreover, the Board finds that the VA examinations are adequate to adjudicate the claims and substantially comply with the Board's remand instructions because, after a review of the record on appeal, after taking a detailed medical history from the claimant, and/or after an examination, the examiners provided opinions as to the origins of his disabilities which opinions were based on citation to relevant evidence found in the claims file. See 38 U.S.C.A. § 5103A(d); Barr v. Nicholson, 21 Vet App 303 (2007); Stegall v. West, 11 Vet. App. 268 (1998); D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict compliance with the terms of a remand request, is required); Dyment v. West, 13 Vet. App. 141, 146-47 (holding that there was no Stegall violation when the examiner made the ultimate determination required by the Board's remand, because such determination more than substantially complied with the Board's remand order). As noted above, the Veteran and his wife testified a hearing before the undersigned in which they presented oral arguments in support of the appeal. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the Court held that 38 C.F.R. § 3.103(c)(2) requires that the "hearing officer" who chairs a hearing fulfill two duties to comply with the above the regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. In this case, during the hearing, the Acting Veterans' Law Judge (VLJ) fully identified the issues on appeal, indicated the evidence necessary to substantiate the claims and asked specific questions directed at identifying the location of any potentially outstanding medical evidence. Additionally, neither the Veteran nor his representative has asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2), nor have they identified any prejudice in the conduct of the hearing. The hearing focused on the elements necessary to substantiate the claims and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that consistent with Bryant, the undersigned has complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). In summary, the facts relevant to this appeal have been properly developed and there is no further action to be undertaken to comply with the provisions of 38 U.S.C.A. §§ 5103(a), 5103A or 38 C.F.R. § 3.159. Therefore, the Veteran will not be prejudiced as a result of the Board proceeding to the merits of the appeal. See Bernard v. Brown, 4 Vet. App. 384, 392-94 (1993). In adjudicating the claims below, the Board has reviewed all of the evidence in the Veteran's claims file including those found in Virtual VA. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that all the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claims and what the evidence in the Veteran's claims folder shows, or fails to show, with respect to the claim See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Timberlake v. Gober, 14 Vet. App. 122, 128-30 (2000). Service Connection - In General Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. An alternative method of establishing the second and third Shedden/Caluza elements for a chronic disability listed under 38 C.F.R. § 3.309(a), is through a demonstration of continuity of symptomatology. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir 2013); see also, Barr v. Nicholson, 21 Vet. App. 303 (2007); Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition listed under 38 C.F.R. § 3.309(a) was "noted" during service; (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. See Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). In addition, where a Veteran served for ninety (90) days or more during a period of war, or during peacetime service after December 31, 1946, and arthritis becomes manifest to a degree of 10 percent within one year of date of termination of such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137 (West 2002); 38 C.F.R. §§ 3.307, 3.309 (2012). Under section 3.310(a) of VA regulations, service connection may also be established on a secondary basis for a disability which is proximately due to or the result of service- connected disease or injury. 38 C.F.R. § 3.310(a). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) proximately caused by or (b) proximately aggravated by a service-connected disability. Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc). Where a service-connected disability aggravates a nonservice-connected condition, a veteran may be compensated for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. Allen, 7 Vet. App. at 448. Temporary or intermittent flare-ups of symptoms of a condition, alone, do not constitute sufficient evidence of aggravation unless the underlying condition worsened. Cf. Davis v. Principi, 276 F.3d 1341, 1346-47 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292, 297 (1991). There was an amendment to the provisions of 38 C.F.R. § 3.310. See 71 Fed. Reg. 52744-47 (Sept. 7, 2006). The amendment sets a standard by which a claim based on aggravation of a non-service-connected disability by a service-connected one is judged. Although VA has indicated that the purpose of the regulation was merely to apply the Court's ruling in Allen, it was made clear in the comments to the regulation that the changes were intended to place a burden on the claimant to establish a pre-aggravation baseline level of disability for the non-service-connected disability before an award of service connection based on aggravation may be made. This had not been VA's practice, which suggests the possibility that the recent change amounts to a substantive change in the regulation. For this reason, and because the Veteran's claims were pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the change, which is more favorable to the claimant. In relevant part, 38 U.S.C. § 1154(a) requires that the VA give "due consideration" to "all pertinent medical and lay evidence" in evaluating a claim to disability or death benefits. 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, 1377 (Fed.Cir.2007). In fact, competent medical evidence is not necessarily required when the determinative issue involves either medical etiology or a medical diagnosis. Id. at 1376-77; see also Buchanan v. Nicholson, 451 F.3d 1331, 1337 (Fed.Cir.2006); Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. Sept 14, 2009). Medical evidence of a "chronic" disease should set forth the physical findings and symptomatology elicited by examination within the applicable period. 38 C.F.R. § 3.307(b); Oris v. Derwinski, 2 Vet. App. 95, 96 (1992). A chronic disease need not be diagnosed during the presumptive period but characteristic manifestations thereof to the required degree must be shown by acceptable medical and lay evidence followed without unreasonable time lapse by definite diagnosis. 38 C.F.R. § 3.307(c); Caldwell v. Derwinski, 1 Vet. App. 466, 469 (1991). An important factor in the factual question of reasonableness in lapse of time from manifestation to diagnosis under 38 C.F.R. § 3.307(c) is the difficulty in diagnosing the disability and the strength of the evidence establishing an identity between the disease manifestations and the subsequent diagnosis. A strong evidentiary link tends to ensure the disease is not due to "intercurrent cause" as set forth in 38 C.F.R. § 3.303(b); Cook v. Brown, 4 Vet. App. 231, 238 (1993). The lapse in time from manifestation to diagnosis under 38 C.F.R. § 3.307(c) "is ultimately a question of fact for the Board to address." Bielby v. Brown, 7 Vet. App. 260, 266 (1994). Right Wrist Disability The Veteran contends that he injured his right wrist during loading exercises on a six-inch gun in service. The Veteran testified that his wrist was placed in a cast and that he was seen for flare-ups off and on after that and was given ibuprofen or anti-inflammatory medications. The Veteran testified that he never sought medical attention for any wrist problems again, until some 20 years after service. Contrary to the Veteran's assertions, the STRs showed no complaints, treatment, abnormalities or diagnosis for any right wrist problems in service or until nearly three decades after service separation. The STRs showed that the Veteran was treated for a painful right thumb after being kicked in the hand during "hemo practice" in February 1975. Other than some swelling and decreased range of motion in the first metacarpal joint, no pertinent abnormalities were noted. The Veteran was seen for his right thumb in May 1975, and the thumb was placed in a spica cast two weeks in June 1975. The spica cast was discontinued and the Veteran was started on range of motion exercises, and returned to duty in mid June 1975. Post-service private medical records showed that the Veteran was seen on numerous occasions for various maladies from 1996 to 2009, but do not reflect any complaints, treatment, or abnormalities referable to any right wrist problems. Private records showed treatment for symptoms associated with lumbar and cervical spine disabilities, including neuropathy into both upper extremities in 2006. The impression on an April 2006 private report included probable cervical radiculopathy and possible mild carpal tunnel syndrome (CTS). At the direction of the October 2010 Board remand, the Veteran was examined by VA in December 2010 and May 2011. The examiners indicated that the claims file was reviewed and included a discussion of the Veteran's complaints, medical history and clinical and diagnostic findings on examination. When examined in December 2010, the Veteran reported that he could not recall the specifics of his wrist injury in service and complained of constant stiffness and persistent pain (7/10) that had progressively worsened over the years. He reported that his hand and wrist go to sleep at night and that he never sleeps for more than two hours due to wrist pain. On examination, there was no evidence of swelling, instability, weakness, tenderness, edema, redness, heat, spasm, painful motion, abnormal movement, guarding, fatigue, lack of endurance, deformity, atrophy or incoordination. The Veteran denied any flare-ups and did not use any assistive devices. X-ray studies showed no evidence of acute fracture, dislocation or bony destructive lesions. There was mild degenerative arthritis in the radial-carpal joints. The diagnosis was mild osteoarthritis of the right wrist with mild functional limitation. The examiner indicated that a solitary thumb contusion was not a proximate cause of, or related to degenerative osteoarthritis of the wrist joints, and opined that the Veteran's right wrist disability was not caused by or related to service. When examined by VA in May 2011, the examiner noted that the first reported treatment for any right wrist problem was on a VA outpatient note in December 2010, and that the diagnosis was right wrist arthralgia. The Veteran reported that he could not recall how he injured his wrist in service, but said that he tore tendons and ligaments, that his wrist was placed in a cast for several weeks and then in a brace for a while after that. The Veteran reported that he had intermittent pain in the wrist after that, but did not seek medical attention in service and just self-medicated. He said that he first sought treatment with VA 10 to 12 years ago, and that they just gave him ibuprofen and took x-rays, but did nothing else. The diagnoses included right thumb contusion; resolved, paresthesias of the right hand and mild degenerative arthritis of the radial carpal joints of the right wrist. The examiner opined that the right wrist arthritis was not caused by or related to the thumb contusion in service and was most likely age-related, and that the paresthesias of the right hand was most likely caused by right CTS. In this case, the Board finds that the VA medical opinions the most persuasive evidence of record, as they were based on a thorough examination of the Veteran and included discussions of all relevant facts. The examiners noted that contrary to the Veteran's assertions of treatment for a right wrist injury in service, the STRs showed that he was treated only for a right thumb injury that subsequently resolved, and that there was no causal relationship between his current right wrist arthritis and his thumb injury in service. See Wray v. Brown, 7 Vet. App. 488, 493 (1995). Furthermore, the Veteran has not presented any competent medical evidence to rebut those opinions. Thus, the most probative evidence of record consists of the December 2010 and May 2011 medical opinions. Regarding the Veteran's and his wife's personal hearing testimony as well as the appellant's written contentions, while the Veteran is competent to describe his experiences and symptoms and his wife is competent to describe what she sees, the etiology of the current wrist disability may not be diagnosed via lay observation alone and they have not been shown to have the expertise to provide credible opinions concerning the complex medical question of the nature or etiology of the claimed disability. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). 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, and consistency with other evidence submitted on behalf of the Veteran. Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996). In this case, the Board does not find the Veteran to be a reliable historian and that his contentions of a right wrist injury and chronic problems since service are not credible, and accord them no probative value. Specifically, the Board notes that while the Veteran alleges that he has had chronic, persistent wrist problems since service, he made no mention of any such problems on his original application for VA compensation benefits, received in April 1978, on a subsequent claim received in December 2001, or when examined by VA in August 2002. In fact, the Veteran never mentioned any right wrist problems until the filing of this claim in 2004, nearly three decades after his discharge from service. That the Veteran would suffer from chronic right wrist problems since an alleged injury in service, but would make no mention of what he now claims has been chronic wrist pain when filing is original claim for VA compensation benefits in 1978 or 2002, is not rational or believable. When there is a lack of continuity of medical treatment, it is crucial that lay evidence of continuity of symptoms be credible in order to fill the void of the absence of medical evidence. In this regard, the Board finds that that the Veteran's propensity for exaggeration and embellishment raises serious doubts as to his ability to provide reliable historical information and reflects negatively on his credibility. For example, when examined by VA in August 2002 the Veteran reported that he injured his left knee in a helicopter crash in service, had surgery on the knee and was placed in a cast for several weeks. He also reported that he suffered a laceration to the knee from flying metal after a steam pipe ruptured, and that he required sutures. On a VA outpatient note in July 2004, the Veteran reported that he suffered a shrapnel wound to the right knee in Vietnam, and on VA examination in April 2005, he reported that he fractured his right wrist in service in 1974. While the STRs showed that the Veteran was seen for left tibia and fibula pain in October 1974, the records do not show any injury or specific findings pertaining the left knee. The tibia and fibula injury was from a fall aboard ship and caused only superficial contusions and abrasions on the anterior mid-shaft area. Furthermore, x-ray studies of the left leg were negative. The STRs did not show that the Veteran required any surgical intervention or that his left leg was placed in a cast, nor do they show any treatment for a left knee injury from any type of a flying object in service. The STRs showed that the Veteran suffered a laceration to his right knee when he dropped a sander on his leg in May 1974, and that he required sutures. The injury, however, was not the result of a shrapnel wound in Vietnam or a steam pipe rupture. In fact, the record showed that the Veteran never set foot in Vietnam during his two years of service. Finally, the STRs do not show any complaints, treatment or findings for any right wrist problems in service, nor do they even remotely suggest that he fractured his right wrist. As there is no credible evidence showing a right wrist injury or disability in service, no evidence showing arthritis within one year of discharge from service, and no credible competent evidence of record suggesting continuity or a causal connection between the Veteran's current right wrist disability and service, the Board finds no basis for a favorable disposition of the Veteran's claim. Accordingly, service connection for a right wrist disability is denied. Heart Disorder The Veteran does not claim, nor do the STRs show any complaints, treatment, abnormalities or diagnosis for any heart problems in service or until more than two decades after service. Rather, the Veteran contends that service connection should be established for heart disease secondary to his service-connected PTSD. In this regard, while the Veteran believes that his current heart disease is related to his service-connected PTSD, he has not provided any competent medical evidence to support that assertion. Regarding the Veteran's and his wife's personal hearing testimony as well as the appellant's written contentions, while the Veteran is competent to describe his experiences and symptoms and his wife is competent to describe what she sees, the etiology of the current heart disorder may not be diagnosed via lay observation alone and they have not been shown to have the expertise to provide credible opinions concerning the complex medical question of the nature or etiology of the claimed disability. See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007); see also Woehlaert v. Nicholson, 21 Vet. App. 456 (2007); Barr v. Nicholson, 21 Vet. App. 303 (2007). Moreover, the evidence showed that the Veteran was first treated for chest pains in June 2004, and that he underwent immediate coronary artery taxus stent placement for coronary artery disease at that time. See June and July 2004 private hospital records. In October 2010, the Board remanded the appeal, in part, for a VA examination to determine the etiology of his current heart disease and specifically, whether his heart disease was proximately due to or aggravated by his service-connected PTSD. When examined by VA in July 2011, the physician indicated that the claims file was reviewed and included a discussion of the Veteran's complaints, symptoms, and medical history. The diagnoses included coronary artery disease with ischemic heart disease and bradycardia. The examiner opined that the Veteran's heart disease with status post pacemaker was not related to service and was not caused or aggravated in any measurable way by his service-connected PTSD. The examiner pointed out that there was no medical literature that linked PTSD as the etiological cause of bradycardia or CAD and opined that the Veteran's CAD was most likely secondary to several factors, including atherosclerosis, family history (of heart disease), increased body mass index (BMI) and history of tobacco abuse. The examiner also opined that the Veteran's symptomatic bradycardia was of unknown etiology and had resolved after pacemaker installation. On VA psychiatric examination in March 2012, the examiner indicated that the claims file was reviewed and included a discussion of the Veteran's complaints, medical history, and the clinical findings on examination. The examiner opined that it was less likely than not that the Veteran's heart disease was proximately due to, the result of, or aggravated by his PTSD. The examiner indicated that there was no current medical literature that PTSD causes coronary artery disease or any evidence suggesting the possibility of developing heart problems as a result of PTSD. The examiner noted that the Veteran had multiple risk factors for CAD, including diabetes mellitus type II, hyperlipidemia, a history of smoking and alcohol use, hypercholesterolemia with poor medication compliance, and the natural aging process. Extrapolating all known risk factors for CAD, the examiner opined that the Veteran's heart disease, including status post pacemaker with multiple stent placement was not caused or permanently aggravated by his PTSD, and was at least as likely as not the result of his positive risk factors. The examiner commented that her opinion was based on an extensive review of the claims file, including mental health records, medical examinations and previous objective testing, as well as her experience, training and diagnostic clinical interview of the Veteran. In this case, the Board finds the July 2011 and March 2012 VA opinions the most persuasive evidence of record as they were based on a thorough review of the record and included a detailed discussion of all relevant facts. The examiners offered a rational and plausible explanation for concluding that the Veteran's heart disease was not related to service and was not proximately due to or aggravated by his service-connected PTSD. See Wray v. Brown, 7 Vet. App. 488, 493 (1995); see also Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Furthermore, the Veteran has not presented any competent medical evidence to rebut these opinions. Thus, the most probative evidence of record consists of the July 2011 and March 2012 medical opinions. As there is no evidence of a heart disorder in service, no credible competent evidence of record suggesting continuity or a causal connection between the Veteran's heart disorder and service, and no competent medical evidence of a causal connection between the Veteran's current heart disease and his service-connected PTSD, the record affords no basis for a favorable disposition of this appeal. Accordingly, service connection for heart disease, including secondary to service-connected PTSD is denied. Based on the discussion above, the Board finds that the most probative evidence of record is against the claims. Therefore, the benefit of the doubt doctrine is not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER Service connection for a right wrist disability is denied. Service connection for a heart disorder, including secondary to service-connected PTSD, is denied. ____________________________________________ NEIL T. WERNER Acting Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs