Citation Nr: 1627311 Decision Date: 07/08/16 Archive Date: 07/14/16 DOCKET NO. 09-41 364 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for a respiratory disorder, to include asthma and residuals of pneumonia. 2. Entitlement to service connection for bilateral carpal tunnel syndrome. 3. Entitlement to service connection for diverticulosis, to include as secondary to service-connected peptic ulcer disease. REPRESENTATION Appellant represented by: The American Legion WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD L. Kirscher Strauss, Counsel INTRODUCTION The Veteran apparently had active service from July 1979 to April 1984. The Board was not able to locate his DD Form 214 in the claims file. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a July 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Columbia, South Carolina, which in pertinent part, denied the claims of service connection for a respiratory disorder, including asthma and residuals of pneumonia; right and left carpal tunnel syndrome; and diverticulosis. In January 2010, the Veteran testified at a hearing before RO personnel. A transcript of the hearing is associated with the electronic claims file. In May 2014, the Board remanded these issues to the agency of original jurisdiction (AOJ) for additional development. The issue of entitlement to service connection for diverticulosis is addressed in the REMAND portion of the decision below and is REMANDED to the AOJ. FINDINGS OF FACT 1. The Veteran does not have an asbestos-related disease. 2. Asthma was not shown in service or for many years thereafter, and the most probative evidence indicates that asthma was not incurred in service or otherwise medically related to service. 3. Bilateral carpal tunnel syndrome was not shown in service or for many years thereafter, and the most probative evidence indicates that carpal tunnel syndrome was not incurred in service or otherwise medically related to service. CONCLUSIONS OF LAW 1. The criteria for establishing service connection for a respiratory disorder, to include asthma and residuals of pneumonia, are not met. 38 U.S.C.A. §§ 1131, 5107 (West 2014); 38 C.F.R. § 3.303 (2015). 2. The criteria for establishing service connection for bilateral carpal tunnel syndrome are not met. 38 U.S.C.A. §§ 1131, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duties to Notify and Assist The Veterans Clams Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C.A. §§ 5103, 5103A; 38 C.F.R. § 3.159. The requirements of the statutes and regulation have been met in this case with regard to the claims being decided herein. VA notified the Veteran in March 2009 of the information and evidence needed to substantiate and complete a claim, to include notice of what part of that evidence is to be provided by the claimant, what part VA will attempt to obtain, and how disability ratings and effective dates are determined. The case was most recently readjudicated in the May 2015 supplemental state of the case (SSOC). VA fulfilled its duty to assist the Veteran in obtaining identified and available evidence needed to substantiate his claims and in substantially complying with the prior remand directives. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008). Here, in an August 2014 letter, the AOJ asked the Veteran to identify any treatment he received for respiratory disorders and arranged for additional VA examinations to evaluate the claims remaining on appeal. The Veteran was provided with VA examinations in May 2009, September 2010, and September and October 2014. For the reasons indicated in the discussion below, these examinations are adequate to decide the claims. The evidence of record also contains the Veteran's service treatment records, post-service private treatment records and medical opinions, records from the Social Security Administration (SSA), VA examination reports pertinent to other claims, and lay statements and hearing testimony. The Board acknowledges that the AOJ did not complete the development with respect to obtaining service personnel records to verify claimed exposure to asbestos. See VA Adjudication Procedures Manual, M21-1, Part IV, Subpart ii, Chapter 1, Section I, Part 3 (outlining development procedures for service connection for asbestos-related diseases). However, the Board finds the omission harmless to the Veteran because the competent medical evidence of record establishes that he does not currently have an asbestos-related disease, but instead has asthma. See id. at IV.ii.2.C.2 (listing diseases that inhalation of asbestos fibers can produce). In other words, even if the Board remanded the respiratory issue to verify the claimed asbestos exposure, the outcome would not change because the Veteran does not have an asbestos-related disease. The Board concludes that VA's duties to the Veteran have been fulfilled with respect to the service connection issues in appellate status. II. Criteria & Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. § 1131; 38 C.F.R. § 3.303. In addition, 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). To establish service connection for a present disability, there must be: "(1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Respiratory Disorder In his February 2009 claim for VA compensation benefits for "chronic asthma/pneumonia," the Veteran asserted that his disability began in September 1979 aboard the USS Savannah [sic] AFS-2 and that he had received ongoing treatment for asthma since 1980. He also asserted that his asthma disability resulted from exposure to asbestos "while in dry dock for [five] months [in] 1980." Pertinent to claims based on exposure to asbestos, there is no specific statutory or regulatory guidance with regard to claims of service connection for asbestos-related diseases. However, VA's Adjudication Procedures Manual addresses these types of claims. See M21-1, Part IV, Subpart ii, Chap. 1, Sec. I, Para. 3 [hereinafter M21-1] (M21-1, IV.ii.1.I.3), entitled "Developing Claims for Service Connection for Asbestos-Related Diseases," and M21-1, IV.ii.2.C.2 entitled "Service Connection for Disabilities Resulting from Exposure to Asbestos." The manual provisions acknowledge that inhalation of asbestos fibers or particles can result in fibrosis and tumors, and produce pleural effusions and fibrosis, pleural plaques, mesotheliomas of the pleura and peritoneum, and cancer of the lung, gastrointestinal tract, larynx, pharynx and urogenital system (except the prostate), with the most common resulting disease being interstitial pulmonary fibrosis (asbestosis). M21-1, IV.ii.2.C.2.b. The clinical diagnosis of asbestosis requires a history of exposure and radiographic evidence of parenchymal lung disease. M21-1, IV.ii.2.C.2.g. Diagnostic indicators include dyspnea on exertion, end-respiratory rales over the lower lobes, compensatory emphysema, clubbing of the fingers at late stages, and pulmonary function impairment and cor pulmonale that can be demonstrated by instrumental methods. Id. Also noted is the increased risk of bronchial cancer in individuals who smoke cigarettes and have had prior asbestos exposure. M21-1, IV.ii.2.C.2.c. Some of the major occupations involving exposure to asbestos include mining, milling, work in shipyards, insulation work, demolition of old buildings, carpentry and construction, manufacture and servicing of friction products such as clutch facings and brake linings, and others. M21-1, IV.ii.2.C.2.d. VA must determine whether military records demonstrate evidence of asbestos exposure in service; whether there is pre-service and/or post-service evidence of asbestos exposure; and then make a determination as to the relationship between asbestos exposure and the claimed disease, keeping in mind the latency and exposure factors pertinent to the veteran. M21-1, IV.ii.2.C.2.h. The Veteran's service treatment records document his military occupational specialty (MOS) as yeoman, his presence aboard the USS Sylvania from approximately May 1980 to August 1983, and his status as a non-smoker. The Board notes that the VA Adjudication Procedures Manual includes a table describing the probability of asbestos exposure by MOS. Yeoman, which is a clerical MOS, holds a minimal probability of asbestos exposure. M21-1, IV.ii.1.I.3.c. The Veteran's service treatment records are silent for complaints, diagnosis, or treatment for asthma or a chronic respiratory disorder. In a July 1979 enlistment medical history report the Veteran denied currently or ever having asthma, shortness of breath, pain or pressure in his chest, or chronic cough. On enlistment examination the same day, the lungs and chest were normal on clinical evaluation and a chest x-ray was reported as negative. The report of an October 1980 chest x-ray, which was performed to rule out pneumonia, described a calcified granuloma right lower lobe; peribronchial infiltrate seen with an interstitial component left lower lobe as well as a right infrahilar region; and no effusion. During follow-up the next day for complaints of cough, sputum, chills, and runny nose for the past three days, the assessment was upper respiratory infection; possible bronchitis, resolving. Subsequent records dated in 1980 documented evaluation and treatment for viral pharyngitis, viral syndrome with elevated temperature, and costochondritis. An April 1983 emergency care and treatment record reflects that the Veteran presented with complaints of chills, nausea, emesis, and general malaise and body aches. A chest x-ray revealed right middle lobe infiltrate. The diagnosis was pneumonia, right middle lobe; questionable mycoplasma. During follow-up treatment two days later, the assessment was right middle lobe pneumonia, resolving. In August 1983, the Veteran complained of cold symptoms. Examination findings of the lungs included no rubs, rhonchi, or wheezing. He was prescribed Sudafed and Robitussin DM for an upper respiratory infection. In February 1984, he complained of stuffy nose, sore throat, and nausea and vomiting. He denied any previous problems with his respiratory system. On examination, the chest was clear to auscultation. The assessment was viral syndrome versus influenza syndrome. On separation examination in April 1984, the Veteran's lungs and chest were normal on clinical evaluation. A chest x-ray was reported as within normal limits, but noted an approximately 4 mm calcified granuloma in the right lung base. The examiner noted that the Veteran had been treated for pneumonia two [sic] years earlier and at present the Veteran had no complaints or no sequelae (abbreviated as "NCNS"). Private treatment records dated in January and February 2007 from W. Miller, M.D., document a reported past medical history of asthma with current medications including Advair and Theophylline. Reported objective findings included normal respiratory effort and lungs normal to auscultation. The assessment was asthma. Similarly, during a new patient visit with H. Allen, M.D., the Veteran reported a history of asthma, being a non-smoker, and using Advair and Theophylline. During a June 2008 examination performed in connection with a claim for SSA disability benefits, the Veteran described having asthma as a child with occasional attacks that began to recur approximately 10 years earlier [in 1998]. He denied any hospitalization for asthma or any shortness of breath and reported he could walk several blocks without difficulty. The Veteran was afforded a VA respiratory examination in May 2009. He reported a history of childhood asthma with the last asthma attack occurring five years prior to joining the navy, with no recurrence until 1999. He described having exacerbations every three to four years with the last attack in January 2009. The examiner noted that the Veteran was treated for pneumonia on active duty and had a calcified granuloma within the right lung base, which he noted was "most likely secondary to prior granulomatous disease." The Veteran denied any exposures to asbestos, chemicals, or fumes and identified his occupation as a yeoman during military service and a truck driver after service. Regarding respiratory symptoms, the Veteran endorsed moderate dyspnea and also reported a 74-pound weight loss due to vigorously trying to lose weight. Examination findings included the following: lungs clear to auscultation; no condition of the chest or spine that would cause a restrictive disease; and heart with regular rate without murmurs. Pulmonary function testing revealed normal lung capacity and spirometry. The diagnosis was asthma, currently well-controlled with Theophylline and Advair. In September 2009 correspondence, the Veteran stated that as a child he had several bouts of pneumonia and was on an inhaler for asthma, which he outgrew prior to entering military service. He recounted working on board the USS Sylvania while it was in dry dock for a few months in 1981 for a complete refit. He asserted that "asbestos dust was in the air" he breathed and it was "responsible for my relapse of asthma that I was diagnosed with back in the mid-1990s." During the January 2010 hearing, the Veteran testified that he had asthma flare-ups during periods of cold weather during service, but they did not last long; taking a break would cause the symptoms to go away. He testified that he never went to sick bay because he did not think it was a "big deal." He also recalled having at least three bouts of pneumonia during service and a military doctor telling him his childhood history of pneumonia and asthma may be triggering his pneumonia. Finally, he testified that after service he was diagnosed with asthma in 2001 or 2002 and that his asthma would come and go with cold weather. In a February 2010 letter, H. Allen, M.D., indicated he "thoroughly reviewed the records" of the Veteran and with "regard to specific questions asked," offered several opinions. Dr. Allen related that the Veteran reported a history of asthma and had been on a combination of Advair and Theophylline. In reviewing the Veteran's records, Dr. Allen could "find no incidents of asthmatic episodes or flareups. There is no mention of wheezing, cough, or shortness of breath in any of the records reviewed. There is a documented episode of pneumonia in 1983 or [19]84. There is no evidence that this exacerbated any underlying or pre-existing lung disease." During a September 2014 VA respiratory examination, the Veteran reported a long-standing history of asthma that started in service, stating he worked on a ship with asbestos in 1981. The diagnosis was asthma and the examiner indicated the Veteran did not have any other respiratory or pulmonary conditions. Following a review of the claims file, the examiner opined that it was less likely than not that the Veteran's current asthma is related to service. In support of his conclusion, the examiner noted that there was a lack of evidence in the claims file to suggest a service causality of asthma, and asbestos exposure was highly unlikely given the dates in service. The Veteran was afforded a final VA respiratory examination in October 2014. He reported a childhood history of asthma, which he outgrew, and having pneumonia five or six times during military service. He stated that except for having some occasional breathing problems, he did well after service until roughly 2001 when he was diagnosed with asthma. A chest x-ray was performed for "asthma with unlikely asbestos exposure in 1981" and reported findings included clear lung fields and cardiac silhouette within normal limits. The impression was chest within normal limits. The diagnosis was asthma and the examining VA physician indicated that the Veteran had no other respiratory or pulmonary conditions. The examiner noted that the Veteran was treated for pneumonia while in the military and was later diagnosed with asthma. The examiner remarked that the pulmonary function tests obtained in 2009 were normal and the current chest x-ray was normal. The examiner explained that there is no evidence that pneumonia will lead to asthma, and therefore, opined that the Veteran's asthma is less than likely related to or incurred in the military when treated for pneumonia. Having considered the medical and lay evidence of record, the Board finds the preponderance of the evidence is against the claim of entitlement to service connection for a respiratory disorder, to include asthma or residuals of pneumonia. The Board finds that the first element necessary to establish service connection, a current disability, is established because competent medical evidence of record from private treatment providers and the VA respiratory examinations establishes that the Veteran has a current asthma disability. See Shedden, 381 F.3d at 1167. Next, the Board must consider whether there is competent and credible evidence of in-service incurrence or aggravation of a disease or injury. Considering the Veteran's condition upon entrance to military service, the Board finds that a respiratory disability was not noted upon entrance examination. The presumption of soundness thus attached. 38 U.S.C.A. § 1111 (West 2014). To rebut the presumption of soundness, it must be shown by clear and unmistakable evidence that a respiratory disability preexisted service. VAOPGCPREC 3-2003. The clear and unmistakable evidence standard requires that the result be undebatable. Cotant v. West, 17 Vet. App. 116, 131 (2003). The Board concludes that this standard is not met. In this regard, while the Veteran has reported having had asthma as a child that he outgrew prior to entering military service and several bouts of pneumonia as a young child, the evidence of record does not include competent medical evidence clearly and unmistakably documenting any preexisting respiratory disability, including asthma or residuals of pneumonia. As a result, the Veteran was presumed sound at entrance examination and the question becomes whether the current respiratory disorder, asthma, was incurred in or otherwise related to military service. In any event, given the Board's finding below that a respiratory disorder was not incurred in service, further discussion of the presumption of soundness is unnecessary. Gilbert v. Shinseki, 26 Vet. App. 48, 52 (2012) ("before the presumption of soundness is for application, there must be evidence that a disease or injury that was not noted upon entry to service manifested or was incurred in service"). The Board has considered the Veteran's contentions that his asthma began or recurred in September 1979 (Feb. 2009 claim), that he had flareups of asthma during service and intermittent symptoms of asthma after service until he was diagnosed with asthma in 2001 (Jan. 2010 DRO Hearing Transcript), and that his claimed exposure to asbestos in service caused his relapse of asthma in the 1990s (Sept. 2009 Veteran statement). In adjudicating this claim, the Board must assess the Veteran's competence and credibility. Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). In Barr v. Nicholson, 21 Vet. App. 303 (2007), the Court emphasized that lay testimony is competent if it is limited to matters that the witness has actually observed and is within the realm of the witness's personal knowledge. See also 38 C.F.R. § 3.159(a)(2) (competent lay evidence means any evidence not requiring that the proponent have specialized education, training or experience. Lay evidence is competent if it is provided by a person who has knowledge of the facts or circumstances and conveys matters that can be observed and described by a lay person). In this capacity, the Board finds the Veteran competent to identify symptoms of asthma or other respiratory disorder symptoms, such as shortness of breath or wheezing, as well as the onset and continuity of such symptomatology. Moreover, lay witnesses are competent to opine as to some matters of diagnosis and etiology, and the Board must determine on a case by case basis whether a veteran's particular disability is the type of disability for which lay evidence is competent. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). In this case, the Board finds that the Veteran is not competent to diagnose asthma or other respiratory disorders, as these are diseases that are identified via X-rays or pulmonary function testing, and their nature and etiology relate to an internal medical process which extends beyond an immediately observable cause-and-effect relationship and are of the type that the courts have found to be beyond the competence of lay witnesses. Compare Jandreau v. Nicholson, 492 F.3d 1372, 1376 (Fed. Cir. 2007) (lay witness capable of diagnosing dislocated shoulder); Barr v. Nicholson, 21 Vet. App. 303, 308-9 (2007); Falzone v. Brown, 8 Vet. App. 398, 403 (1995) (lay person competent to testify to pain and visible flatness of his feet); with Clemons v. Shinseki, 23 Vet. App. 1, 6 (2009) ("It is generally the province of medical professionals to diagnose or label a mental condition, not the claimant"); Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (unlike varicose veins or a dislocated shoulder, rheumatic fever is not a condition capable of lay diagnosis); Jandreau, 492 F.3d at 1377, n.4 ("sometimes the layperson will be competent to identify the condition where the condition is simple, for example a broken leg, and sometimes not, for example, a form of cancer"). To the extent the Veteran asserts that his current asthma disability began in September 1979, that he had flareups of asthma during service for which he did not seek treatment, and that symptoms of asthma would come and go after service, the Board finds his statements are not credible because they conflict with the other evidence of record. Most significantly, on the April 1984 separation examination, the Veteran specifically denied having any complaints or sequelae with regard to his in-service pneumonia. Had the Veteran experienced any asthma-related symptoms such as breathing difficulty, it would be expected that such would have been noted in connection with a disorder affecting the respiratory system such as pneumonia. See Buczynski v. Shinseki, 24 Vet. App. 221, 224 (2011) (citing Fed. R. Evid. 803(7) for the proposition that the absence of an entry in a record may be evidence against the existence of a fact if it would ordinarily be recorded). Moreover, the separation examiner specifically found that there were no sequelae associated with the Veteran's pneumonia. Similarly, although he testified that symptoms of asthma would come and go after service, in multiple prior statements he described the initial recurrence of childhood asthma occurring in 1998 (June 2008 SSA examination), 1999 (May 2009 VA examination), and the mid-1990s (Sept. 2009 Veteran statement), and being clinically diagnosed with asthma in 2001. Because these prior statements regarding the recurrence of his asthma during the 1990s are consistent, the Board finds them more credible and persuasive than subsequent statements and testimony suggesting that he experienced asthma symptoms during service that continued intermittently after service to the present time. Moreover, the contemporaneous statements made to the health care providers are of more evidentiary weight than those made years later during the course of an appeal from the denial of compensation benefits. See Fed. R. Evid. 803(4) (recognizing that statements made for the purpose of medical treatment generally are reliable); Pond v. West, 12 Vet. App. 341, 345 (1999) (interest may affect the credibility of testimony). In addition, the Board concludes that these consistent statements along with the other evidence indicating that the Veteran did not have a chronic asthma disability during service or for many years thereafter, weigh against a conclusion that the Veteran's asthma was incurred in or related to military service. The lack of any evidence of continuing asthma or respiratory symptoms for many years between the period of active duty and the initial findings or documented complaints of asthma weighs against the claim when considered with the other evidence discussed above. A prolonged period without medical complaint can be considered, along with the other factors discussed above, as evidence of whether a disability was incurred in service or whether an injury, if any, resulted in any chronic or persistent disability which still exists currently. Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000). The only medical opinions to address the etiology of the current asthma disability are from the Veteran's private physician, H. Allen, M.D., the September 2014 VA examiner, and the October 2014 VA examiner. The Board finds these opinions persuasive and probative against the claim for service connection because each was based on a review of service treatment records, physical examination, and supported by an articulated medical explanation that is consistent with the remaining records. The VA examiners also reviewed the entire claims file. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008) (holding that it is the factually accurate, fully articulated, sound reasoning for the conclusion that contributes to the probative value to a medical opinion). As detailed, Dr. Allen apparently had an opportunity to review the Veteran's service treatment records and found no in-service incidents of asthmatic episodes or flareups; no mention of wheezing, cough, or shortness of breath; and no evidence that the documented episode of pneumonia exacerbated any underlying or pre-existing lung disease. The September 2014 examiner also reviewed the claims file and found the Veteran's asthma to be less likely than not related to service because the claimed asbestos exposure was highly unlikely and there was no other evidence of causality of asthma in the claims file. Finally, the October 2014 examiner reached a similar conclusion, determining that the only current disability found on examination, asthma, was less than likely related to or incurred in service because pneumonia, for with the Veteran was treated once in service, is not known to lead to asthma. The Board accepts these private and VA medical opinions as being the most probative medical evidence on the subject, as they were based on a review of available historical records and each contains a rationale for the medical conclusion that is consistent with and supported by the record. See Boggs v. West, 11 Vet. App. 334 (1998). The private physician and VA examiners were aware of the Veteran's treatment for pneumonia in service and contentions regarding the current asthma disability, but concluded that an asthma disability did not manifest during service and was not related to his in-service episode of pneumonia. The Veteran's contentions are outweighed by the medical evidence and opinions of Dr. Allen and the VA medical examiners, which reflect that he does not have a current asbestos-related disease and that the current asthma disability that manifested ten or more years after separation from service was not incurred in or otherwise related to military service. For the foregoing reasons, the preponderance of the evidence is against the Veteran's claim for entitlement to service connection for a respiratory disorder, including asthma and residuals of pneumonia. The benefit of the doubt doctrine is thus not for application, and the claim must be denied. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. Carpal Tunnel Syndrome The Veteran reports that his duties as a Navy yeoman for five years involved repetitive motion, typing on an electric typewriter, manually writing, and keyboarding. He indicates that after service he worked as a long-distance truck driver, which required completing daily log books, reports and paperwork, bills of ladings, etc. He consistently states that he was diagnosed with bilateral carpal tunnel syndrome in August 2001, more than 17 years after separation from service. He believes that his bilateral carpal tunnel syndrome may be related to his duties during military service. See Veteran correspondence received Sept. 29, 2009. The Veteran's service treatment records are silent for complaints, diagnosis, or treatment for carpal tunnel syndrome or problems with his hands or wrists. An August 1979 submarine training examination report documents his weight as 176 pounds. A November 1983 nutrition note documents his weight as 215.5 pounds and a treatment record approximately two weeks later in November 1983 reflects the Veteran's report that he had gained 6 to 8 pounds in the past week and had a family history of the males being overweight. The impression was exogenous obesity. On separation examination in April 1984, the Veteran's upper extremities and neurological function were reported as normal on clinical evaluation and his weight was recorded as 220 pounds. An October 2005 private treatment record from D. Bullard, M.D., indicates that the Veteran had been diagnosed with bilateral carpal tunnel syndrome, right greater than left. His weight was recorded as 255 pounds. During a May 2007 new patient visit with H. Allen, M.D., the Veteran disclosed a history of carpal tunnel syndrome and indicated he was a retired truck driver on disability due to numerous musculoskeletal problems. He also reported being diagnosed in 2002 with rheumatoid arthritis, although he never saw a rheumatologist. His weight was recorded as 263 pounds. An August 2008 treatment record from Dr. Allen notes the Veteran's previous report of having been diagnosed with rheumatoid arthritis, but documents that rheumatoid factor was negative when tested. Dr. Allen commented that the Veteran "probably has an element of fibromyalgia contributing to his generalized pain." During the January 2010 hearing, the Veteran testified that he was diagnosed with carpal tunnel syndrome in both hands in 2001. He described his military duties as a yeoman involving typing, repetitive motion, and a lot of paperwork. In February 2010 correspondence, H. Allen, M.D., indicated he had "thoroughly reviewed" the Veteran's records and in response to specific questions opined that it was unlikely that the Veteran's carpal tunnel syndrome is related to his military service 25 years earlier. In support of his conclusion, Dr. Allen pointed out that he could find no documentation that the Veteran's carpal tunnel syndrome had ever been investigated and there were no reports of nerve conduction studies. Dr. Allen acknowledged that carpal tunnel syndrome may be caused by repetitive motion, but explained that "once that motion ceases, the carpal tunnel symptoms usually resolve." He added that carpal tunnel symptoms "are often precipitated by significant weight gain, which is documented in [the Veteran's] records." In March 2010 correspondence, the Veteran's private chiropractor, B. Wenner, D.C., also offered an opinion regarding the etiology of the Veteran's carpal tunnel syndrome. Dr. Wenner noted that "carpal tunnel syndrome has been linked to repetitive use of the wrist or while typing and holding the carpal bones in a compromising position." Dr. Wenner opined that the Veteran's "use of a keyboard while in the service, without proper care of his extremity joints, as likely as not, would have been a major contributor to his joint and nerve pain." During a September 2014 VA examination of his wrists, the Veteran reported typing in service and denied having wrist issues while in service. He stated he drove a truck for 22 years after leaving service and that he was diagnosed with bilateral carpal tunnel syndrome in 2001. The examiner remarked that Tinel's and Phalen's tests were negative, bilateral hand and wrist nerve examination was normal, and that the Veteran denied "having much problem these days with [carpal tunnel syndrome]." Following a review of the electronic claims file, the examiner opined it was less likely than not that bilateral carpal tunnel syndrome was caused by an in-service injury, event, or illness. Instead, the examiner explained that the carpal tunnel syndrome was most likely due to 20-plus years as a truck driver after leaving service and that this conclusion was congruent with the medical literature. The Veteran was afforded a VA peripheral nerves examination in October 2014. He indicated he was diagnosed with carpal tunnel syndrome in 2001 after having been a truck driver for the previous 19 years. He identified his military occupation as a processor and doing a lot of typing. Following a review of the electronic claims file and examination of the Veteran, the examiner opined that it is likely that the Veteran's repetitive movements with truck driving contributed to his carpal tunnel syndrome more than his typing performed 20 [sic] years earlier while in the military service. In support of the conclusion, the examiner emphasized that the Veteran was diagnosed with carpal tunnel syndrome in 2001 and had left the military roughly 20 years earlier. The examiner also observed that the Veteran had been told by another doctor that he had rheumatoid arthritis, which the examiner explained is a known cause of carpal tunnel syndrome as well. Considering the medical and lay evidence of record, the Board finds the preponderance of the evidence is against the claim of service connection for bilateral carpal tunnel syndrome. In this case, the Veteran's upper extremities and neurological function were normal on separation examination in April 1984 and in his February 2009 claim for VA compensation benefits, he reported that his carpal tunnel syndrome began in August 2001. Consistent with his service treatment records, he also denied experiencing wrist problems during service at the VA examination in September 2014. Therefore, while Veteran was required to perform repetitive work in his military duties as a yeoman, the medical and lay evidence of record reflects that he did not experience symptoms of carpal tunnel syndrome during service or for many years after separation from service. Thus, to the extent that carpal tunnel syndrome can be considered a chronic disease because it is an organic disease of the nervous system, neither chronicity nor continuity of symptomatology have been shown. 38 U.S.C.A. §§ 1101(3), 1112(a)(1), 1137 (West 2014); 38 C.F.R. §§ 3.303(b), 3.307(a), 3.309(a) (2015); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Turning to the medical opinion evidence, the Board finds that the March 2010 opinion from the Veteran's chiropractor, B. Wenner, D.C., is entitled to little, if any, probative value because it was unsupported by a rationale and did not address the repetitive activity associated with the Veteran's occupation as a truck driver contemporaneous in time to mid-1990s manifestations or the 2001 diagnosis of carpal tunnel syndrome. See Nieves-Rodriguez, 22 Vet. App. at 203 (describing contributions to the probative value of a medical opinion). In comparison, the Board finds persuasive the opinions from Dr. Allen and the two VA examiners because they were based on a review of service treatment records, the entire claims file (in the case of the VA examiners), physical examination, and articulated medical rationales that are consistent with the remaining record. For example, Dr. Allen and both VA examiners attributed the Veteran's carpal tunnel syndrome, which was diagnosed in 2001 more than 17 years after separation from service, to his contemporaneous repetitive-use activities associated with his occupation as a truck driver. In addition, Dr. Allen's suggestion that the Veteran's carpal tunnel syndrome is associated with the documented significant weight gain is consistent with the record, which reflects a 43-pound weight gain between separation from service and the initial visit with Dr. Allen in May 2007 and a 44-pound weight gain during military service. Moreover, Dr. Allen's remark that carpal tunnel symptoms usually resolve once the repetitive activity or motion ceases appears consistent with the Veteran's report on VA examination in September 2014 that he had not had much problem with carpal tunnel syndrome recently and other evidence that he had retired from truck driving. For the foregoing reasons, the Board finds that the opinions of Dr. Allen and the 2014 VA examiners outweigh the opinion by Dr. Wenner and the Veteran's lay assertions claiming a link between the carpal tunnel syndrome that manifested in the 1990s and the repetitive activities performed in service. As the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102. ORDER Service connection for a respiratory disorder, to include asthma and residuals of pneumonia, is denied. Service connection for bilateral carpal tunnel syndrome is denied. REMAND The Veteran seeks service connection for diverticulosis. In his February 2009 claim and in other statements, he reported that his diverticulosis began in April 2004. His service treatment records reflect some complaints of diarrhea and abdominal pain or cramping; however, those complaints were attributed to gastroenteritis, viral syndrome, and anxiety versus possible alcohol withdrawal. The records are silent for complaints of rectal bleeding or testing, diagnosis, or treatment for diverticulosis. On separation examination in April 1984, the abdomen and viscera were reported as normal on clinical evaluation. The report of an April 2005 air-contrast barium enema (lower gastrointestinal (GI) tract radiography) noted a clinical history of blood in stool and history of motor vehicle accident. The impression included mild diverticulosis at junction of descending and sigmoid colon; no evidence of diverticulitis. During an October 2014 VA intestinal examination, the Veteran related that his private physician believed the diverticulosis was related to service-connected peptic ulcer disease. Unfortunately, the evidence of record does not include a medical opinion addressing diverticulosis from the Veteran's private physician, H. Allen, M.D., and the medical opinion provided by the VA examiner did not address service connection for diverticulosis on a secondary basis. Therefore, remand is necessary to obtain an additional medical opinion. Accordingly, the claim for entitlement to service connection for diverticulosis is REMANDED for the following action: 1. Provide notice to the Veteran regarding the information and evidence necessary to establish service connection on a secondary basis. 2. With any necessary assistance from the Veteran, obtain any VA or private treatment records, including from his private physician, H. Allen, M.D., pertinent to his claimed diverticulosis disability and service-connected peptic ulcer disease. 3. After completing the above development, arrange for a VA intestinal examination to evaluate the claimed diverticulosis disability. The electronic claims file must be made available to the examiner, and the examiner must specify in the examination report that the claims file has been reviewed. All necessary testing should be accomplished and reports of any testing should be associated with the examination report. The examiner is asked to provide an opinion as whether it is at least as likely as not (a 50 percent or greater probability) that the Veteran's diverticulosis (or any diverticular disease or diverticulitis) was either (a) caused by service-connected peptic ulcer disease or (b) aggravated by peptic ulcer disease. If aggravated, specify the baseline of disability prior to aggravation, and the permanent, measurable increase in disability resulting from the aggravation. The examiner should also indicate whether it is at least as likely as not that diverticulosis (or any diverticular disease or diverticulitis) is related to service. A medical analysis and rationale are to be included with all opinions expressed. 4. After undertaking any other development deemed appropriate, the AOJ should readjudicate the claim of entitlement to service connection for diverticulosis, to include as secondary to service-connected peptic ulcer disease. If the benefit sought is not granted in full, the Veteran and his representative should be furnished with a supplemental statement of the case and afforded an appropriate period of time for response. Thereafter, the case should be returned to the Board, if in order. The Veteran has the right to submit additional evidence and argument on the matter the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West 2014). ______________________________________________ Jonathan Hager Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs