Citation Nr: 1803703 Decision Date: 01/19/18 Archive Date: 01/29/18 DOCKET NO. 13-01 956 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for Raynaud's syndrome, to include as a residual of cold weather injury and as a manifestation of CREST syndrome. REPRESENTATION Appellant represented by: Matthew I. Wilcut, Attorney WITNESS AT HEARINGS ON APPEAL Appellant ATTORNEY FOR THE BOARD Joseph P. Gervasio, Counsel INTRODUCTION The Veteran, who is the appellant, served on active duty from May 2006 to September 2006. He had additional service with the National Guard. This case comes to the Board of Veterans' Appeals (Board) on appeal of a January 2011 rating decision of the Winston-Salem, North Carolina, Regional Office (RO) of the Department of Veterans Affairs (VA), which, in pertinent part, found that new and material evidence had not been received to reopen a claim of service connection for Raynaud's syndrome. In March 2015, a travel Board hearing was held before the undersigned at the Winston-Salem, North Carolina, RO. A transcript of the hearing is associated with the Veteran's claims file. The case was before the Board in June 2015. At that time, the claim of service connection for Raynaud's syndrome was reopened. The matter, which now included consideration of residuals of a cold weather injury or as a manifestation of CREST syndrome, was remanded by the Board for further development of the evidence. The case was returned to the Board, but was again remanded in August 2016 so that the Veteran could offer additional testimony at a second hearing on appeal. In July 2017, a travel Board hearing was held before the undersigned in Winston-Salem, North Carolina. A transcript of the hearing is associated with the Veteran's claims file. FINDINGS OF FACT 1. Raynaud's syndrome was not present during service and is not shown to have been caused by any in-service event. 2. Residuals of a cold injury were not evident during service and are not shown to have been caused by any in-service event. 3. CREST syndrome was not evident during service and is not shown to have been caused by any in-service event. CONCLUSION OF LAW Raynaud's syndrome, to include as a residual of cold weather injury and as a manifestation of CREST syndrome was neither incurred in nor aggravated by service. 38 U.S.C. §§ 101(21), (24); 1110 (2012); 38 C.F.R. §§ 3.6(a), (d), 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist VA's duty to notify was satisfied by a letter dated in September 2010. See 38 U.S.C. §§ 5102, 5103, 5103A (2012); 38 C.F.R. § 3.159 (2017); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). With regard to the duty to assist, the Veteran's service treatment records (STRs) and pertinent post-service treatment records have been secured. The Veteran was afforded VA medical examinations, most recently in February 2016. The Board finds that the opinions obtained are adequate. The opinions were provided by qualified medical professionals and were predicated on a full reading of all available records. The examiners also provided a detailed rationale for the opinions rendered. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008). Neither the Veteran nor the representative has challenged the adequacy of the examination obtained. Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011) (holding that the Board is entitled to presume the competence of a VA examiner and the adequacy of his opinion). Accordingly, the Board finds that VA's duty to assist, including with respect to obtaining a VA examination or opinion, has been met. 38 C.F.R. § 3.159(c)(4) (2017). Service Connection Laws and Regulations Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). For the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. With chronic disease shown as such in service, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. If a condition, as identified in 38 C.F.R. § 3.309(a), noted during service is not shown to be chronic, then generally, a showing of continuity of symptoms after service is required for service connection. 38 C.F.R. § 3.303(b). Service connection may also 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). In order to prevail on the issue of service connection, there must be medical evidence of current disability; medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and medical evidence of a nexus between the claimed in-service disease or injury and the present disease or injury. See Hickson v. West, 12 Vet. App. 247 (1990). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and an evaluation of its credibility and probative value. Baldwin v. West, 13 Vet. App. 1 (1990); 38 C.F.R. § 3.303(a). The Board has reviewed all of the evidence in the Veteran's claims file, with an emphasis on the evidence relevant to this appeal. Although the Board has an obligation to provide reasons and bases supporting its decision, there is no need to discuss, in detail, every piece of evidence of record. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000). Hence, the Board will summarize the relevant evidence where appropriate and the analysis below will focus specifically on what the evidence shows, or fails to show, as to the claim. When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C. § 5107(b) (2012); 38 C.F.R. § 3.102 (2017). When all of the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which case the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). Active military, naval, or air service includes any period of active duty for training (ACDUTRA) during which the individual concerned was disabled or died from a disease or injury incurred in or aggravated in line of duty, or any period of inactive duty training (INACDUTRA) during which the individual concerned was disabled or died from injury incurred in or aggravated in line of duty. 38 U.S.C. § 101(21), (24); 38 C.F.R. § 3.6(a), (d); Biggins v. Derwinski, 1 Vet. App. 474, 477-78 (1991). Presumptive periods do not apply to ACDUTRA or INACDUTRA. Id. Therefore, consideration of 38 C.F.R. §§ 3.307 and 3.309 (presumptive service connection for certain chronic diseases) for the periods of ACDUTRA or INACDUTRA is not appropriate. ACDUTRA is, generally, full-time duty in the Armed Forces performed by reserves for training purposes. 38 C.F.R. § 3.6(c)(1). A pre-existing disorder will be considered to have been aggravated by active military service when there is an increase in disability during service, unless there is clear and unmistakable evidence (obvious and manifest) that the increase in disability is due to the natural progress of the disorder. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(a), (b) (2017). Aggravation of a pre-existing condition may not be conceded where the disability underwent no increase in severity during service on the basis of all the evidence of record pertaining to the manifestations of the disability prior to, during, and subsequent to service. 38 U.S.C. § 1153; 38 C.F.R. § 3.306(b). Lay statements may support a claim for service connection by establishing the occurrence of lay-observable events or the presence of disability or symptoms of disability subject to lay observation. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed Cir. 2007); Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), they are not competent to provide opinions on medical issues that fall outside the realm of common knowledge of a lay person. See Jandreau, 492 F.3d 1372. Competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). Raynaud's Syndrome, to include as a Residual of Cold Weather Injury and as a Manifestation of CREST Syndrome The Veteran contends that service connection should be established for Raynaud's syndrome that later developed into CREST syndrome that he asserts is the result of a cold weather injury that he sustained during service. During the Board hearings before the undersigned, the Veteran testified that he believed that this disorder is the result of exposure to cold while in service. Specifically, he stated that he sustained a frostbite injury while on reserve duty in February 2007. After review of the record, the Board finds that neither Raynaud's nor CREST syndromes were manifested during service and are related to any incident in service. Moreover, there is no indication that the Veteran had residuals of a cold weather injury that may have been sustained during service. It is initially noted that review of the Veteran's STRs shows no evidence that he manifested Reynaud's or CREST syndrome during service or that he sustained a chronic cold weather injury that resulted in residual disability while performing ACDUTRA or INACDUTRA. The record shows that private treatment records dated in March 2007 showed a diagnosis of Reynaud's phenomenon. At that time, the Veteran reported having had poor circulation to the hands and feet for the "past couple months." He had cool touch and a bluish color to the hands and feet. He reported that pinkness came back when he heated his hands up, but that the color changed when he got cold. An examination was conducted by VA in January 2009. At that time, the Veteran related that he had been diagnosed with Raynaud's syndrome while in Michigan in 2006. He stated that he had been working in cold weather when his fingers turned dusky blue and hurt. He was evaluated and told that he had Raynaud's syndrome and advised to take aspirin. The Veteran reported that this continued when temperatures dropped below 50 degrees. He described the pain as numb and achy. He was currently employed making tires and stated that cold water caused his symptoms. On examination, the skin was warm and capillary refill was brisk. Skin color was normal. Pulses were strong. Hair growth was noted on the knuckles. Allen's test was negative. There was no evidence of skin atrophy, ulceration, edema, or dermatitis. The diagnosis was Raynaud's syndrome. In February 2015 statements, the Veteran's mother and a fellow serviceman both indicate that the Veteran sustained a cold weather injury during a drill in February 2007. Since that time, the Veteran's mother stated that she had witnessed the Veteran's fingers turning blue at times. This was accompanied by pain, a red rash on the face and complications with acid indigestion. Examinations were conducted by VA in February 2016. Regarding the diagnosis of Reynaud's syndrome, the examiner noted the Veteran reported that he began noticing a bluish tint to his fingertips without pain in 2006 during a period when he was not on active duty, ACTUTRA or INACDUTRA. The Veteran reported that during severe cold weather while at drill in February 2007, the Veteran suffered a "cold weather injury" that he described as numbness and tingling in his hands. He noted that his fingers were bluish in color. He stated that he was treated by putting his hands and feet in room temperature water for 10 minutes. After his hands were rewarmed, his hands were red and painful. After this incident, he began having daily episodes of pain with blue discoloration and numbness in the hands and fingertips. The examiner was requested to render an opinion regarding whether it was at least as likely as not that during the Veteran's active duty, ACDUTRA or INACDUTRA, he sustained Raynaud's syndrome or had suffered a cold injury resulting in Raynaud's syndrome or CREST syndrome. After examination, the examiner opined that it was less likely than not that the claimed conditions were incurred in or caused by the claimed, in-service injury, event or illness. The rationale was that the Veteran clearly described the onset of Raynaud's syndrome after he had completed active duty training, during a period when he was not on active duty, ACDUTRA, or INACDUTRA. This history was consistent with the history given to previous examiners. The Veteran had typical digital ulcers with scaring and neuropathy of the thumbs due to Raynaud's, but given that the onset of the Raynaud's was not during an applicable period of service and had occurred before the claimed cold injury in February 2007, it was less likely than not that the syndrome was incurred in or caused by his period of service. Regarding CREST syndrome, it was noted that Raynaud's can often be the earliest sign of CREST, but that lay evidence from the Veteran's mother described that the Veteran had frequent symptoms after a period of symptoms in February 2007, but she did not mention the onset of symptoms. Additional signs of CREST did not occur during a period of service and, while the Veteran's mother mentioned a "red rash" of telangiectasia and complaints of reflux, she did not give a time frame and the Veteran's own history placed the appearance of these symptoms after this time, which was not during a period of service. In addition, CREST is an autoimmune condition and, while the underlying cause is unknown, the current medical literature did not support any relationship to cold exposure. Therefore, because Raynaud's and other signs of CREST appeared outside a period of service and there was no demonstrated relationship between cold exposure and the development of CREST, it was less likely than not that the Veteran's CREST syndrome with gastroesophageal reflux disease, Raynaud's, chondrocalcinosis, and telangiectasia was incurred in or due to service. Regarding the contentions related to a residuals of a cold injury, specifically in February 2007, it was noted that there was no medical documentation in the record regarding this injury. There was lay evidence supporting the incurrence of an injury for which the Veteran received treatment, but, while this was found to document medical treatment, it was not competent to diagnose a cold injury. The Veteran described his hands as developing numbness, tingling, and pain, with the fingers turning blue. The examiner stated that a blue appearance of the skin is not typical of a cold injury. Rather the skin is found to be white and waxy. Non-freezing cold injuries are also characterized by white/blanched skin. A cold injury and attack of Raynaud's vasospasm brought on by cold can be differentiated on the basis of the blue appearance of the skin. A blue appearance of the skin does not occur in a direct cold injury except after re-warming, although a red appearance is more typical. The examiner stated that, given the subtlety of differentiation of these two conditions, it was understandable that a lay person would call an attack of Raynaud's precipitated by cold, a cold injury when it is not. The absence of white, blanched skin and the presence of a blue appearance of the fingers supported a diagnosis of Raynaud's and excluded a diagnosis of cold injury. As there was no cold injury that damaged the skin or supporting structures directly due to the effect of cold exposure, the Veteran's claimed condition of cold injury, now diagnosed as Raynaud's syndrome, was less likely than not incurred in or due to service. The examiner also rendered an opinion, in light of some of the statements made by the Veteran, regarding whether a pre-existing Raynaud's syndrome could have been aggravated by service. The examiner opined that the Raynaud's symptoms would have likely progressed into CREST regardless of any other factors. Therefore, it was less likely than not that the Veteran's CREST syndrome, first manifested as Raynaud's, was aggravated beyond its nature progression by cold exposure or other aspects of the Veteran's service. The rationale was that there was no evidence that the Veteran had actually sustained an actual cold injury, specifically damage to the skin due to cold exposure. Rather the episode in service was that of vasospasm due to Raynaud's syndrome triggered by cold exposure. The symptoms of Raynaud's that occurred in service had completely resolved and there are no reports in the medical literature of Raynaud's syndrome being permanently worsened by cold exposure. Therefore, it was less likely than not that the Veteran's Raynaud's was aggravated beyond the natural progression by cold exposure or other aspects of the Veteran's service. The record shows that the Veteran did not report symptoms of Raynaud's syndrome while he was performing active duty, ACDUTRA or INACDUTRA. Rather the disorder post-dated his brief period of active service and is not shown to have been incurred while he was on active duty or during a period of ACDUTRA or INACDUTRA. Significantly, the only medical opinions in the record are that there is no relationship between the development of Reynaud's and CREST syndrome and service, including whether these disorders may have been aggravated by a cold injury in February 2007, which is one of the main contentions on which the Veteran testified at the Board hearings in the record. The rationale regarding this, that the Veteran did not actually show symptoms of a cold injury, specifically blanching of the skin, but rather symptoms of an exacerbation of his Raynaud's syndrome, specifically a blueish coloring of the skin, is adequate. Given the very persuasive medical opinion in the record, the Board finds that a preponderance of the evidence is against the Veteran's claim so that it must be denied. Because the preponderance of the evidence is against the claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107; 38 C.F.R. § 3.102. ORDER Service connection for Raynaud's syndrome, to include as a residual of cold weather injury and as a manifestation of CREST syndrome, is denied. ____________________________________________ BARBARA B. COPELAND Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs