Citation Nr: 18142151 Decision Date: 10/16/18 Archive Date: 10/12/18 DOCKET NO. 12-25 646 DATE: October 16, 2018 ORDER Entitlement to service connection for hepatitis C is denied. Entitlement to service connection for carpal tunnel syndrome of the right hand is denied. FINDINGS OF FACT 1. The Veteran’s current hepatitis C did not manifest in service and is not otherwise etiologically related to his military service. 2. The Veteran’s current carpal tunnel syndrome of the right hand did not manifest in service and is not otherwise etiologically related to his military service. CONCLUSIONS OF LAW 1. Hepatitis C was not incurred in active service. 38 U.S.C. §§ 1110, 1154, 5103, 5103A, 5107 (2012); 38 C.F.R. § 3.102, 3.159, 3.303 (2017). 2. Carpal syndrome of the right hand was not incurred in active service. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Air Force from June 1975 to March 1979. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a March 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Newark, New Jersey. The Veteran testified at a hearing before the undersigned Veterans Law Judge in November 2013. A transcript is of record. The Board remanded the case for further development in January 2014 and August 2017. That development was completed, and the case has since been returned to the Board for appellate review. Law and Analysis Service connection may be established for disability resulting from personal injury suffered or disease contracted in line of duty in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. That an injury or disease occurred in service is not enough; there must be chronic disability resulting from that injury or disease. 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). The disorders at issue in this case are not considered chronic diseases as enumerated for VA compensation purposes. As such, the provisions for continuity of symptomatology after discharge are not for application in this case. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Recognized risk factors for contracting the hepatitis C virus (HCV) include intravenous drug use, blood transfusions before 1992, hemodialyses, intranasal cocaine use, high risk sexual activity, accidental exposure while a health care worker, and various kinds of percutaneous exposure such as tattoos, body piercing, acupuncture with non-sterile needles, and shared toothbrushes or razor blades. See VBS Fast Letter 211B (98-110) (November 30, 1998). According to VA Fast Letter 04-13 (June 29, 2004), HCV is spread primarily by contact with blood and blood products. The highest prevalence of HCV infection is among those with repeated, direct percutaneous (through the skin) exposures to blood (e.g., injection drug users, recipients of blood transfusions before screening of the blood supply began in 1992, and people with hemophilia who were treated with clotting factor concentrates before 1987). The Fast Letter further states that occupational exposure to HCV may occur in the health care setting through accidental needle sticks. Thus, a veteran may have been exposed to HCV during the course of his or her duties as a military corpsman, a medical worker, or as a consequence of being a combat veteran. According to the Fast Letter, there have been no case reports of HCV being transmitted by an air gun injection. Nevertheless, it is biologically plausible. The Fast Letter concludes that it is essential that the examination report upon which the determination of service connection is made include a full discussion of all modes of transmission and a rationale as to why the examiner believes that a particular mode of transmission was the source of a veteran’s hepatitis C. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the weight of the evidence must be against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Entitlement to service connection for hepatitis C In considering the evidence of record under the laws and regulations as set forth above, the Board concludes the Veteran is not entitled to service connection for hepatitis C. The Veteran’s service treatment records are negative for any complaints, treatment, or diagnosis of hepatitis C. In fact, he was not diagnosed with the hepatitis C until 1992. The Board does acknowledge the Veteran’s contention that he had symptomatology in service that was an early manifestation of hepatitis C. In this regard, he stated that he first noticed fatigue, diarrhea, loss of appetite, muscle aches, and frequent colds in service. His service treatment records do document an instance of nausea in September 1978 and treatment for pharyngitis in April 1977. However, the March 2018 VA examiner stated that those symptoms are non-specific, generalized, and common with many medical conditions experienced when one has any bacterial or viral infections. They are not specific or unique to hepatitis C. Thus, he concluded that the symptoms cannot be contributed to hepatitis C without mere speculation. In addition, the examiner stated that, if the Veteran contracted hepatitis C at the start of his military service, it would be unlikely that he would experience symptoms in such a short period. Moreover, if he was experiencing symptoms of hepatitis C in the late 1970s, it would be unlikely that it would take until 1992 to first diagnose the disorder. For these reasons, the Board finds that hepatitis C did not manifest in service. In addition to the lack of evidence showing that hepatitis C manifested during service, the weight of the probative evidence of record does not relate the current disorder to the Veteran’s military service. The Veteran has asserted that he contracted hepatitis C from air gun inoculations during service. He has stated that he noticed blood on the air gun after the solider before him in line received vaccinations. See e.g. November 2013 Board hearing transcript; October 2010 medical record (Veteran reported that the solider in front of him passed out during inoculations and started bleeding). Notably, the evidence shows that the Veteran had other risk factors for hepatitis C. In this regard, an October 1992 letter from a private physician indicated that the Veteran had reported that he had been exposed to hepatitis C by his ex-wife who was an intravenous drug user. He also has tattoos. Although the Veteran testified at the November 2013 hearing that he received all of his tattoos during the summer of 1992 after being diagnosed with hepatitis C, a May 2005 private medical record indicated he had a history of multiple tattoos greater than 30 years ago. In addition, the March 2018 VA examiner indicated that the Veteran also had a brother with hepatitis C. The March 2014 VA examiner noted that the major risk factors for hepatitis C transmission include intravenous and intranasal drug abuse, high risk sexual activities, blood transfusions before 1992, and accidental exposure to contaminated blood. She stated that the risk of transmission from vaccinations using an air gun under medical supervision is possible, but extremely low. Similarly, she indicated that the risk of transmission of hepatitis C from a monogamous heterosexual relationship is low. Given the complete history in this case, the examiner opined that it is more likely than not that the Veteran’s hepatitis C was transmitted from his ex-wife, who had been an intravenous drug user, and less likely related to his military service. The March 2018 VA examiner stated that it is not at least as likely as not that the Veteran’s hepatitis C is causally or etiologically related to an in-service inoculation by way of an air gun. He explained that an air gun (also called jet injector) uses high pressure to force a vaccine or other medication through a person's skin; an air gun does not involve needles. He also indicated that there is no evidence in the form of confirmatory test to support or establish the relationship without mere speculation. In addition, the examiner observed that the Veteran had multiple risk factors, including sexual activity with his ex-wife who was an intravenous drug user with hepatitis and ultimately died of an overdose and having tattoos greater than 30 years ago (citing to a May 2005 private medical record). He also noted that the Veteran's brother also had chronic hepatitis C, which suggests the possibility of exposure to a family member with the same illness. The March 2018 VA examiner stated that, even if there was a solider bleeding in front of the Veteran while in line for inoculations, one would also have to assume that the soldier had hepatitis C and that the disease was then delivered intravenously to the Veteran. He explained that the purpose of the air gun is to minimize the risk of blood contracted illness by not containing a needle. Thus, the examiner believed that the greater risk factor for contracting hepatitis C was from the Veteran’s family members, who were known to have hepatitis C, rather than a random young soldier. As previously discussed, the March 2018 VA examiner also discussed the Veteran reported symptoms in service. He further estimated that the Veteran contracted hepatitis C in the 1980s either from a family member or a tattoo prior to his diagnosis in 1992. The Board acknowledges the Veteran’s assertions that he contracted hepatitis C in service. However, such statements appear to be based on conjecture. Indeed, the diagnosis and etiology of hepatitis C deals with an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is 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) (lay testimony is competent to establish the presence of varicose veins); 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”). Moreover, even assuming that the Veteran is competent to opine on this medical matter, the Board finds that the specific, reasoned opinion of the VA examiners are of greater probative weight than the Veteran’s more general lay assertions. The Board finds that the March 2018 VA examiner provided the most probative medical opinion. The examiner reviewed and considered the evidence of record, including the Veteran’s statements; relied on his medical training, knowledge, and expertise; and provided thorough rationale for the conclusion reached. There is no medical opinion otherwise relating the Veteran’s current hepatitis C to his military service. Accordingly, the preponderance of the evidence is against finding that hepatitis C was incurred in service. As such, the benefit of the doubt rule does not apply, and the Veteran’s claim for service connection for hepatitis C is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 2. Entitlement to service connection for carpal tunnel syndrome of the right hand In considering the evidence of record, the Board finds the Veteran is not entitled to service connection for carpal tunnel syndrome of the right hand. The Veteran’s service treatment records do not document any complaints, treatment, or diagnosis of carpal tunnel syndrome of the right hand. They do show that he had a cyst on his right index finger. Moreover, the evidence shows that the Veteran was not diagnosed with carpal tunnel syndrome of the right hand for many years after his military service. In fact, he told a November 2010 VA examiner that he did not have any pain or problems after the cyst was removed in service and that he started developing right hand numbness a few years after service. He later underwent surgery in 2003. The Board does acknowledge that the Veteran has since reported that he first noticed symptoms of numbness, tingling, and difficulty grasping in his right hand during service in 1976 when his began his work as a photo processing specialist. However, the March 2018 examiner stated that it is highly unlikely given the absence of medical evidence showing symptoms, a diagnosis, or treatment in service. He commented that, if the symptoms had appeared in service almost 40 years ago, he suspected that the diagnosis and surgery for severe symptoms would have been required sooner. The examiner also stated that it less likely that the Veteran’s carpal tunnel syndrome would have slowly progressed for over 25 years. Rather, it is much more likely that his repetitive use of his wrists and hands during his post-service occupation led to the development of his carpal tunnel syndrome with the added factors of progressive aging and development of age-related arthritis. The examiner explained that carpal tunnel syndrome is caused by pressure on the median nerve. The median nerve runs from the forearm through a passageway in the wrist (carpal tunnel) to the hand and provides sensation to the palm side of your thumb and fingers, except the little finger. The more severe conditions of carpal tunnel syndrome affect both hands, causing numbness, tingling, and weakness. If the Veteran had those severe symptoms in service, he would have needed to seek medical attention. For these reasons, the Board finds that carpal tunnel syndrome of the right hand did not manifest in service. In addition to the lack of evidence showing that carpal tunnel syndrome of the right hand manifested during service, the weight of the probative evidence of record does not relate the current disorder to the Veteran’s military service. The November 2010 VA examiner opined that the Veteran’s current carpal tunnel syndrome was not related to his military service. In so doing, he noted that a ganglion cyst was removed over the base of the first index finger over the second metacarpal joint, which is not where the carpal tunnel is located. Rather, the carpal tunnel is at the wrist or base of the hand. Thus, the examiner stated that it is impossible that he would develop carpal tunnel from a ganglion cyst at the base of the index finger. The May 2014 VA examiner also observed that the Veteran had a cyst removal on the base of the index finger in service, but found that it was less likely to result in carpal tunnel syndrome. He also noted that there was no treatment related to his claimed right carpal tunnel syndrome in the service treatment records. However, in responding to whether the disorder could be related to his duties in service, the examiner stated that he could not resolve these issues without resorting to mere speculation. The Board notes that medical opinions that are speculative, general, or inconclusive in nature do not provide a sufficient basis upon which to support a claim. See, e.g., McLendon v. Nicholson, 20 Vet. App. 79, 83(2006); Jones v. Shinseki, 23, Vet. App. 382, 389-90 (2010) (noting that the phrase, "without resort to mere speculation," must not become a mantra that short circuits the careful consideration to which each claimant's case is entitled). The March 2018 VA examiner opined that it is not at least as likely as not the Veteran's right hand carpal tunnel syndrome manifested during service or is otherwise related to his period of service, to include his duties as a film processor therein. As previously noted, the examiner acknowledged the Veteran’s report of symptoms in service, but found it highly unlikely that he had such severe symptoms of carpal tunnel syndrome in service. In addition, the March 2018 VA examiner indicated that the cause of ganglion cysts is not known. The most likely theory involves a flaw in the joint capsule or tendon sheath that allows the joint tissue to bulge out. He stated that carpal tunnel syndrome is not known to cause a ganglion cyst. He also noted that the Veteran developed carpal tunnel syndrome more than 25 years later; therefore, it is not at least as likely as not that his ganglion cyst in service caused his carpal tunnel syndrome. Moreover, the March 2018 VA examiner noted that there was an indication that the Veteran worked as a bank or ATM machine repairman, which would most likely require repetitive use of his wrists and hands. He commented that a review of the most likely jobs to cause carpal tunnel includes mechanic and locksmith as well as cashier, but photo processer is not considered a high-risk job. Lastly, the March 2018 VA examiner indicated that arthritis is a non-occupational risk factor for carpal tunnel syndrome. The Veteran was only 23 years old when he separated from military service, and carpal tunnel syndrome was diagnosed when he was in his forties. The examiner indicated that progressive aging and age-related arthritis increases the risk for developing the disorders. The Board acknowledges the Veteran’s assertions that he first began experiencing symptoms of carpal tunnel syndrome in service and that his current disorder is related to service. However, the diagnosis and etiology of carpal tunnel syndrome deals with an internal medical process, which extends beyond an immediately observable cause-and-effect relationship that is 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) (lay testimony is competent to establish the presence of varicose veins); 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”). Moreover, even assuming that the Veteran is competent to opine on this matter, the Board finds that the specific, reasoned opinion of the March 2018 VA examiner has greater probative weight than the Veteran’s more general lay assertions. The examiner reviewed and considered the evidence of record, including the Veteran’s statements; relied on his own medical training, knowledge, and expertise; and provided a thorough rationale for the conclusion reached. There is no medical opinion otherwise relating the Veteran’s current right hand carpal tunnel syndrome to his military service. Accordingly, the preponderance of the evidence is against finding that carpal tunnel syndrome of the right hand was incurred in service. As such, the benefit of the doubt rule does not apply, and the Veteran’s claim for service connection for right hand carpal tunnel syndrome is denied. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD K.M. Walker, Associate Counsel