Citation Nr: 18146809 Decision Date: 11/01/18 Archive Date: 11/01/18 DOCKET NO. 16-36 215 DATE: November 1, 2018 ORDER Service connection for a left wrist condition is denied. Service connection for mouth ulcers is denied. Service connection for pseudofolliculitis barbae (PFB) is denied. Service connection for residuals of pneumonia is denied. REMANDED Entitlement to service connection for a right wrist condition is remanded. Entitlement to service connection for a low back condition is remanded. Entitlement to service connection for a neck condition is remanded. Entitlement to service connection for left hallux valgus is remanded. Entitlement to service connection for right hallux valgus is remanded. Entitlement to service connection for sleep apnea is remanded. Entitlement to service connection for dermatitis is remanded. FINDINGS OF FACT 1. The preponderance of the evidence is against a showing that the Veteran has had a post-service diagnosis of a left wrist condition, mouth ulcers, or PFB. 2. The preponderance of the evidence indicates that the Veteran does not suffer from residuals from his in-service pneumonia. CONCLUSIONS OF LAW 1. The criteria for service connection for a left wrist condition have not been met. 38 U.S.C. §§ 1131, 5107(b) (2012); 38 C.F.R. §§ 3.102, 3.303(a) (2017). 2. The criteria for service connection for mouth ulcers are not met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 3. The criteria for service connection for PFB are not met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). 4. The criteria for service connection for residuals of pneumonia are not met. 38 U.S.C. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303(a). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from August 1985 to July 1991. At a May 2018 Travel Board hearing, the Veteran testified before the undersigned Veterans Law Judge. A transcript of the proceeding has been associated with the claims file. The Board notes that VA medical treatment records were added to the claims file after issuance of the September 2017 Supplemental Statement of the Case. The records consisted of documents previously already reviewed by the Regional Office (RO), and new documents, namely records from July 2016 to February 2018. However, careful review of the additional records revealed that they contained no new relevant diagnoses or treatment for the claimed conditions decided herein. Accordingly, the Board may proceed to consider the claims. The existence of a current disability is the cornerstone of a claim for VA disability compensation. See Degmetich v. Brown, 104 F. 3d 1328 (1997); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). To establish service connection, there must be competent, credible evidence of (1) a current disability, (2) in-service incurrence or aggravation of an injury or disease, and (3) a nexus, or link, between the current disability and the in-service disease or injury. See, e.g., Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Pond v. West, 12 Vet. App. 341 (1999). This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). 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). 1. Left Wrist Condition The Veteran contends that a left wrist disability had its onset during active service. His service treatment records (STRs) contain one October 1987 complaint of a lump, popping, and pain in his left wrist. Upon examination, he had full range of motion with crepitus, mild pain on flexion to 90 degrees and extension to 60 degrees over the tendons, and a small non-tender cyst. He was diagnosed with a ganglion cyst and tendonitis. An x-ray examination of the wrist had normal results. The cyst was removed without complication, the Veteran was given a no push-up profile for two weeks, and Motrin was prescribed for pain. There are no further in-service notations regarding the left wrist. In February 2013, the Veteran underwent a VA examination. He reported that he continued to have pain in his left wrist. He is left hand dominant and he stated that when he used the wrist a lot, it would start aching. Upon examination, there was normal range of motion and no additional abnormal findings. The examiner determined that it was less likely than not that any left wrist condition was incurred in or caused by service, as following the October 1987 tendonitis diagnosis, there was no further complaint in service, and there was no ongoing record of continued issues with the wrist. As such, no chronicity of care was documented. VA treatment records do not contain any complaints, symptoms, diagnoses, or treatment of the Veteran’s left wrist. At the May 2018 hearing, the Veteran stated that the reason he had no medical records after separation from service until January 2011, when he first sought treatment with VA, was because he only sought treatment at free medical clinics and he was unable to obtain records from those clinics due to closures and passage of time. He also noted that he often self-medicated with over-the-counter medications and did not seek medical treatment due to financial constraints. The Board finds that service connection for a left wrist disability is not warranted. Although the Veteran had one notation regarding his left wrist in service, the cyst was removed and the diagnosis of tendonitis was not mentioned again in service. Though there are no medical records from the period immediately after separation, the available medical records do not report any symptoms or diagnoses regarding the left wrist. The Veteran has reported to the VA examiner that he had pain in his wrist, especially with overuse, but has not made complaints regarding his left wrist to his treating clinicians, and no condition or functional impairment has been diagnosed. Accordingly, there is no probative evidence of a current disability or of a condition continuing since service. Therefore, service connection is not established. 2. Mouth Ulcers The Veteran has contended that service connection is warranted for mouth ulcers which were diagnosed in active service. His STRs contained two relevant notations. In November 1987, examination revealed a lesion in his mouth on the right posterior soft palate. He was diagnosed with a small, shallow ulcer with erythematous base without purulent discharge, probably viral in origin. In February 1988, he sought dental treatment with complaints of sore gums on the lower right side which he scrubbed with a toothbrush. The clinician noted that the gingiva was macerated, secondary to toothbrush abrasion, and that the probable diagnosis was aphous ulcer, abraded with toothbrush. In February 2013, the Veteran underwent a VA examination at which he did not mention a history of or current complaints of oral ulcers. Upon examination, no ulcers were observed. VA treatment records did not contain any complaints, symptoms, diagnosis, or treatment for mouth ulcers or any oral condition. At the May 2018 hearing, the Veteran reported that when he had mouth ulcers in service, he was given something to gargle, which relieved his symptoms. He reported that he has a similar recurrence of ulcers at least once per year, for which he gargled salt water. The Board finds that service connection for mouth ulcers is not warranted. Although he had a diagnosis of the condition in service, he reported that gargling cleared up his symptoms and there are no further notations in service. There is no other medical evidence of an ongoing or current condition. At the VA examination, the Veteran did not even mention mouth ulcers as a concern. Though there are lay reports of recurrent symptoms, the most competent and credible evidence of record indicates that there is no current diagnosis of mouth ulcers continuing since service. As such, service connection is not established. 3. PFB The Veteran has contended that service connection is warranted for PFB that was diagnosed in active service. The Veteran’s STRs contained an October 1985 notation of several lesions to the side of his face and under his chin, some secondary to infection, and difficulty shaving with some bleeding. A profile for 30 days was provided to limit shaving to a one-quarter inch, neatly-trimmed beard. In January 1986, mild PFB was diagnosed and a two-week profile was given. In May 1986, a one-year profile for PFB was given. In January 1988, the Veteran had pustules and papules on his face; he was diagnosed with acne. In September 1989, a shaving profile for two weeks was given. In April 1991, the Veteran was given a 30-day shaving profile. Also, PFB was listed as a temporary, minor problem on an undated record. The Veteran underwent a VA examination in February 2013 at which PFB was not observed and it was noted that his skin was clear. The examiner found that the condition was less likely as not incurred in or caused by service because he did not have a current diagnosis of PFB and no history of current treatment for the condition. Further, the examiner stated that PFB is a genetic condition which is related to persons who have short, curly hair. When such persons shave closely, the hair grows out and then re-enters the skin carrying bacteria from the skin surface into the pores, causing inflammation. He concluded that although the Veteran had the condition during his service, he was given a shaving profile which resolved the issue. VA treatment records contained no complaints, symptoms, treatment, or diagnosis of PFB or other facial dermatological conditions. At the May 2018 hearing, the Veteran stated that he did not shave to avoid getting bumps on his face and neck. The Board finds that service connection for PFB is not warranted. Although the Veteran had a diagnosis of PFB in service, during the appeal period there has been no medical evidence of a current diagnosis. Without evidence of a current disability, service connection for PFB has not been established. 4. Residuals of Pneumonia The Veteran has contended that service connection is warranted for a diagnosis of pneumonia that had its onset in active service. His STRs indicated that he was diagnosed with pneumonia in December 1988 following a chest x-ray demonstrating pneumonic infiltrate. Another x-ray conducted in January 1989 showed that the previously diagnosed pneumonic infiltrate had almost cleared. A follow-up that month stated that his pneumonia was improving. Finally, later that month, it was noted that his pneumonia was resolved. There are no further notations in service regarding pneumonia or any other respiratory condition. In January 2011, a chest x-ray was conducted which revealed that the lungs were clear bilaterally, demonstrating no active disease. He reported to clinicians that he had a chronic cough for at least three years but denied shortness of breath or wheezing. A pulmonary function test (PFT) suggested an obstructive pattern but had normal spirometry. The Veteran received a Pneumovax in April 2011. There are no additional medical records indicating symptoms, treatment, or diagnosis of pneumonia. In February 2013, the Veteran underwent a VA examination at which he reported developing a chronic cough over the past three years. He also stated that he had smoked cigarettes since 1991, but was trying to quit. He described still having a cough if he was tired or was over-stressed. No residuals of pneumonia were found upon examination and no other pulmonary conditions were observed. The examiner determined that the claimed condition was less likely than not incurred in or caused by service because he was diagnosed and treated for pneumonia only once in 1988-1989. Since that time, he had no recurrence of pneumonia. His chest x-ray and PFT results were normal. The examiner found that his chronic cough was most likely related to his cigarette smoking history. At the May 2018 hearing, the Veteran stated that he had gotten a pump prescribed in service to treat his pneumonia symptoms and that he continued to use it after service. He also reported that VA clinicians had told him that he had been misdiagnosed with pneumonia and actually had sleep apnea. The Board finds that service connection for residuals of pneumonia is not warranted. Although the Veteran was diagnosed with the condition in service, it had effectively resolved, and there is no further evidence in service or throughout the appeal period that he was diagnosed with pneumonia or residual conditions. Given the normal chest x-ray and PFT results and the VA examiner’s competent and credible conclusion that the Veteran’s described symptom of chronic cough was more likely related to smoking, there is insufficient evidence that the Veteran has a current pneumonia-related disability. Accordingly, service connection has not been established. The preponderance of the evidence is thus against a finding that a left wrist condition, mouth ulcers, PFB, or residuals of pneumonia is related to active service and the Veteran’s claims must be denied. The benefit-of-doubt rule does not apply when the Board finds that a preponderance of the evidence is against the claim. Ortiz v. Principi, 274 F. 3d 1361, 1365 (Fed. Cir. 2001). REASONS FOR REMAND 1. Right Wrist Condition/Low Back Condition The Veteran has contended that an October 1989 in-service incident in which he fell two stories off a balcony onto his right wrist and back led to his current complaints of pain in his wrist and degenerative changes in his back. The February 2013 VA examinations of each condition determined that there was no relation to service, given the gap in time from the in-service incident and his first documented treatment in 2011. Subsequent VA treatment records indicated ongoing symptoms in his right wrist and back. As noted above, the Veteran has given competent and credible testimony that he had no medical records after separation from service until January 2011 because he only sought treatment at free medical clinics from which records were no longer available. He also has stated that he often self-medicated with over-the-counter medications and did not seek medical treatment due to financial constraints. As such, the medical opinions of record which base their opinions merely upon a lack of documentation since service separation are not adequate bases from which to render decisions regarding service connection. As there is evidence of an in-service incident and the Veteran has current symptomatology, new VA examinations and opinions are needed to determine whether his current conditions are related to service. 2. Neck Condition The Veteran has contended that the October 1989 incident also caused injury to his neck. At the February 2013 VA examinations, the Veteran reported that he had experienced neck pain since that incident and was recently diagnosed with degenerative disc disease. No examination of his neck was conducted and no opinion was rendered regarding etiology of any neck disability. Although the treatment record regarding the in-service incident did not report an injury to the Veteran’s neck, given the competent lay testimony from the Veteran regarding his symptoms since the documented incident, and current VA records diagnosing degenerative changes to the cervical spine, a VA examination and opinion are needed to determine the etiology of any current condition. 3. Left Hallux Valgus/Right Hallux Valgus The Veteran’s service entrance examination noted mild hallux valgus bilaterally, asymptomatic. As such, it appears that the bilateral condition preexisted service. The February 2013 VA opinion of record found that the Veteran’s bilateral hallux valgus was less likely than not incurred in or caused by service, given the gap in time between service and treatment, and also finding that the etiology was likely multifactorial in nature. The opinion did not discuss the notation at service entrance or provide an opinion on aggravation. Because there is evidence that the condition preexisted service, an opinion on aggravation is needed. Therefore, a new examination and opinion should be sought upon remand. 4. Sleep Apnea The Veteran has contended that his currently-diagnosed sleep apnea is related to his in-service pneumonia. He reported at the May 2018 hearing that he had been told by clinicians that he had been misdiagnosed in service and that his respiratory condition was actually sleep apnea. He has not been afforded a VA examination and opinion to determine the etiology of his condition. As such, an examination and opinion should be conducted upon remand. 5. Dermatitis There are numerous notations in service regarding diagnoses of pustules and papules, rashes, allergies, and contact dermatitis. The February 2013 VA examiner determined that the Veteran did not have dermatitis and that there was no evidence of a skin condition since discharge. However, the Veteran reported to the examiner that he used topical moisturizers to prevent outbreaks. An October 2014 VA treatment record diagnosed a fine, maculopapular rash on the Veteran’s trunk and chest. Steroids and Benadryl were prescribed. As there is medical evidence of a skin condition post-service, a new examination and opinion are needed to determine whether any current condition is related to his in-service diagnoses. The matters are REMANDED for the following action: 1. Schedule the Veteran for appropriate VA examinations to determine the nature and etiology of any diagnosed conditions of the right wrist, low back, neck, and skin, the etiology of his currently-diagnosed sleep apnea, and whether his bilateral hallux valgus was aggravated by service. The record should be made available and the examiner’s review of the record should be indicated. The examination report should include discussion of the Veteran’s documented medical history and assertions. All appropriate tests and studies should be accomplished and all clinical findings should be reported in detail. (a.) Identify all current diagnoses of the right wrist, low back, and neck. (b.) After reviewing the record and examining the Veteran, offer an opinion for each diagnosed disorder as to the following: 1. Whether it is at least as likely as not (50 percent or higher degree of probability) that any diagnosed disorder of the right wrist, low back, and neck is related to the Veteran’s active service, to include the October 1989 documented fall. (c.) Identify all current dermatological diagnoses. (d.) After reviewing the record and examining the Veteran, offer an opinion for any diagnosed disorder as to the following: 1. Whether it is at least as likely as not (50 percent or higher degree of probability) that any skin disorder is related to the Veteran’s active service, to include the various dermatological diagnoses made in April 1986, June 1986, January 1988, January 1989, May 1989, July 1989, March 1990, and March 1991 service treatment records. (e.) After reviewing the record and examining the Veteran, offer an opinion for the currently-diagnosed sleep apnea as to the following: 1. Whether it is at least as likely as not (50 percent or higher degree of probability) that the currently-diagnosed sleep apnea is related to the Veteran’s active service, to include the in-service diagnosis of pneumonia. (f.) After reviewing the record and examining the Veteran, offer an opinion for the currently-diagnosed left and right hallux valgus as to the following: 1. Does the evidence of record clearly and unmistakably show that the Veteran had bilateral hallux valgus prior to his entrance into active duty? The examiner must consider the July 1985 entrance examination report. a. If the answer is yes, does the evidence of record clearly and unmistakably show that the preexisting bilateral hallux valgus was not aggravated by service or that any increase in disability was due to the natural progression of the disease? b. The examiner is informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the opinion provider should indicate, to the extent possible, the approximate level of hallux valgus disability present (i.e., a baseline) before the onset of the aggravation. (g.) In offering the requested opinions, the examiner is asked to consider the Veteran’s lay statements, including his competent and credible statements regarding the lack of treatment records from separation until January 2011. H.M. WALKER Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Rachel E. Jensen, Associate Counsel