Citation Nr: 18148212 Decision Date: 11/07/18 Archive Date: 11/07/18 DOCKET NO. 14-23 326 DATE: November 7, 2018 ORDER Service connection for right carpal tunnel syndrome (CTS) is granted. Service connection for left CTS is granted. Service connection for irritable bowel syndrome (IBS) is granted.   FINDINGS OF FACT 1. The Veteran’s right and left CTS had its onset in service. 2. The Veteran’s IBS had its onset in service. CONCLUSIONS OF LAW 1. The criteria for right CTS have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for left CTS have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for IBS have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from October 1981 to September 1985, and from January 1995 to June 2009. The case is on appeal from an August 2009 rating decision. In February 2016, the Board dismissed five withdrawn claims. At that time, the Board also remanded the claims remaining on appeal for additional development. Legal Criteria Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. “To establish a right to compensation for a present disability, a veteran must show: “(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”—the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004)). In addition, 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 preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Service connection for a right arm disorder to include CTS. 2. Service connection for a left arm disorder to include CTS. The Veteran seeks service connection for a bilateral arm disorder; particularly, epicondylitis and CTS, which she contends began during service. With respect to the first element, the evidence of record establishes that the Veteran has suffered from a bilateral arm disorder throughout the pendency of her claim. The Veteran’s claim was received in June 2009. The Veteran stated that her symptoms, which she describes as pain and numbness, bothered her for several years before she retired from service and continued thereafter. See August 2010 notice of disagreement (NOD). The Veteran’s credible lay statement regarding the presence of symptoms related to a bilateral arm disorder are bolstered by the medical evidence of record including a July 2010 nerve conduction study and an October 2018 Veterans Health Administration (VHA) expert opinion. The July 2010 nerve conduction study results suggested that at that time the Veteran had bilateral CTS. The October 2018 VHA expert opinion notes that the Veteran’s service treatment records (STRs) indicate symptoms of numbness, paresthesias, and weakness as early as 2008 and continued until the Veteran had surgery on her right arm, which appeared to relieve her symptoms. The Board acknowledges that the Veteran underwent a VA examination in April 2016 in which the examiner indicated that at that time the Veteran’s bilateral CTS had resolved. However, the presence of a disability at any time during the claim process can justify a grant of service connection, even if it resolves. McClain v. Nicholson, 21 Vet. App. 319 (2007). As such, the evidence of record establishes that the current disability element of the claim has been established. The evidence of record also demonstrates the in-service incurrence of bilateral arm problems. On entry into active duty service the Veteran did not express any arm, elbow, or wrist complaints, and no abnormality was detected on physical examination. See October 1981 enlistment examination report. However, STRs dating from 1999 document complaints of and show treatment for bilateral arm/elbow/wrist pain, diagnosed as lateral epicondylitis. See, e.g., STRs dated in July and August 1999, and in January and February 2001. A diagram in the January-February 2001 physical therapy records indicates the Veteran had weakness and tingling in her left wrist as well as dull pain and weakness in her left elbow, and she reported problems with pain when grasping things. A March 2001 STR describes the Veteran as “active duty active duty Guard with history of chronic lateral epicondylitis.” In December 2008, the Veteran complained of slight numbness and tingling in her arms and hands for the past month; and said that she had to “shake out” her arms to get relief and that this helped somewhat, but not entirely. Thus, the remaining question is whether a nexus between the incurrence of the Veteran’s in-service bilateral arm disorder and the bilateral arm disorder she has experienced during the pendency of the claim. The Board finds that the evidence supports a positive relationship at least to a state of equipoise. The Board requested an expert VHA medical opinion on the matter, which was received in October 2018. The opinion was authored by a Chief of Neurology at a VA Medical Center; thus, a medical professional with great expertise in this area of medicine. The physician gave the opinion that it is at least as likely as not that the Veteran had bilateral CTS while on active duty and shortly after service. In support of the opinion, the physician noted that a review of the Veteran’s records shows in-service symptoms that continued until the Veteran had surgery after service. As the VHA expert opinion is based on a well-reasoned analysis and is consistent with the facts of the case, the Board finds it highly probative as to the nexus element of the claim. Accordingly, all elements of the service connection claim are at least in equipoise, and when reasonable doubt is resolved in the Veteran’s favor, the Board finds that her right and left CTS had its onset in service. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Accordingly, service connection is warranted for right and left CTS. 3. Service connection for a gastrointestinal disorder to include IBS. The Veteran seeks service connection for a gastrointestinal disorder that she contends had its onset in service. With respect to the first element, the evidence of record establishes that the Veteran suffered from a gastrointestinal disorder within the appeals period. In a June 2014 lay statement, the Veteran reported that she suffers constantly from alternating bouts of diarrhea, constipation, and nausea. These credible complaints are bolstered by the Veteran’s private and VA treatment records. Private treatment records indicate that the Veteran was diagnosed with abdominal pain and gastroenteritis in May 2014. The Veteran was also provided with a multifactorial differential diagnosis including IBS, Celiac disease, HP infection, bacterial overgrowth, and gastroparesis. See June 2014 private treatment record. June 2014 VA medical records also indicate that the Veteran reported complaints of abdominal discomfort with nausea, intermittent diarrhea, and constipation. In addition, a July 2018 VHA opinion indicates that the Veteran has IBS. The evidence of record also demonstrates the in-service incurrence of a gastrointestinal problems. On entry into active duty service the Veteran did not express any bowel complaints, and no abnormality was detected on physical examination. See October 1981 enlistment examination report. However, service treatment records (STRs) dating from 1996 chronicle a history of abdominal pain and bowel problems. For example, a notation in a STR dated March 22, 1996 indicates that the Veteran has a history of IBS. In addition, a September 27, 1996 entry indicates that the Veteran had recurrent diarrhea and abdominal cramps. STRs also show that the Veteran underwent a CT scan on October 9, 2008, which returned a diagnosis of left sided colitis. Thus, the remaining question is whether a nexus between the Veteran’s in-service incurrence of gastrointestinal problems and her current disorder. With regard to the nexus element, the Board finds that the evidence of record supports a link between the Veteran’s current IBS and in-service incurrence of the Veteran’s gastrointestinal disorder. The Veteran underwent an April 2016 VA examination. The Veteran complained of abdominal pain and alternating bouts of constipation and diarrhea. She reported having hard, minimal bowel movements every 1-3 days, and of loose and/or watery stools occurring twice per month with nausea and lower abdominal pain during her bouts of diarrhea. See April 2016 VA examination. According to the examiner, the Veteran’s complaints were less likely than not related to service because “none of veteran’s post-service gastrointestinal imaging and endoscopies have revealed recurrent or persistent colitis, to include the most recent abdominal CT completed on 5/1/14.” The examiner rationalized that “the colitis on imaging during active duty appears to have been an isolated episode” and added “although the veteran subjectively reports a bout of colitis three weeks ago, there are no medical records available to substantiate such a diagnosis.” However, the examiner only discussed colitis and did not discuss any previous gastrointestinal related diagnoses or address the June 2014 private physician’s impression that there might be a multifactoral basis for the Veteran’s complaints, including gastroenteritis, IBS, Celiac disease, HP infection, bacterial overgrowth, gastroparesis, and diabetic autonomic neuropathy. Thus, the Board also requested a VHA expert opinion in connection with this claim. Thereafter, a July 2018 VHA opinion was received. The author is a physician with a specialty in gastroenterology; thus, a medical professional with great expertise in this area of medicine. The physician stated that it is at least as likely as not that the Veteran’s IBS had its onset in service. The physician based her opinion on the Veteran’s in-service complaints related to abdominal pain and the subsequent work up to determine the cause of the Veteran’s abdominal pain. The Board finds the July 2018 VHA expert medical opinion to be persuasive and of significant probative value. It is apparent in the opinion that the entire claims file was reviewed and considered in rendering the opinion. Additionally, the opinion was based on an accurate history and contained a well-reasoned explanation. As such, this opinion is entitled to the greatest probative weight. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). Accordingly, all elements of the service connection claim are at least in equipoise, and when reasonable doubt is resolved in the Veteran’s favor, the Board finds that her IBS had its onset in service. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Therefore, service connection is warranted for IBS. RYAN T. KESSEL Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD E. Gray