Citation Nr: 1808591 Decision Date: 02/09/18 Archive Date: 02/20/18 DOCKET NO. 08-25 470 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Atlanta, Georgia THE ISSUES 1. Entitlement to service connection for a left upper extremity disorder, diagnosed as carpal tunnel syndrome of the left wrist, to include as secondary to a service-connected cervical spine disability. 2. Entitlement to a separate disability rating for neurological impairment of the upper right extremity due to the service-connected degenerative disc disease (DDD) of the cervical spine. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD J. Setter, Associate Counsel INTRODUCTION The Veteran served on active duty in the United States Army from August 1984 to August 2004. This case comes before the Board of Veterans' Appeals (Board) on appeal from a November 2004 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. The RO in Atlanta, Georgia currently has jurisdiction of the claim. The Board remanded the issues on appeal for additional development in August 2014, February 2016, and April 2017. The directives having been substantially complied with, the matter again is before the Board. D'Aries v. Peake, 22 Vet. App. 97, 105 (2008); Stegall v. West, 11 Vet. App. 268, 271 (1998). FINDINGS OF FACT 1. A left upper extremity disorder was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 2. A left upper extremity disorder is not caused or aggravated by a service-connected disability. 3. A right upper extremity neurological impairment was not manifest during active service, and is not shown to be causally or etiologically related to an in-service event, injury, or disease. 4. A right upper extremity neurological impairment is not caused or aggravated by a service-connected disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a left upper extremity disorder are not met. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). 2. The criteria for service connection for a right upper extremity neurological impairment are not met. 38 U.S.C. § 1110, 1131 (2012); 38 C.F.R. §§ 3.303, 3.310 (2017). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Veterans Claims Assistance Act of 2000 (VCAA) The Veterans Claims Assistance Act of 2000 (VCAA) and implementing regulations impose obligations on VA to provide claimants with notice and assistance. 38 U.S.C. §§ 5102, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326(a) (2017). The Veteran in this case has not referred to any deficiencies in either the duties to notify or assist; therefore, the Board may proceed to the merits of the claim. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015, cert denied, U.S.C. Oct.3, 2016) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board....to search the record and address procedural arguments when the [appellant] fails to raise them before the Board"); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to an appellant's failure to raise a duty to assist argument before the Board). The Board has reviewed all of the evidence in the Veteran's claims file. Although the Board has an obligation to provide adequate reasons and bases supporting this decision, there is no requirement that the evidence submitted by the Veteran or obtained on his behalf be discussed in detail. Rather, the Board's analysis below will focus specifically on what evidence is needed to substantiate the claim and what the evidence in the claims file shows, or fails to show, with respect to the claim. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) and Timberlake v. Gober, 14 Vet. App. 122, 128-130 (2000). II. Service Connection for Right and Left Upper Extremity Disabilities A. Legal Criteria for Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish entitlement to service-connected compensation benefits, 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)). Service connection may also be granted for disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For secondary service connection, it must be shown that the disability for which the claim is made is proximately due to or aggravated by a service-connected disability. See 38 C.F.R. § 3.310 (2017); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc). VA is required to give due consideration to all pertinent medical and lay evidence in evaluating a claim for disability benefits. 38 U.S.C. § 1154(a). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Lay evidence cannot be determined to be not credible merely because it is unaccompanied by contemporaneous medical evidence. Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran's lay statements. Id. Further, a negative inference may be drawn from the absence of complaints or treatment for an extended period. Maxson v. West, 12 Vet. App. 453, 459 (1999), aff'd sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). After the evidence is assembled, it is the Board's responsibility to evaluate the entire record. See 38 U.S.C. § 7104(a) (2012). When there is an approximate balance of evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each issue shall be given to the claimant. See 38 U.S.C. § 5107 (2012); 38 C.F.R. §§ 3.102, 4.3 (2017). In Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990), the United States Court of Appeals for Veterans Claims (Court) stated that "a veteran need only demonstrate that there is an 'approximate balance of positive and negative evidence' in order to prevail." To deny a claim on its merits, the preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. B. Evidence and Analysis The Veteran asserts her right and left upper extremity disorders have been painful since service and are also related to her service-connected degenerative disc disease of the cervical spine. The Veteran is currently service-connected, inter alia, for cervical spine DDD, right shoulder rotator cuff tendonitis, and right wrist ganglion cyst. While in service, the Veteran was diagnosed and treated for a right wrist ganglion cyst, for which she is now service-connected. During the Veteran's separation examination in June 2004, pain in her left shoulder was shown secondary to lifting. The Veteran had complained about multiple arthralgias over her body, to include both upper extremities. In addition, pertinent to this appeal, the Veteran complained of left wrist pain in service and had sought service connection for a left wrist disorder in her initial claim, which was denied in November 2004. However, a rheumatology examination as part of the overall June 2004 examination indicated no clinical findings regarding the left wrist. The ganglion cyst in the right wrist was noted. No other injury or chronic disability of the left or right upper extremity, to include her wrists, is shown in her military service treatment records. An August 2005 VA treatment record reflects that the Veteran has had constant pain in the cervical/upper trapezius, upper arms, and headaches since service. A July 2008 VA treatment record reflects an assessment of "CH. Neck, (upper back) and shoulder pain secondary to degenerative disc disease and degenerative joint disease." A February 2009 VA treatment record reflects the Veteran's complaints of chronic neck pain going into her right shoulder and upper arm. An August 2008 letter from a private chiropractor, Dr. O., indicates that the Veteran has degenerative disc disease of the cervical spine with osteophytes. The private examiner stated that the entire spine showed degenerative/arthritic changes with osteopenia, indicating associated neurological implications (paresthesia), and referred the Veteran for treatment from an orthopedist and/or a neurologist. In June 2012, the Veteran received VA examinations for her cervical spine, for her shoulders and arms, and for her wrists. The examiner made a diagnosis of degenerative arthritis of the cervical spine. The Veteran reported that she has increased pain at night with no known cause. The pain is at a level of 7/10 to 9/10. The examiner indicated that there was functional loss and/or functional impairment of the neck in terms of less movement than normal and pain on movement. The examiner noted that there is localized tenderness or pain to palpation of the joints/soft tissue of the neck. There was muscle spasm or guarding of the cervical spine, but it was not severe enough to result in abnormal gait or spinal contour. Muscle strength testing was full for all tests performed on the upper extremities. There was no atrophy. Deep tendon reflexes were all normal for the upper extremities and light touch sensory examination was normal. The examiner stated that there was no radiculopathy. The examiner also stated that the Veteran does not have intervertebral disc syndrome. There are no scars due to the cervical spine disability. There is no vertebral fracture. Imaging studies revealed arthritis. On the shoulders and arms portion of the examination, the same examiner found and continued a diagnosis for right shoulder rotator cuff tendonitis with impingement syndrome. For the wrists portion of the examination, the ganglion cyst of the right wrist was noted, for which the Veteran is already service-connected, and the examiner pointed out there were no other diagnoses of either upper extremity to be made. In April 2015, the Veteran received VA examinations for her cervical spine and her peripheral nerves. Per previous examinations, the diagnosis of cervical spine DDD was confirmed and continued, with some left upper extremity radicular pain noted. In the peripheral nerves portion of the examination, there was no diagnosis of any peripheral nerve issue or neuropathy on either upper extremity. The examiner took note of the Veteran's left upper extremity radicular pain noted in the cervical spine portion of the examination but remarked that it was described as "tingling," and that it did not rise to level of a definitive diagnosis of peripheral neuropathy. This examiner presented an opinion for secondary service connection, saying it was less likely than not (less than 50 percent probability) that the claimed neurological abnormalities associated with the Veteran's service-connected cervical spine disability was proximately due to or the result of that cervical spine condition. The examiner's rationale was that the Veteran does not have an established diagnosis of peripheral neuropathy, nor any definitively demonstrated peripheral nerve condition that has ever been diagnosed or related to her DDD of the cervical spine. The Veteran received a VA peripheral nerves examination in August 2015 to address the contentions that her cervical spine disability is causing radiculopathy or tingling in her left arm. She stated that she reported this left arm pain in service and her doctor told her it was due to her degenerative spine condition, and prescribed a muscle relaxer and physical therapy. Under Section 3, for symptoms, the examiner indicated "no" for the question of whether the Veteran has any symptoms attributable to any peripheral nerve condition. However, noted underneath that answer is "paresthesias and/or dysesthesias." Examination revealed full muscle strength for bilateral elbow extension, bilateral wrist flexion, bilateral wrist extension, grip, right pinch, and right elbow flexion. Left pinch and left elbow flexion were 4/5. The examiner noted that there was no muscle atrophy. Light touch sensation was normal for the upper extremities. There were no trophic changes. The examiner indicated that special tests were not indicated or performed for median nerve evaluation. Radicular nerve, median nerve, ulnar nerve, musculocutaneous nerve, circumflex nerve, long thoracic nerve, upper radicular group, and middle radicular group were noted to be normal bilaterally. The examination report reflects that an electromyogram (EMG) test was not performed. The examiner noted that while the Veteran reports some tingling in the left upper extremity, there is no definitive diagnosis of peripheral neuropathy and no additional deficits, disability, or limitations other than previously described for neck/cervical spine disability. In July 2016, VA provided a new examination for the Veteran's claimed disabilities, to include whether those disabilities were related to her cervical spine DDD. During that examination the Veteran reported left arm tingling down to her wrist, sometimes associated with shooting pain and numbness. The July 2016 VA examiner found that the Veteran did not have left arm radiculopathy, but that she did have mild left upper extremity carpal tunnel syndrome. An EMG test was performed which also showed carpal tunnel syndrome in the left wrist. In an accompanying opinion, the examiner opined there is it less likely than not (less than 50 percent probability) that the diagnosed left wrist carpal tunnel syndrome was related to her active service. The examiner's rationale was that her service treatment records did not contain any reports of treatment for a left wrist disorder while in service. In September 2016, VA provided an opinion for secondary service connection for the left carpal tunnel syndrome, saying the condition was less likely than not (less than 50 percent probability) proximately due to or as the result of the Veteran's service connected condition. The examiner's rationale was that the July 2016 EMG showed evidence only of mild left carpal tunnel syndrome, but did not show any evidence of impingement of the nerves at the level of the cervical spine. The examiner cited from authoritative medical literature, pointing out that carpal tunnel syndrome derives from compression of the nerves to the hand in the wrist, and is not caused by impingement of any nerves of the arm at the level of the cervical spine. The examiner stated she could not determine a baseline level of severity because of insufficient evidence in the available records to support a determination of a baseline of severity. She continued, stating that regardless of the lack of a baseline, that the Veteran's claimed condition was not as likely to be aggravated beyond its natural progression, because the July 2016 EMG showed only objective evidence of carpal tunnel syndrome in the wrist and not any impingement of nerves at the level of the cervical spine. In September 2017, the Veteran received a VA examination for her right and left wrist. The examiner noted a right wrist ganglion cyst with an onset in 1988 during active service, and for which the Veteran is now service-connected. The examiner noted it was drained by aspiration and it has been asymptomatic since. The examiner also discussed the Veteran's periodic complaints over time about tingling and numbness in both extremities, to include her fingers and thumb "for a long time." The Veteran had also complained of cramps to where she would have to massage out her palms to reduce pain. The examiner noted these complaints and discussed relative to the Veteran's cervical spine disability, for which she is service-connected, concluding that the Veteran's complaints of wrist tingling relate more likely than not to her cervical disc issue, especially when the Veteran describes tingling and numbness also in the scapular region in the upper back. This examiner also noted that the Veteran's complaints were not consistent with carpal tunnel syndrome in the right wrist because the median nerve involved in carpal tunnel syndrome does not innervate or send a branch to the thumb, but that a cervical nerve root compression could produce such a phenomenon. With regard to the left wrist, the examiner noted abnormal limited range of motion and evidence of pain with weight bearing. The Veteran received a separate VA peripheral nerves examination as well, also in September 2017. Here, the examiner diagnosed left wrist carpal tunnel syndrome. Phalen's and Tinel's testing was performed and was positive for the median nerve, indicating abnormalities. The examiner determined a normal evaluation for radial/musculospiral nerves, the ulnar nerve, and the remainder of the upper extremity nerve groups, except for the median nerve, where moderate incomplete paralysis of the left median nerve was noted. The right median nerve was normal. The examiner noted EMG studies had been performed in July 2016 and were normal for the right upper extremity but abnormal for the left upper extremity, noting mild carpal tunnel syndrome on the left upper extremity. This September 2017 examiner provided an opinion on service condition for the left wrist, saying it was less likely than not (less than 50 percent probability), that the diagnosed left wrist carpal tunnel syndrome was incurred in service or caused by any service-connected condition. The examiner pointed out that carpal tunnel syndrome is an entrapment of the median nerve at or near the wrist, and that a left wrist carpal tunnel syndrome was first noted in July 2016 after an EMG. That July 2016 examiner had recorded the Veteran at the time complaining about a tingling that began about one year prior to the July 2016 examination, well after the Veteran's separation from active service in August 2004. The September 2017 examiner also discussed the right wrist, noting the service-connected right ganglion cyst and also a September 2013 EMG that showed nerve function of the right upper extremity to be normal, which rules out neurological problems with that extremity prior to that point. The right wrist ganglion cyst was noted to have been treated with aspiration back in 2004 and has been asymptomatic since then, and is not related to any neurological issue. The September 2017 examiner also provided an opinion regarding secondary service connection, noting the diagnosed left wrist carpal tunnel syndrome, noting it was not caused by nor aggravated by her service-connected cervical spine disability. The examiner's rationale was that carpal tunnel syndrome is a separate diagnosis and separate pathophysiological diagnosis than cervical spine DDD-one does not cause the other and they are causally unrelated. The examiner did note those two issues can created similar symptoms of tingling and numbness, but the cervical spine DDD derives from a pinched nerve originating in the neck, and the carpal tunnel syndrome originates in the wrist and is a compression of the median nerve, and one does not cause, affect, or worsen the other. The examiner also noted that no right upper extremity neurological disorder was found and diagnosed that is related to the cervical spine DDD. The spine disability may cause radicular-type symptoms as a residual, but the examiner noted such symptoms are not a separate neurological disorder. The Board finds the VA examinations and opinions and other VA physician treatment notes to be probative, because the examiners were thorough and examined the Veteran's claims file in detail. The June 2012, April 2015, August 2015, September 2016, and September 2017 VA examinations and opinions were sound and thorough, and had sufficiently clear and well-reasoned rationale, as well as a basis in objective supporting medical literature and clinical data. See Bloom v. West, 12 Vet. App. 185, 187 (1999); Hernandez-Toyens v. West, 11 Vet. App. 379, 382 (1998); see also Claiborne v. Nicholson, 19 Vet. App. 181, 186 (2005). The September 2017 opinion thoroughly discussed both direct and secondary service connection, to include the possibility of the service-connected cervical spine disabilities. Left Upper Extremity Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed left upper extremity disorder, diagnosed as carpal tunnel syndrome of the left wrist, to include as secondary to a service-connected cervical spine disability. The previously mentioned VA examinations from June 2016 forward find diagnoses of left carpal tunnel syndrome, and thus the requirement for a current disability is met. However, beyond the one complaint in the June 2004 service treatment record regarding complaints of multiple arthralgias, there is no evidence in the record of a problem with the left wrist until 2016, 12 years after active service. The Board finds that the VA medical opinions are the most probative evidence and demonstrate that this left upper extremity condition was not incurred in service and is not caused or aggravated by a service-connected disability. The Board notes the lay statements and complaints of the Veteran, but also notes that her symptoms are accounted for either in the diagnosis of the carpal tunnel syndrome or in symptoms traced to existing service-connected disabilities, especially the cervical spine DDD. The Veteran's lay statements are competent and probative as to the description of symptoms. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms such as pain in the upper extremities, she is competent to comment on and endorse these symptoms. However, the determination of the etiology of a upper extremity neurological condition is a complex medical determination beyond her competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, her assertions to that effect are of no probative value, and are outweighed by the competent and probative VA opinions. See McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006); Bostain v. West, 11 Vet. App. 124 (1993). Because the Veteran has no in-service or related disease or injury that occurred in service or within one year after leaving active service that is not already accounted for in her other service-connected disabilities, the second prong of the test for entitlement to direct service connection is not met. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. . Further, the Board has considered the Veteran's contentions that her left upper extremity condition arose from her service-connected cervical spine DDD disabilities. The weight of the competent and probative medical opinions demonstrate that the service-connected cervical spine DDD did not cause or aggravate the diagnosed upper extremity conditions. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed left upper extremity condition was not incurred in service and was not caused or aggravated by the Veteran's service-connected disabilities. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a left upper extremity condition on a direct or secondary basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. Right Upper Extremity Upon review of the evidence of record, the Board finds that the weight of the competent and probative evidence does not demonstrate that entitlement to service connection is warranted for the Veteran's claimed right upper extremity disorder, to include as secondary to a service-connected cervical spine disability. While the Veteran is already diagnosed with, and service-connected for, right wrist ganglion cyst, right shoulder rotator cuff tendonitis, and cervical spine DDD, no VA examiner has diagnosed any additional disabilities in or related to the upper right extremity that are not accounted for in the other mentioned diagnosed disabilities. The previously mentioned VA examinations found no diagnoses of disorders or injuries of the right upper extremity other than those mentioned, and thus the requirement for a current disability is not met. In the absence of proof of a present disability, there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The Board notes the lay statements and complaints of the Veteran, but also notes that her symptoms are accounted for either in the diagnoses of the right shoulder rotator cuff tendonitis or right wrist ganglion cyst, or in symptoms traced to existing service-connected disabilities, especially the cervical spine DDD. The Veteran's lay statements are competent and probative as to the description of symptoms. Generally, lay evidence is probative with regard to a disease with "unique and readily identifiable features" that is "capable of lay observation." See Barr v. Nicholson, 21 Vet. App. 303, 308-09 (2007). Lay evidence on its own can be sufficient evidence of a diagnosis if (1) the layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007). Additionally, a lay person may speak to etiology in some limited circumstances in which nexus is obvious merely through observation, such as sustaining a fall leading to a broken leg. Id. A layperson cannot provide evidence as to more complex medical questions and, specifically, cannot provide an opinion as to etiology in such cases. See Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007) (concerning rheumatic fever). See 38 C.F.R. § 3.159(a)(2). To the extent that the Veteran can observe symptoms such as pain in the upper extremities, she is competent to comment on and endorse these symptoms. Pain alone, without any functional impairment or underlying diagnosis, is not a service connectable disability. Sanchez-Benitez v. West, 13 Vet.App. 282, 285 (1999), vacated in part, dismissed in part by Sanchez-Benitez v. Principi, 259 F.3d 1356 (Fed. Cir. 2001). The determination of the diagnosis and etiology of a upper extremity neurological condition is a complex medical determination beyond her competence. See Layno v. Brown, 6 Vet. App. 465 (1994); see also Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Accordingly, her assertions to that effect are of no probative value, and are outweighed by the competent and probative VA examinations and opinions. See McLendon v. Nicholson, 20 Vet. App. 79, 85 (2006); Bostain v. West, 11 Vet. App. 124 (1993). Because the Veteran has no in-service or related disease or injury that occurred in service or within one year after leaving active service that is not already accounted for in her other service-connected disabilities, the first and second prongs of the test for entitlement to direct service connection are not met. See Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); 38 C.F.R. § 3.303. . Further, the Board has considered the Veteran's contentions that her right upper extremity condition arose from her service-connected cervical spine DDD disabilities. The weight of the competent and probative medical opinions demonstrate that the service-connected cervical spine DDD do not cause or aggravate the diagnosed upper extremity conditions. Based on the above, the Board finds that the weight of the competent and credible evidence demonstrates that the Veteran's claimed right upper extremity condition was not incurred in service and was not caused or aggravated by the Veteran's service-connected disabilities. For these reasons, the Board finds that a preponderance of the evidence is against the claim of service connection for a right upper extremity condition on a direct or secondary basis, and the claim must be denied. Because the preponderance of the evidence is against the claim, the benefit-of-the-doubt doctrine is not for application. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. ORDER Entitlement to service connection for a left upper extremity disability is denied. Entitlement to service connection for a right upper extremity neurological impairment is denied. ____________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs