Citation Nr: 20021611 Decision Date: 03/26/20 Archive Date: 03/26/20 DOCKET NO. 19-27 510 DATE: March 26, 2020 ORDER Entitlement to service connection for Raynaud's disease is denied. Entitlement to service connection for a bilateral leg disability is denied. FINDINGS OF FACT 1. At no time during the relevant appeal period did a causal relationship exist between the Veteran’s Raynaud's disease and his active duty service. 2. The evidence does not show a bilateral leg disability during the relevant appeal period. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for Raynaud's disease have not been met. 38 U.S.C. § 1110, 1131, 1154, 5107; 38 C.F.R. § 3.303. 2. The criteria for entitlement to service connection for a bilateral leg disability have not been met. 38 U.S.C. § 1110, 1131, 1154, 5107; 38 C.F.R. § 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served as a member of the United States Army, with active duty service from June 1989 to July 2014. This appeal comes to the Board of Veterans’ Appeals (Board) from a rating decision, dated April 2017, issued by a Department of Veterans Affairs (VA) Regional Office (RO). In its decision, the RO denied service connection for Raynaud’s disease because this condition neither occurred in nor was caused by service. This appeal also comes to the Board of Veterans’ Appeals (Board) from a rating decision, dated February 2018, issued by a Department of Veterans Affairs (VA) Regional Office (RO). In its decision, the RO denied service connection for a bilateral leg condition because this condition neither occurred in nor was caused by service. The Veteran timely appealed both decisions. Service Connection In seeking VA disability compensation, a Veteran generally seeks to establish that a current disability results from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110, 1131. “Service connection” basically means that the facts, shown by evidence, 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 C.F.R. § 3.303. Establishing service connection generally requires competent evidence showing: (1) the existence of a current 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. Shedden v. Principi, 381, F.3d 1163, 1167 (Fed. Cir. 2004). 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 determination of whether the requirements of service connection have been met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). In making these determinations, the Board must consider and assess the credibility and weight of all evidence in the claim file, including the medical and lay evidence, to determine its probative value. In doing so, the Board must provide its reasoning for rejecting any evidence favorable to the claimant. 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; 38 C.F.R. §§ 3.102, 4.3. A claimant need only demonstrate an approximate balance of positive and negative evidence in order to prevail. See Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). For a claim to be denied on the merits, a preponderance of the evidence must be against the claim. See Alemany v. Brown, 9 Vet. App. 518, 519 (1996). 1. Entitlement to service connection for Raynaud's disease The Veteran claims entitlement to service connection for Raynaud’s disease. Following a thorough review of the Veteran’s medical records, the Board finds that he is not entitled to an award of service connection. As an initial matter, the Board finds that the Veteran has satisfied the first element of service connection, a current disability of Raynaud’s disease. A review of the Veteran’s March 2017 VA examination shows the Veteran has a current diagnosis of Raynaud’s syndrome that was diagnosed in 2016. Therefore, the Board finds that the Veteran has satisfied the first prong of service connection, the existence of a current disability. 38 U.S.C. §§ 1110, 1131; Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000). As to evidence of an in-service incurrence or aggravation of a disease or injury, the Veteran reported that while in service he began noticing the numbness and tingling in his fingers while he was deployed to Afghanistan for rotation 09-11 from December 2008 to December 2009. See Statement in Support of Claim dated June 2019. He performed duties as a door gunner that required his hands to be “positioned on the weapon during all modes of flight (almost outside of the aircraft).” He reported that flying in the mountainous regions of Afghanistan, his hands would often become extremely numb and sore during the flight and he attributed this to the extreme cold and vibration caused by the aircraft. This pain would also occur in his foot and toes and again he attributed this to conditions in which he was performing his duties. He was required to wear gloves and boots at all times during the flight so he could not see if he had the discoloration associated with Raynaud’s at the times he was experiencing these symptoms. The Veteran stated that he would report this during his yearly flight physical and it was attributed to cold weather. The Veteran’s service treatment records (STRs) dated May 1990 show that the Veteran had toe and finger contusions. As these were not mentioned again, they appear to have resolved. STRs also show a history of a fractured ring finger prior to service. A January 2007 STR showed that the Veteran reported numbness or tingling for his shoulder, elbow, or wrist. He elaborated that his shoulder had numbing pain and that his right index finger hurt often. The contemporaneous report of medical examination (RME) showed that his upper extremities were all normal. A subsequent RME from March 2008 showed that all clinical evaluations were normal. The Veteran’s STRs from November 2009 and January 2013 show that the Veteran denied numbness or tingling of hands and feet. While there is conflicting lay and medical evidence regarding the nature of his symptoms during service, the Board finds that the evidence is at least in equipoise to establish the Veteran has satisfied the second prong of service connection, evidence of an in-service disease or injury. 38 U.S.C. §§ 1110, 1131; Boyer, 210 F.3d at 1353. Turning next to evidence of a causal relationship between the present disability and the disease or injury incurred or aggravated during service, the Board finds the weight of the probative evidence does not support a nexus. In reaching this determination, the Board finds the medical opinions of the March 2017 and July 2019 VA examiners to be probative and entitled to significant weight. As described above, the Veteran’s lay evidence is that he had symptoms of Raynaud’s in service; specifically feeling cold and pain in his hands and feet. The Veteran is competent to report experiencing these symptoms. Also as described above, the Veteran’s STRs show he denied experiencing numbness or tingling of the hands and feet several times, and his upper and lower extremities were clinically normal on examination. However, he did report recurrent pain in his right index finger and numbness and tingling in his shoulder, elbow, or wrist. STRs indicate the finger pain was related to a pre-service fracture of the finger. Treatment records from Rheumatology Associates of North Alabama dated May 2016 show the Veteran presented for evaluation of Raynaud’s phenomenon. “For the past four months he has been having Raynaud’s phenomenon mainly in his fingers, not in the toes. . . . In a cold environment or when there is change in the weather, his fingers will turn a pale while and then later turn a purple/blue. He showed me pictures of these, as well.” In a June 2016 follow up appointment he had experienced some numbness and tingling at times in the fingertips but “has not had any Raynaud’s phenomenon during the interim.” In September 2016 he had completed vascular studies that were unremarkable. The rheumatologist noted some paresthesias in his fingers and stated, “it is possible that the paresthesias in the fingers could be due ot the degenerative arthritis in the cervical spine. He is not showing any active Raynaud’s phenomenon at this time.” In January 2017 the Veteran felt he had developed some symptoms of Raynaud’s disease in his left second toe. Vascular studies were completed for the toe and were unremarkable. Treatment records dated August 2017 showed the Raynaud’s was “not very active or significant” so treatment was unnecessary at that time. The Veteran has already been awarded service connection for radiculopathy of the upper right extremity secondary to degenerative arthritis of the cervical spine. In a March 2017 VA examination, the VA examiner opined that the Veteran’s Raynaud’s disease was less likely than not incurred in or caused by the claimed in-service exposure to cold. The Veteran had an onset of symptoms in 2016 described as pain and blanching in the second and fifth digits bilaterally in cold weather followed by purple discoloration for up to 30 minutes. He used gloves or warmth for relief. He reported about 15 episodes the year prior. He was referred to a rheumatologist but had no medical treatment at the time of the examination. In this case, the Raynaud’s condition was diagnosed two years after separation. The VA examiner distinguished between etiologies of the current Raynaud’s disease and the symptoms seen in service. Specifically, the causation of the symptoms of numbness in the hands prior to separation was diagnosed as ulnar compression at the wrists by NCV testing. Blanching or discoloration of the fingers was not noted in his STRs. The Veteran was diagnosed with primary Raynaud’s disease in 2016. Therefore, the VA examiner opined that the Veteran’s Raynaud’s disease was less likely than not incurred in or caused by the claimed in-service illness, event, or injury. In a July 2019 VA examination, the VA examiner opined that the Veteran’s claimed Raynaud’s disease was less likely than not incurred in or caused by the claimed in-service illness, event, or injury. The Veteran continued to have episodes when exposed to extremes of cold, generally twice a month during the months from November to March, depending on the temperature. He had not required treatment. The examiner noted that no similar symptoms with characteristic skin color changes of Raynaud’s were reported or described during military service. The examiner reasoned that the Veteran’s left fourth and fifth finger tingling and numbness had a clear ulnar nerve localization which contrasted with the locale of his current involvement with Raynaud’s and, during military service, he did not have color changes of the fingers and toes which accompanied Raynaud’s episodes. His wrist and leg conditions similarly had separate and distinct localization and were accompanied by no color changes of Raynaud’s. In addition, Raynaud’s affected the fingers and sometimes the toes, and not the wrist or bilateral legs. Therefore, the VA examiner opined that the Veteran’s Raynaud’s disease was less likely than not incurred in or caused by the claimed in-service illness, event, or injury. Although the Veteran is competent to report symptoms and experiences that are observable to an ordinary person, there is no indication that he has the qualifications or experience necessary to offer an expert opinion on a matter of medical complexity such as the etiology of his current Raynaud’s disease. Cf. Layno v. Brown, 6 Vet. App. 465, 470 (1994); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n. 4 (Fed. Cir. 2007). The probability that a relationship exists between his Raynaud’s disease and his service is a matter of medical complexity and not the proper subject of lay testimony. The Board finds the March 2017 and July 2019 VA examiners’ medical opinions provide clear and well-reasoned explanations with supporting data, and reasoned medical explanations connecting the two. Accordingly, the Board places greater probative value on the opinions reached by the March 2017 and July 2019 VA examiners. The Veteran’s medical records did not show any reports of symptoms consistent with Raynaud’s disease until years following his separation from active duty service. The Board has considered the Veteran’s testimony that he could not have seen discolorations that were happening during his episodes of feeling cold and pain because he was required to wear gloves and boots while flying in the helicopters. The Board cannot determine that lay evidence lacks credibility merely because it is unaccompanied by contemporaneous medical evidence. See Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006). Here, the Board is not basing its conclusions solely on the lack of discoloration observed in service, but by viewing it in the context of the entire record. As made clear by the private rheumatology records, there is a distinction between Raynaud’s phenomenon (discolorations in the fingers or toes) and feeling numbness or tingling (paresthesias). The private rheumatologist treated the paresthesias as separate from Raynaud’s, often finding the paresthesias to be present while Raynaud’s was inactive. The VA examiners also noted this distinction, as well as the distinction between the localizations of symptoms of Raynaud’s and paresthesias and/or nerve compression diagnosed by NCV testing. Without any evidence of discoloration in service and in light of the evidence showing an onset of Raynaud’s symptoms in 2016, two years after separation from service, the Board does not find competent evidence of Raynaud’s in service. Therefore, the Board finds the weight of the probative evidence of record is against a finding of a causal relationship between the Veteran’s Raynaud’s disease and service. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim for service connection. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. 2. Entitlement to service connection for a bilateral leg disability The Veteran claims entitlement to service connection for a bilateral leg disability. Following a thorough review of the Veteran’s medical records, the Board finds that he is not entitled to an award of service connection. The Board finds that the Veteran has not satisfied the first element of service connection: a current disability. 38 U.S.C. §§ 1110, 1131. Specifically, the Veteran has not identified pain or a disability of the bilateral legs during the appeal period for which service connection is not already established. This claim was filed in October 2017. In an August 2019 rating decision, the Veteran was awarded service connection for radiculopathy of the lower right extremity secondary to degenerative arthritis of the lumbar spine. Private treatment records dated August 2017 showed the Veteran was having symptoms of paresthesias in his legs after running. The assessment showed that the Veteran had a history of paresthesias in his legs. At a February 2018 VA examination of the legs, the Veteran reported “current symptoms of intermittent tingling sensations at the back of his upper thighs followed by the numbness that proceeds down both legs to include the lower legs, feet, and toes. Episodes occur “a few times each month” in both legs (right leg more prominent than left) and are precipitated by running a half-mile and prolonged car rides (30-40 minutes).” The Veteran reporting undergoing a nerve conduction study in a private Neurologist’s office a few months prior with normal results. Following physical examination, the VA examiner found no objective evidence of any persistent disability. Review of records indicated an EMG of the left lower extremity was performed in May 2013 with no evidence of sciatica or any other neuropathy. The Board has no reason to doubt the credibility of the Veteran with respect to reporting the intermittent tingling sensations in his legs. However, he has no diagnosed disability related to these symptoms and did not report pain of the legs. The Board has considered Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018), but finds it does not support a current bilateral leg disability in this case. The Veteran notably has not made any specific contentions regarding current, subjective bilateral leg symptoms of pain, or how he believes the intermittent tingling he does experience has resulted in specific functional impairments. Cf. Mitchell v. Shinseki, 25 Vet. App. 32, 38, 43 (2011) (stating, “pain itself does not rise to the level of functional loss;” “pain must affect some aspect of the normal working movements of the body...in order to constitute functional loss;” and “painful motion alone is not [the equivalent of] limited motion” (internal quotation marks omitted)); Thompson v. McDonald, 815 F.3d 781, 786 (Fed. Cir. 2016) (disability occurs “if a veteran cannot perform the normal working movements of the body with normal excursion, strength, speed, coordination, and endurance” (citing 38 C.F.R. § 4.40)); Read v. Shinseki, 651 F.3d 1296, 1301 (Fed. Cir. 2011) (“disability” in VA regulations is “generally associated with the veteran’s inability to perform certain acts”). Moreover, even assuming for the sake of argument that the Veteran subjectively experiences bilateral leg pain, there is no objective medical evidence of record that any current bilateral leg symptoms such as pain or intermittent tingling have resulted in functional impairment in earning capacity. Saunders. In the absence a current disability, service connection must be denied. LAURA E. COLLINS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Bristor The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.