Citation Nr: 21002559 Decision Date: 01/14/21 Archive Date: 01/14/21 DOCKET NO. 15-24 404 DATE: January 14, 2021 ORDER Entitlement to a compensable rating for residuals of a fracture of the left fifth metacarpal is denied. Entitlement to service connection for a left ankle and/or foot disability is denied. Entitlement to service connection for a right ankle and/or foot disability is denied. FINDINGS OF FACT 1. The Veteran already has the highest disability rating assignable by law for the residuals of his left fifth finger fracture; the evidence does not support finding that this service-connected disability also affects his other digits. 2. The most probative (competent and credible) evidence is against finding that he has a right foot or ankle disability and/or a left foot or ankle disability because of an injury or a disease or an event during his military service. 3. Upon entrance into service, it was noted he had 1st degree pes planus (flat feet). 4. The most probative evidence of record is against finding that his pre-existing pes planus increased in severity during his service beyond its natural progression, i.e., that it was aggravated by his service. CONCLUSIONS OF LAW 1. The criteria are not met for an initial compensable disability rating for the left fifth finger fracture and consequent residuals. 38 U.S.C. §§ 1155, 5107 (2012); 38 C.F.R. §§ 3.321(b)(1), 4.1, 4.2, 4.3, 4.7, 4.40, 4.45, 4.59, 4.71a, Diagnostic Code (DC/Code) 5230. 2. The criteria are not met for entitlement to service connection for a left foot and/or ankle disability or for a right foot and/or ankle disability. 38 U.S.C. §§ 1110, 1111, 1153, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.306. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active military service from March 1982 to March 1984. In support of these claims, the Veteran testified during a June 2019 hearing before the undersigned Veterans Law Judge at the Board. The Board subsequently remanded these claims in October 2019 for further development and consideration – including to have the Veteran undergo VA examinations for needed medical opinions and to obtain records potentially pertinent to these claims. There since has been the required compliance with those remand directives, certainly the acceptable substantial compliance. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (holding that a remand by the Board confers upon the Veteran, as a matter of law, the right to compliance with the remand instructions); but see also D'Aries v. Peake, 22 Vet. App. 97, 105 (2008) (holding that only "substantial" rather than strict or exact compliance with the Board's remand directives is required under Stegall); accord Dyment v. West, 13 Vet. App. 141, 146-47 (1999).   Increased Ratings Disability evaluations are determined by comparing a Veteran’s present symptomatology with criteria set forth in VA’s Schedule for Rating Disabilities (Rating Schedule), which is based on average impairment in earning capacity. 38 U.S.C. § 1155; 38 C.F.R. Part 4. When a question arises as to which of two ratings applies under a particular diagnostic code, the higher evaluation is assigned if the disability more closely approximates the criteria for the higher rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7. All reasonable doubt material to the determination is resolved in the Veteran’s favor. Id. § 4.3. A disability rating may require re-evaluation in accordance with changes in a Veteran’s condition. It thus is essential in determining the level of current impairment that the disability is considered in the context of its entire recorded history. Id. § 4.1. Nevertheless, the present level of disability is of primary concern. Francisco v. Brown, 7 Vet. App. 55, 58 (1994). “Staged” ratings are appropriate for an increased-rating claim when the factual findings show distinct time periods when the service-connected disability exhibits symptoms that would warrant different ratings – irrespective of whether an initial or established rating. See Hart v. Mansfield, 21 Vet. App. 505 (2007) (established ratings); Fenderson v. West, 12 Vet. App. 119 (1999) (initial ratings). 1. Entitlement to an increased (compensable) rating for the little/small finger disability The residuals of the fracture of the Veteran’s left fifth metacarpal have been rated under DC 5230. For any limitation of motion of the little finger or ring finger (fifth or fourth digit), there is only a 0 percent, i.e., noncompensable rating. 38C.F.R. §4.71a, DC 5230. During a January 2014 VA examination, the examiner observed that there was limitation of motion or painful motion in both the Veteran’s left little and ring fingers. He also reported discomfort and “locking” of the 4th and 5th digits. A combined rating based on limitation of motion of both the little and ring fingers would still be noncompensable. 38 C.F.R. § 4.71a, DC 5230. The January 2014 VA examiner also noted that arthritis was present on an X-ray of the Veteran’s left hand – which provides the possibility of a compensable rating (more specifically, a minimum 10 percent rating) when considering DC 5003. See also 38 C.F.R. § 4.59; Mitchell v. Shinseki, 25 Vet. App. 32 (2011). In his February 2014 Notice of Disagreement (NOD), the Veteran asserted that he was wearing a brace. However, the most probative (competent and credible) evidence is against finding that this was due to his service-connected little finger disability. The records indicate, instead, that he fell on ice in February 2014 and resultantly had increased pain in his hand and wrist. Carpal tunnel syndrome (CTS) in his left hand was diagnosed in April 2014. The evidence also reflects that he consequently underwent CTS corrective surgery in August 2014, but then fell again in August 2014 when knocked down by a dog and re-injured his left hand/wrist. During a November 2014 VA examination, the examiner noted that, after the CTS surgery, the Veteran still had numbness in the thumb, index, and middle finger, and had pain with range of motion. Notably, however, this evidence does not suggest the numbness and even the painful motion were in some way attributable to his service-connected little finger disability – rather than his CTS and surgery. A January 2015 Disability Benefits Questionnaire (DBQ) indicates he developed CTS symptoms approximately 31 years after his service-connected left-hand injury, and there is no evidence in the STRs to account for his post-service CTS. He has not established entitlement to service connection for CTS and, in any event, the 2014 DBQ explains he did not have a gap between any fingertips and the proximal transverse crease of his palm and did not have a gap between his thumb pad and fingers. During his June 2019 hearing before this Board, the Veteran testified that he believes his service-connected fracture of his left fifth metacarpal has gotten worse and, in turn, is impacting his grip strength and range of motion in his index finger. And, partly because of that hearing testimony, and this assertion, the Board remanded this claim in October 2019 to have him reexamined to reassess the severity of his left little finger disability.   To this end, a February 2020 DBQ was obtained and reflects the Veteran’s assertion of pain in his left hand with overuse and difficulty gripping with this hand. On objective physical examination, however, he had full (so normal) range of motion of his index finger, long finger, ring finger, and thumb. The only digit that had less than normal range of motion was his little finger, but it was not ankylosed. Ankylosis is essentially defined as total absence of motion, meaning fixation in a certain position (favorable or unfavorable). Citing Dorland's Illustrated Medical Dictionary (28th ed. 1994), the higher U. S. Court of Appeals for Veterans Claims (Veterans Court/CAVC) repeatedly has recognized that, at least for VA compensation purposes, ankylosis is defined as "immobility and consolidation of a joint due to disease, injury or surgical procedure." See Colayong v. West, 12 Vet. App. 524, 528 (1999); Shipwash v. Brown, 8 Vet. App. 218, 221 (1995). The Veteran did not have this extent of impairment in this finger. Moreover, there was not a gap between the pad of the thumb and the finger or a gap between the finger and the proximal transverse crease of the hand on maximal finger flexion. The Veteran has reported being unable to use his 5th finger for gripping. But, with regard to pain, no pain was noted on examination and he was able to perform repetitive-use testing with no additional loss of range of motion. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). The examiner surmised that, based on his examination, the Veteran’s reported history, and review of the clinical records, there was no basis to offer additional losses of function or motion when it comes to repetitive use or a flare-up. See Sharp v. Shulkin, 29 Vet. App. 26, 34-36 (2017). The examiner conceded the Veteran “may” have difficulty with gripping tools with his left hand. The term “may” is speculative in nature and given little probative weight. See Bostain v. West, 11 Vet. App. 124, 127-28, quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (a medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a causal relationship).   The DBQ also indicates the Veteran had 4/5 grip strength in his left hand, albeit, as already alluded to, degenerative arthritis in this hand. The X-ray showed deformity of the distal fifth metacarpal consistent with well-healed old fracture. There also were minimal degenerative changes in the first and third metacarpal phalangeal joints, but those other joints are not service connected. Although 38 C.F.R. § 4.59 and Burton v. Shinseki, 25 Vet. App. 1 (2011), provide that actual painful, unstable, or malaligned joints, due to healed injury, are entitled to at least the minimum compensable rating for the joint (meaning at least a 10 percent rating), there is no compensable rating for limitation of motion under DC 5230 or any other potentially applicable DC. Therefore, a compensable rating for the Veteran's finger disability is not warranted. See Sowers v. McDonald, 27 Vet. App. 472, 480 (2016); Petitti v. McDonald, 27 Vet. App. 415, 428-29 (2015) (a compensable rating is warranted for joint pain pursuant to § 4.59 for orthopedic disabilities, but only if they are rated under DCs containing a compensable rating). As also already alluded to, DC 5003 rates degenerative arthritis, including consequent painful motion, even when there is noncompensable limitation of motion. This DC provides that degenerative arthritis established by X-ray findings will be rated based on limitation of motion under the appropriate DCs for the specific joint or joints involved (e.g., DCs 5228 to 5230), provided the limitation of motion is compensable; however, when limitation of motion of the specific joint involved is noncompensable under the appropriate DC, DC 5003 explains that a rating of 10 percent is for application for each such major joint or two or more minor joint groups affected by limitation of motion. Here, though, the Veteran's left fifth finger disability is not a major joint or group of minor joints, and the most probative evidence does not tend to show that this service-connected finger disability affects more than just that finger. Therefore, the weight of the evidence is against finding that his service-connected left fifth finger disability warrants consideration for a rating under DC 5003. As such, a minimum 10 percent disability rating under DC 5003 for limitation of motion is not warranted, and this claim is denied. In sum, the preponderance of evidence is against finding the Veteran has ankylosis of this service-connected finger. DCs 5227 and 5230 are the only ones applicable to the ring finger as an individual digit, as granted in his service connection award. Since the preponderance of evidence is against a finding of ankylosis, DC 5227 is inapplicable. DC 5230 does not provide for compensable ratings even when symptoms such as pain and loss of grip strength are present. The Note in this rating code reflects that VA should consider whether an additional evaluation is warranted for resulting limitation of motion of other digits or interference with overall function of the hand. But, in this case, the most probative evidence does not show that the Veteran’s service-connected disability results in loss of range of motion of the other fingers, instead, shows that the other digits have normal range of motion, with the exception of the 2014 examination and the ring finger. In addition, any symptom (i.e. pain and numbness) of the 1st, 2nd, or 3rd digits are more likely than not due to his nonservice-connected CTS. Finally, the Board has considered whether the Veteran is entitled to a total disability rating based on individual unemployability (TDIU). A claim for a TDIU may be raised as a derivative claim stemming from a Veteran's claim of entitlement to an increased rating for a service-connected disability, provided the disability is at least one of the reasons he is unemployable or claims to be. See Rice v. Shinseki, 22 Vet. App. 447 (2009). The Veteran is in receipt of service connection for tinnitus, this fracture of his left fifth metacarpal at issue, left ear hearing loss, and hemorrhoids, for a combined evaluation of 10 percent. Thus, he does not meet the rating criteria for a schedular TDIU. See 38 C.F.R. § 4.16(a). In this circumstance, the Board's analysis is limited to determining whether this claim should be referred to the Director of the Compensation Service to consider whether this TDIU benefit is warranted, instead, on an extra-schedular basis pursuant to the special provisions of § 4.16(b). Anderson v. Shinseki, 22 Vet. App. 423, 428-29 (2009). However, the Board will refer the matter to the Director under § 4.16(b) only when there is at least the required suggestion that the Veteran is unemployable due to his service-connected disability, and there is not this suggestion in this instance.   After consideration of the record on appeal, the Board finds that this referral is not warranted because the most probative evidence does not support the notion that the Veteran's service-connected disabilities – and this left fifth finger disability, especially, preclude him from obtaining and maintaining substantially gainful employment when considering his level of education, prior training and work experience. The Veteran is a graduate of a carpentry program and was self-employed for more than two decades. He is also right-hand dominant. An April 2015 VA clinical record reflects that he had been working until the year prior (i.e. so until 2014) when he hurt his shoulder. The record on appeal affirms he is in receipt of Social Security Administration (SSA) disability benefits but does not indicate that these benefits are due to a service-connected disability, certainly not owing to his left fifth finger disability. Rather, the indication is that he is receiving these benefits because of his shoulder injury and resultant disability. Golz v. Shinseki, 590 F.3d 1317 (Fed. Cir. 2010) (explaining that VA is only obligated to obtain SSA records when they are relevant to the VA claim). A December 2014 record notes that he was an “active contractor” until his shoulder injury. Therefore, VA does not have a duty to obtain his SSA records. The most probative evidence does not support the notion that it is as likely as not that his service-connected disabilities, separately or in combination, preclude substantially gainful employment. Although he has complained that he cannot hear his wife, his tinnitus interferes with his sleep, his hemorrhoids cause occasional pain and blood, and his left-hand little finger interferes with his grip (but still had a 4/5 grip strength when evaluated), his disabilities in any event are not shown to preclude physical (manual labor) jobs consistent with his level of education and training, much less job activity not so much physically demanding. In conclusion, then, entitlement to an increased rating is not warranted, and the evidence also is against finding that the Veteran’s service-connected disabilities preclude substantially gainful employment; thus, referral is not warranted. See 38 U.S.C. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). Service Connection In general, establishing service connection requires medical evidence or, in certain circumstances, lay evidence of the following: (1) a current disability; (2) in-service incurrence or aggravation of a relevant disease or an injury; and (3) a correlation (“nexus”) between the disease or injury in service and the present disability. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). See also 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Also, pursuant to 38 C.F.R. § 3.303(b), if a chronic disease (to include arthritis) according to § 3.309(a), a Veteran may establish the second and third elements of service connection by demonstrating continuity of symptomatology since service. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). Continuity of symptomatology may be established if a Veteran can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage v. Gober, 10 Vet. App. 488, 495-97 (1997); 38 C.F.R. § 3.303(b). The Veteran’s April 1981 Report of Medical Examination for enlistment purposes indicates he had 1st degree pes planus (flat feet). Thus, since this condition was “noted” in the report of his enlistment examination, he had a pre-existing disability of flat feet even when entering service. In this circumstance of notation of pre-existing disability, 38 U.S.C. § 1153 applies and the burden falls on him, not VA, to establish aggravation of this disability during or by his service. Smith v. Shinseki, 24 Vet. App. 40, 47-48 (2010), citing Wagner v. Principi, 370 F.3d 1089, 1096 (Fed. Cir. 2004); Jensen v. Brown, 19 F.3d 1413, 1417 (Fed. Cir. 1994). The Board has considered that the mere "[h]istory of preservice existence of conditions recorded at the time of examination does not constitute a notation of such conditions and that "[o]nly such conditions as are recorded in examination reports are to be considered as noted." 38 C.F.R. § 3.304(b). But, in this case, the Veteran's pes planus was in fact "noted" on the actual examination report. See Quirin v. Shinseki, 22 Vet. App. 390 (2009). In Clemons v. Shinseki, 23 Vet. App (2009), the Court held that an appellant's diagnoses that arise from the same symptoms for which he is seeking benefits do not relate to entirely separate claims not yet filed by the appellant. Rather, these diagnoses should be considered to determine the nature of the appellant's current condition relative to the claim he did submit. With this in mind, the Board has considered whether the Veteran’s claim for service connection for a left ankle disability should also include a left foot disability and whether his claim for a right foot disability should also include a right ankle disability. However, as discussed below, service connection is not warranted, regardless, so for any of his conditions and no matter the scope of his claims or how they are characterized. 2. Entitlement to service connection for a left foot/ankle disability (claimed as left ankle sprain) AND 3. Entitlement to service connection for a right foot/ankle disability (claimed as right foot fracture) An April 1982 service treatment record (STR) notes the Veteran complained of ankle pain for more than a month in duration; this STR does not specify which ankle, but indicates he was to wear insoles and an ankle brace. A July 1982 STR shows he reported sore feet and that he thought he might have flat feet. He said his feet only hurt when he ran. A November 1982 STR reflects that he reported foot pain of 8 months’ duration; he was assessed with calluses (“corns”) on his feet. November and December 1982 STRs show he complained of bilateral (so left and right) foot pain of nine months in duration, one year in duration, and/or since childhood. Mild pes planus was diagnosed. The Board finds that the notation of “mild” tends to refute any notion of worsening of the Veteran’s pre-existing pes planus during or owing to his service. A pre-existing injury or disease will be considered to have been aggravated by active military, naval or air service, where there is an increase in disability during such service, unless there is a specific finding that the increase in disability is due to the natural progress of the disease. 38 U.S.C.A. § 1153; 38 C.F.R. § 3.306(a).   Mere temporary or intermittent flare-ups during service of a pre-existing injury or disease are insufficient to be considered aggravation in service – unless the underlying disability, as contrasted to the symptoms of the disability, has worsened. See Crowe v. Brown, 7 Vet. App. 238, (1994); Hunt v. Derwinski, 1 Vet. App. 292 (1991). There are no STRs (or records shortly after separation from service) suggesting pes planus of 2nd degree or worse degree or showing the Veteran continued to have characteristic calluses (corns) or that those in service were symptoms of an increase in the underlying disability and not merely temporary or intermittent flare-ups of the underlying disability. More recent VA podiatry records are unremarkable for corns or calluses, including to any greater extent than was noted during his service. With specific regard to the left ankle, a January 1984 STR reflects that the Veteran complained of left ankle pain – but of just two days in duration; he was assessed with a P. Brevis strain. February 1984 STRs reflect that he reported twisting his ankle by sliding off a curb onto the side of his foot. He was assessed with a grade I sprain of his left ankle; the x-ray was negative for a fracture. With specific regard to the right foot/ankle, January 1983 STRs reflect that the Veteran dropped a refrigerator on his right foot; it was casted and, a week later, was assessed as a healing calcaneal of the right foot. A March 1983 STR notes continued ankle pain of the right ankle, but x-rays were negative. A September 1983 STR shows he complained of one day of right heel pain after jumping off a truck onto a piece of equipment; the assessment was a contusion (meaning bruise), and the x-ray was negative. The Veteran’s February 1984 Report of Medical History for separation reflects that he reported that he had, or previously had had, foot trouble. The evaluating physician’s “summary and elaboration” explains that the Veteran had a history with the right foot. The left foot/ankle was not mentioned. His military service ended in March 1984.   There are no clinical records in the claims file for the next two decades noting any complaints of or treatment for the feet/ankles. That long a lapse of time between service separation and the earliest documentation of the now claimed disability is a factor for consideration in deciding a service-connection claim and tends to refute the notion of continuing disability since service. See Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000).); Horn v. Shinseki, 25 Vet. App. 231, 239 (2012). However, records dated in 2014 indicate the Veteran reported that, in 1994 or 1999, he had right ankle surgery with three screws inserted. Even if that surgery was in 1994, that still was some 10 years after his separation from the military. A January 2014 VA DBQ indicates the Veteran reported fracturing his right ankle in 2001 (so long after conclusion of his service) and having left ankle problems for about ten years, so since 2004 or thereabouts. The January 2014 examiner found that it is less likely than not the Veteran has a current left ankle disability causally related to his service. This examiner acknowledged the Veteran had a left ankle sprain in service (although this examiner misidentified it as in 1983) but, in any event, still determined there was not a likely causal relationship between a current disability and the disability in service The Board again acknowledges that the examiner incorrectly referred to the left ankle sprain as having occurred in 1983, rather than in 1984, but the Board finds that error de minimus given that the sprain was correctly identified as just a Grade I sprain and the mere one-year discrepancy is relatively slight compared to the several decades since service when there was no further suggestion of any consequent disability. Moreover, the examiner found that the uncomplicated mild sprain in service was less likely than not the cause of the Veteran’s arthritis years later. As well, the 2014 examiner found that it is less likely than not the Veteran has a current right foot disability causally related to his service. This examiner pointed out that, after treatment in service, there were no further problems at that time, and the Veteran had a “more serious injury to the right foot about 10 years ago. His current foot condition is consistent with the second more serious injury that occurred after leaving the service.” A February 2019 private record (Cooley Dickson Orthopedics & Sports Medicine) reflects that the Veteran sought evaluation of his left foot; he reported pain with walking longer distances, and going up and down stairs. The pain was primarily on the dorsum of the left foot. Upon examination, he had full and pain free range of motion. He had stiffness at the midfoot. X-rays showed arthritis in the midfoot. A February 2020 DBQ reflects a history as follows: “in 1983 he had a chip fracture of his right calcaneal. A refrigerator fell onto his foot. He was casted. He continued to have pain on the dorsum of the right foot. He then injured his right foot and ankle in the 1990s in a motorcycle accident. Injury included a fracture of the ankle. He had surgery to repair the fracture. Since then he has had pain and loss of motion in the right ankle. He continues to have pain on the dorsum of the right foot. February 13, 1984, he sprained his left ankle. He had a grade 1 sprain and was treated with crutches. He continued to have discomfort in his left foot and ankle. He states that over the past 6-7 years he has had increased pain in the dorsum of his left foot.” The examiner noted that the pain in the left lower extremity was in the foot, and not the ankle. Moreover, the Veteran had normal range of motion of the left ankle. The Board finds that the Veteran’s contention as to chronic symptoms since service for the left foot/ankle is less than credible given the record as a whole, to include that the report upon separation related specifically to the right foot, there is a lack of clinical records noting complaints for several decades, and in January 2014, the Veteran reported having left ankle problems for about ten years, or since 2004. Thus, any clinical opinion based on the Veteran’s less than accurate clinical history lacks probative value. With regard to the left ankle, the 2020 examiner found that the Veteran does not have a current left ankle disability, but has left naviculocuneiform (midfoot) arthritis and dorsal midfoot exostosis. The Board is cognizant of the Court’s ruling in Saunders v. Wilkie 886 F.3d 1356, 1368 (Fed. Cir. 2018), which found that pain alone can constitute a disability. However, the Court in Saunders cautioned that a Veteran cannot demonstrate service connection simply by asserting subjective pain. Rather, the Court stated “[t]o establish the presence of a disability, the veteran will need to show that [his or] her pain reaches the level of functional impairment of earning capacity.” Id. In this case, the VA examiner found no evidence of pain of the left ankle. Even considering that the Veteran had subjective reports of pain, the pain is not severe enough to reach the level of functional impairment of earning capacity. The Board bases its finding on the examination reports and clinical records. Thus, it is less likely as not that the Veteran has a left ankle disability causally related to service. There is also no competent and credible evidence of record that the Veteran has a left foot disability (to include the midfoot conditions noted above) causally related to service, to include his in-service complaints and diagnoses. With regard to the right foot/ankle, the examiner found it is less likely as not that the Veteran has a current disability causally related to service. The examiner found no competent and credible evidence of a residual of an in-service complaint or injury. The Veteran reported that he injured his right foot and ankle after service, and the radiograph records support that he has hardware in his right ankle and a surgery. The examiner found that the x-rays are not consistent with the Veteran’s calcaneal injury in service. The 2020 examiner found no evidence in the STRs of arthritis in the ankles or feet while in the service, or within a year of service. The Veteran has not been shown to have the experience, training, or education necessary to give a probative opinion regarding the origins of foot and/or ankle disabilities, including in terms of whether related or attributable to anything that occurred during his time in the military, especially with intervening years and an accident requiring surgery. This determination is beyond his lay competence. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). See also King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012) (indicating lay evidence must demonstrate some competence and affirming the Court's conclusion that the Board did not improperly discount the weight of a lay opinion in finding a medical expert's opinion more probative on the issue of medical causation).   For these reasons and bases, service connection is not warranted. And, as the preponderance of the evidence is against the claims, the benefit of the doubt rule is not applicable. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 54-56 (1990). KEITH W. ALLEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Wishard 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.