Citation Nr: 21068345 Decision Date: 11/10/21 Archive Date: 11/10/21 DOCKET NO. 11-27 335 DATE: November 10, 2021 ORDER Entitlement to service connection for residuals of a traumatic brain injury (TBI), to include headaches and memory loss, is denied. Entitlement to service connection for carpal tunnel syndrome of the right upper extremity is denied. Entitlement to service connection for carpal tunnel syndrome of the left upper extremity is denied. Entitlement to service connection for a neurological disability of the right lower extremity, to include peripheral neuropathy and radiculopathy is denied. REMANDED Entitlement to service connection for a neurological disability of the left lower extremity, to include peripheral neuropathy and radiculopathy, is remanded. Entitlement to service connection for a skin disability of the bilateral lower extremities, to include tinea changes, is remanded. FINDINGS OF FACT 1. The Veteran does not have diagnosed residuals of a traumatic brain injury, and his headaches and memory loss are not etiologically related to an in-service event. 2. The Veteran's carpal tunnel syndrome of the bilateral upper extremities are not etiologically related to an in-service event. 3. The Veteran does not have a diagnosis of radiculopathy of the right lower extremity and his peripheral neuropathy of the right lower extremity is not etiologically related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for residuals of a traumatic brain injury, to include headaches and memory loss, are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for service connection for carpal tunnel syndrome of the bilateral upper extremities are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 3. The criteria for service connection for a neurological disability of the right lower extremity, to include peripheral neuropathy and radiculopathy, are not met. 38 U.S.C. §§ 1101, 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty service from February 1971 to February 1973. This matter comes to the Board of Veterans' Appeals (Board) from a rating decision dated in October 2010 of a Department of Veterans Affairs (VA) Agency of Original Jurisdiction (AOJ). The Veteran testified at a Board hearing in May 2017. A copy of the transcript has been associated with the record. This appeal was most recently before the Board in September 2020, at which time it was remanded for additional development. On remand, the AOJ granted service connection for depressive disorder in February 2021; that issue is no longer in appellate status. The remaining issues have since returned to the Board for adjudication. With respect to the claim for TBI residuals, carpal tunnel syndrome, and the right lower extremity disability, the Board finds that the AOJ substantially complied with remand directives and the case is ready for adjudication. Stegall v. West, 11 Vet. App. 268 (1998). However, the claim for a disability of the left lower extremity and a skin disability must again be remanded. The Board sincerely apologizes for any additional delay in rendering a decision for these claims on appeal; however, to ensure the Veteran is afforded every opportunity to substantiate his claims, a remand is required. 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. Service connection can be established by evidence that shows "(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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). For certain chronic diseases, such as organic diseases of the nervous system, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from a period of active duty. 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). When a chronic disease is not shown within one year after service, under 38 C.F.R. § 3.303 (b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). For certain diseases with a relationship to herbicide exposure a presumption of service connection arises if the disease manifests to a degree of 10 percent or more following service in the Republic of Vietnam any time during the period from January 9, 1962 to May 7, 1975. 38 U.S.C.A. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). If a preexisting disorder is noted upon entry into service, the Veteran cannot bring a claim for service connection for that disorder, but the Veteran may bring a claim for service-connected aggravation of that disorder. Jensen v. Brown, 19 F.3d 1413 (Fed.Cir.1994). Where a preexisting disease or injury is noted on the entrance examination, section 1153 of the statute provides that "[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. § 1153 ; 38 C.F.R. § 3.306 (a). The Veteran bears the burden of showing that the preexisting condition worsened in service. See Wagner v. Principi, 370 F.3d 1089 (Fed.Cir.2004). Until the Veteran shows an increase in disability occurred in service, the presumption of aggravation does not attach and, thus, does not shift the burden of rebuttal to the Secretary. Once the presumption has been established, the burden shifts to the Government to show by clear and unmistakable evidence that the increase in disability was a result of the natural progress of the disease. Id. ; see also Horn v. Shinseki, 25 Vet. App. 231 (2011). Temporary or intermittent flare-ups of symptoms of a preexisting condition, alone, do not constitute sufficient evidence for a non-combat Veteran to show increased disability for the purposes of determinations of service connection based on aggravation under section 1153 unless the underlying condition worsened. Davis v. Principi, 276 F. 3d 1341 (Fed. Cir. 2002); Hunt v. Derwinski, 1 Vet. App. 292 (1991). In the absence of proof of a current disability, there can be no valid claim for service connection. Brammer v. Derwinski, 3 Vet. App. 223 (1992). Service connection may only be awarded to an applicant who has a disability existing on the date of application or at any time during the appellate period, not for past disability. Degmetich v. Brown, 8 Vet. App. 208 (1995); 104 F.3d 1328, 1332 (1997)); Romanowsky v. Shinseki, 26 Vet. App. at 294. In adjudicating a claim, the Board is charged with the duty to assess the credibility and weight given to evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 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. 1. Entitlement to service connection for residuals of a traumatic brain injury, to include headaches and memory loss The Veteran contends that he has residuals of a traumatic brain injury (TBI), including headaches and memory loss. The Veteran reported that, in 1971, he was riding in a tank with his head exposed when it came to an abrupt halt, and the hatch hit him on his head. As explained in more detail below, the claim must be denied because the most probative evidence is against a finding that the Veteran is diagnosed with any TBI residuals, and the evidence is insufficient to find that there is a nexus between Veteran's headaches or memory loss and the hatch incident. Turning to the evidence, the Board initially notes that the Veteran's service treatment records (STRs) are silent for any diagnosed TBI or TBI residuals. At an enlistment examination in September 1970, the Veteran reported occasional headaches, but he was not noted to have a headache disorder. His pre-induction clinical examination was normal, except for a scar. The Veteran's records indicate that he had all four fingers of one hand "mashed on tank hatch cover." There is no note of the tank hatch cover hitting his head in the STRs. The Veteran underwent a separation examination in January 1973. Clinical evaluation of all systems was normal, and there are no TBI residuals documented. The Veteran reported that he was in "good health," and no headaches were noted. The Veteran's records from the Social Security Administration (SSA) have been associated with the claims file. The Veteran did not report TBI residuals to SSA when he claimed disability benefits. The records obtained by SSA show that the Veteran intermittently complained of headaches as detailed below. In February 2001, the Veteran complained of headaches with painful ears. In March 2001, he complained of headaches with a sore throat and stuffy nose. The Veteran was diagnosed with acute bronchitis. In October 2001, the Veteran reported a posterior occipital headache "off and on." In September 2002, the Veteran indicated that he was working seven days a week and felt tired. He had a posterior occipital headache at times. The impression was depression. The Veteran denied headaches at appointments in February 2003, April 2003, December 2003, and April 2004. The Veteran reported head pain around the ear and toward his neck in May 2004. The Veteran also had blisters. The impression was shingles. The head pain was noted to be gone in June 2004. The diagnosis was still shingles. The Veteran denied headaches in October 2004, March 2005, September 2005, and March 2006. In May 2006, the Veteran had a headache with a sore throat. He was diagnosed with acute pharyngitis. The Veteran denied headaches at appointments in November 2006, August 2007, and December 2007. In February 2008, the Veteran complained of headaches with discomfort in the chest. He was diagnosed with an upper respiratory infection. In December 2008, the Veteran reported a bitemporal headache. He also had swollen glands, itchy eyes, and a sore throat. He was diagnosed with sinusitis and otitis media. In March 2009, the Veteran had a headache with scratchy throat and eyes. The diagnosis was sinusitis. In October 2009, the Veteran denied headaches. In November 2009, the Veteran reported that he had been having short-term memory issues for the previous two or three weeks. He wondered if it was related to medication he was taking. In June 2010, the Veteran submitted a written statement in which he indicated his belief that his headaches were caused by an in-service head injury. At a VA appointment in July 2010, the Veteran reported that he had been experiencing recurrent headaches since the 1980s. The Veteran also reported that he lost consciousness after being hit in the head in service. At a VA examination of the Veteran's spine in September 2010, the Veteran reported that he was hit in the back between the shoulder blades and low back with a hatch from an Army vehicle in 1971. At an audiology VA examination in September 2010, the Veteran reported that he was unsure if he lost consciousness after being hit in the head in service. In his December 2010 Notice of Disagreement, the Veteran described how he was hit in the head. He indicated that he was wearing a helmet when he was hit. The Veteran testified at a Board hearing in May 2017. He explained that he had experienced headaches since service and received continuous treatment for them since. The Veteran also testified that his memory problems did not exist prior to service, that they began shortly after service, and had worsened over the years. The Veteran indicated that he was not diagnosed with a TBI, but he attributed his symptoms to being hit in the head. In October 2017, Dr. B.B. at Advanced Neurologic Associates wrote a letter on the Veteran's behalf. Dr. B. explained that the Veteran was followed in the neurology clinic for various symptoms. Dr. B. opined that the Veteran suffered a closed head injury that caused a traumatic brain injury resulting in loss of consciousness for a period of up to 15 minutes. The Veteran's TBI would be classified as moderate to severe based on his report of symptoms. Dr. B. reported that since the head injury, the Veteran experienced chronic headaches and short-term memory issues that are chronic and relatively unchanged. The persistence of the Veteran's symptoms is consistent with post-concussive syndrome. Dr. B. wrote, "I do feel that since he has not suffered any other closed head injuries that it is with reasonable medical certainty that these would most likely be related to his traumatic brain injury." The Veteran had an appointment with Dr. B. at Advanced Neurologic Associates in January 2018. The Veteran reported that he was injured in the service and had had problems with memory and headaches since. The assessment was diffuse traumatic brain injury with loss of consciousness of 30 minutes or less. However, Dr. B. made reference to a female patient having "memory loss likely due to TBI. She has [restless leg syndrome] due to underlying neuropathy." The Veteran underwent a VA examination for TBI and TBI residuals in March 2019 with a psychiatrist. The VA examiner reviewed the Veteran's STRs and outpatient treatment records. The examiner explained that the Veteran demonstrated some cognitive defects on testing, but his records showed no diagnosis of TBI during service. The examiner determined that the Veteran did not have any residuals of a TBI. The Veteran reported that after he was hit in the head, he lost consciousness, was examined, and released to duty. The examiner also reviewed the Veteran's Board testimony, where he reported that he started to have symptoms about a month after his injury. The examiner explained that if the Veteran had a TBI caused by 90 pounds of steel, he would have had immediate symptoms, and there were none documented in the records. The examiner concluded that the Veteran did not have a diagnosis of TBI because there were no findings, signs, or symptoms to support a diagnosis. Thus, the examiner opined that it is less likely than not that the Veteran had a TBI diagnosis and his symptoms were most likely related to another etiology other than TBI. On examination, the examiner noted no symptoms of impairment of memory, attention, concentration, or executive functions. Judgment was normal, and social interaction was routinely appropriate. The Veteran was also oriented. Motor activity and visual spatial orientation were normal. Further, the examiner found no subjective symptoms or neurobehavioral effects. The Veteran was able to communicate by spoken and written language, and he was able to comprehend spoken and written language. Finally, consciousness was normal. Regarding any additional residuals or other findings, the Veteran did not have any subjective symptoms or any mental, physical, or neurological symptoms attributable to a TBI. The examiner reviewed Dr. B.'s 2017 opinion and indicated that the conclusion that memory loss was related to a TBI was not based on objective medical evidence. Dr. B. noted that the Veteran had a normal neurological examination in October 2008 and denied memory loss. The Veteran had multiple other diagnoses, and the examiner opined that his reported symptoms are most likely related to his multiple medical problems. The Veteran's headaches were tension headaches and not related to a TBI. Therefore, it is less likely than not that the Veteran had a diagnosis of a TBI or any residuals. Also in March 2019, the Veteran was afforded a VA examination for headaches with a nurse practitioner. The Veteran was diagnosed with tension headaches and posttraumatic headache pain. The Veteran reported he had a contusion after the hatch hit his head, and he lost consciousness for approximately 5 minutes. He reported that he was released to duty within 3 weeks. The AOJ obtained a supplemental opinion from a nurse practitioner in April 2019. The examiner explained that the Veteran's headaches were a residual of a TBI and it is at least as likely as not a condition that started during active duty service, and is related to the head injury where the Veteran lost consciousness and had subsequent problems with head pain. The rationale included that the Veteran reported occasional headaches on separation and his headaches still existed and had gotten worse. The AOJ obtained another opinion from a nurse practitioner in May 2019. The examiner opined that it is at least likely as not that the Veteran's headaches were incurred as a result of his in-service TBI. The opinion was "based on the claimant's repeated report of being struck in the head by the tank hatch" and Dr. B.'s letter in support of the claim. The Veteran was afforded another VA examination for headaches with a nurse practitioner in June 2019. The Veteran reported that, after being hit in the head, he had loss of consciousness for about one minute. He explained that he was treated with medication and rest, and was off duty for 3 weeks. The examiner noted that the Veteran had been seen in service for a hand injury caused by the hatch, but not a brain injury or loss of consciousness. The Veteran underwent another VA examination for TBI with a physiatrist in February 2021. The following definition of a TBI was provided: "a traumatically-induced physiological disruption of brain function manifested by at least one of the following: (1) loss of consciousness of less than or equal to 30 minutes; (2) loss of memory for events immediately before (retrograde amnesia) or events after the accident (post-traumatic amnesia); (3) any alteration in mental state at the time of the injury (dazed, disoriented, confused); (4) presence of focal neurological deficits; (5) Glasgow Coma Scale score greater than or equal to 13." In the examination, the Veteran reported that he was knocked out for up to 10 minutes, was taken to the infirmary for treatment, and was off duty for 2 or 3 weeks. The Veteran also reported that he had headaches after the injury and memory problems began about 2 years after service. The Veteran reported his work history. On examination, the examiner noted no complaints of impairment of memory, attention, concentration, or executive functions. Judgment was normal, and social interaction was routinely appropriate. The Veteran was also oriented. Motor activity and visual spatial orientation were normal. Further, the examiner found no subjective symptoms or neurobehavioral effects. The Veteran was able to communicate by spoken and written language, and he was able to comprehend spoken and written language. Finally, consciousness was normal. Regarding any additional residuals or other findings, the Veteran did not have any subjective symptoms or any mental, physical, or neurological symptoms attributable to a TBI. The examiner noted that the records did not show any treatment for a TBI in service, or any medical visits for memory complaints until 2018, and no neurological complaints on separation from service, even though the Veteran complained of headaches at enlistment. The Veteran's cognitive limitations were consistent with his other diagnoses. The examiner also explained that Dr. B.'s opinion did not refer to any objective evidence, imaging, or testing to support a diagnosis of TBI, and the diagnosis was based on a report of symptoms. Dr. B. started the Veteran on medication that was not a specific treatment for TBI, but rather is generally for cognitive decline. Additionally, Dr. B. did not indicate that other differential diagnoses were considered. Therefore, there was lack of objective medical evidence of a TBI related to the Veteran's service. The examiner also explained that, despite complaints of memory loss, the Veteran was able to work full-time until physical ailments interfered with work. A diagnosis other than TBI, such as age, diabetes mellitus, hypertension, and coronary artery bypass, was the likely cause of the Veteran's reports of cognitive limitations. The Veteran's mild cognitive limitations on testing were consistent with his chronic diseases. The Veteran's functional history and lack of documented injury meant that a nexus to service could not be established. In sum, the Veteran's claimed TBI is less likely than not caused by or incurred in service The Veteran was also afforded a VA examination for headaches with a physiatrist in February 2021. The Veteran was diagnosed with tension headaches, but the date of onset was unclear. The examiner explained that, based on the Veteran's history, headaches began primarily after service. In his civilian occupation, the Veteran did not recall missing work because of headaches. While the Veteran reported headaches at entrance, discharge documentation showed no history of headache or other neurologic complaint. Headaches were also not documented when the Veteran was treated for finger injuries caused by the hatch, and there was no indication of a blow to the head in the treatment records. After a review of the record, the Board finds that the most probative evidence of record demonstrates that the Veteran presently does not have disability arising from residuals of a TBI. In making this finding, the Board affords significant probative weight to the findings of the February 2021 VA examinations and opinions, and some, but not significant, weight to the April 2019 VA examination reports. In making this finding, the Board is cognizant of the findings of the Veteran's private neurologist in October 2017, who assessed traumatic brain injury and residuals of headaches and memory loss. However, the Board may place greater weight on one medical professional's opinion over another's depending on such factors such as reasoning employed by the medical professionals, and whether or not and to what extent they review prior clinical records and other evidence. Gabrielson v. Brown, 7 Vet. App. 36 (1994). The opinion is considered probative if it is definitive and supported by a detailed rationale. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). The February 2021 VA examiner provided a negative medical opinion, finding that the Veteran did not have residuals of a TBI. The examiner is a qualified physiatrist, and the VA examination report explained the basic elements in determining whether a TBI occurred and whether residuals of a TBI exist. The examiner specifically provided normal findings in his assessment of the facets of TBI-related cognitive impairments and subjective symptoms of TBI. Further, his opinion was predicated on his clinical interview with the Veteran, a review of the Veteran's treatment records, to include his service treatment records and post-service clinical records. Thus, after careful consideration of all the competent medical opinions, the Board finds that the February 2021 VA opinion to be the most persuasive evidence on the threshold issue of a TBI diagnosis. Gabrielson, 7 Vet. App. 36; Id. The opinion contained a detailed explanation to support the determination and even addressed Dr. B.'s private opinion. The Board considers Dr. B.'s opinion less persuasive and affords it little weight. Dr. B.'s opinion was based on history reported by the Veteran, and did not include any objecting testing or a review of the STRs. Moreover, the opinion does not use the "at least as likely as not" standard. The Board finds the February 2021 VA examiner's opinion regarding headaches and memory loss, that such symptoms were better explained by the Veteran's other diagnoses, to be more probative, as the conclusion, again, was supported by a thorough examination and reported findings. The Board also affords the favorable VA opinions dated in April 2019 and May 2019 little weight. First, the Board notes that, under VA regulations, VA examinations regarding the presence of TBI residuals must be performed a qualified TBI examiner, such as a physiatrist, psychiatrist, neurologist, or neurosurgeon. The two favorable VA opinions were provided by nurse practitioners, who are not qualified under VA regulations. Moreover, the April 2019 VA opinion is based on incorrect information. The examiner indicated that the Veteran reported headaches at separation, when he, in fact reported them at enlistment but not separation. The May 2019 VA opinion receives little weight because it is based on Dr. B.'s private opinion and the Veteran's reported history, but not medical principles. The Board further notes that the Veteran's report of symptoms has changed over time. For instance, in July 2010, the Veteran reported the onset of headaches in the 1980s. However, in May 2017, he testified to the onset of headaches during service. The Veteran also reported in a September 2010 VA examination that he was unsure if he lost consciousness. He reported to other examiners that he lost consciousness, and his reports varied from one minute to five minutes' duration. The Veteran testified that he had memory problems shortly after service, but in November 2009, he was seen for memory problems of two or three weeks. Finally, the Veteran reported to September 2010 VA examiner of his spine that he was hit with the hatch between the shoulders and low back; he has reported to other examiners that he was hit in the head, while the STRs only document a hit on the hands. Because the Veteran's reports have been inconsistent, the Board affords an opinion based on his reported history little weight. The Board has also considered the Veteran's lay statements contending that he suffers from residuals of a TBI. While the Veteran believes that his claimed disability is related to service, the Board concludes that the Veteran is not competent to make this determination. The issue is medically complex, as it requires the interpretation of symptoms and application of medical principles by a trained medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). There is no evidence that the Veteran has any medical training. See 38 C.F.R. §§ 4.125, 4.130. Therefore, the Board must rely on the competent evidence, particularly the April 2019 and February 2021 VA examinations, in making its decision. Here, the Veteran is competent to comment on observable symptoms such as headaches and reduced memory. However, there is no indication that the Veteran possesses the requisite medical knowledge or education to render an opinion on the diagnosis of TBI. Consequently, his statements regarding TBI are insufficient to establish a current diagnosis. To the extent the Board must consider aggravation of a pre-existing disability with regards to the Veteran's headaches, the Board finds that the claim fails on these grounds as well. While clinical evaluation did not "note" a headache condition on entrance, the Veteran reported headaches. Thus, with regard to aggravation of preexisting headaches, the Veteran bears the burden of showing worsening during service. 38 C.F.R. § 3.306. Here, the Veteran's service treatment records are silent for any complaints of headache pain during active duty. Additionally, the Veteran did not report headaches on separation. Thus, the evidence is against a finding that headaches were aggravated or worsened during service. In short, the Board has considered all of the evidence of record, but finds that the record does not provide an approximate balance of negative and positive evidence on the merits. The record contains an opinion against the claim with significant weight and one with some weight, the opinions in favor of the claim with little weight, and STRs and outpatient treatment notes with significant weight. Thus, the Board finds the preponderance of the evidence is against the claim and the claim must be denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990); 38 U.S.C.A. § 5107 (b); 38 C.F.R. § 3.102. 2. Entitlement to service connection for carpal tunnel syndrome of the right upper extremity 3. Entitlement to service connection for carpal tunnel syndrome of the left upper extremity The Board notes that the Veteran is service-connected for polyneuropathy of the bilateral upper extremities. However, he is not service-connected for carpal tunnel syndrome. The Veteran contends that his bilateral carpal tunnel syndrome (CTS) is related to the incident in service when a tank hatch fell on his hands. As explained in more detail below, the claim must be denied as the competent evidence does not support a nexus between the Veteran's disability and the in-service event. Turning to the evidence, the Board initially notes that the Veteran's STRs are silent for any diagnosed wrist disabilities or residuals from the hatch injury. At an enlistment examination in September 1970, clinical evaluation of all body systems was normal, except for a scar. The Veteran's records indicate that he had all four fingers of one hand "mashed on tank hatch cover." The Veteran underwent a separation examination in January 1973. Clinical evaluation of all systems was normal, and there are no residuals from the hatch injury documented. The Veteran reported that he was in "good health." At an outpatient appointment in October 2008, the Veteran complained of pain in his hands for the previous four or five years. He reported a history of diabetes mellitus for 14 years, and noticing issues with pain and cramping the past few years. The assessment was "likely" diabetic peripheral neuropathy. The Veteran was referred for nerve conduction studies. The Veteran underwent a nerve conduction study in November 2008. It demonstrated bilateral median neuropathy at or distal to the wrist, such as CTS. The Veteran did not have cervical radiculopathy. Records from the SSA show that in December 2008, the Veteran was evaluated for disability. The examiner explained that within a reasonable degree of medical probability, the Veteran's CTS is causally related to his employment as a machine repairman. The Veteran had repetitive use of hand tools with gripping and squeezing as part of his job, and the movements resulted in the development of bilateral CTS. At an appointment in April 2009, the Veteran reported that he had undergone bilateral surgery for carpal tunnel. The note indicates it was "work related." The Veteran submitted his Notice of Disagreement in December 2010. He argued that his CTS was due to the repetitive motion of loading magazines for the firing line during basic training. At a Board hearing in May 2017, the Veteran testified that he had received treatment for hand pain since he was released from active duty. A May 2017 note indicates that the Veteran's painful hands were due, in part, to CTS, and also to peripheral neuropathy. The Veteran was afforded a VA examination in March 2019. He reported numbness in the fingers of both hands, a history of diabetes mellitus, and having worked in a job as a repairman with lots of repetitive finger and hand movements. The Veteran indicated he had surgery for CTS. He was diagnosed with diabetic peripheral neuropathy and carpal tunnel. The examiner checked a box indicating that it is less likely than not that the Veteran's CTS was caused by or related to the in-service injury, but then wrote that carpal tunnel is at least as likely as not incurred in or related to service. Despite the examiner's conflicting conclusions, a negative rationale was provided. The Veteran had over 30 years of work involving repetitive movements of the wrist and CTS can be caused by repetitive use of tools. However, the examiner also noted that it can be caused injury to the nerves of the hand. The Veteran also underwent a VA examination in May 2019. He was again diagnosed with CTS and peripheral neuropathy. The examiner concluded it is less likely than not that carpal tunnel was caused by an in-service injury because the Veteran's CTS is caused by repetitive movements and is secondary to his use of tools as a machine repairman. The examiner explained that CTS is a median nerve condition caused by compression of the wrist tendons and muscles, which results from repetitive movements that bulk up the structures around the carpal tunnel and compresses the nerve. Being hit in the head by a tank hatch would not cause CTS. The AOJ obtained a supplemental opinion in November 2020. The examiner noted that the Veteran's STRs did not indicate which hand was hit with the tank hatch, but that the Veteran reported it was both. The Veteran had diagnoses of both CTS and diabetic peripheral neuropathy. The examiner opined that it is less likely than not that the claimed conditions were attributable to service. The CTS is less likely than not related to an in-service hand injury, and is much more likely attributed to repetitive motions in post-service employment as a repairman. The AOJ obtained an addendum opinion in May 2021. The examiner reviewed the March 2019 opinion and explained that the rationale was not plausible, and it was broad and general. CTS is due to impingement of the median nerve at the wrist, and there was no evidence of wrist involvement with the in-service hatch injury, which would have been readily apparent at the time. The STRs did not indicate any wrist injury and it was highly unlikely that a significant wrist injury would have gone unnoted or unreported. The injury the Veteran sustained was distal to the wrist and the anatomical location of his impingement syndrome. Therefore, it is less likely than not that the Veteran's bilateral CTS is due to the events in service, including residuals of a hand injury. It is more likely than not that CTS arose due to the nature of his work after service. After reviewing the record, the Board concludes that service connection for CTS of the bilateral upper extremities is not warranted. The most probative evidence shows that the Veteran's CTS is attributed to his post-service work involving repetitive movements with his hands. The Board acknowledges that none of the VA opinions directly address the Veteran's contention that his CTS is due to firing weapons. However, the Board finds that the record, as a whole, is adequate to decide the claim. It logically follows that, since the Veteran's CTS is less likely than not due to service and is more likely due to post-service work, it is also less likely than not due to firing weapons. In forming the above conclusion regarding CTS, the Board affords some, but not significant, weight to the December 2008 workman's evaluation in the SSA records, the April 2009 outpatient record, and the May 2019 VA examination report. The Board affords the March 2019 VA examination report little weight, and the November 2020 and May 2021 VA examination reports receive significant weight. The December 2008 evaluation receives some weight because it provides adequate rationale regarding the etiology of the Veteran's CTS, but it does not receive significant weight because it does not use the correct legal standard. The April 2009 outpatient receives some weight because it is consistent with the rest of the record in attributing the Veteran's CTS to his post-service employment, but it is not significant in the Board's analysis because there is no rationale or legal standard provided. The May 2019 VA examination provides adequate rationale regarding the etiology of CTS, but it does not receive significant weight because it addresses whether the Veteran's CTS was related to being hit in the head, and does not discuss the Veteran's contention of being hit in the hands or firing weapons. The March 2019 VA examination receives little weight because it is contradictory, and suggests that the Veteran's CTS is both attributable and not attributable to service. The November 2020 VA examination receives significant weight because it uses the correct legal standard, and provides adequate rationale regarding CTS being caused by repetitive motions in his post-service job. The May 2021 VA examination receives significant weight because it considers and directly addresses the March 2019 VA examination report, and addresses the Veteran's contentions in explaining why his CTS was not related to an in-service hatch injury. In sum, regarding a nexus between CTS and the Veteran's service, there is no positive probative and competent opinion in the Veteran's favor. The March 2019 VA examination was contradictory and received little weight. With several negative opinions receiving significant weight, and several records against the claim receiving some but lesser weight, the Board finds that the preponderance of the evidence weighs against the Veteran's claim. While the Veteran believes that his carpal tunnel syndrome of the bilateral upper extremities is related to service, including firing weapons in basic training or a hatch injury, the Board concludes that the Veteran is not competent to make this determination. The issue is medically complex, as it requires the interpretation of symptoms and application of medical principles by a trained medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). There is no evidence that the Veteran has any medical training. See 38 C.F.R. §§ 4.125, 4.130. Therefore, the Board must rely on the competent evidence, particularly the adequate VA examinations as noted above, in making its decision. The Board, therefore, affords the examinations more weight than the Veteran's contention in determining that his symptoms are due to post-service employment. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). 4. Entitlement to service connection for a neurological disability of the right lower extremity, to include peripheral neuropathy and radiculopathy The Veteran contends that he has a nerve disability of the right lower extremity that was caused when he was hit with a tank hatch. Specifically, the Veteran contends that when he was hit, "everything was compacted" from his head down and he got nerve damage in his legs. As explained in detail below, the Board finds that the Veteran's peripheral neuropathy is not attributable to an in-service injury, and he does not have a diagnosis of radiculopathy of the right lower extremity. Turning to the evidence, the Board initially notes that the Veteran's STRs are silent for any diagnosed nerve disability of the right lower extremity. At an enlistment examination in September 1970, clinical evaluation of his lower extremities was normal. The Veteran underwent a separation examination in January 1973. Clinical evaluation of all systems was normal, and there are no residuals from the hatch injury documented. The Veteran reported that he was in "good health." The Board notes that the Veteran's private treatment records and VA records are silent for a diagnosis of radiculopathy of the right lower extremity, but the record contains references of radiculopathy of the left lower extremity. In August 2008, the Veteran was seen for paresthesias, pain, and tingling in the bilateral lower extremities. Diabetic neuropathy was suspected. An October 2008 note indicates that the Veteran had experienced pain in his feet for the previous 4-5 years. There was concern about peripheral neuropathy. The Veteran underwent a nerve conduction study in November 2008 for numbness, tingling, and pain the bilateral lower extremities, which diagnosed peripheral neuropathy, but not radiculopathy. Records from the SSA show that in December 2008, the Veteran was evaluated for disability. The examiner explained that the Veteran's peripheral neuropathy diagnosis was not related to employment, but rather diabetes mellitus. The Veteran had a 14-year history of diabetes and peripheral neuropathy was a common complication for patients with a prolonged history of the condition. In February 2010, the Veteran was noted to have had peripheral neuropathy in his legs. His symptoms included pain, ataxia, balance issues, and gait instability. A June 2010 VA treatment record indicates that the Veteran reported overseas service in Germany, but not Vietnam. At a psychiatry consultation in July 2010, when discussing his military history, the Veteran reported he felt "lucky" he did not go to Vietnam. The Board notes that the Veteran's military personnel records are also silent for service in Vietnam. The Veteran testified in May 2017 to his belief that the symptoms in his feet and legs were caused by compression of his spine and body in the hatch injury. A medical opinion dated in March 2019 indicates that the Veteran's peripheral neuropathy clearly and unmistakably preexisted service, and it at least as likely as not was aggravated beyond its natural progression during active duty as it is related to diabetes mellitus. Another opinion from March 2019 indicates that the Veteran's diabetic peripheral neuropathy of the right lower extremity at least as likely as not either began during active duty service or related to an in-service event or injury and is related to diabetes mellitus. The AOJ obtained a supplemental opinion in May 2019. The examiner reviewed the Veteran's medical records and the March 2019 opinions. The examiner concluded that the Veteran's peripheral neuropathy did not exist prior to service, and therefore could not have been aggravated by service. The records "clearly" show that the Veteran's peripheral neuropathy is a result of his diabetes mellitus. Additionally, it was noted that the Veteran did not have radicular pain. Another May 2019 opinion indicates that the Veteran's peripheral neuropathy is less likely than not related to service. The examiner explained that the Veteran's neuropathy was deemed to be due to diabetes mellitus, according to his neurologist. The May 2019 VA examination report regarding CTS is relevant here. The examiner opined that the Veteran's peripheral neuropathy was less likely than not caused by service because the nerves injured are peripheral and not emanating from the spinal cord, and a tank hatch hitting the head or spine would not cause a peripheral injury. A November 2020 opinion is also of record. The examiner indicated that the Veteran's peripheral neuropathy is related to diabetes. The Veteran's symptoms of paresthesias, numbness, burning, sore legs, and cold feet were addressed in 2008 and 2009 by his neurologist, Dr. B., who noted that the Veteran had diabetes mellitus for 13 years and that his symptoms were "likely diabetic peripheral neuropathy." The Veteran's diabetic neuropathy symptoms were not present during service and the diagnosis of diabetes mellitus was not made until around 1995. Therefore, the peripheral neuropathy is less likely than not related to service. The Veteran underwent another VA examination in April 2021. The examiner explained that the Veteran's peripheral neuropathy is less likely than not related to service. The Veteran was diagnosed with diabetes mellitus around 1985 or 1990, and was on insulin by 2000. The Veteran was noted to have symptoms of diabetic peripheral neuropathy in October 2000, and he had complained of numbness, tingling, and pain 2008, at which time his neurologist determined that his right lower extremity complaints were the result of a long-standing history of diabetes. Therefore, there was no nexus to service. Additionally, the examiner noted that there was an inability to confirm a diagnosis of radiculopathy. After reviewing the record, the Board concludes, first, that service connection for peripheral neuropathy of the right lower extremity is not warranted due to lack of medical nexus between the diagnosis and an in-service event. Second, the Board concludes that the Veteran does not have a diagnosis of radiculopathy of the right lower extremity for which service connection may be granted. First, regarding peripheral neuropathy, the most probative evidence shows that the Veteran's peripheral neuropathy is attributable to diabetes mellitus, not an in-service injury or event, including a tank hatch injury. The Board has also considered whether service connection should be granted for diabetes mellitus, which would make peripheral neuropathy secondarily service connected. However, the record reflects that the Veteran's diabetes did not manifest to a degree of 10 percent within a year of separation, as the records reflect that in 2008, the Veteran had at least a 13-year history of diabetes mellitus. Additionally, the Veteran's outpatient records and personnel records show he did not have service in Vietnam, meaning presumptive service connection for diabetes mellitus is not available. Finally, the Veteran has not asserted that his diabetes is etiologically related to service. The Board recognizes that the May 2019 VA examination regarding peripheral neuropathy of the bilateral lower extremities, the November 2020 VA examination, and the April 2021 VA examination report do not directly address the Veteran's contention regarding his lower extremity symptoms being caused by being hit with a tank hatch. For these reasons, the opinions receive some, but not significant weight. Nevertheless, the Board finds the opinions, especially when viewed with the remaining evidence cited above, adequate to decide the claim. The Board further notes that the May 2019 VA examiner who addressed the Veteran's bilateral upper extremities provided a rationale that applies to the Veteran's right lower extremity as well. Specifically, the examiner explained that being hit in the head with a tank hatch would not cause peripheral nerve injuries, as the Veteran contends. Moreover, given the conclusions of the other May 2019, November 2020, and April 2021 VA examination reports, that the Veteran's peripheral neuropathy is "clearly" due to diabetes mellitus and less likely due to service, it follows that the Veteran's peripheral neuropathy is less likely specifically due to a compression injury caused by the tank hatch. The Board affords the favorable March 2019 VA opinions little weight. They are conclusory and do not provide any rationale involving medical principles. Moreover, one of the opinions is directly contradicted by the Veteran's STRs. It cannot be said that the Veteran's peripheral neuropathy clearly and unmistakably preexisted service when the Veteran was not diagnosed with peripheral neuropathy until after separation, and there was no notation of the disability at entrance. Thus, the Veteran was considered sound at enlistment with respect to peripheral neuropathy of the right lower extremity, and the principles of aggravation of a preexisting disability do not apply. For these reasons, the opinion receives little weight. Second, regarding claimed radiculopathy of the right lower extremity, the Board notes that the Veteran does not have such diagnosis. As outlined above, the pertinent legal criteria require that the evidence establish a current disability. This criterion is not met in this case with respect to radiculopathy. The April 2021 VA examination report receives significant weight in this regard, as the examiner noted that there was diagnosed radiculopathy of the right lower extremity. Thus, the Board finds that the Veteran does not have radiculopathy of the right lower extremity, and has not had this diagnosis at any time during the pendency of the claim or recent to the filing of the claim. 38 U.S.C. §§ 1110, 1131, 5107(b); Holton v. Shinseki, 557 F.3d 1363, 1366 (Fed. Cir. 2009); Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007); 38 C.F.R. § 3.303 (a), (d). Therefore, service connection is not warranted. While the Veteran believes that he has radiculopathy of the right lower extremity and that his peripheral neuropathy of the right lower extremity is related to service, the Board concludes that the Veteran is not competent to make these determinations. The issues are medically complex, as they require the interpretation of symptoms and application of medical principles by a trained medical professional. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). There is no evidence that the Veteran has any medical training. See 38 C.F.R. §§ 4.125, 4.130. Therefore, the Board must rely on the competent evidence, particularly the adequate VA examinations as noted above, in making its decision. The Board, therefore, affords the examinations more weight than the Veteran's contentions in determining that the Veteran does not have radiculopathy and that his symptoms of peripheral neuropathy in the right lower extremity are due to nonservice-connected diabetes mellitus and not service. In reaching the above conclusion, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable in the instant appeal. Ortiz v. Principi, 274 F.3d 1361, 1364 (Fed. Cir. 2001). REASONS FOR REMAND 1. Entitlement to service connection for a neurological disability of the left lower extremity, to include peripheral neuropathy and radiculopathy is remanded. The Veteran contends that his nerve disability is related to an injury he sustained in service. This issue was remanded most recently in September 2020 for the AOJ to obtain an opinion that addressed the November 1972 service treatment record documenting pain radiating to the Veteran's left lower extremity. The Veteran was afforded a VA examination in November 2020. The VA examiner observed that the Veteran reported low back pain with radiation to his leg in October 1972 and again in November 1972, but the Veteran reported a pre-service motorcycle accident, which was the cause of his radiculopathy and not an in-service injury. Additionally, an opinion dated in April 2021 indicates that the Veteran's radiculopathy diagnosis could not be confirmed, so no nexus was established. The Board finds the opinions inadequate to adjudicate the Veteran's claim. Since the evidence establishes that the Veteran had a pre-existing disability at the time of enlistment, an opinion is required regarding whether the Veteran's disability was aggravated during service. Therefore, another remand is required. The Board also notes that the Veteran is service-connected for a spine disability. Therefore, on remand, an examiner should opine, if the Veteran's radiculopathy of the left lower extremity was not aggravated by service, whether it is secondary to his back disability. 2. Entitlement to service connection for a skin disability of the bilateral lower extremities, to include tinea changes is remanded. After the Board's September 2020 remand, the Veteran was afforded a VA examination of the skin in November 2020. The examiner provided a negative opinion and explained that the claims file "is silent for any visits relating to skin complaints...during the time in service. Due to this fact, there is no evidence to support that the skin complaints this Veteran is currently experiencing existed while in service." The provided rationale is inadequate to decide the Veteran's claim. First, it is based on a lack of documented treatment or care, and does not explain relevant medical principles. The Board notes that a complete explanation must not be based solely on lack of documentation. Additionally, the Board notes that a September 1972 record seems to indicate a foot condition. Second, the rationale does not account for the Veteran's competent reports of chronic skin problems since service. Therefore, another remand is required for the AOJ to obtain an adequate opinion that addresses the Veteran's reports of symptoms. The matters are REMANDED for the following action: 1. Obtain a supplemental opinion from a qualified VA examiner regarding the etiology of the Veteran's radiculopathy of the left lower extremity. If the examiner determines that he or she cannot respond to the Board's inquiries herein without examining the Veteran, then an examination must be afforded. If an in-person examination is not feasible, then the Veteran should be afforded an examination by other means. All necessary tests should be conducted. The entire claims file and a copy of this remand should be made available to the examiner for review. The examiner is asked to address the following: (a.) The examiner should directly address the October 1972 and November 1972 STRs indicating a pre-service motorcycle accident and pain radiating to the Veteran's left leg. (b.) The examiner should provide an opinion as to whether it is at least as likely as not (50 percent or greater) that any nerve condition of the left lower extremity that pre-existed service was aggravated by military service. (c.) If the examiner finds that it is at least as likely as not or more likely than not that the Veteran's military service aggravated a left lower extremity condition, the examiner should provide an opinion as to whether there is clear and unmistakable evidence that the increase in disability was a result of the natural progress of the disease. (d.) If the examiner finds that the Veteran's disability of the left lower extremity was not aggravated by service, the examiner should also opine whether it is at least as likely as not (50 percent or greater) that the Veteran's radiculopathy is proximately due to or aggravated by the Veteran's service-connected back disability. 2. Obtain a supplemental opinion from a qualified examiner to determine the nature and etiology of the Veteran's skin disability. The electronic claims file, to include a copy of this remand, must be made available to and be reviewed by the examiner. If the examiner determines that he or she cannot respond to the Board's inquiries herein without examining the Veteran, then an examination must be afforded. If an in-person examination is not feasible, then the Veteran should be afforded an examination by other means. All necessary tests should be conducted. The entire claims file and a copy of this remand should be made available to the examiner for review. The examiner is asked to address the following: (a.) In rendering the requested opinion, the examiner should discuss the Veteran's competent statements regarding onset of symptomatology in service. The examiner should also address a September 1972 note indicating a possible foot condition. (b.) The examiner must provide an opinion as to whether it is at least as likely as not (50 percent or greater) that the Veteran has a skin disability that is the result of, caused by, incurred in, or related to, active duty service. A complete explanation for all opinions expressed must be provided. A clearly stated rationale must not be based solely on lack of documentation or records. The reasons for any opinion must include a discussion of the relevant evidence. If the clinician cannot provide a requested opinion without resorting to speculation, it must be so stated, and the clinician must provide the reasons why. S. L. Kennedy Veterans Law Judge Board of Veterans' Appeals Attorney for the Board M. Smith, Associate Counsel 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.