Citation Nr: 21072109 Decision Date: 12/02/21 Archive Date: 12/02/21 DOCKET NO. 12-34 843 DATE: December 2, 2021 ORDER Entitlement to service connection for a neurologic disability, including peripheral neuropathy (PN) of the left lower extremity (LLE) is granted. Entitlement to service connection for left shoulder disability is denied. Entitlement to service connection for bilateral carpal tunnel syndrome (CTS) is denied. FINDINGS OF FACT 1. The Veteran's LLE PN is at least as likely as not related to the radiation of his low back pain to the left side during service. 2. Symptoms in the Veteran's left shoulder during service were not followed by any chronic or recurrent disorder that continued through and after service. The Veteran's left shoulder disability manifested years after service, is not related to symptoms in service, and was not proximately caused or aggravated by the service-connected disabilities of his cervical spine and lumbar spine. 3. Numbness noted in the Veteran's right hand and fingers during service did not constitute CTS. The Veteran's bilateral CTS manifested years after service, is not related to symptoms in service, and was not proximately caused or aggravated by the service-connected disabilities of his cervical spine and lumbar spine. CONCLUSIONS OF LAW 1. The criteria for service connection for an LLE neurologic disability, diagnosed as PN, have been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for service connection for left shoulder disability have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. 3. The criteria for service connection for bilateral CTS have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from November 1975 to November 1995. In a July 2010 rating decision, a Department of Veterans Affairs (VA) Regional Office (RO) denied service connection for a neurologic disability of the LLE. The Veteran appealed that denial to the Board of Veterans' Appeals (Board). In a January 2011 rating decision, the RO denied service connection for bilateral shoulder disability, bilateral CTS, erectile dysfunction (ED), and circulatory problems. The Veteran appealed those denials to the Board. In June 2017 the Board remanded to the RO, for additional action, the issues of service connection for a neurological disability of the LLE, bilateral shoulder disability, bilateral CTS, ED, and circulatory problems. In an April 2021 rating decision, the RO granted service connection for ED. That grant resolved the appeal on that issue. In a June 2021 rating decision, the RO granted service connection for circulatory problems, specifically granting service connection for left leg varicose veins and right leg varicose veins. That grant resolved the appeal on that issue. In a July 2021 rating decision, the RO granted service connection for a right shoulder disability, resolving the appeal as to the right shoulder. The issues that remain on appeal before the Board are service connection for a neurological disability of the LLE, left shoulder disability, and bilateral CTS. Service Connection Service connection may be established on a direct basis for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Service connection may also be granted for any disease diagnosed after service when all the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In general, service connection requires (1) evidence of a current disability; (2) medical evidence, or in certain circumstances lay evidence, of in-service incurrence or aggravation of a disease or injury; and (3) evidence of a nexus between the claimed in-service disease or injury and the current disability. See Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection for certain chronic diseases, including arthritis and organic diseases of the nervous system, may be established based upon a legal presumption by showing that the disease manifested itself to a degree of 10 percent disabling or more within one year from the date of discharge from service. 38 U.S.C. §§ 1112, 1137; 38 C.F.R. §§ 3.307, 3.309. Service connection may be granted on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Aggravation of a non-service-connected disease or injury by a service-connected disability may also be service-connected. 38 C.F.R. § 3.310(b). The United States Court of Appeals for Veterans Claims (Court) has indicated that the Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a claim, VA shall give the benefit of the doubt to the claimant. 38 U.S.C. § 5107. To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54. 1. Neurologic disability of the LLE The Veteran previously sought, and VA established, service connection for low back disability described as lumbosacral herniated nucleus pulposus (HNP) with radiculopathy in the right lower extremity (RLE). The Veteran contends that a neurologic disability of his LLE, to include neuropathy, and claimed as loss of feeling in his left leg, had onset during service and continued after service. Alternatively, he asserts the disability is secondary to his service-connected back disability including lumbosacral HNP. On examination of the Veteran in October 1975 for entrance to service, the Veteran did not report any history of problems affecting either lower extremity. The examiner marked normal for the condition of the Veteran's lower extremities. During service, the Veteran had treatment from the late 1970s forward for painful calluses, plantar warts, corns, warts, and tinea pedis affecting both feet. He had treatment in service for low back pain. In March 1993, he reported low back pain radiating to his left testicle and to his right knee. In July 1995, the Veteran had treatment for low back pain with radicular symptoms down his right LE. On examination in August 1995 for separation from service, the Veteran reported foot trouble since 1979 and back pain since 1989. The examiner noted a history of corns and tinea pedis of the Veteran's feet and a history of mechanical low back pain. The examiner marked normal for the condition of the Veteran's lower extremities at the time of the examination. In March 1996, the Veteran submitted a claim for service connection for a disability manifested by low back pain that radiated into his right hip and leg. The RO established service connection for a low back disorder. In a July 1999 claim, the Veteran noted his low back pain radiated into his RLE. When the Veteran lived outside of the United States, he had medical examinations for VA benefits purposes in the country where he lived. In a VA-directed examination in January 2000, the Veteran reported low back and RLE pain since the 1990s. He related ongoing low back pain that radiated into the right buttock and leg. In a VA-directed examination in April 2002, the Veteran reported that reinjury of his low back in February 2001 that was followed by increased low back problems. He stated continuous standing and frequent bending required in his work as a restaurant manager caused pain in his low back and both legs. Testing for sciatic neuropathy was positive on the right side and negative on the left side. The examiner reviewed a May 2001 MRI of the Veteran's lumbar spine. The examiner's impression was HNP L5-S1 with neurocompressive effect on nerve root S1 on the right. In a VA-directed examination in July 2004, the Veteran reported ongoing low back pain and right leg pain, numbness, and weakness after standing for more than ten minutes. Lasegue (straight leg raising) testing was positive at 50 degrees on the right and pseudo-positive at 80 degrees on the left. The examiner's diagnoses included right-sided lumbar sciatica and nerve root irritation. In a June 2009 statement, the Veteran wrote his low back pain was accompanied by loss of sensation in his left leg. In September 2010, he asserted he had LLE neuropathy secondary to his low back disability. In VA treatment in April 2012, the Veteran reported low back pain radiating into both lower extremities, more into the RLE. He related numbness in the tips of all toes and pain in the left foot. On straight leg raising testing there was pain in both lower extremities. The clinician found decreased strength in both lower extremities. In VA treatment in October 2012, the Veteran reported numbness in both feet. A clinician noted 2/4 pedal pulses bilaterally. In December 2012, the Veteran related numbness and tingling in both feet. In April 2013, VA electrodiagnostic testing showed evidence of peripheral neuropathy (PN) in both legs. In VA primary care in June 2013, the Veteran reported pain and altered sensation in his feet. The clinician's assessment was symptomatic disc disease with lumbar radiculopathy. On VA neurology consultation in August 2013, the Veteran reported a one-year history of numbness in all of his toes. He reported progression of the symptoms to numbness in the dorsum of both feet and the anterior aspects of the distal parts of both legs. On motor nerve function testing, the distal portion of each LE was 4+/5. There was decreased sensory function in both legs. No radiculopathy pattern was found. In private treatment in March 2014, the Veteran reported his lower limbs had numbness, tingling, sensory loss, weakness, and pain. He indicated these symptoms had been present since his military service. C. E. M. Q., M.D., diagnosed disorders including PN of the lower limbs. Dr. M. Q. expressed the opinion that the disorders were more probably than not secondary to the Veteran's military service. In December 2020, private neuropathologist L. H. S., M.D., found that the Veteran had polyneuropathy of the distal areas of both lower extremities. On VA examination in May 2021, the Veteran reported having numbness in both legs for several years. On examination, there was decreased sensation in the thigh, knees, lower legs, ankles, feet, and toes bilaterally. There were trophic changes in both lower extremities. The examiner found the Veteran had bilateral sciatic nerve paralysis, bilateral peroneal nerve paralysis, and bilateral tibial nerve paralysis. The examiner found testing in 2013 showed peripheral neuropathy without any radiculopathies. The examiner was asked to express an opinion as to whether any neurologic disability of the Veteran's LLE at least as likely as not was incurred in service or otherwise causally related to the Veteran's service or events during that service. In response, the examiner noted medical records from the Veteran's service and the year after did not contain evidence of bilateral LE (BLE) PN. The examiner noted testing in 2013 showed evidence of BLE PN without evidence of radiculopathy. The examiner did not provide an explicit opinion as to the relative likelihood that any neurologic disability of the Veteran's LLE was incurred in service or otherwise causally related to the Veteran's service or events during that service. The examiner expressed opinions that the Veteran's LLE peripheral neuropathy was less likely than proximately caused and less likely than not aggravated by his lumbar spine disorder. The examiner explained the Veteran had LLE peripheral neuropathy but did not have left-sided lumbar radiculopathy. The examiner stated peripheral nerve disease affecting distal areas of extremities is not related to spine disorders. Medical treatment and examination records show that the Veteran has a current LLE neurologic disability, specifically, PN. During service and soon after service the Veteran often reported low back pain radiating into his RLE. One treatment record from service, in March 1993, contains his report that back pain radiating to the left side, into his left testicle. Over the years after service, from as early as 2002, the Veteran sometimes reported and clinicians sometimes found evidence of involvement of the BLE in neurological issues, typically with worse symptoms on the right. In 2014, Dr. M.Q. opined in favor of a nexus to service for PN in the left and right LE. The Board gives probative weight to this opinion because it was consistent with the report of radiation to low back pain to the left side in service in 1993 and the post service reports of progressive radiation of low back pain into the LLE. The 2021 VA examiner's statement noted a lack of evidence to support a nexus between the Veteran's LLE PN and his service. The Board gives less probative weight to this opinion because the examiner did not explicitly opine on the relative likelihood of a nexus. The 2021 examiner's suggestion that a nexus was unlikely does not carry greater evidentiary weight than Dr. M. Q.'s opinion supporting a nexus. As such, the Board finds the persuasive weight of the evidence for and against a nexus is at least approximately balanced. In summary, the Veteran has current LLE PN. Evidence of radiation of his low back pain to the left side in service at least suggests left-sided neuropathy in service. There is equivocal evidence of a nexus between symptoms in service and the current LLE PN. Resolving reasonable doubt in the Veteran's favor, the Board grants service connection for the Veteran's LLE PN. 2. Left shoulder disability In a July 2021 rating decision, the RO established service connection, effective from August 2010, for a disability of the Veteran's right shoulder, described as right trapezius myositis of the right shoulder. As the Veteran appealed for service connection for disabilities of both shoulders, he has an ongoing appeal for service connection for a left shoulder disability. He contends that a left shoulder disability had onset during service and continued after service. Alternatively, he asserts the disability is secondary to his service-connected cervical spine disability, which includes intervertebral disc disease. The Veteran is right handed. In the Veteran's October 1975 service entrance examination, the Veteran did not report any history of problems affecting either shoulder. The examiner marked normal for the conditions of the Veteran's upper extremities and other musculoskeletal areas. In treatment in October 1985, the Veteran reported neck pain. In November 1989, the Veteran sought treatment for pain in his right shoulder and the right side of his neck. In December 1989, he reported neck pain that began a month earlier with stretching. He had treatment in January 1990 for chronic neck pain and recurrent right trapezius muscle spasm. He reported pain in the right side of his neck and down his right arm to the elbow. In May 1990, the Veteran sought treatment for right arm pain and numbness in his right hand and fingers. The clinician's impression was medial epicondylitis and overuse syndrome. In August 1993, the Veteran was seen for pain in his neck. The clinician found trapezius muscle tenderness, more in the right than the left. In February 1994, the Veteran had treatment for chronic recurrent neck pain with radiating to the right arm to the elbow. Clinicians assessed pinched nerve in the cervical spine and impingement syndrome. In March 1994, a clinician assessed right trapezius spasm. In physical therapy in April 1994, the Veteran reported the pain had resolved. He related he continued to have occasional mild paresthesia with reaching. In July 1995, the Veteran had treatment for right upper trapezius pain with numbness and tingling down the entire right upper extremity. A clinician assessed right trapezius myofascial pain. He had physical therapy to address the issue. In the Veteran's August 1995 service separation examination, the Veteran reported a history of myofascial pain in his right upper trapezius. The examiner noted myofascial pain in the right upper trapezius. After service, in March 1996 the Veteran sought service connection for temporary numbness of his entire right side. In an August 1996 rating decision, the RO granted service connection for myofascial pain of the right upper trapezius. In October 1996, x-rays of the Veteran's right elbow showed no definite pathological findings that would explain the pain and the stretching blockage. In the January 2000 VA-directed examination, the Veteran reported having neck pain radiating into his right shoulder and arm since 1994. On examination, the Veteran had pulling sensations on motion of his neck. He had pain and tightness in his right trapezius muscle with movement of his head to the left. Right and left rotation of his neck were limited. Strength of the cervical spine was reduced. The right hand had weakness and numbing on exertion. X-rays showed cervical spine degenerative joint disease (DJD) and intervertebral disc disease at C5-C6. In August 2001, the Veteran sought service connection for chronic neck pain with limitation of motion and pain radiating into the right shoulder and arm. In the July 2004 VA-directed examination, the examiner noted a long history of complaints involving the neck and thoracic regions, most recently with radiation into the left shoulder and elbow. There was limitation of motion of the left shoulder. There was pain to palpation in the left elbow. The examiner diagnosed left shoulder joint irritation with slight restriction of shoulder elevation. In VA treatment in June 2010, the Veteran reported right shoulder and elbow pain. On VA examination in October 2010, the Veteran reported bilateral shoulder pain, worse with overhead movements. On examination each shoulder had tenderness, guarding, and limitation of motion. The examiner diagnosed bilateral shoulder tendinopathy. The examiner expressed the opinion that the Veteran's bilateral shoulder conditions were not related to his low back condition. In VA treatment in January, March, and May 2011, the Veteran reported pain in both shoulders. In March 2014, private physician Dr. M. Q. reported that since active service the Veteran had reported pain, stiffness, limitation of motion, numbness, tingling, cramps, weakness, and sensorial loss in his neck and shoulders. Dr. M. Q. diagnosed chronic myositis in the paracervical spine muscles and shoulders. Dr. M. Q. expressed the opinion that the Veteran's musculoskeletal and neurologic disorders were more probably than not secondary to events in his military service. In June 2017, the Board noted the opinion in the November 2010 VA examination against a causal link between the Veteran's lumbar spine disability and disorders of both of his shoulders. The Board remanded the bilateral shoulder disorder service connection issue for additional examination with opinions as to direct service connection, secondary causation by the cervical spine disability, and secondary aggravation by the lumbar or cervical spine disabilities. On VA examination in May 2021, the Veteran reported having pain in both shoulders, worse in the right, for several years. The examiner found the Veteran had rotator cuff tendinitis in both shoulders from 2010. The examiner found the Veteran had myositis of the right trapezius from 1980. The examiner expressed the opinion that current right trapezius myofascial pain might be related to right trapezius myositis in service. The examiner opined that rotator cuff tendinitis in the right and left shoulders was less likely than not related to events in service. The examiner explained that there was no evidence supporting such a relationship. The examiner opined the Veteran's right and left shoulder disorders were less likely than not caused by and less likely than not aggravated by his cervical spine disorder. The examiner explained the affected areas in his right and left shoulders are not biomechanically or anatomically related to his cervical spine disorder. The Veteran has a current left shoulder disability, diagnosed as rotator cuff tendinitis. His service treatment records do not contain any diagnosis of a left shoulder disorder. Trapezius muscle tenderness was noted on the right and left sides in treatment in service in August 1993. However, later treatment in 1994 and 1995, and on his separation examination, noted issues with his right trapezius, shoulder and upper extremity, but not in the counterparts on the left. Post-service, there is evidence of ongoing problems with the Veteran's right trapezius and shoulder, but there is no indication of left shoulder problems before 2004. The Board gives probative weight to treatment and examinations in service and following service that reported chronic recurrent right shoulder symptoms, but were silent for left shoulder symptoms. The Board finds left shoulder symptoms are the type of symptom that would ordinarily be reported and noted during treatment visits where the Veteran is describing neck and right shoulder symptoms. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (statements made to physicians for purposes of diagnosis and treatment are exceptionally trustworthy because the declarant has a strong motive to tell the truth in order to receive proper care). As such, the Board finds the probative evidence is against finding left shoulder problems that were chronic or recurrent in service and continued or regularly recurred after service. The Board gives low probative weight to Dr. M. Q.'s opinion supporting a nexus between bilateral shoulder problems in service and such problems after service. Dr. M.Q. did not discuss the absence in the Veteran's medical records of chronic or recurrent left shoulder problems during and soon after service. The lack of such discussion limits the probative value of Dr. M. Q.'s opinion on the question of continuity. The Board gives probative weight to the 2021 VA examiner finding rotator cuff tendinitis in the left shoulder was less likely than not related to events in service. The examiner noted his review of the claims file. The opinion was based on an accurate medical history and provided a clear conclusion and supporting data. Considering the information in the medical records, and the relative weights of the medical opinions, the greater persuasive weight of the evidence is against a nexus between events in the Veteran's service and his current left shoulder disability. The Board gives probative weight to the 2021 VA examiner finding the Veteran's left shoulder disorder was less likely than not caused by and less likely than not aggravated by his cervical spine disorder. The opinion provided a clear conclusion and supporting data. The examiner explained the affected areas in his right and left shoulders are not biomechanically or anatomically related to his cervical spine disorder. No clinician has opined in favor of secondary service connection. The Board considered the Veteran's contention that his left shoulder disability is secondary to his service-connected cervical disability. The Veteran is not competent to opine on the etiology of his left shoulder disability, as that requires medical testing and expertise that is outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the preponderance of the evidence is against secondary service connection. The Board denies service connection for the Veteran's left shoulder disability on a direct basis and secondary basis. 3. Bilateral CTS The Veteran contends bilateral CTS had onset during service and continued after service. Alternatively, he asserts the disability is secondary to his service-connected cervical spine disability, which includes intervertebral disc disease. In the Veteran's October 1975 service entrance examination, the Veteran reported history of left wrist sprain, with no sequelae. The examiner marked normal for the conditions of the Veteran's upper extremities and neurologic systems. During service, in treatment in November 1982, the Veteran reported an abscess on his left arm for five years, with intermittent pain. On examination in November 1983, the examiner noted asymptomatic ganglionic cysts on the Veteran's right arm. In treatment in October 1985, the Veteran reported neck pain. In November 1989, he sought treatment for pain in his right shoulder and the right side of his neck. In December 1989, he reported neck pain that began a month earlier with stretching. In January 1990, he was seen for chronic neck pain and recurrent right trapezius muscle spasm. He reported pain in the right side of his neck and down his right arm to the elbow. In May 1990, the Veteran sought treatment for pain in his right arm and numbness in his right hand and fingers. The clinician's impression was medial epicondylitis and overuse syndrome. In August 1993, the Veteran was seen for pain in his neck. The clinician found trapezius muscle tenderness, more in the right than the left. In February 1994, the Veteran had treatment for chronic recurrent neck pain with radiation down the right arm to the elbow. Clinicians provided assessments of a pinched nerve in the cervical spine and of impingement syndrome. In March 1994, a clinician assessed right trapezius spasm. In physical therapy in April 1994, the Veteran reported the pain had resolved and that he continued to have occasional mild paresthesia with reaching. In July 1995, the Veteran had treatment for right upper trapezius pain with numbness and tingling down the entire right upper extremity. A clinician assessed right trapezius myofascial pain. He had physical therapy to address the issue. In the Veteran's August 1995 service separation examination, the Veteran did not report any problems affecting his wrists or hands. The examiner did not note any problems affecting the Veteran's wrists or hands. In March 1996, the Veteran sought service connection for temporary numbness of his entire right side. In an August 1996 rating decision, the RO granted service connection for myofascial pain of the right upper trapezius. In October 1996, x-rays of the Veteran's right elbow showed no definite pathological findings that would explain reported pain and the stretching blockage. In the January 2000 VA-directed examination, the Veteran reported having neck pain radiating into his right shoulder and arm since 1994. On examination, the Veteran had pulling sensations on motion of his neck. He had pain and tightness in his right trapezius muscle with movement of his head to the left. Right and left rotation of his neck were limited. Strength of the cervical spine was reduced. The right hand had weakness and numbing on exertion. X-rays showed cervical spine degenerative joint disease and intervertebral disc disease at C5-C6. In August 2001, the Veteran sought service connection for chronic neck pain with limitation of motion and pain radiating into the right shoulder and arm. In the July 2004 VA-directed examination, the examiner noted a long history of complaints involving the neck and thoracic regions, most recently with radiation into the left shoulder and elbow. There was limitation of motion of the left shoulder. There was pain to palpation in the left elbow. The examiner diagnosed left shoulder joint irritation with slight restriction of shoulder elevation. In VA treatment in June 2010, the Veteran reported right shoulder and elbow pain. On VA examination in October 2010, he reported numbness in both hands, with onset in 1988 and gradual worsening over time. The examiner found hypoactive peripheral nerve reflexes in the biceps, triceps, and brachioradialis bilaterally. The right and left upper extremities each had decreased pain on pinprick. Other sensory examination findings were normal. The examiner found that there was no clinical evidence of upper extremities neuropathy. On VA peripheral nerves examination in November 2010, the Veteran reported onset about ten years earlier of occasional numbness and pins-and-needles sensations in both of his hands. He stated that these symptoms became more noticeable with prolonged work using a computer keyboard. He also reported frequent right wrist pain that made him unable to grip things properly. The examiner diagnosed bilateral CTS. The examiner expressed the opinion that CTS, with entrapment neuropathy at the wrist, involved anatomical regions completely different from the cervical and lumbar areas of the spine. On VA neurological consultation in August 2013, the clinician found the Veteran had decreased soft touch, pinprick, and sensation in the proximal areas of his arms. There were decreased reflexes of the left biceps. In December 2017, the Board noted that a 2010 VA examiner expressed an opinion against the likelihood of a connection between the Veteran's lumbar spine disability and his CTS. The Board remanded the CTS issue to the RO for a new VA with opinions addressing direct service connection and secondary service connection to cervical spine, with consideration of a service treatment record that reflected numbness in the Veteran's hands and fingers. On VA examination in May 2021, the examiner noted that the Veteran reported right hand and fingers numbness in treatment in service, but that CTS was not diagnosed then. The examiner noted that in July 1995, late in the Veteran's service, testing showed intact sensation in the Veteran's hands. The examiner also noted that CTS was not diagnosed soon after service. The examiner expressed the opinion that the Veteran's current bilateral CTS was less likely than not incurred in service or related to events in service. The examiner opined that it was less likely than not that the Veteran's cervical spine disability proximately caused or aggravated his bilateral CTS. The examiner explained that peripheral nerve entrapments that caused CTS and nerve root impingements that caused radiculopathies involved two distinct anatomical areas. The Veteran has a current diagnosis of bilateral CTS. A treatment record shows a report of right-hand numbness and tingling during service. However, CTS was not diagnosed at that time or at any time during service. The Veteran was not diagnosed with CTS soon after service or earlier than 2010. The Board gives probative weight to the May 2021 VA examiner finding bilateral CTS was less likely than not incurred in service or related to events in service. The opinion was based on an accurate medical history and provided a clear conclusion and supporting data. The examiner discussed the report of right hand and fingers numbness in service, but noted CTS was not diagnosed at the time and later July 1995 testing showed intact sensation in the Veteran's hands. The opinion is consistent with the Veteran not being diagnosed with CTS prior to 2010. As such, the preponderance of the evidence is against direct service connection for the Veteran's CTS. The Board gives probative weight to the May 2021 VA examiner finding it was less likely than not that the Veteran's cervical spine disability proximately caused or aggravated his bilateral CTS. The examiner provided a clear conclusion and supporting data. The examiner explained that peripheral nerve entrapments that caused CTS and nerve root impingements that caused radiculopathies involved two distinct anatomical areas. The Board considered the Veteran's contention that his CTS is secondary to his service-connected cervical disability. The Veteran is not competent to opine on the etiology of his CTS, as that requires medical testing and expertise that is outside the realm of common knowledge of a layperson. Kahana v. Shinseki, 24 Vet. App. 428 (2011); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). As such, the preponderance of the evidence is against secondary service connection. The Board denies service connection for the Veteran's bilateral CTS on a presumptive basis, a direct basis, or a secondary basis. TESS WINKLER Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K. J. Kunz, 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.