Citation Nr: 21073892 Decision Date: 12/13/21 Archive Date: 12/13/21 DOCKET NO. 20-00 430A DATE: December 13, 2021 ORDER Entitlement to service connection for recurrent pancreatitis, to include as secondary to posttraumatic stress disorder (PTSD), is denied. REMANDED Entitlement to service connection for a left wrist disability, to include as secondary to PTSD, is remanded. FINDING OF FACT There is no competent evidence of record showing that the Veteran has a diagnosis of recurrent pancreatitis. CONCLUSION OF LAW The criteria for service connection for recurrent pancreatitis are not met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the United States Air Force from September 1962 to September 1966. These matters come before the Board of Veterans' Appeals (Board) on appeal from June 2016 and September 2017 rating decisions by an Agency of Original Jurisdiction (AOJ) of the United States Department of Veterans Affairs (VA). These issues were previously before the Board in September 2020, at which time they were remanded for additional development. Duty to Assist With respect to the Veteran's claims decided herein, VA has met all statutory and regulatory notice and duty-to-assist provisions. See 38 U.S.C. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126; 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326. Neither the Veteran nor his representative has advanced any procedural arguments in relation to VA's duty to notify and assist. See Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015) (holding that "absent extraordinary circumstances...we think it is appropriate for the Board and the Veterans Court to address only those procedural arguments specifically raised by the veteran...."). Service Connection Service connection may be established for disability resulting from personal injury suffered or disease contracted in the line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C. §§ 1110, 1131. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In order to establish service connection on a direct basis, the record requires competent evidence showing: (1) the existence of a present disability; (2) in service incurrence or aggravation of an injury or disease; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). In the absence of proof of a present disability there can be no valid claim. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). Some chronic diseases may be presumed to have been incurred in service if they become manifest to a degree of ten percent or more within the applicable presumptive period. 38 U.S.C. §§ 1101(3), 1112(a); 38 C.F.R. §§ 3.307(a), 3.309(a). For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection. 38 C.F.R. § 3.303 (b); Walker v. Shinseki, 708 F. 3d 1331 (Fed. Cir. 2013). Arthritis, with a presumptive period of one year following separation from service, is a listed condition. Competent medical evidence is evidence provided by a person who is qualified through education, training, or experience to offer medical diagnoses, statements, or opinions. Competent medical evidence may also include statements conveying sound medical principles found in medical treatises. It also includes statements contained in authoritative writings, such as medical and scientific articles and research reports or analyses. 38 C.F.R. § 3.159(a)(1). Competent lay evidence is any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159(a)(2). This may include some medical matters, such as describing symptoms or relating a contemporaneous medical diagnosis. Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). A layperson is generally not capable of opining on matters requiring medical knowledge. In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. Pancreatic Attacks The Veteran contends that he has recurrent pancreatitis that is related to his service-connected PTSD. Service treatment records are negative for a diagnosis of and/or treatment for pancreatitis and/or pancreatic attacks. There is no record of recurrent pancreatitis on his April 1966 separation physical examination. VA treatment records dated November 2015 note the Veteran reported a "pancreatic attack" in which "his doctors are aware." VA treatment records reflect a reported medical history of recurrent pancreatitis. Private medical records from Dr. WD are negative for a diagnosis of pancreatitis or pancreatic attacks. Post service medical records are negative for a diagnosis of pancreatitis. In a March 2017 letter, the Veteran's wife, CWP, stated that the Veteran was "diagnosed in 1997 with severe pancreatic attacks which were brought on by intense stress." The issue was remanded by the Board in September 2020 for a VA examination and opinion as to the etiology of his claimed recurrent pancreatitis. The Veteran underwent a VA gallbladder and pancreas condition examination in October 2020. The VA examiner conducted a review of all available medical records and examined the Veteran. The VA examiner noted that the Veteran had not been diagnosed with any pancreas condition. The Veteran reported that his last episode of pancreatitis was 6 years ago. He stated that he gets pancreatitis whenever he experiences a death or funeral. He has extreme abdominal pain that is burning in sensation. The VA examiner noted that the Veteran had no current symptoms and did not take any medication for this claimed condition. Physical examination revealed not symptoms attributable to any pancreas condition or residuals of treatment for a pancreas condition. Amylase testing and Lipase testing was conducted. The VA examiner noted that pancreatitis can cause amylase and lipase levels to be increased up to 3 times the normal limit. The Veteran's amylase was 151 and lipase was 57. The VA examiner stated that both values should be increased to carry diagnosis of pancreatitis. The Veteran's lipase level is normal therefore, no diagnosis is made for the claimed condition. The VA examiner stated that there is no association between recurrent pancreatitis and PTSD in medical literature, and, notably, the Veteran does not have a diagnosis of recurrent pancreatitis. The Board concludes that the Veteran does not have a current diagnosis of recurrent pancreatitis and has not had one at any time during the pendency of the claim or recent to the filing of the claim. Romanowsky v. Shinseki, 26 Vet. App. 289, 294 (2013); McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). Despite the Veteran's reports of pancreatic attacks, he has not provided any medical evidence to support that he was formally diagnosed with pancreatitis by a medical professional. The Veteran's medical records do not demonstrate any findings of or treatment for pancreatitis. The Veteran's separation examination in April 1966 and his post service medical records are negative for any reports or findings of pancreatitis. While the Veteran believes he has or has had pancreatitis that is related to his service-connected PTSD, he is not competent to provide a diagnosis in this case. The issue is medically complex, as it requires specialized medical education and the ability to interpret complicated diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007); Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). Further, while he is competent to report what a medical professional may have told him about a diagnosis, the medical evidence of record contradicts his reported history; there is simply no credible evidence of a current disability. The Board finds the evidence insufficient to establish a current disability, or to show an injury in service. Congress has specifically limited entitlement to service connection to cases where such incidents have resulted in a disability. Brammer v. Derwinski, 3 Vet. App. 223, 255 (1992). In the absence of proof of a present disability there can be no valid claim. Id. Accordingly, service connection for recurrent pancreatitis is not warranted. The Board has considered the doctrine of reasonable doubt; however, as the preponderance of the evidence is against the Veteran's claim for service connection for pancreatitis, the doctrine is not applicable. See 38 C.F.R. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 56 (1990). REASONS FOR REMAND The Veteran is seeking service connection for a left wrist disability, as secondary to his service-connected PTSD. The Board finds that additional development is need The Veteran's STRs are negative for treatment for symptoms and/or a diagnosis of a left wrist disability in service. VA treatment records show the Veteran was seen on March 11, 2017 in the emergency room for his left wrist. He reported that he slipped and fell that day when it started to rain; "I just slipped. I guarded the fall with my left wrist. My left wrist hurts." The left wrist was positive for moderate dorsal swelling, and decreased range of motion. X-rays taken revealed a normal left wrist, no acute fractures or bony malalignment, mild ulnar positive variance, incidental. A wrist brace was ordered for the Veteran. The Veteran was diagnosed with a left wrist contusion and advised to follow up with his primary care physician. On April 5, 2017 he was again seen in the emergency room for left wrist pain. He reported that he sprained his left wrist while fishing one month earlier. He stated that he had nightmares and while swinging to keep zombies away in his dream, he fell out of bed. The Veteran denied hitting his head or loss of consciousness; he denied difficulty with range of motion of the left hand. The Veteran had good range of motion of the left wrist; no crepitus/deformity was noted with examination; slight edema noted. X-rays revealed no convincing interval change; degenerative changes with distal radial subarticular sclerosis; ulnar positive variance; suggestion of dorsal swelling or mass. Notes dated August 2017 indicate the Veteran was scheduled for arthroscopic debridement TFCC left wrist. Mental health treatment notes show the Veteran was taking medication for left wrist pain that was described as a 1 out of 10 in intensity. Private medical records dated April 25, 2017 from Dr. OO, a hand specialist. The Veteran presented for left wrist pain. He reported that he has nightmares, due to PTSD, which are sometimes violent. He described an incident at the end of March in which he fell out of bed and landed on his left wrist. Pain was described as being aggravated by use of his left hand. He has been treating with medication with little relief. Physical examination of left-hand revealed tenderness over the SL and LT interval. Flexion was to 45 degrees, extension to 45 degrees, ulnar deviation to 20 degrees and radial deviation to 15 degrees. Impression was TFCC ligament tear left wrist, ulnar impaction syndrome, left wrist and possible SL ligament degenerative tear, left wrist. A May 2017 report of an arthrogram left wrist found "no fracture or dislocation of the left wrist, there was narrowing of the radiocarpal joint space and ulnocarpal joint space. Contrast was noted extending from the radiocarpal joint space into the radio ulnar joint space, indicating underlying TFCC tear which will be further investigated with a follow up CT." Treatment records dated May 16, 2017 indicate the Veteran was to undergo a Wafer procedure. No additional records from Dr. OO are associated with the file. The Veteran underwent a VA wrist examination in January 2020. The VA examiner noted the Veteran's diagnosis of triangular fibrocartilaginous complex (TFCC) injury, left. The Veteran reported that he injured his left wrist in 2017. He has nightmares and sometimes some somnambulation. He reported he was having a nightmare about driving and picking up a hitchhiker who turned out to be a zombie in the nightmare he struck out at the zombie and then fell out of bed. He stated he injured his left wrist when he fell out of bed. He reported that he had an arthroscopic repair of a TFCC tear. In an October 2020 addendum opinion, the VA examiner determined that the current severity of the Veteran's left wrist disability was not greater than the baseline. On remand, records relating to the Veteran's arthroscopic repair of his left wrist TFCC tear should be obtained and associated with the file. An addendum opinion should be obtained as to whether it is at least as likely as not that the Veteran's left wrist disability which required arthroscopic repair of TFCC tear is related to service, to include as due to any injury he sustained as a result of a fall from his bed due to nightmares caused by PTSD. The matters are REMANDED for the following action: 1. Associate with the claims file updated VA treatment records and private medical records. 2. Take appropriate steps to obtain complete treatment records and surgical records from private medical providers, including Dr. OO, to include securing any necessary release from the Veteran. 3. Return the file to VA examiner who provided the January 2020 examination and the October 2020 addendum opinion. The claims file must be reviewed by the examiner. If the examiner is not available, another appropriate medical professional may be consulted. If the examiner determines another VA examination is necessary, one should be scheduled. The examiner must identify any currently diagnosed left wrist disability. The examiner must opine as to whether it is at least as likely as not (50 percent probability or greater) that any currently diagnosed left wrist disability is caused or aggravated by his PTSD, to include his report that he reinjured his left wrist in April 2017 (after initially injuring it when he slipped and fell in the rain in March 2017) when he fell from his bed while having a PTSD-related nightmare. The examiner is asked to comment on the arthroscopic surgery the Veteran underwent for repair of his left wrist TFCC. With respect to aggravation, the examiner is asked to specifically comment as to whether it is at least as likely as not that any diagnosed left wrist disability is aggravated by (i.e., has increased in severity beyond the natural progress due to) a fall sustained due to a PTSD related nightmare. If aggravation is found, the examiner should address the following medical issues: (1) the baseline manifestations of the Veteran's left wrist disability found prior to aggravation; and (2) the increased manifestations which, in the examiner's opinion, are proximately due to service-connected PTSD related nightmare. The Veteran's arthroscopic repair of left TFCC tear should be addressed. A full and complete rationale for all opinions expressed is required. 4. Then, readjudicate the remanded issues. If the benefit sought remains denied, issue a supplemental statement of the case. The case should then be returned to the Board for appellate review if otherwise in order. WILLIAM H. DONNELLY Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Margaret M. Lunger, 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.