Citation Nr: 21076017 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 14-25 332A DATE: December 22, 2021 ORDER Entitlement to service connection for left wrist carpal tunnel syndrome is denied. Entitlement to service connection for a left trigger finger disorder is denied. Entitlement to service connection for a right trigger finger disorder is denied. Entitlement to service connection for residuals of a stroke is denied. Entitlement to service connection for left leg peroneal neuropathy is denied. Entitlement to service connection for trigeminal neuralgia is denied. REMANDED Entitlement to service connection for a disorder manifested by dizziness is remanded. FINDING OF FACT The most probative evidence of record does not show that the Veteran has left wrist carpal tunnel syndrome, bilateral trigger finger disorder, residuals of a stroke, left leg peroneal neuropathy, or trigeminal neuralgia that is etiologically related to a disease, injury, or event in service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for left wrist carpal tunnel syndrome has not been met. 38 U.S.C. §§ 1101, 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2020). 2. The criteria for entitlement to service connection for left trigger finger disorder has not been met. 38 U.S.C. §§ 1101, 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2020). 3. The criteria for entitlement to service connection for right trigger finger disorder has not been met. 38 U.S.C. §§ 1101, 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2020). 4. The criteria for entitlement to service connection for residuals of a stroke has not been met. 38 U.S.C. §§ 1101, 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2020). 5. The criteria for entitlement to service connection for left leg peroneal neuropathy has not been met. 38 U.S.C. §§ 1101, 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2020). 6. The criteria for entitlement to service connection for trigeminal neuralgia has not been met. 38 U.S.C. §§ 1101, 1110 (West 2014); 38 C.F.R. §§ 3.303, 3.304 (2020). REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from May 1973 to May 1979 and from April 1981 to April 1998. In June 2017, the Veteran testified at a hearing before the undersigned Veterans Law Judge (VLJ). These issues were remanded in April 2018, November 2020 and August 2021 for further development. Other than as discussed immediately below, neither the Veteran nor his representative has raised any issues with the duty to notify pertaining to these claims. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to a duty to assist argument). Thus, the Board need not discuss any potential issues in this regard. With regard to the duty to assist, the Board notes that the Veteran asserted in an April 2021 statement that the October 2019 VA examiner was not familiar and/or qualified to evaluate the long-term medical consequences of diving; she was not a board-certified neurologist; she disregarded and changed a board-certified neurologist's nexus opinion of "as least as likely as not" to "as less likely than not"; and her findings that several of the Veteran's conditions did not exist contradicted the diagnosis of civilian medical professionals from 2010 to the present. In the September 2020 Written Brief Presentation, the representative asserted that the 2019 VA opinions addressed diverse medical issues faced by the Veteran that are too varied and complex for a general practice nurse practitioner to address. The representative essentially questioned the examiner's competency to provide such opinions. Further, the Veteran asserted in an August 2020 statement that the examiner examined the wrong trigger finger during the examination. Firstly, the Board notes that both trigger fingers are on appeal, and the examiner addressed all fingers on both hands at the 2019 examination. Regarding the assertion that the examiner disregarded and changed a board-certified neurologist's nexus opinion of "as least as likely as not" to "as less likely than not", the Board finds the examiner reviewed the claims file and provided her own original opinions on the matters at hand. She is not bound by other medical opinions. Regarding the assertions that the examiner is not qualified or not competent to render opinions on the matters before the Board, the Board notes that VA is not required to provide a specialist, so long as the medical professional who conducts the examination is competent to do so and provides an adequate opinion. In this case, the Board notes that the VA examiner reviewed the claims file, examined the Veteran, and provided detailed rationales for her opinions. There is no requirement that she must be a board-certified neurologist to provide adequate opinions on these matters. To the extent that her opinion or findings differed from opinions or findings of record, the Board notes that she provided rationales to support these opinions, and it is the Board's responsibility to weigh the probative value of all medical opinions. Moreover, the examiner acknowledged that certain conditions, like trigger fingers, a random ischemic neurological deficit, and trigeminal neuralgia were noted in the past but were not presenting with current symptoms or had no current residuals at the time of the 2019 VA examination. As such, the Board has considered the concerns shared by the Veteran and his representative regarding the 2019 VA examiner but ultimately finds the opinions are adequate. Therefore, the duty to assist has been met. The Veteran has not alleged any deficiency with his 2017 Board hearing as to the duties discussed in Bryant v. Shinseki, 23 Vet. App. 488, 496-97 (2010). In this regard, the Federal Circuit ruled in Dickens v. McDonald, 814 F.3d 1359 (Fed. Cir. 2016) that a Bryant hearing deficiency was subject to the doctrine of issue exhaustion as laid out in Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015). Thus, the Board need not discuss any potential Bryant problem because the Veteran has not raised that issue before the Board. Additionally, the Board notes that the Veteran indicated in an October 2021 statement that he was scheduled for an appointment with a neurologist in January 2022. To the extent that this future appointment is pertinent to the claims being decided in this determination, the Board advises the Veteran that he will be free to file a Supplemental Claim and submit or identify this evidence in the future. If the evidence is new and relevant, VA would issue another decision on the claims, considering the new evidence in addition to the evidence previously considered. He did not expressly request the Board hold the record open in the current appeal so he could submit additional evidence, and since this concerns a future scheduled appointment (that may or may not occur), it was not a reference to existing medical evidence that VA could have a duty to obtain. The Board has thoroughly reviewed all the evidence in the Veteran's VA files. In every decision, the Board must provide a statement of the reasons or bases for its determination, adequate to enable an appellant to understand the precise basis for the Board's decision, as well as to facilitate review by the United States Court of Appeals for Veterans Claims (Court). 38 U.S.C. § 7104 (d)(1); see Allday v. Brown, 7 Vet. App. 517, 527 (1995). Although the entire record must be reviewed by the Board, the Court has repeatedly found that the Board is not required to discuss, in detail, every piece of evidence. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000); Dela Cruz v. Principi, 15 Vet. App. 143, 149 (2001) (rejecting the notion that the Veterans Claims Assistance Act mandates that the Board discuss all evidence). Rather, the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant. See Timberlake v. Gober, 14 Vet. App. 122 (2000). The points below focus on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake, infra. In order to establish service connection for a claimed disability, there must be (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical, or in certain circumstances, lay evidence of a nexus between the claimed in-service disease or injury and the current disability. See 38 C.F.R. § 3.303 (2019); see also Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Hickson v. West, 12 Vet. App. 247, 253 (1999); Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). The Veteran is seeking service connection for left wrist carpal tunnel syndrome, bilateral trigger finger disorder, residuals of a stroke, left leg peroneal neuropathy, and trigeminal neuralgia. Specifically, he contends that these disabilities are a result of his service in the military as a diver. Service treatment records reflect that the Veteran had a stroke on September 22, 1994. In an October 3, 1994, letter, a physician noted that he believed the Veteran had a cerebellar infarct secondary to the onset of atrial fibrillation. The physician noted that he was unable to explain the cause of his atrial fibrillation unless, as suggested, it might be secondary to large and acute intake of alcohol. However, the physician noted that this did not seem to be the cause of the atrial fibrillation. An August 2012 VA examiner concluded that there was no right index finger condition, the Veteran's trigeminal neuralgia had resolved without residuals, and the left leg peroneal neuropathy had resolved without residuals. She further concluded that the Veteran had left wrist carpal tunnel syndrome but opined that it was unrelated to service because it manifested more than 10 years after separation from service. The examiner noted that his service treatment records documented an episode of cerebral ischemia with no evidence of a stroke. In March 2013, another VA examiner opined that the Veteran's left wrist carpal tunnel syndrome, left leg peroneal neuropathy, trigeminal neuralgia, and stroke were unrelated to diving in service. In April 2017, the Veteran provided a medical opinion from his private neurologist, which stated that the Veteran currently experiences left wrist carpal tunnel syndrome, left leg peroneal neuropathy, trigeminal neuralgia, bilateral stenosing tenosynovitis of both middle fingers, and bilateral essential tremors of the hands, symptoms which "correlate to the symptoms outline[d] in the references cited in the Department of Veterans Affairs, Medical Consequences of Diving Training Letter" and "may be associated with his time served as a military diver." Furthermore, in June 2017, his neurologist opined that the stroke (random ischemic neurological deficit), bilateral trigger finger condition, bilateral carpal tunnel syndrome, left leg neuropathy, and trigeminal neuralgia (right face) were related to diving in service. In October 2019 Disability Benefits Questionnaires (DBQs), the Veteran was noted as having diagnoses of carpal tunnel syndrome and peroneal neuropathy of the left leg. The October 2019 examiner noted that the Veteran was diagnosed with peroneal neuropathy of the left leg in 2011. Standard neurological tests did not reveal abnormalities as a result of diving. MRR does not present new evidence regarding random ischemic neurological deficit or neuropathy. The Veteran was noted in an October 2019 DBQ as having had an ischemic event in 1994. The event, reviewed by a neurologist, was not considered or classified as a stroke, but instead a random ischemic neurological deficit. The initial condition began with atrial fibrillation in 1994. In an October 2019 Cranial Nerves Diseases DBQ, the examiner noted that the Veteran was diagnosed with trigeminal neuralgia in 2011. A 2012 evaluation noted trigeminal neuralgia had resolved with no residuals. A 2017 neurology letter noted that the condition is stable. The Veteran initially presented as having a tooth ache and was prescribed codeine. The condition resolved (2011). Separately, the examiner noted that there is no diagnosis because there are no findings, signs, or symptoms to support a diagnosis. In an October 2019 VA opinion, the examiner determined that the Veteran's claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that the Veteran's left carpal tunnel syndrome, left lower extremity peroneal neuropathy, bilateral trigeminal neuralgia, and cerebellar stroke are less likely than not incurred in or caused by his deep-sea diving that occurred between May 1973 and April 1998. Although this Veteran had a history of deep-sea diving during service, his service treatment records are silent regarding decompression sickness (Type II DCS) that causes neurologic sequelae. The examiner further noted that the cerebellar stroke in this Veteran had a definite etiology not related to decompression sickness caused by deep sea diving. (DCS did not occur in this Veteran.) The stroke was likely due to thrombus embolism from atrial fibrillation brought about by heavy drinking prior to the event (documented in the September 1994 neurological consultation). Regarding carpal tunnel syndrome, the examiner determined that there is no nexus between the etiologic cause of carpal tunnel syndrome and the neurologic sequelae which result from decompression sickness caused by deep-sea diving. Although the Veteran had a history of deep-sea diving, service treatment records are silent regarding DCS during active duty. In an October 2019 DBQ, the VA examiner determined that the Veteran has no evidence of triggers fingers on examination. The condition was acknowledged (2017- neurologist letter) as a new condition. The Veteran had no encounters regarding trigger fingers while in service. The examiner concluded that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In a June 2020 advisory opinion, the Executor Director of Compensation Service determined that review of the cumulative evidence of record does not support the Veteran's contentions of service connection related to deep sea diving. She noted that negative medical opinions are provided for bilateral knees, stroke, left wrist neurological/carpal tunnel syndrome complaints, dizziness, trigeminal neuralgia, left peroneal neuralgia, and bilateral trigger fingers. Medical opinions and other evidence obtained in connection with the Veteran's claims for service connection related to diving in service do not support findings in favor of service connection for the claimed conditions. The Director of Compensation Service does not find service connection to be warranted for bilateral knees, stroke, left wrist carpal tunnel syndrome, dizziness, trigeminal neuralgia, left peroneal neuralgia, or bilateral trigger fingers, claimed as due to and residuals of deep-sea diving during service. Regulations provide that service connection may be granted for any disease diagnosed after discharge, when all evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). Upon review of the claims file, the Board finds that the October 2019 VA opinions are the most probative medical evidence of record on the matter. The VA examiner reviewed the Veteran's claims file and offered opinions supported by detailed rationales. As such, the Board places the most significant weight on the 2019 VA medical opinions, which find against service connection. The Veteran's claims for service connection for left wrist carpal tunnel syndrome, bilateral trigger finger disorder, residuals of a stroke, left leg peroneal neuropathy, and trigeminal neuralgia must fail on a direct basis. See Shedden, supra. The Board has considered the April 2017 and June 2017 private medical opinions on these matters. However, the Board notes that the June 2017 medical opinions did not provide rationales, and the April 2017 determination that something "may be associated" with certain events is simply too speculative to establish a nexus. See Bostain v. West, 11 Vet. App. 124, 127-28 (1998), quoting Obert v. Brown, 5 Vet. App. 30, 33 (1993) (medical opinion expressed in terms of "may" also implies "may or may not" and is too speculative to establish a medical nexus). As such, the Board finds the 2019 VA opinions to be more probative on these matters. Those opinions quite clearly considered the in-service diving activities and provided medical principles as to why the Veteran's claimed conditions are not related to those activities, mainly that the STRs show no evidence of decompression sickness. That statement is factually correct. Additionally, the Board has considered the July 5, 2007, VA Training Letter 07-04, regarding the medical consequences of diving. The Board notes that this letter indicated that its purpose was to provide information on the disabilities that may result from diving. However, the Board finds that such generic texts, which do not address the facts of this particular Veteran's case, and with a sufficient degree of medical certainty, do not amount to competent medical evidence of causality. Sacks v. West, 11 Vet. App. 314 (1998); Libertine v. Brown, 9 Vet. App. 521 (1996); Beausoleil v. Brown, 8 Vet. App. 459 (1996). Moreover, the use of the word "may" is, again, too speculative to establish a nexus. See Bostain, supra. While this letter can serve to advise of possible consequences from diving, it does not provide for definitive nexus between the Veteran's in-service diving and any currently diagnosed disabilities. The Board notes the Veteran's assertions that the claimed disabilities on appeal are related to his service, to particularly include diving in service. Here, the Veteran's complaints as to duration of symptoms are certainly capable of lay observation. However, the Board finds that the cause of any diagnosed disabilities on appeal is not capable of lay observation, as the Veteran does not have medical training or expertise. As such, the Veteran's opinion is afforded little weight in the analysis of whether a nexus between the claimed disabilities on appeal and his service exists. Finally, the Board notes the references made in a June 2021 Written Brief Presentation regarding the Veteran's status as a Persian Gulf War Veteran. In this regard, the Board notes that service connection may be established for a chronic disability resulting from an undiagnosed illness, which became manifest either during active service in the Southwest Asia Theater of operations during the Persian Gulf War, or to a degree of 10 percent or more. 38 C.F.R. § 3.317 (a)(1)(i). It is not clear from the record whether the Veteran had the requisite service to qualify for consideration of this regulation. Regardless, however, as the Veteran was diagnosed with disabilities related to left wrist carpal tunnel syndrome, bilateral trigger finger disorder, residuals of a stroke, left leg peroneal neuropathy, and trigeminal neuralgia at some point time in time, even if he is not demonstrating current symptoms or residuals of these disabilities at this point in time, service connection is not available under the 38 C.F.R. § 3.317. The claimed conditions are not "undiagnosed," nor are they chronic multisymptom illness, neither as defined as such by VA's regulation nor by any medical opinion. In summary, for the reasons stated above, the Board finds that the preponderance of the evidence is against the claims for service connection for left wrist carpal tunnel syndrome, bilateral trigger finger disorder, residuals of a stroke, left leg peroneal neuropathy, and trigeminal neuralgia, and the benefit-of-the-doubt rule is not for application. REASONS FOR REMAND The Veteran is seeking entitlement to service connection for a disorder manifested by dizziness. The Veteran's service treatment records document complaints of dizziness. In an October 2019 DBQ, the examiner concluded that the Veteran does not have any encounters regarding dizziness while in service. The Veteran's dizziness, a symptom, not a diagnosis, is noted in 2011, absent of any of the longterm effects of diving noted in the medical consequences of diving training letter. The examiner concluded that the claimed condition was less likely than not incurred or caused by the claimed in-service injury, event, or illness. Separately, in an October 2019 DBQ, the examiner noted that, for the claimed condition of dizziness, there is no diagnosis because there are no findings, signs, and/or symptoms to support a diagnosis. The Veteran has occasional symptoms, but no diagnosis was warranted at this time. The Board finds this opinion is inadequate. Specifically, the examiner noted the Veteran's occasional symptoms of dizziness but failed to render a diagnosis. In the June 2021 Written Brief Presentation, the representative referenced the Veteran's status as a Persian Gulf War Veteran. It is unclear from the record whether the Veteran served in the Southwest Asia Theater of operations during the Persian Gulf War. Therefore, after verification of his service, an addendum opinion may be needed. The matters are REMANDED for the following action: 1. Verify the Veteran's service in the Southwest Asia theater of operations. 2. If, and only, if, the Veteran is verified to have served in the Southwest Asia theater of operations such that he is considered a Persian Gulf War veteran, obtain an addendum medical opinion that addresses the etiology of the Veteran's occasional dizziness. After a review of the claims file, the examiner should determine whether the Veteran's claimed dizziness is attributable to a known clinical diagnosis of any kind or whether the reported problem is a manifestation of an undiagnosed illness. A complete rationale for all opinions rendered is required. MICHELLE L. KANE Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L, Durham, 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.