Citation Nr: 21008527 Decision Date: 02/17/21 Archive Date: 02/17/21 DOCKET NO. 15-38 434 DATE: February 17, 2021 ORDER 1. The application to reopen the claim for service connection for chronic sinusitis is granted. 2. The application to reopen the claim for service connection for nerve damage of the right wrist, to include carpal tunnel syndrome, (right wrist disability) is granted. 3. Entitlement to service connection for lower back nerve damage (lumbar spine disability) is denied. 4. Entitlement to service connection for neuropathy of the left lower extremity, to include as secondary to a lumbar spine disability, is denied. 5. Entitlement to service connection for neuropathy of the right lower extremity, to include as secondary to a lumbar spine disability, is denied. 6. Entitlement to service connection for a left knee disability, claimed as left knee numbness and to include as secondary to the lumbar spine disability, is denied. 7. Entitlement to service connection for a right knee disability, claimed as right knee numbness and to include as secondary to a lumbar spine disability, is denied. 8. Entitlement to service connection a left hip disability, to include as secondary to a lumbar spine disability, is denied. 9. Entitlement to service connection for a right hip disability, to include as secondary to a lumbar spine disability, is denied. 10. Entitlement to service connection for a left ankle disability, to include as secondary to the lumbar spine, is denied. 11. Entitlement to service connection for a right ankle disability, to include as secondary to the lumbar spine, is denied. 12. Entitlement to service connection for obstructive sleep apnea, to include as secondary to exposure to Agent Orange (AO)/herbicides, is denied. 13. The reopened claim of entitlement to service connection for chronic sinusitis is denied. 14. The reopened claim of entitlement to service connection for a right wrist disability, to include carpal tunnel syndrome, is denied. FINDINGS OF FACT 1. In a February 2012 rating decision, the claim for service connection for chronic sinusitis was denied based on a finding that chronic sinusitis did not occur in service nor was it caused by service. 2. Evidence submitted since the February 2012 rating decision relates to an unestablished fact necessary to substantiate the claim for service connection for chronic sinusitis. 3. In a February 2012 rating decision, the claim for service connection for a right wrist disability was denied based on a finding that a right wrist disability did not occur in service nor was it caused by service. 4. Evidence submitted since the February 2012 rating decision relates to an unestablished fact to substantiate the claim for service connection for a right wrist disability. 5. The preponderance of the evidence is against finding that the lumbar spine disability had an onset in service, manifested to a compensable degree within one year of service discharge, or is otherwise related to service. 6. The preponderance of the evidence is against finding that the neuropathy of the left lower extremity had an onset in service, manifested to a compensable degree within one year of service discharge, is secondary to a service-connected lumbar spine disability, or is otherwise related to service, to include as the result of exposure to AO/herbicides. 7. The preponderance of the evidence is against finding that the neuropathy of the right lower extremity had an onset in service, manifested to a compensable degree within one year of service discharge, is secondary to a service-connected lumbar spine disability, or is otherwise related to service, to include as the result of exposure to AO/herbicides. 8. The preponderance of the evidence is against finding that the left knee disability had an onset in service, manifested to a compensable degree within one year of service discharge, is secondary to a service-connected lumbar spine disability, or is otherwise related to service. 9. The preponderance of the evidence is against finding that the right knee disability had an onset in service, manifested to a compensable degree within one year of service discharge, is secondary to a service-connected lumbar spine disability, or is otherwise related to service. 10. The preponderance of the evidence is against finding that the left hip disability had an onset in service, manifested to a compensable degree within one year of service discharge, is secondary to a service-connected lumbar spine disability, or is otherwise related to service. 11. The preponderance of the evidence is against finding that the right hip disability had an onset in service, manifested to a compensable degree within one year of service discharge, is secondary to a service-connected lumbar spine disability, or is otherwise related to service. 12. The preponderance of the evidence is against finding that the left ankle disability had an onset in service, manifested to a compensable degree within one year of service discharge, is secondary to a service-connected lumbar spine disability, or is otherwise related to service. 13. The preponderance of the evidence is against finding that the right ankle disability had an onset in service, manifested to a compensable degree within one year of service discharge, is secondary to a service-connected lumbar spine disability, or is otherwise related to service. 14. The preponderance of the evidence is against finding that obstructive sleep apnea had an onset in service or is otherwise related to service, to include as the result of exposure to AO/herbicides. 15. The preponderance of the evidence is against finding that chronic sinusitis began during active service or is otherwise related to an in-service injury or disease. 16. The preponderance of the evidence is against finding that a right wrist disability began during active service, manifested within one year of service discharge, or is otherwise related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The February 2012 rating decision denying service connection for chronic sinusitis is final. New and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. §§ 3.156(a), 20.1103 (2019). 2. The February 2012 rating decision denying service connection for a right wrist disability is final. New and material evidence has been received to reopen the claim. 38 U.S.C. §§ 5108, 7105 (2012); 38 C.F.R. §§ 3.156(a), 20.1103 (2019). 3. The criteria for entitlement to service connection for a lumbar spine disability have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 4. The criteria for entitlement to service connection for neuropathy of the left lower extremity, to include as secondary to a lumbar spine disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 5. The criteria for entitlement to service connection for neuropathy of the right lower extremity, to include as secondary to a lumbar spine disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 6. The criteria for entitlement to service connection for a left knee disability, claimed as left knee numbness and to include as secondary to the lumbar spine disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 7. The criteria for entitlement to service connection for a right knee disability, claimed as right knee numbness and to include as secondary to a lumbar spine disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 8. The criteria for entitlement to service connection a left hip disability, to include as secondary to a lumbar spine disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 9. The criteria for entitlement to service connection for a right hip disability, to include as secondary to a lumbar spine disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 10. The criteria for entitlement to service connection for a left ankle disability, to include as secondary to a lumbar spine disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 11. The criteria for entitlement to service connection for a right ankle disability, to include as secondary to a lumbar spine disability, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310 (2019). 12. The criteria for entitlement to service connection for obstructive sleep apnea, to include as secondary to exposure to AO/herbicides, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). 13. The criteria for entitlement to service connection for chronic sinusitis have not been met. 38 U.S.C. §§ 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2019). 14. The criteria for entitlement to service connection for a right wrist disability, to include carpal tunnel syndrome, have not been met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2019). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from August 1962 to February 1966 and from August 1990 to June 1991, with additional reserve service. The Veteran testified at a video conference hearing before the undersigned Veterans Law Judge in May 2019. A transcript of the hearing was prepared and associated with the claims file. The record was held open for 90 days to allow the Veteran to obtain additional records, and in that time, the Veteran submitted private treatment records. The Board remanded these matters in October 2019 for additional development. In consideration of the appeal, the Board is satisfied there was substantial compliance with the remand directives and will proceed with review. Stegall v. West, 11 Vet. App. 268 (1998). Initially, the Board notes that the Veteran has noted throughout the claims file that she served in the Persian Gulf during Desert Storm. While the Board acknowledges that the Veteran did serve during this time period, the record does not document service in Southwest Asia. For example, the DD Form 214 from that period of service shows an affirmative finding of no foreign service and no awards or decorations confirming service in Southwest Asia. Thus, the Board finds as fact that the Veteran did not have service in Southwest Asia during her service from August 1990 to June 1991. New and Material Evidence Prior unappealed decisions of the RO are final. 38 U.S.C. § 7105(c); 38 C.F.R. § 20.1103. The Board does not have jurisdiction to consider a claim that has become final before it determines that new and material evidence has been presented, irrespective of what the regional office may have determined with respect to new and material evidence. Barnett v. Brown, 83 F.3d 1380, 1383 (Fed. Cir. 1996). If, however, new and material evidence is presented or secured with respect to a claim which has been disallowed, VA shall reopen the claim and review the former disposition of the claim. Manio v. Derwinski, 1 Vet. App. 145 (1991). New evidence means existing evidence not previously submitted to agency decision makers. 38 C.F.R. § 3.156(a). Material evidence means existing evidence that, by itself or considered with previous evidence of record, relates to an unestablished fact necessary to substantiate the claim. New and material evidence can be neither cumulative nor redundant of the evidence of record at the time of the last prior final denial of the claim sought to be reopened and must raise a reasonable possibility of substantiating the claim. Id. New and material evidence need not be received as to each previously unproven element of a claim in order to justify reopening thereof; the threshold for determining whether new and material evidence raises a reasonable possibility of substantiating a claim is “low.” Shade v. Shinseki, 24 Vet. App. 110, 117–20 (2010). Initially, the Board notes that additional STRs and military personnel records were associated with the claims file in May 2014. When VA receives relevant service department records that existed at the time of a prior final decision, VA will reconsider the prior decision without the need for new and material evidence. 38 C.F.R. § 3.156(c). However, in this case, after a thorough review of the newly added records, the Board finds that the new records are not relevant to the claim for chronic sinusitis or a right wrist disability. The new examinations include May 1964 entrance examination and another examination in June 1962 prior to the Veteran’s entrance to active service. However, these records would not assist in support the claim as the award of service connection relates to the disability status during and after her active service and not prior to service, and the presumption of soundness is not at issue. Therefore, new and material evidence is necessary to reopen the claims. 1. Whether new and material evidence has been received to reopen the claim for service connection for chronic sinusitis The claim for service connection for chronic sinusitis was previously considered and denied by the RO in a February 2012 rating decision based on of a finding there was no onset in service or evidence of a nexus between a diagnosis of chronic sinusitis and active service. At the time of the February 2012 rating decision, the relevant evidence consisted of service treatment records (STRs), VA treatment records, private treatment records, and the application for compensation benefits. The Veteran was notified of that decision and of her appellate rights. The Veteran did not appeal the decision and did not submit new and material evidence within one year of the February 2012 rating decision, and it became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. In July 2013, the Veteran filed an informal application to reopen the claim for service connection for chronic sinusitis. Relevant evidence added to the file consists of VA treatment records, private medical records, May 2019 testimony, the Veteran’s contentions, and the application to reopen the claim. An August 2014 rating decision denied the claim to reopen, finding that there was no new and material evidence. Since the February 2012 rating decision, the Veteran, in an August 2013 statement, reported that she had a severe flu that included sinusitis and problems with hoarseness and lasted for weeks during her first period of service in approximately 1965 or 1966. She testified that she was treated at Letterman General Hospital during that time. She also testified at the May 2019 hearing that she had a sinus issue while she was serving in Vietnam, noting that she went to sick call at that time because a flu was going around. These contentions were not of record at the time of the February 2012 rating decision. Accordingly, the Board finds that new and material evidence has been received to reopen the claim for service connection for chronic sinusitis. Therefore, the application to reopen the previously-denied claim is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. 2. Whether new and material evidence has been received to reopen the claim for service connection for a right wrist disability The claim for service connection for a right wrist disability was previously considered and denied by the RO in a February 2012 rating decision based on of a finding there was no onset in service or evidence of a nexus between a diagnosis of a right wrist disability and active service. At the time of the February 2012 rating decision, the relevant evidence consisted of STRs, VA treatment records, private treatment records, and the application for benefits. The Veteran was notified of that decision and of her appellate rights. The Veteran did not appeal the decision and did not submit new and material evidence within one year of the February 2012 rating decision, and it became final. 38 U.S.C. § 7105; 38 C.F.R. § 20.1103. In July 2014, the Veteran filed an informal application to reopen the claim for service connection for a right wrist disability. Relevant evidence added to the file consists of VA treatment records, private medical records, the Veteran’s contentions at the May 2019 hearing, and the application to reopen the claim. An August 2014 rating decision denied the claim to reopen, finding that there was no new and material evidence. Since the February 2012 rating decision, the Veteran testified that she remembers going to sick call for a right wrist injury, including getting injections and a splint while she was serving at Fort Bragg. She also testified that she believed constant repetitive movement of trays and carts in the operating room may have caused her current wrist problems. These contentions were not of record at the time of the February 2012 rating decision. Accordingly, the Board finds that new and material evidence has been received to reopen the claim for service connection for a right wrist disability. Therefore, the application to reopen the previously-denied claim is granted. 38 U.S.C. § 5108; 38 C.F.R. § 3.156. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran must show: (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. Service connection may 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). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). Additionally, where a veteran served 90 days or more of active service, and certain chronic diseases, such as arthritis, which is also known as degenerative joint disease, and peripheral neuropathy, which is an organic disease of the nervous system, become manifest to a degree of 10 percent or more within one year after the date of separation from such service, such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309(a). Initially, the Board finds that entitlement to VA examinations or medical opinions is not warranted in connection with the claims for service connection for a lumbar spine disability, a bilateral hip disability, a bilateral knee disability, neuropathy of the bilateral lower extremities, a bilateral ankle disability, or obstructive sleep apnea. VA must provide a medical examination and/or medical opinion when there is (1) competent evidence of a current disability or persistent or recurrent symptoms of a disability, (2) evidence establishing that an event, injury, or disease occurred in service, or establishing certain diseases manifesting during an applicable presumptive period for which the claimant qualifies, and (3) an indication that the disability or persistent or recurrent symptoms of a disability may be associated with the veteran’s service or with another service-connected disability, but (4) there is insufficient competent medical evidence on file for the Secretary to make a decision on the claim. McLendon v. Nicholson, 20 Vet. App. 79 (2006). In this case, the evidence does not show an event, injury, or disease occurred in service for any of the aforementioned disabilities, which will be described in more detail below. For a VA examination and/or medical opinion to be warranted, all the McLendon criteria have to be met, and at least one of the criteria is not met. Therefore, entitlement to VA examinations and/or medical opinions is not warranted for these service-connection claims. 3. Entitlement to service connection for a lumbar spine disability The Veteran, when she filed the claim in March 2014, reported that her back problems, including pain, swelling, and stiffness, began during her service in Vietnam. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a lumbar spine disability. The reasons follow. As to evidence of a current disability, private treatment records from January 2011 document a diagnosis of spondylosis and myelopathy of the lumbar spine and private treatment records from March 2014 document a diagnosis of degenerative disc disease, degenerative joint disease, and herniated discs. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of a disease or injury in service, the STRs do not show that the Veteran sustained a disease or injury to the lumbar spine during service. For example, examinations conducted in February 1980, April 1981, November 1985, December 1986, February 1988, and May 1991 (which was conducted just prior to the Veteran’s separation from her second period of active service) all document that a clinical evaluation of the spine was normal. The Veteran completed a Report of Medical History at the time of each of these examinations, with the exception of the February 1980 examination, and in each one, the Veteran specifically denied having or having had recurrent back pain, swollen or painful joints, and arthritis. The evidence suggests that the Veteran thoroughly and completely filled out these Reports of Medical History given that she did report various other symptomatology on these reports, including having or having had a history of broken bones; a tumor, growth, cyst, or cancer (which she described as a breast cyst); an adverse reaction to a drug; frequent or painful urination; sea sickness; a toe fusion because of a bone chip; a history of urinary tract infections; foot trouble; and a recent loss or gain of weight. Additionally, the Veteran frequently reported on these Reports of Medical History that she was in good health and denied having been treated for any other illness or injury other than those noted, which did not include treatment for a lumbar spine disease or injury, including numbness or nerve damage in the lumbar spine. Given that the Veteran specifically reported having or having had many other symptoms during her service, including hand-written descriptions of the various injuries and illness that were reported, the Board finds that these Reports of Medical History are highly probative evidence that the Veteran would have reported any symptoms related to her lumbar spine had she experienced any such symptoms during her reserve service or either period of active service. The Board acknowledges that the STRs from her first period of service from October 1964 to February 1968 are largely unavailable and that this is the time period in which the Veteran asserted that the lumbar spine disability had its onset. However, as noted above, the preponderance of the evidence is against finding that the Veteran had any continuing symptomatology of a lumbar spine disability prior to or during her second period of active service from August 1990 to June 1991, nor do the available records from her reserve service between the two periods of active service document such symptoms, and, instead, document her denial of such symptoms. Thus, the preponderance of the evidence is against a finding that the second element of a service-connection claim, which requires an onset of the disability in service, is met. The Board also acknowledges the Veteran’s reports that she first noticed symptoms of pain, swelling, and stiffness in her back during her first period of service while serving in Vietnam and throughout her active service and that, though she did not seek treatment for these symptoms, she did take Tylenol to self-manage her symptoms. However, the Board finds that the symptoms of any back pain, stiffness, or swelling that may have occurred during the first period of service were more likely than not acute and resolved prior to her discharge because, as is described above, in treatment records from February 1980 onward, the Veteran specifically denied current or past symptoms of recurrent back pain, arthritis, or joint pain, and clinical evaluations of the spine were normal. Though the Veteran is competent to report experiencing symptoms related to her lumbar spine following service discharge from her first period of service, the Board finds the contemporaneous STRs from 1980 through 1991 to be the most probative evidence that the Veteran was not experiencing and had not experienced recurrent symptoms of pain, stiffness, or swelling in her lumbar spine relating back to her first period of service, as she consistently and repetitively denied any such symptomatology throughout that 11-year period, which is evidence against continuity of symptomatology. Furthermore, VA treatment records from August 2002 included a section for the provider to document significant health problems, and the box related to back problems was not checked. Rather, the claims file does not document that the Veteran began reporting such symptomatology related to pain in her lumbar spine until approximately 2003, which is over 30 years after she now alleges she first began experiencing pain. Even after the Veteran was diagnosed with degenerative changes in the lumbar spine, records from as late as May 2019 private treatment records document that the Veteran denied that she was experiencing symptoms in her spine. Despite not meeting the requirements for service connection on a direct basis, the Board notes that degenerative joint disease and arthritis are chronic diseases under 38 C.F.R. § 3.309, which allows for service connection on a presumptive basis if the chronic disease is manifested to a compensable degree within one year of discharge from service. However, in this case the preponderance of the evidence is against finding that the Veteran had a diagnosis of arthritis or degenerative joint disease of the spine within one year of discharge from service. Rather, the earliest documentation in the claims file of either diagnosis was a notation of degenerative changes in the lumbar spine in February 2003 VA treatment records. As the onset of a chronic disability was approximately 12 years, at the earliest, after the Veteran’s discharge from active service, service connection on a presumptive basis is also denied. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for a lumbar spine disability is denied. 4. – 5. Entitlement to service connection for neuropathy of the bilateral lower extremities, to include as secondary to a lumbar spine disability The Veteran testified at the May 2019 hearing that she has pain and numbness as well as hot and cold-type intolerances in her lower extremities. She testified that this impacted the entirety of her bilateral lower extremities, including her hips, knees, and ankles. She testified that these symptoms were secondary, at least in part, to her lumbar spine disability. Alternatively, when the Veteran filed the claim in March 2014, she reported that she started having problems with her legs in service, reporting pain that radiated into her lower extremities causing pain and discomfort. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for neuropathy of the bilateral lower extremities. The reasons follow. As to evidence of a current disability, February 2007 VA records document that the Veteran was experiencing radicular symptoms related to her lumbar spine and the associated EMG report documented nerve dysfunction in both lower extremities. July 2010 private treatment records document a diagnosis of peripheral neuropathy of the bilateral lower extremities. Therefore, the facts establish that the first element of a service-connection claim is met. Initially, though the Veteran has not specifically alleged that her neuropathy of the bilateral lower extremities is related to exposure to AO/herbicides, the Board notes that peripheral neuropathy (organic disease of the nervous system) is a chronic disease under 3.309(a) and that early-onset peripheral neuropathy is a disease associated with herbicide exposure (e), and the claims file documents that the Veteran served in Vietnam during her first period of active service. If a veteran was exposed to an “herbicide agent,” such as Agent Orange, used in support of the United States and allied military operations in the Republic of Vietnam from January 9, 1962, to May 7, 1975, then, absent affirmative evidence to the contrary, certain diseases will be service-connected even if there is no in-service record of the disease in service. 38 C.F.R. § 3.307(a)(6), (d), 3.309(e). Notwithstanding the foregoing presumptions, a veteran is not precluded from establishing service connection due to exposure to herbicides with proof of direct causation. Combee v. Brown, 38 F.3d 1039, 1042 (Fed. Cir. 1994). For chronic diseases, the disease must have an onset to a compensable degree within one year of discharge from active service. For early-onset peripheral neuropathy, the presumption of service connection based on exposure to AO/herbicides also requires an onset of within one year after the last date on which the Veteran was exposed to an herbicide agent during active service. 38 C.F.R. § 3.307(a)(6)(ii). In this case, the preponderance of the evidence is against finding that the neuropathy of the bilateral lower extremities had an onset within one year of her last date of service in Vietnam or within one year of her discharge from active service. As noted above, the claims file documents the onset of nerve dysfunction in the lower extremities in February 2007, though there was no diagnosis of peripheral neuropathy until July 2010. However, that is, at the earliest, approximately 40 years after the Veteran’s last date of service in Vietnam and approximately 16 years after the Veteran’s discharge from active service. Furthermore, the claims file specifically documents that the Veteran did not have nerve dysfunction prior to February 2007. As will be fully assessed below, the STRs include repeated documentation that the Veteran had not experienced the onset of symptoms related to peripheral neuropathy of the bilateral lower extremities prior to the Veteran’s discharge from active service. Additionally, the Veteran specifically denied a history of paralysis, weakness, paresthesias or radiculopathy in November 2002 VA treatment records, and July 2006 VA treatment records documented that muscle tone, strength, and coordination were normal. The July 2006 VA treatment records also document that a sensory examination was nonremarkable. The Board finds this to be highly probative evidence that the Veteran was not experiencing symptoms of an onset of peripheral neuropathy in the lower extremity prior to February 2007. The Board also acknowledges the Veteran’s assertion that her lower extremity neuropathy is related to her lumbar spine disability. While that may be true, service connection as secondary to the lumbar spine disability is not available for these disabilities, as the lumbar spine disability is not service connected. Despite not meeting the requirements for service connection on a presumptive or secondary basis, the Board will still assess whether or not the Veteran meets the requirements for service connection on a direct basis. As to evidence of a disease or injury in service, the STRs do not show that the Veteran sustained a disease or injury to the bilateral lower extremities, nor did she report symptoms that show an onset of peripheral neuropathy in the lower extremities during her active service. For example, examinations conducted in February 1980, April 1981, November 1985, December 1986, February 1988, and May 1991 (which was conducted just prior to the Veteran’s separation from active service) all document that clinical evaluations of the neurologic system and the lower extremities were normal. Additionally, the Veteran completed a Report of Medical History at the time of each of these examinations, with the exception of the February 1980 examination, and in each one, the Veteran specifically denied having or having had paralysis or neuritis. The evidence suggests that the Veteran thoroughly and completely filled out these Reports of Medical History given that she did report various other symptomatology on these reports, including having or having had a history of broken bones; a tumor, growth, cyst, or cancer (which described as a breast cyst); an adverse reaction to a drug; frequent or painful urination; sea sickness; a toe fusion because of a bone chip; a history of urinary tract infections; foot trouble; and a recent loss or gain of weight. Additionally, the Veteran frequently reported on these Reports of Medical History that she was in good health and denied having been treated for any other illness or injury other than those noted, which did not include treatment for numbness, tingling, or any other symptoms related to the onset of peripheral neuropathy in the bilateral lower extremities. Given that the Veteran specifically reported having or having had many other symptoms during her service, including hand-written descriptions of the various injuries and illness that were reported, the Board finds that these Reports of Medical History are highly probative evidence that the Veteran would have reported any symptoms related to neuropathy of the lower extremities had she experienced any such symptoms during her reserve service or either period of active service. Additionally, the Board notes that all of the aforementioned examinations, except the November 1985 examination in which the PULHES section was not completed, documented that the Veteran had received a PULHES score of 1 for “L.” The “PULHES” profile reflects the overall physical and psychiatric condition of an individual on a scale of 1 (high level fitness) to 4 (medical condition or physical defect is below the level of medical fitness required for retention in military service). The “P” stands for “physical capacity or stamina,” the “U” stands for “upper extremities,” the “L” stand for “lower extremities,” the “H” reflects the condition of the “hearing and ears,” the “E” is indicative of the “eyes,” and the “S” stand for “psychiatric condition.” Odiorne v. Principi, 3 Vet. App. 456, 457 (1992). The Board finds this to be highly probative evidence that the Veteran was not experiencing significant symptoms related to an onset of peripheral neuropathy in her lower extremities between her first and second period of service or during her second period of service. The Board acknowledges that the STRs from her first period of service from October 1964 to February 1968 are unavailable. However, as noted above, the preponderance of the evidence is against finding that the Veteran had continuing symptomatology related to neuropathy of the lower extremities prior to or during her second period of active service from August 1990 to June 1991, nor do the available records from her reserve service between the two periods of active service suggest continuing symptomatology from her first period of service. The Board also acknowledges the Veteran’s reports that she first noticed symptoms of pain, swelling, and stiffness her extremities during her active service, and that, though she did not seek treatment for these disabilities, she did take Tylenol to self-manage her symptoms. However, the Board finds that the symptoms in her lower extremities were more likely than not acute in nature as the Veteran, in treatment records from 1980 onward, specifically denied current or past symptoms related to peripheral neuropathy of the lower extremities, as noted above. Though the Veteran is competent to report experiencing symptoms related to her lower extremities during her service, the Board finds the contemporaneous STRs from 1980 through 1991 to be the most probative evidence that the Veteran was not experiencing and had not experienced recurrent symptoms of peripheral neuropathy during service as she consistently and repetitively denied any such symptomatology throughout that more than 10-year period. Furthermore, VA treatment records from November 2002 and July 2006 noted that the Veteran did not have paralysis, weakness, paresthesias, or radiculopathy, and a sensory examination was non-remarkable, which is probative evidence that symptoms of peripheral neuropathy had not yet manifested at that time. Rather, the claims file documents that the Veteran did not begin reporting such symptomatology, which was ultimately diagnosed as peripheral neuropathy of the bilateral lower extremities, until approximately February 2007, over 16 years after the Veteran’s discharge from active service. Thus, the Veteran does not meet the second element of a service-connection claim, which requires an onset of the disability in service. The Board also finds that the preponderance of the evidence is against finding a nexus between the current diagnosis of neuropathy of the bilateral lower extremities and the Veteran’s service. VA treatment records from as early as November 2002 document that the Veteran had bilateral lower leg edema and hyperpigmentation above the ankles that was consistent with her diagnosis of thyroid disease. Private treatment records from January 2011 document that her peripheral neuropathy, though idiopathic, is likely related to the edema and other adrenal gland enlargement, and private records from April 2012 document that the EMG did not show any myopathy and the nerves in the lower extremities were functioning normally and that the symptomatology in the lower extremities was due to some other condition such as thyroid arthritis, another connective tissue disorder, or chronic edema. The Board finds this is probative evidence that the current bilateral lower extremity neuropathy is likely related to her thyroid disease, which is not service connected, and is evidence against a finding that it is related to the Veteran’s active service. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for a neuropathy of the bilateral lower extremities is denied. 6. – 11. Entitlement to service connection for a bilateral knee disability, claimed as left knee numbness and to include as secondary to the lumbar spine disability; a bilateral hip disability, to include as secondary to a lumbar spine disability; and a bilateral ankle disability, to include as secondary to a lumbar spine disability The Veteran testified at the May 2019 hearing that the claims for service connection for bilateral knee, hip, and ankle disability were all related to her neuropathy, which she asserts is secondary to her lumbar spine disability, rather than to a musculoskeletal disability. However, when the Veteran filed the claim, she reported that she has developed degenerative joint disease and limited range of motion in her hips and knees due to the pain she reported she experienced in these joints in service. She also reported at that time that she had pain and swelling in her ankles during service as a result of standing on a concrete floor in an operating room all day. The Veteran testified that she did not seek treatment in service for the pain in her lower extremities because, especially compared to those she was caring for as a registered nurse, her aches and pains seemed minor. She testified she took Tylenol to treat and self-manage her aches and pains. The Board has fully assessed the lower extremity disabilities to the extent the symptoms are associated with neuropathy above. However, when the Veteran filed these claims, she asserted an onset of pain in service that later caused the development of degenerative joint disease in these joints. Thus, the Board will also assess a musculoskeletal claim as it relates to the bilateral hips, knees, and ankles. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for bilateral ankle, knee, and hip disabilities. The reasons follow. As to evidence of a current disability, VA treatment records from November 2002 document a diagnosis of bilateral knee osteoarthritis, and private treatment records from January 2011 document a diagnosis of arthritic changes in the bilateral ankles. Therefore, the facts establish that the first element of a service-connection claim is met as to the bilateral knees and ankles. As to the bilateral hip, it is unclear from the record whether the Veteran has a diagnosis of a bilateral hip disability. April 2013 VA treatment records document the Veteran reported pain in the hips, and August 2002 VA treatment records document a history of arthritis without noting to which joints the diagnosis applied. While it is unclear whether the facts establish that the first element of a service-connection claim as to the hips is met, the Board finds that a remand to determine the nature of any hip disability is unnecessary as the record does not support a finding that any currently diagnosed hip disability had an onset in service. As to evidence of a disease or injury in service, the STRs do not show that the Veteran sustained a disease or injury to the bilateral lower extremities, including the knees, hips, or ankles, nor did she report symptoms that show an onset of degenerative joint disease or arthritis in the knees, hips, or ankles during her active service. For example, examinations conducted in February 1980, April 1981, November 1985, December 1986, February 1988, and May 1991 (which was conducted just prior to the Veteran’s separation from active service) all document that a clinical evaluation of the lower extremities was normal. Additionally, the Veteran completed a Report of Medical History at the time of each of these examinations, with the exception of the February 1980 examination, and in each one, the Veteran specifically denied having or having had swollen or painful joints; arthritis, rheumatism, or bursitis; or a trick or locked knee. The evidence suggests that the Veteran thoroughly and completely filled out these Reports of Medical History given that she did report various other symptomatology on these reports, including having or having had a history of broken bones; a tumor, growth, cyst, or cancer (which described as a breast cyst); an adverse reaction to a drug; frequent or painful urination; sea sickness; a toe fusion because of a bone chip; a history of urinary tract infections; foot trouble; and a recent loss or gain of weight. Additionally, the Veteran frequently reported on these Reports of Medical History that she was in good health and denied having been treated for any other illness or injury other than those noted, which did not include treatment for painful or swollen joints or any other symptoms related to the onset of degenerative joint disease or arthritis in the bilateral lower extremities, including the hips, knees, or ankles. Given that the Veteran specifically reported having or having had many other symptoms during her service, including hand-written descriptions of the various injuries and illness that were reported, the Board finds that these Reports of Medical History are highly probative evidence that the Veteran would have documented any symptoms related to her hips, knees, or ankles had she experienced any such symptoms during her reserve service or either period of active service. The Board acknowledges the Veteran’s reports that she did not seek treatment for these aches and pains throughout service, but the Board still finds that the Veteran would have documented a history of pain in these joints on these Reports of Medical History, as many of the other symptoms that she reported having or having had were also not reported in other treatment records throughout service, such as an adverse reaction to a drug, a recent loss or gain of weight, and sea sickness. The Board finds this tends to show that the Veteran was documenting symptoms on these Reports of Medical History for which she did not specifically seek treatment during her active service. Additionally, the Board notes that all of the aforementioned examinations, except the November 1985 examination in which the PULHES section was not completed, documented that the Veteran had received a PULHES score of 1 for “L,” which represents the lower extremities. The Board finds this to be highly probative evidence that the Veteran was not experiencing symptoms related to an onset of a disability or significant symptomatology in her lower extremities, including her hips, knees, or ankles between her first and second period of active service or during her second period of active service. The Board acknowledges that the STRs from her first period of service from October 1964 to February 1968 are unavailable. However, as noted above, the preponderance of the evidence is against finding that the Veteran had any continuing symptomatology related to her knees, hips, or ankles during her second period of active service from August 1990 to June 1991, nor do the available records from her reserve service between the two periods of active service. Thus, the Veteran does not meet the second element of a service-connection claim, which requires an onset of the disability in service. The Board notes the Veteran’s assertion that her bilateral knee, hip, and ankle disabilities are related to her lumbar spine disability. While that may be true, service connection as secondary to the lumbar spine disability is not available for these disabilities as the lumbar spine disability is not service connected. Finally, despite not meeting the requirements for service connection on a direct basis, the Board notes that degenerative joint disease and osteoarthritis are chronic disease under 38 C.F.R. § 3.309, which allows for service connection on a presumptive basis if the chronic disease is manifested to a compensable degree within one year of discharge from service. However, in this case the preponderance of the evidence is against finding that the earliest documentation of diagnosed osteoarthritis or degenerative joint disease of the ankles, hips, or knees had an onset within one year of discharge from service. Rather, the earliest documentation of osteoarthritis in the knees is in November 2002 VA treatment records, approximately 11 years after discharge from active service; the earliest documentation of arthritic changes in the bilateral ankles are January 2011 private treatment records, which suggests an onset approximately 20 years after discharge from active service; and even if the August 2002 records that document a diagnosis of arthritis was referring to the knees, hips, and, ankles, this onset is still approximately 11 years after discharge from active service. Thus, service connection on the basis of chronic presumption is also denied. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for the claimed bilateral knee, hip, and ankle disabilities are denied. 12. Entitlement to service connection for obstructive sleep apnea, to include as secondary to exposure to AO/herbicides The Veteran testified at the May 2019 hearing that believes that her obstructive sleep apnea was caused by exposure to AO/herbicides. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for obstructive sleep apnea. The reasons follow. As to evidence of a current disability, March 2006 VA treatment records document a probable diagnosis of sleep apnea, which is confirmed in September 2006 private treatment records. Therefore, the facts establish that the first element of a service-connection claim is met. The Board acknowledges the Veteran’s assertion that her obstructive sleep apnea is due to exposure to AO/herbicides. While she has been presumed to have been exposed to AO/herbicides due to her service in Vietnam, obstructive sleep apnea is not a disability for which presumptive service connection due to herbicide exposure applies under 38 C.F.R. § 3.309(e), and the Veteran has not provided any other evidence or medical literature to support a connection between her obstructive sleep apnea and presumed exposure to AO/herbicides in Vietnam. A vague assertion of a nexus is not sufficient to warrant an examination, and thus, service connection based on exposure to AO/herbicides alone is denied. The Board will still assess whether the obstructive sleep apnea meets the criteria for direct service connection. As to evidence of a disease or injury in service, the STRs do not show that the Veteran had a diagnosis related to obstructive sleep apnea during service. For example, examinations conducted in February 1980, April 1981, November 1985, December 1986, February 1988, and May 1991 (which was conducted just prior to the Veteran’s separation from active service) all document that a clinical evaluation of the mouth and throat was normal. Additionally, the Veteran completed a Report of Medical History at the time of each of these examinations, with the exception of the February 1980 examination, and in each one the Veteran specifically denied having or having had frequent trouble sleeping. The evidence suggests that the Veteran thoroughly and completely filled out these Reports of Medical History given that she did report various other symptomatology on these reports, including having or having had a history of broken bones; a tumor, growth, cyst, or cancer (which described as a breast cyst); an adverse reaction to a drug; frequent or painful urination; sea sickness; a toe fusion because of a bone chip; a history of urinary tract infections; foot trouble; and a recent loss or gain of weight. Additionally, the Veteran frequently reported on these Reports of Medical History that she was in good health and denied having been treated for any other illness or injury other than those noted, which did not include treatment for sleep apnea, difficulty sleeping, waking without feeling rested, snoring, or difficulty breathing during sleep. Given that the Veteran specifically reported having or having had many other symptoms during her service, including hand-written descriptions of the various injuries and illness that were reported, the Board finds that these Reports of Medical History are highly probative evidence that the Veteran would have reported any symptoms related to difficulty sleeping or obstructive sleep apnea had she experienced any such symptoms during her reserve service or either period of active service. Thus, the preponderance of the evidence is against a finding that the second element of a service-connection claim is met, which requires an onset of the disability in service. Additionally, the preponderance of the evidence is also against a nexus between the post-service diagnosis of sleep apnea and service. For example, it is not until VA treatment records in November 2002, approximately 11 years after discharge from service that the Veteran first reports that she was having difficulty sleeping. More importantly, when the Veteran was first noted to have a possible diagnosis of sleep apnea in March 2006, she specifically reported that the onset of her difficulty sleeping was a “new” symptom rather than reporting that she had experienced symptoms dating back to her active service. The Board finds this to be highly probative evidence that the symptomatology did not date back to her active service, as such a statement contradicts her contemporaneous medical record around the date of her diagnosis and weighs against the Veteran’s credibility when she later reported an onset in service. Additionally, the statement she made in March 2006 is highly credible, as she reported such facts while seeking treatment. Thus, the facts do not support a finding that the third element of a service-connection claim is met. The Board understands that the Veteran is a registered nurse and has competence to provide some medical opinions; however, to the extent that she alleges that sleep apnea had its onset in service, the Board finds that her opinion is outweighed by the facts described above, which show she reported the onset of sleep apnea symptoms as being a “new onset” of sleeping trouble in 2006, which is more than 10 years following service discharge. To the extent she has claimed that these symptoms started in service, the Board finds such allegation not credible. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for obstructive sleep apnea is denied.  13. Entitlement to service connection for chronic sinusitis The Veteran testified at the May 2019 hearing the she had a sinus issue while she was serving in Vietnam during her first period of service. She testified that she went to sick call related to a flu that was going around and that she was hoarse for a month. In an August 2013 statement, the Veteran testified that she had a sinusitis problem, including flu symptoms and hoarseness, during her first period of service and that she received treatment at Letterman General Hospital. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for chronic sinusitis. The reasons follow. As to evidence of a current disability, private records from May 2019 document a diagnosis of acute maxillary sinusitis. However, an “acute” disability does not necessarily constitute a diagnosis for VA purposes. However, even if the diagnosis of acute maxillary sinusitis is indicative of a disability for which service connection may be granted, further development is not necessary as the Board finds the preponderance of the probative evidence of record is against finding that the acute maxillary sinusitis had an onset in service. For example, examinations conducted in February 1980, April 1981, November 1985, December 1986, February 1988, and May 1991 (which was conducted just prior to the Veteran’s separation from active service) all document that a clinical evaluation of the nose and sinuses was normal. On Reports of Medical History between the periods of active service in April 1981, November 1985, and in February 1988, the Veteran did report having or having had sinusitis, noting that she did not know whether she has or had sinusitis, and that she had seasonal sinusitis, respectively. However, on the Report of Medical History associated with the separation examination conducted in May 1991 at the end of her second period of service, the Veteran specifically denied having or having had sinusitis. In weighing this evidence, the Board notes that the Veteran has a diagnosis of allergic rhinitis, a diagnosis separate from her later diagnosed acute maxillary sinusitis, and the November 1985 Report of Medical History documented that the Veteran was allergic to hair die, pollen, and house dust, which is consistent with seasonal allergies and her diagnosis of allergic rhinitis. These symptoms are unrelated to a sinusitis disability, and the examiner who clinically examined the sinuses on each of the examinations related to the Reports of Medical History in which the Veteran reported symptomatology that the Veteran described as sinusitis, documented that the sinuses were clinically normal. Furthermore, in all of the Reports of Medical History in which the Veteran documented symptoms related to sinusitis, the Veteran was between periods of active service. In the period in which the Veteran was on active service, the May 1991 separation Report of Medical History, the Veteran specifically denied having or having had symptoms related to sinusitis, despite her history of reporting symptoms related to her perceived sinus disability in the past. The Board finds this to be highly probative evidence that the Veteran was not experiencing these symptoms at the time of the separation from active service or during her active service as she had a documented history of reporting these symptoms in the past. Additionally, the evidence suggests that the Veteran thoroughly and completely filled out these Reports of Medical History, including the May 1991 completed at separation, as is thoroughly noted above. Finally, the Board finds that the Veteran’s statements related to the onset of her sinusitis in active service are not probative as they are inconsistent. At the May 2019 hearing, the Veteran testified that she had a sinus issue for which she went to sick call while she was serving in Vietnam. She testified that she was hoarse for a month as a result of this flu. However, in an August 2013 statement, the Veteran reported that during her first period of service she was treated at Letterman General Hospital in San Francisco for flu and sinus symptoms, including hoarseness, that had lasted for weeks. The Veteran does not seem to suggest she had two separate incidents of illness, but she does report that this illness took place at two separate times in her service, one in Vietnam and one in San Francisco. This noteworthy inconsistency calls into question the credibility of the Veteran’s reports, and thus, the Board finds the Veteran’s statements as to the onset of disability during her first period of service to be not probative. Thus, the preponderance of the evidence is against a finding that the second element of a service-connection claim is met, which is evidence of a disease or injury in service. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for chronic sinusitis is denied. 14. Entitlement to service connection for a right wrist disability The Veteran testified that she remembers going to sick call for her right wrist and that she was given an injection and a splint. She testified that she first had problems while she was at Fort Bragg, and she believed that the constant movement of trays, carts, and surgical equipment in the operating room may have caused her current wrist problems. The Board has carefully reviewed the evidence of record and finds that the preponderance of the evidence is against the claim for service connection for a right wrist disability. The reasons follow. As to evidence of a current disability, private treatment records document that the Veteran had a right carpal tunnel release in July 2014. Therefore, the facts establish that the first element of a service-connection claim is met. As to evidence of a disease or injury in service, the STRs do not confirm the Veteran’s reports that she received injections and a splint for her right wrist in service. Additionally, examinations conducted in February 1980, April 1981, November 1985, December 1986, February 1988, and May 1991 (which was conducted just prior to the Veteran’s separation from active service) all document that a clinical evaluation of the upper extremities and neurologic system was normal. Furthermore, the Veteran completed a Report of Medical History at the time of each of these examinations, with the exception of the February 1980 examination, and in each one the Veteran specifically denied having or having had swollen or painful joints, paralysis, or neuritis. The evidence suggests that the Veteran thoroughly and completely filled out these Reports of Medical History given that she did report various other symptomatology on these reports, including having or having had a history of broken bones; a tumor, growth, cyst, or cancer (which described as a breast cyst); an adverse reaction to a drug; frequent or painful urination; sea sickness; a toe fusion because of a bone chip; a history of urinary tract infections; foot trouble; and a recent loss or gain of weight. Additionally, the Veteran frequently reported on these Reports of Medical History that she was in good health and denied having been treated for any other illness or injury other than those noted, which did not include treatment for a right wrist disability, which is inconsistent with her statements made decades later and weighs against the credibility of the Veteran’s lay statements made many years later. Given that the Veteran specifically reported having or having had many other symptoms during her service, including hand-written descriptions of the various injuries and illness that were reported, the Board finds that these Reports of Medical History are highly probative evidence that the Veteran would have reported symptoms related to being given an injection in her wrist and a splint during her reserve service or either period of active service. Additionally, the Board notes that all of the aforementioned examinations, except the November 1985 examination in which the PULHES section was not completed, documented that the Veteran had received a PULHES score of 1 for “U,” which represents the upper extremities. The Board finds this to be highly probative evidence that the Veteran was not experiencing symptoms related to an onset of a disability or significant symptomatology in her upper extremities, including her right wrist, between her first and second period of active service or during her second period of active service. It is unclear whether the Veteran was testifying to treatment in her first or second period of service, but, regardless, the Board finds the Veteran’s statement that she was treated during service to be less probative than the contemporaneous STRs from February 1980 to her separation examination and Report of Medical History in May 1991. If the reported injury was in the first period of service, the lack of reporting related to ongoing pain or injury in the right wrist despite the Veteran’s detailed and complete reporting of having or having had other injuries and normal clinical evaluations of the upper extremities are not consistent with an ongoing right wrist injury from her first period of service. If the reported injury took place during the second period of service, the Board finds it unlikely that treatment, which included an injection or splint, would not have been documented either in the service treatment records for the date of treatment or by the Veteran as the Veteran completed such a detailed report of her ongoing symptoms, as fully discussed above. The Board also finds the preponderance of the evidence is against a nexus between the diagnosed right carpal tunnel syndrome and the Veteran’s service. For example, the earliest documentation of a history of right carpal tunnel syndrome is noted in private treatment records from July 2014, more than 20 years after the Veteran’s discharge from service. When the Veteran was seen in November 2002, the examiner performed a review of systems. When addressing the Veteran’s musculoskeletal system, the examiner wrote that the Veteran denied any unusual weakness, joints that were painful, swollen or frozen with the exception of osteoarthritis in both knees. When addressing the Veteran’s neurological system, the examiner wrote it was negative for paralysis, weakness, paresthesias, and radiculopathy. The Veteran had the wherewithal to report symptoms involving her knees, and the fact that she did not report symptoms involving her right wrist is evidence against a finding that she was experiencing symptoms involving her right wrist at that time. At this point, it had been more than 10 year since the most recent discharge from active duty. This is evidence that weighs against a finding that a right wrist disability is related to service. This is also evidence against carpal tunnel syndrome, an organic disease of the nervous system, was manifested within one year following service discharge. Thus, presumptive service connection based on a chronic disease is not warranted. Given the greater than 20 years between the Veteran’s discharge from service and the first notation of a diagnosis of right carpal tunnel syndrome and the lack of reporting of symptoms dating back to service, the Board finds the preponderance of the evidence is against finding that the current carpal tunnel syndrome is related to a period of active duty. The Board acknowledges the Veteran’s statements that she believes her current right wrist symptoms are related to repetitive motion and lifting in her job as an operating nurse in service. Even though the Veteran is a registered nurse, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. Thus, the Veteran’s own opinion is nonprobative evidence. However, if the Veteran’s opinion is competent to establish a possible nexus to service, the Board finds it is not probative because there is no rationale to explain how her job in service caused a neurological disability more than 20 years after service. At the present time, there is no competent and probative evidence of a nexus between the right carpal tunnel syndrome and the Veteran’s periods of active duty. In reaching the above conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, that doctrine is not applicable where, as here, there is not an approximate balance of positive and negative evidence. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Thus, the claim for service connection for a right wrist disability, to include carpal tunnel syndrome, is denied. A. P. SIMPSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board A. Keninger, 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.