Citation Nr: 22016228 Decision Date: 03/21/22 Archive Date: 03/21/22 DOCKET NO. 09-22 626 DATE: March 21, 2022 ORDER Entitlement to service connection for a hernia disability, to include ventral hernia (claimed as ventral hernia surgery) and hiatal hernia (also claimed as loss of energy, nausea, low grade fever, and vomiting) (hereinafter hiatal hernia), to include as secondary to service-connected Crohn's disease, is denied. FINDING OF FACT The evidence persuasively supports a finding against the Veteran's hernia disability, to include as secondary to service-connected Crohn's disease, was incurred in or caused by any in-service injury, event, or illness, or due to, the result of, or aggravated beyond its natural progression by, his service-connected Crohn's disease. CONCLUSION OF LAW The criteria for service connection for a hernia disability, to include as secondary to service-connected Crohn's disease, have not been met. 38 U.S.C. §§ 1110, 1154, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310, 3.385. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1973 to April 1979 and from October 1979 to May 1993. He served in the Reserves from August 1994 to April 2002. This matter comes to the Board of Veterans' Appeals (Board) from a September 2008 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO), which denied entitlement to service connection for both ventral and hiatal hernia conditions. The two conditions were subsequently addressed together and at other times separately by the Veteran and the RO, as recounted in detail in the Board's November 2020 remand order. Since during the pendency of his appeal the Veteran has referred to his hernia disability as ventral hernias, hiatal hernias, and generally as simply hernias, the Board has found that the issue on appeal encompasses both ventral and hiatal hernias under the umbrella of a hernia disability. The Board conducted a hearing in September 2020 addressing service connection for hernia disability before the undersigned Veteran's Law Judge (VLJ). A transcript of the hearing has been associated with the claims file. An earlier hearing before a Decision Review Officer (DRO) was conducted in February 2018. As previously noted, the Board remanded this claim in November 2020. Substantial compliance with the remand request having been achieved, the Board may proceed to consider the claim. See Stegall v. West, 11 Vet. App. 268 (1998). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Service Connection The Veteran contends that his ventral and hiatal hernias are the result of his service or are secondary to his service-connected Crohn's disease. In particular, the Veteran notes various times during his active duty in which he complained of stomach and intestinal trouble and recalls being hospitalized in September 1983 after lifting a heavy generator. His medical records, on the other hand, do not show a diagnosis or surgical treatment for any kind of hernia until September 2005, over 20 years after this lifting injury and several years after his service in the Reserves concluded. Even so, it is the Veteran's contention that his current hernia disability is a product of the 1983 injury or was caused or aggravated by his service-connected Crohn's disease. For the reasons outlined below, the Board finds service connection must be denied. Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. This means that the facts establish that a particular injury or disease resulting in disability was incurred coincident with service in the Armed Forces, or if preexisting such service, was aggravated therein. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing direct service connection generally requires (1) medical evidence of a current disability; (2) medical, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303(a). Secondary service connection is warranted where a disability is proximately due to, the result of, or aggravated beyond its natural progression by, a service-connected disease or injury. 38 C.F.R. § 3.310(a); see also Allen v. Brown, 7 Vet. App. 439, 448 (1995). In making all determinations, the Board must fully consider the lay assertions of record. A layperson is competent to report on the onset and continuity of his current symptomatology. See Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a Veteran is competent to report on that of which he or she has personal knowledge). Lay evidence can also be competent and sufficient evidence of a diagnosis or to establish etiology if (1) the layperson is competent to identify the medical condition; (2) the layperson is reporting a contemporaneous medical diagnosis; or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Jandreau v. Nicholson, 492 F.3d at 1376-77. When considering whether lay evidence is competent the Board must determine, on a case-by-case basis, whether the Veteran's particular disability is the type of disability for which lay evidence may be competent. Kahana v. Shinseki, 24 Vet. App. 428 (2011); see also Jandreau v. Nicholson, 492 F.3d at 1376-77. Entitlement to service connection for a hernia disability, to include ventral hernia and hiatal hernia, to include as secondary to service-connected Crohn's disease, is denied. Turning to the relevant evidence of record, as noted in the introduction, the Veteran's confirmed periods of service include active duty from July 1973 to April 1979, from October 1979 to May 1993, and in the Reserves from August 1994 to April 2002 with various periods of ACDUTRA and INACDUTRA. The Veteran's entrance exam notes surgery as an infant for an unknown condition, possibly pyloric stenosis, with a large right abdominal scar, but no discussion of a hernia. His Service Treatment Records (STRs) indicate that he was admitted to the hospital in December 1974 for a partial small bowel obstruction, but there were no complications. He was evaluated January 1976 for right groin pain and was noted to have an undescended right testicle. During a physical in February 1979 the Veteran did not report any complaints and the physical uncovered no injuries or disease. He was seen in September 1983 with a complaint of sudden right inguinal pain after lifting several heavy generators. Initially it was suspected that the Veteran had a right inguinal hernia, but doctors later determined that he actually had an undescended testicle in the right inguinal canal. Urologists confirmed the latter diagnosis. Physicians found no evidence of a ventral hernia. He was seen November 1984 with a complaint of right lower quadrant pain lasting 15 minutes, after reportedly performing only light work. It was again determined that his right testicle had entered his inguinal canal. He was not found to have a ventral or inguinal hernia. Two months later, in January from 1985, the Veteran chose surgery for elective orchiectomy of his right testicle. A medical exam and history in October 1989 is silent for ventral hernia or hiatal hernia. Three years later, in June 1992 he complained of abdominal bloating, nausea, vomiting and diarrhea. He was admitted with a possible diagnosis of small bowel obstruction. He was not found to have a ventral or hiatal hernia. He was seen in September 1992 for abdominal bloating and pain. The records make no mention of a hiatal or ventral hernia. Later that month he was found to suffer unexplained and non-anatomic symptoms with a remote undocumented diagnosis of Crohn's disease. The records make no mention of a hiatal hernia or ventral hernia. His separation examination in May 1993 did not note diagnoses of ventral hernia, hiatal hernia, indigestion, or any complaint of loss of energy, nausea, low grade fever, or vomiting. The Veteran also served in the Reserves from 1994 through 2002 with various periods of ACDUTRA. The Veteran testified his service included approximately two weeks of ACDUTRA annually and during one of these years, he recalled being hospitalized for a week in Wyoming after, once again, lifting a heavy generator. See Hearing Transcript at p. 5. Significant efforts were made by VA to obtain any additional treatment records from his Reserves period, and while the record contains confirmation of his Reserves service, there is no record of any such injury or hospitalization. Indeed, the record does not show any indication of treatment for any confirmed hernia until 2005, over 20 years after the 1983 lifting injury and several years after his Reserves duty concluded. In September 2005, records indicate the Veteran had surgery for ventral hernia repair and jejunal diverticulum. The ventral hernia was repaired with mesh. The Veteran recovered quickly and was discharged within days. A computerized tomography (CT) scan in December 2008 revealed a small umbilical hernia containing only fat. Treatment included pain management, support devices, and general exercise. By August 2014, attending physicians noted the presence of three ventral hernias, "all reducible." In November, he was advised that his ventral hernias could be corrected surgically, but the surgeon recommended that he lose weight first. And examination and CT scan in 2017 confirmed the presence of ventral hernias. During a hearing before a DRO in February 2018 the Veteran testified that in 1982 or 1983 he noticed bulging from a hernia caused by his having to lift heavy generators. He asserted that he noticed it getting "bigger and bigger" until "finally" it was fixed with mesh in 2005 when he was "already out of the military." In November 2019, the Veteran was examined by a VA examiner who, after an in-person physical and review of the medical records, opined that his hiatal hernia was less likely than not incurred in or caused by an in-service injury or event. The same examiner concluded that the Veteran's hiatal hernia was less likely than not caused by his Crohn's disease. In September 2020, the Veteran testified before the Board that he had realized he had "pulled something" while lifting a portable generator alone while on active reserve training in Wyoming. He stated that he had been hospitalized for a week then transported home. The same day, the Veteran's representative submitted two medical journal articles for the Board's consideration that, he maintained, contradicted a statement in the November 2019 VA examiner's report. Additionally, he argued, the reports established a nexus between hiatal hernia and Crohn's disease. An in-person VA examination in January 2021 noted diagnoses of Gastroesophageal disease (GERD) and hiatal hernia. After a thorough review of the medical records, the examiner opined that the Veteran's hernia disability, to include ventral and hiatal hernia, to include loss of energy, nausea, low grade fever, and vomiting, were less likely than not incurred in or caused by the claimed in-service injury, event, or illness, to include the result of a September 1983 incident involving the Veteran's attempt to lift a heavy generator. The examiner explained that there was no evidence in the Veteran's medical history to support a diagnosis of a hernia hiatal or ventral while he was on active service. His medical records did not reveal ongoing symptoms or complaints suggesting hernias, the examiner observed, nor did repeated physical examinations reveal their presence. The earliest date that a ventral hernia was diagnosed was in June 2005, when it was repaired, 12 years after separation from active service and three years after his discharge from the reserves in 2002. Moreover, the examiner explained, ventral hernias are typically due to weakness in the supporting fascia/muscles of the abdominal wall and often occur in old surgical scars like the one noted on the Veteran's entrance examination from his surgery as an infant. Similarly, a hiatal hernia was not diagnosed until 2008, more than 15 years after his separation from active service and more than six years after he left the reserves. Hiatal hernias occur due to relaxation of the diaphragmatic opening, allowing herniation of the stomach into the chest cavity, the examiner noted, and are more common in patients over the age of 50 with obesity. The Veteran had gained over 100 pounds since leaving active service. The examiner dismissed the Veteran's lay report of symptoms and treatment for a hernia during service in September 1983 when he suffered pain after lifting heavy generator. She pointed out that the records indicate that at the time the medical providers speculated that he may have suffered an inguinal hernia, but further evaluation showed that he actually had an undescended testicle in the right groin - a deformity from childhood that can cause a number of health complications - and not a hernia, either hiatal, ventral, or inguinal. The examiner also discounted any connection between the Veteran's hernia and his service-connected Crohn's disease. She concluded that the hernia conditions were less likely than not proximately due to or the result of the Veteran's Crohn's disease because Crohn's is not known to be a cause of a ventral hernia and the Veteran had never had a surgical intervention for Crohn's disease. Likewise, the hiatal hernia discovered in 2008 was revealed by an upper endoscopy, which did not uncover any sign of Crohn's disease in the esophagus, stomach, or duodenum, as noted in the report. Medical records indicate that the Veteran's Crohn's was in remission by at least 1995, and although he reported a variety of symptoms in June 2008 such as cramping, abdominal pain with alternating diarrhea and constipation, fever, and worsening asthma, he did not complain of heartburn or excess vomiting, symptoms of Crohn's. Thus, the examiner summarized, there was no evidence that his small hiatal hernia is related in any way to his Crohn's disease. The examiner further concluded that there was no nexus between the Veteran's Crohn's disease and either hernia condition. Because a hiatal hernia relaxes the diaphragmatic opening allowing herniation of the stomach into the chest cavity, it "predisposes to gastroesophageal reflux" by "contributing to failure of the lower esophageal sphincter." As the examiner had already observed, the Veteran expressed no gastroesophageal complaints at time his hiatal hernia was discovered. Similarly, the records do not reflect any evidence of a ventral hernia after one was discovered and repaired in 2005. The ventral hernia, then, could not be said to have been aggravated by the Veteran's Crohn's disease "in any way." Although the examiner did not specifically address the conclusions of the medical treatises the Veteran submitted, she indicated that she had considered them in the course of formulating her opinion. Finally, the examiner clarified that the Veteran had never been diagnosed with an inguinal hernia. It was suspected in September 1983 that he might have one when he complained of pain after lifting a heavy generator, but further examination indicated that the problem stemmed from an undescended right testicle first observed in January 1976. At no time was the Veteran diagnosed with or treated for inguinal hernia. Furthermore, the examiner maintained, the undescended testicle was not associated with any of the Veteran's hernias, as the hernias were developed around the abdomen, not the right groin. The January 2021 VA examiner's opinion sets forth the results of her comprehensive reviews of the claims file and the Veteran's lay reports; reviewed the applicable medical literature; and provided clear and consistent rationales for her opinions. Hence, the Board finds the opinion highly probative and, taken in conjunction with the lay and medical evidence of record, attaches significant weight to it on the matter of nexus between the Veteran's hernia disability and his military service. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Stefl, 21 Vet. App. at 124. As the Board's November 2020 remand order set out in detail, the November 2019 VA examiner's conclusions are deficient in a number of ways, chiefly in failing to fully address the Veteran's lay testimony, failing to address references in the Veteran's STRs regarding a possible inguinal hernia, and failing to consider whether the Veteran's service-connected Crohn's disease may have aggravated his hernia disability. See Bloom v. West, 12 Vet. App. at 187 (the Board must consider whether the examining medical provider had a sufficiently clear and well-reasoned rationale when weighing how probative an opinion may be). The Board accordingly places little probative value the opinion. See Bloom, 12 Vet. App. at 187. Medical articles or treatises "can provide important support when combined with an opinion of a medical professional" if the medical article or treatise evidence discusses generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least "plausible causality" based upon objective facts rather than on an unsubstantiated lay medical opinion. Mattern v. West, 12 Vet. App. 222, 228 (1999); see also Sacks v. West, 11 Vet. App. 314 (1998). In the present case, however, the articles submitted by the Veteran's representative tend to be general in nature and do not relate to the specific facts of the Veteran's claim. Furthermore, the articles are not combined with an opinion of a medical professional. Therefore, the Board finds that both articles on their own constitute less probative evidence, particularly in light of the fact that the January 2021 VA examiner explicitly noted that she had considered them in forming her opinion. While the Veteran's statements are competent to describe his medical history and diagnosis, he is not competent to render complex medical opinions regarding etiology of hernia conditions or the interaction of hernias with Crohn's disease. Davidson, 581 F.3d at 1316; Jandreau, 492 F.3d at 1376-77. Moreover, his testimony and lay statements are at times inconsistent with his own or other evidence. For example, the Veteran testified at the hearing before the DRO that he first noticed symptoms of a hernia while on active service in 1983. He had told a surgeon in 2008, however, that he was "unaware" that he had a hernia until he was diagnosed with one in 2005. Still later, he testified at the Board hearing in 2020 that he noticed symptoms while on reserve training, almost two decades after the 1983 incident. In addition, he claimed that he had been assisting others to lift generators weighing between 500 and a 1,000 pounds when he felt the development of a hernia in 1983, while he claimed he had been lifting a portable generator on his own while on reserve training many years later. Additionally, there is no record of the Veteran's hospitalization in Wyoming. The question of etiology in this case thus may not be competently addressed by lay evidence, and Board affords the Veteran's opinion on this point little weight. See McLendon v. Nicholson, 20 Vet. App. 79, 84 (2006) (competent lay testimony can be rejected if found to be mistaken or otherwise not credible). The Board attaches significant probative value to the medical evidence in the claims file and the January 2021 VA examiner's opinion, which is supported by an adequate rationale and medical literature. The Board accords the Veteran's own testimony lesser probative weight, for the reasons outlined above. Accordingly, the Board finds the competent and credible evidence of record is persuasively against a finding that the Veteran's hernia disability, to include ventral hernia (claimed as ventral hernia surgery) and hiatal hernia (also claimed as loss of energy, nausea, low grade fever, and vomiting) (hereinafter hiatal hernia), to include as secondary to service-connected Crohn's disease, is service connected. Because the evidence persuasively weighs against the claim, it is not in approximate balance, and the benefit of the doubt rule is not applicable. See Lynch, 999 F.3d at 1391. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Wilkinson, Edward L. 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.