Citation Nr: 0306933 Decision Date: 04/10/03 Archive Date: 04/14/03 DOCKET NO. 97-29 968 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office and Insurance Center in St. Paul, Minnesota THE ISSUE Entitlement to service connection for bilateral carpal tunnel syndrome. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States ATTORNEY FOR THE BOARD J. Barone, Associate Counsel INTRODUCTION The veteran had active military service from September 1951 to August 1971. This matter came before the Board of Veterans' Appeals (Board) on appeal of a rating decision of the Department of Veterans Affairs (VA) Regional Office and Insurance Center (RO) in St. Paul, Minnesota. When the case was previously before the Board, it was remanded for additional development. The case was returned to the Board in August 2002, at which time the Board decided one of the issues on appeal. The Board deferred its decision on the veteran's claim for service connection for bilateral carpal tunnel syndrome in order to undertake further development pursuant 38 C.F.R. § 19.9(a)(2) (2002). Thereafter, the Board provided the appellant and his representative with notice of the development and afforded both an opportunity to submit additional evidence and argument. FINDINGS OF FACT 1. All available information and evidence necessary for an equitable disposition of the veteran's claim have been obtained. 2. The veteran's bilateral carpal tunnel syndrome originated during his active service. CONCLUSION OF LAW Bilateral carpal tunnel syndrome was incurred during active duty. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. § 3.303 (2002). REASONS AND BASES FOR FINDINGS AND CONCLUSION I. Factual Background Service medical records are negative for any diagnosis, complaint or abnormal finding pertaining to the veteran's upper extremities. April 1992 surgical reports from a private physician indicate that the veteran worked as a mechanic and had developed increasing hand pain. He had been diagnosed with bilateral carpal tunnel syndrome and had been recommended for carpel tunnel release. In March 1997 the veteran submitted to X-ray, electromyography (EMG) and nerve conduction studies. The EMG consultation report indicates that the veteran had a 10 to 15 year history of carpal tunnel symptoms with carpal tunnel surgery in the early 1990s. The veteran complained of bilateral hand and wrist pain and numbness, right worse than left. Nerve conduction studies revealed evidence of right median neuropathy without signs of denervation, consistent with carpal tunnel syndrome. The examiner indicated that she could not determine whether the neuropathy was new or old. X-rays revealed slight widening of the right scapholunate joint. The radiocarpal, carpal and carpometacarpal joints appeared normal bilaterally. On VA general medical examination in March 1997 the impression was chronic right median nerve dysfunction distal to the right carpal tunnel as a residual of previous carpal tunnel syndrome. The examiner noted that the condition persisted even after carpal tunnel release in the early 1990s. With regard to the left upper extremity, the examiner noted that clinical examination and EMG failed to reveal continued left median neuropathy at the wrist. A hand-written statement from the veteran's private physician, dated in August 1997, indicates the author's belief that the veteran's longstanding symptoms consistent with carpal tunnel syndrome may have started during the veteran's military service. In his October 1997 substantive appeal, the veteran noted that while he had worked as a mechanic subsequent to his retirement from the Air Force, he had been a jet engine mechanic during his military service. He pointed out that his military occupational specialty involved a great deal of repetitive wrist movement and stated that his hands and wrists fell asleep and would tingle and go numb. He indicated that he did not seek medical treatment during service, but massaged his hands and wrists until the circulation and feeling had been restored. A September 2000 letter from the veteran's private physician indicates that the veteran had experienced long standing symptoms consistent with carpal tunnel syndrome that had more likely than not started during military service. The veteran was afforded a VA examination in October 2000. The veteran reported that he had experienced tingling in his hands while on active duty. The examiner noted that carpal tunnel syndrome was diagnosed in the 1980s, with surgical release being performed in 1992. The veteran indicated that numbness and weakness had recurred subsequent to his surgery. Physical examination revealed mild atrophy of the thenar eminence bilaterally. The diagnosis was bilateral carpal tunnel syndrome. A March 2001 VA progress note indicates that a review of the veteran's service medical records revealed no evidence to suggest carpal tunnel syndrome. The author noted that the veteran had worked as a mechanic subsequent to his retirement from military service. On VA examination in March 2001, the veteran related the gradual onset of symptoms during military service while working as a mechanic. Nerve conduction studies revealed bilateral median neuropathy due to loss of motor axons bilaterally and mild entrapment at the right wrist, and bilateral ulnar neuropathy at the elbow. The examiner noted that the veteran's discharge physical examination indicated an absence of neuritis or upper extremity impairment, and noted that the evidence of record was insufficient to determine the date of onset of the veteran's symptoms. He indicated that the veteran's private treatment records should be obtained. The veteran submitted to a further VA examination in January 2003. The examiner noted the veteran's history of bilateral carpal tunnel syndrome. The veteran stated that he had served as a jet engine mechanic and reported onset of his symptoms during the 1950s. He indicated that he had developed parasthesias in both hands while working with tools, elicited by any rotating motion of the wrists. The examiner noted that the veteran worked as a mechanic after his retirement from military service and that his symptoms worsened over time. The veteran reported that his symptoms improved after surgery in 1992, but had gradually worsened. The assessment was bilateral carpal tunnel syndrome, symptomatic, with evidence of bilateral median nerve neuropathy. The examiner noted the veteran's report of onset of symptoms during service but pointed out that the service medical records revealed no evidence of treatment. However, he opined that it was as likely as not that the veteran's bilateral carpal tunnel syndrome had its onset during his military service. II. Veterans Claims Assistance Act of 2000 During the pendency of the veteran's appeal, the Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (2000), was signed into law. In addition, regulations implementing the VCAA (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002)), were published at 66 Fed. Reg. 45,620, 45,630- 32 (August 29, 2001) (codified at 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326 (2002)). The liberalizing provisions of the VCAA and the implementing regulations are applicable to the issues on appeal. The Act and implementing regulations essentially eliminate the requirement that a claimant submit evidence of a well- grounded claim, and provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim but is not required to provide assistance to a claimant if there is no reasonable possibility that such assistance would aid in substantiating the claim. They also require VA to notify the claimant and the claimant's representative, if any, of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative, if any, of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The Board has found the evidence and information currently of record to be sufficient to substantiate the veteran's claim for service connection for bilateral carpal tunnel syndrome. Therefore, no further development is required under the VCAA or the regulations implementing it. III. Analysis Entitlement to service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active duty. 38 U.S.C.A. § 1110. Additionally, service connection may be granted for any disease initially diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). When there is an approximate balance of positive and negative evidence regarding the merits of an issue material to the determination of the matter, the benefit of the doubt in resolving each such issue shall be given to the claimant. 38 U.S.C.A. § 5107(b)(West 2002); 38 C.F.R. § 3.102 (2002). As discussed above, the veteran's service medical records do not contain evidence of carpal tunnel syndrome. However, the evidence does document that the veteran served as a mechanic during his nearly 20 years of active duty. The veteran has consistently stated that his symptoms had their inception during his military service, but that they were mild and he did not seek medical attention at that time. The veteran's private physician has opined that the veteran's bilateral carpal tunnel syndrome might have had its inception during military service. Moreover the January 2003 VA examiner, while taking into account the absence of evidence demonstrating treatment in service, concluded that it was as likely as not that the veteran's bilateral carpal tunnel syndrome had its onset during military service. Although the medical opinions supporting the veteran's claims are necessarily based in part on history provided by the veteran, the Board has found the veteran's statements concerning the onset of his symptoms to be credible. Therefore, the Board is satisfied that the evidence supporting the claim is at least in equipoise with that against the claim. Accordingly, service connection is in order for bilateral carpal tunnel syndrome. ORDER Entitlement to service connection for bilateral carpal tunnel syndrome is granted. Shane A. Durkin Veterans Law Judge Board of Veterans' Appeals IMPORTANT NOTICE: We have attached a VA Form 4597 that tells you what steps you can take if you disagree with our decision. We are in the process of updating the form to reflect changes in the law effective on December 27, 2001. See the Veterans Education and Benefits Expansion Act of 2001, Pub. L. No. 107-103, 115 Stat. 976 (2001). In the meanwhile, please note these important corrections to the advice in the form: ? These changes apply to the section entitled "Appeal to the United States Court of Appeals for Veterans Claims." (1) A "Notice of Disagreement filed on or after November 18, 1988" is no longer required to appeal to the Court. (2) You are no longer required to file a copy of your Notice of Appeal with VA's General Counsel. ? In the section entitled "Representation before VA," filing a "Notice of Disagreement with respect to the claim on or after November 18, 1988" is no longer a condition for an attorney-at-law or a VA accredited agent to charge you a fee for representing you.