Citation Nr: 1048131 Decision Date: 12/28/10 Archive Date: 01/03/11 DOCKET NO. 08-19 124 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Jackson, Mississippi THE ISSUES 1. Entitlement to service connection for a bilateral upper extremity peripheral neuropathy. 2. Entitlement to service connection for a bilateral lower extremity peripheral neuropathy. REPRESENTATION Appellant represented by: Mississippi Veterans Affairs Commission ATTORNEY FOR THE BOARD Emily L. Tamlyn, Associate Counsel INTRODUCTION The Veteran served on active military duty from October 1968 to October 1970. These issues come before the Board of Veterans' Appeals (Board) on appeal from a September 2007 rating action of the Department of Veterans Affairs Regional Office (RO) in Jackson, Mississippi. In that decision, the RO denied claims for service connection for peripheral neuropathy of the feet and of the hands, including as secondary to herbicide and service-connected diabetes mellitus. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, DC. VA will notify the appellant if further action is required. REMAND The Veteran has filed a claim for service connection for peripheral neuropathy of both the hands and feet. The Veteran is service-connected for diabetes mellitus as secondary to herbicide exposure in service (20 percent disabling). Service treatment records do not reflect any findings of peripheral neuropathy. An August 1970 separation examination was negative for extremity problems. Dr. Prosser's records show treatment for extremity problems in the late 1990s. In December 1998, the Veteran had tendonitis type pain over a past injury he had to his left arm; this was from an accident years ago. He worked as a meat cutter about 70 hours per week. He was right handed, but also used his left arm at work. The assessment was tendonitis of the left forearm. In April 1999, Dr. Prosser provided an initial diagnosis of "newly discovered" diabetes mellitus. VA records also address extremity problems. In April 2004, he was given a diabetic foot examination. His feet were normal and checked with a monofilament; there were no lesions or pressure points. In October 2004, the Veteran complained of neck and arm pain. He felt no numbness in the arms, but he did say he felt a burning sensation in the neck. In March 2005, after an MRI of the cervical spine was completed, a letter informed the Veteran that disc bulging was found, but there was no narrowing or compression of the spinal cord. In March 2008, a VA primary care record noted that the Veteran was a meat cutter for about 40 years. His hands were rubor thickened and blanched when moved. His knuckles were enlarged and he had swelling and pain in both hands. His symptoms were probably from a cold injury. He had been off of work for one month with the flu and feared returning to work due to pain. In August 2008, the Veteran received a VA neurology examination. He was referred for an assessment of possible diabetic neuropathy. His tendon repair in the left forearm for a laceration was noted. It was noted that he had a probable cold injury in his hands from working as a butcher. For the upper extremities, the examiner initially stated that the left hand deficits were related to a non-service laceration injury. The examiner noted that there appeared to be peripheral neuropathy involving the hands, but there were also findings of cold injury that clouded the picture. An addendum shows that several tests were given: B12, folate, Reiter protein, heavy metals screen, B1, B6, erythrocyte sedimentation rate, and serum protein electrophoresis. These tests were all normal. Nerve conduction velocity was also normal. However, median distal latency was delayed on the left. The examiner diagnosed left carpal tunnel syndrome by electrodiagnosis. The examiner stated "This is likely related to the old laceration injury, but may be exacerbated by diabetes mellitus." The examiner concluded that there is no eclectrophysiologic evidence of a large fiber polyneuropathy that would be expected to be present with diabetes and the Veteran's subjective clinical findings. There was no diagnosis of diabetic neuropathy. An August 2008 EMG elsewhere in the file shows no electrophysiological evidence of a large fiber peripheral neuropathy. There was median neuropathy at the wrist and evidence suggestive of an active left S1 radiculopathy. In February 2009 statements to the Social Security Administration, the Veteran's wife noted a lack of strength in the Veteran's arms, that his hands bother him a lot and his left hand often stays cold. For the lower extremities, the August 2008 examiner also initially noted that there was mild sensory loss in the feet that could be related to diabetes mellitus. The examiner did state that mild left-sided sensory loss was likely secondary to a lacunar stroke and that diabetes mellitus and hypertension were risk factors for that kind of stroke. They likely contributed to the stroke and thus the sensory loss. A needle examination showed mild acute and chronic dennervation change only in the left medial gastrocnemius muscle. After the August 2008 VA examination, several other VA records document that the monofilament showed normal sensation on right foot and decreased sensation on the left (see December 2008 and November 2009 VA records). Decreased sensation of the left heel was detected by a monofilament in May 2010. However, at a November 2009 VA diabetes mellitus examination, there was no noted history of neurological symptoms or neuropathy. Upon examination, monofilament testing was intact at the bottom of the feet. Reflexes were intact, motor and sensory functions were normal, and there were no abnormal cranial nerve functions. His gait was also normal. A remand is warranted to determine whether any neurological defects and/or the residuals of a lacunar stroke are related to the service-connected diagnosed diabetes mellitus or to service. On remand, the agency of original jurisdiction (AOJ) should return the file to the August 2008 examiner. If that examiner is not available, the Veteran should be scheduled for a new VA examination. For the upper extremity disability claim, the examiner should explain if carpal tunnel syndrome is related to service or whether the Veteran's diabetes mellitus has caused the carpal tunnel syndrome to increase in severity. If an increase in severity is found, the examiner should identify the baseline level of disability (prior to aggravation) and the permanent, measurable increase in the severity of the carpal tunnel syndrome attributable to the service-connected diabetes mellitus. For both claims, the examiner should discuss the lacunar stroke. The Veteran is service-connected for diabetes mellitus but not hypertension. The examiner should determine the residuals of the stroke and its etiology. The examiner should address whether the diabetes mellitus caused the stroke and its residuals (apparently, mild left-sided sensory loss). Accordingly, the case is REMANDED for the following action: 1. Return the claim file to the August 2008 examiner, or, if that examiner is not available, schedule the Veteran for a new VA examination in order to determine the nature and etiology of his currently diagnosed carpal tunnel syndrome and stroke residuals. The claims file and a copy of this remand must be made available to and be reviewed by the examiners in conjunction with the examination. The examiner(s) must indicate in the examination report that the claims file was reviewed in conjunction with the examination. All necessary tests should be conducted. First, the examiner should determine whether it is at least as likely as not that his current upper and lower extremity disabilities had their clinical onset in service or are otherwise related to active duty. All opinions and conclusions expressed must be supported by a complete rationale. The examiner should reference evidence summarized above, including the August 2008 VA neurology examination, the November 2009 VA diabetes examination and the August 2008 EMG report. Next, if the examiner finds stroke residuals and/or carpal tunnel syndrome not related to service, the examiner should determine if the Veteran's service-connected diabetes mellitus caused stroke residuals and/or carpal tunnel syndrome or if the diabetes mellitus increased the severity of the stroke residuals and/or carpal tunnel syndrome. If the latter, the examiner should specify what measurable increase in severity of either disability is due to the service-connected diabetes mellitus. The examiner should identify the baseline level of disability (prior to aggravation) and the permanent, measurable increase in the severity of the disability attributable to the service- connected diabetes mellitus. 2. Re-adjudicate the claims of service connection for upper and lower extremity disabilities. If the decision remains in any way adverse to the Veteran, provide a supplemental statement of the case (SSOC) to the Veteran and his representative. The SSOC must contain notice of all relevant actions taken on the claim for benefits, to include the applicable law and regulations considered pertinent to the issue remaining on appeal. An appropriate period of time should be allowed for response. The Veteran has the right to submit additional evidence and argument on the matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board or by the United States Court of Appeals for Veterans Claims (Court) for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp.2010). _________________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board is appealable to the Court. This remand is in the nature of a preliminary order and does not constitute a decision of the Board on the merits of your appeal. 38 C.F.R. § 20.1100(b) (2010).