Citation Nr: 1124828 Decision Date: 06/30/11 Archive Date: 07/06/11 DOCKET NO. 09-13 330 ) DATE ) ) On appeal from the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky THE ISSUE Entitlement to service connection for bilateral carpal tunnel syndrome, to include as secondary to service-connected disabilities. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARINGS ON APPEAL Veteran ATTORNEY FOR THE BOARD J.B. Freeman, Counsel INTRODUCTION The Veteran served on active duty from August 1981 to August 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2007 rating decision of the RO in Louisville, Kentucky, which, in relevant part, denied service connection for bilateral carpal tunnel syndrome. Evidence has been received subsequent to the final consideration of the claim by the RO. The Veteran, through her representative, has waived RO consideration of that evidence. The Board may consider the appeal. See 38 C.F.R. § 20.1304(c) (2010). The Veteran testified before the undersigned at a March 2011 videoconference hearing. The Veteran also testified before a Decision Review Officer at a March 2010 hearing at the RO. Transcripts have been associated with the file. FINDINGS OF FACT 1. The Veteran's bilateral carpal tunnel syndrome was not present during service, has not been continuous since service, was not manifest within one year of separation, and is not otherwise associated with service. 2. The Veteran's bilateral carpal tunnel syndrome was not caused or aggravated by a service-connected disability, to include diabetes mellitus, type 2. CONCLUSION OF LAW The Veteran's bilateral carpal tunnel syndrome was not incurred in or aggravated by active service, may not be presumed to have been incurred in active service, and was not caused or aggravated by a service-connected disability. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1154(b), 5107 (West 2002); 38 C.F.R. §§ 3.303, 3.304, 3.307, 3.309, 3.310 (2010). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed all the evidence in the Veteran's claims folders. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the Veteran or on her behalf. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The Veteran must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. See Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the appellant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). I. Veterans Claims Assistance Act (VCAA) VA has met all statutory and regulatory notice and duty to assist provisions as to the Veteran's claim for service connection. See 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, 5126 (West 2002 & Supp. 2010); 38 C.F.R. §§ 3.102, 3.156(a), 3.159, 3.326 (2010). Under the VCAA, when VA receives a complete or substantially complete application for benefits, it is required to notify the claimant and his representative, if any, of any information and medical or lay evidence that is necessary to substantiate the claim. 38 U.S.C.A. § 5103(a) (West 2002); 38 C.F.R. § 3.159(b) (2010). The United States Court of Appeals for Veterans Claims (Court) held that VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that VA will seek to provide; and (3) that the claimant is expected to provide. Quartuccio v. Principi, 16 Vet. App. 183 (2002). The Court observed that a claim of entitlement to service connection consists of five elements, of which notice must be provided prior to the initial adjudication: (1) veteran status; (2) existence of a disability; (3) a connection between the veteran's service and the disability; (4) degree of disability; and (5) effective date. See 38 U.S.C. § 5103(a); see also Dingess v. Nicholson, 19 Vet. App. 473, 490 (2006). Compliance with the first Quartuccio element requires notice of these five elements. See id. Prior to initial adjudication of the Veteran's claim, a February 2007 letter fully satisfied the duty to notify provisions. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1); Quartuccio, at 187. The Board also concludes VA's duty to assist has been satisfied. The Veteran's service treatment records and VA medical records are in the file. The Veteran has repeatedly made reference to relevant treatment records at the Dupont clinic in Louisville, Kentucky. The Dupont clinic is a VA facility and records from that clinic were obtained in the course of development. The Veteran has at no time referenced outstanding records that she wanted VA to obtain or that she felt were relevant to the claim. The duty to assist also includes providing a medical examination or obtaining a medical opinion when such is necessary to make a decision on the claim, as defined by law. McLendon v. Nicholson, 20 Vet. App. 79 (2006). If VA provides a claimant with an examination in a service connection claim, the examination must be adequate. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). The probative value of a medical opinion is derived from a factually accurate, fully articulated, and soundly reasoned opinion. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 300 (2008). The Veteran was afforded medical examinations in 2007 and 2010 to obtain an opinion as to whether her carpal tunnel syndrome was the result of service or was related to her service-connected diabetes mellitus, type 2, or hypothyroidism. These opinions were rendered by medical professionals following a thorough examination and interview of the Veteran and review of the claims file. The examiners obtained an accurate history and listened to the Veteran's assertions. The examiners laid a factual foundation and reasoned basis for the conclusions that were reached. Therefore, the Board finds that the examinations and opinions are adequate. See Nieves-Rodriguez, supra. As there is no indication that any failure on the part of VA to provide additional notice or assistance reasonably affects the outcome of this case, the Board finds that any such failure is harmless. See Newhouse v. Nicholson, 497 F.3d 1298 (Fed. Cir. 2007). II. Service Connection The Veteran contends that her current bilateral carpal tunnel syndrome (CTS) is secondary to her service-connected diabetes mellitus, type 2. She has also argued alternative theories of direct and presumptive bases of service connection. Having carefully considered the claim in light of the record and the applicable law, the Board is of the opinion that the preponderance of the evidence is against the claim and that the appeal will be denied on the basis that the preponderance of the evidence indicates that the Veteran's current bilateral CTS is not related to service on a direct, presumptive, or secondary basis. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131. For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time. 38 C.F.R. § 3.303(b). If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. Id. Service connection may be granted for any disease diagnosed after discharge, when all of the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Veteran's primary contention is that the CTS is secondary to other, service-connected disabilities. Service connection may be established on a secondary basis for disability which is proximately due to, or the result of, a service connected disease or injury. 38 C.F.R. § 3.310(a) (2010). Secondary service connection may also be established for a disorder which is aggravated by a service- connected disability; compensation may be provided for the degree of disability (but only that degree) over and above the degree of disability existing prior to the aggravation. 38 C.F.R. § 3.310(c). Establishing service connection on a secondary basis essentially requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service connected disability. Id. The Veteran has two service-connected disabilities which she has generally argued may have caused her CTS-diabetes mellitus, type 2, and hypothyroidism. The Board will consider each below. The Veteran established care at the Dupont Community Based Outpatient Clinic in March 2005. At that time, the Veteran sought a physical to apply for a job at the Post Office. The physical findings showed no focal findings, reflexes that were 2/4 and symmetrical in the upper and lower extremities with intact sensation. The Veteran received regular care for her service-connected diabetes mellitus, type 2. She was seen for a follow up in June 2006. At that time, she reported that her hands felt numb and tingly, especially on waking in the morning. She denied significant neck pain at the time. The Veteran was given questioned diagnoses of CTS and neuropathy. The Veteran was diagnosed with carpal tunnel syndrome in both upper extremities three weeks later by EMG. The Veteran was found to have median nerve neuropathy across her wrists. The note indicates that the diagnosis was CTS. There is no indication in the EMG report that the condition was due to service or a service-connected disability. The Veteran was seen for a surgery consultation in July 2006. She was not considered a candidate for surgery at that time. The Veteran was provided splints to wear at night. The Veteran was seen for a VA examination to evaluate her diabetes mellitus, type 2, in May 2007. The VA examination report indicated that the splints had helped her numbness. She had been achy at times from her job at the Post Office. The report indicates that CTS is most often caused by repetitive motions of the wrist along with compression of the median nerve. The examiner indicated that the condition was not worsened or increased by the Veteran's diabetes mellitus, type 2. The examiner noted that there is an association between CTS and diabetes, with more cases of CTS diagnosed in diabetic patients, but a causal relationship has not been established. The Board notes that the May 2007 VA examination report states that there were symptoms of diabetic neuropathy, listing paresthesias and tingling and numbness in the hands due to CTS. The report lists onset as 1994, apparently in reference to the diabetes mellitus, type 2. The report goes on to indicate that the CTS is unrelated to the Veteran's diabetes mellitus, type 2. The Board notes that the report also listed visual symptoms due to diabetes mellitus, type 2, listing nearsightedness, with a note that a doctor had told the Veteran the nearsightedness was not a diabetes complication. The portion of the report where the examiner indicated symptoms of diabetic neuropathy is a yes or no checklist of relevant considerations. The Board finds that the examiner indicated a yes in order to enter the information regarding the presence of CTS, not to indicate a final opinion. The Board finds that the report, on the whole, tends to show that a causal or aggravation relationship between the Veteran's service-connected diabetes mellitus, type 2, and her CTS is not at least as likely as not. The Veteran was provided a peripheral neuropathy VA examination in February 2010. The VA examination report indicates an onset of 1999, with chronic, gradual progression. The Veteran reported that she starting experiencing occasional numbness and tingling while in service but was not seen for this during service. She reported being initially seen for this in 2004 through VA. CTS was diagnosed in 2006 by EMG. The Veteran reported using splints at night and taking a vitamin B6 supplement and Motrin. Her current symptoms were bilateral hand weakness, numbness and tingling of all fingers. She has been seen at the hand clinic but has not had carpal tunnel release surgery. The Veteran reported an EMG through the University of Louisville Hospital Neurology service the week prior to the VA examination. The Veteran's sensory function test was normal in bother upper and lower extremities. Her motor function was full and normal against resistance in both upper and lower extremities. All tested reflexes were normal. The test results from University of Louisville Hospital were reviewed. The EMG studies were performed to check for CTS with a possible superimposed polyneuropathy. The impression was bilateral median neuropathies across the wrists (CTS), moderate in degree. There was no electrodiagnostic evidence of a neuropathy. The report indicates that the etiology of the CTS was unknown. The examiner reviewed the Veteran's service treatment records. The examiner noted that the April 2001 retirement examination included a notation that the Veteran occasionally had tingling in her arms, hands and feet, usually in the morning. The physical findings were normal at that time. A June 2001 general medical examination, conducted in association with a prior claim for VA benefits, contained no complaints of neurological symptoms in the hands or fingers and the neurologic examination findings were normal. The examiner indicated that the June 2006 EMG did not show evidence of diabetic or other (such as hypothyroid) neuropathy. The Veteran gave a history of repetitive hand/wrist movements while working in radio control/administrative capacities in service and as a postal carrier and in warehouse fulfillment post-service. The examiner indicated agreement with the May 2007 opinion, in that a higher incidence of CTS was present in diabetic patients, but that any specific causal relationship was unknown. The examiner stated that a similar incidence was present in patients with hypothyroidism. The examiner noted that the Veteran had only one complaint of tingling during service, at her retirement examination, but continued repetitive work post-service and had no complaints until 2006, five years after separation. The examiner indicated that asserting the CTS was due to service or to her work since service would be speculative. The RO returned the claims file to the examiner for a supplemental opinion, which was provided in May 2010. The examiner provided a more complete review of the Veteran's service treatment records, noting the diagnosis of hypothyroidism in 1993, with subsequent euthyroid findings in 2000 and 2001. The Veteran's diabetes mellitus, type 2, was noted to have been diagnosed in 1993 as well. The Veteran had no complaints of numbness or tingling in the arms or hands on a periodic examination in 1995. Some glucose intolerance was noted. The Veteran was routinely followed by an endocrinology specialist. The examiner noted the lack of positive Review of Symptoms for numbness or tingling in October and December 2000 and March and May 2001 endocrinology visits. The Veteran was clinically and chemically euthyroid (normal) at these times. The first mention of tingling was at the April 2001 retirement physical. The examiner noted that the Veteran had not reported numbness and tingling when establishing care through VA in March 2005. Importantly, the examiner indicated that the timeline of onset of symptoms, diagnosis and clinical manifestations of the potential in-service etiological conditions (diabetes mellitus, type 2, hypothyroidism, repetitive work) and subsequent complaints and diagnostics post-service negate their causative effects. The examiner emphasized that the Veteran was routinely followed for eight years by the endocrine specialty clinic for hypothyroidism and glucose intolerance without any complaints of numbness/tingling in any extremities elicited or documented in the routine Review of Symptoms. The Veteran's glucose and thyroid levels were controlled at the time of complaints on separation. There had been no adjustments in thyroid dosage for more than one year prior to the retirement physical. The examiner noted the lag between separation and the first complaints in 2006. The examiner indicated that the first EMG negated the presence of peripheral neuropathy as would be expected with symptoms as a result of diabetes or glucose intolerance. The Veteran submitted an April 2011 opinion in support of her claim. The opinion states that her diabetes mellitus, type 2 at least as likely as not caused her bilateral carpal tunnel syndrome. The opinion is without supporting rationale. Without such a rationale, the opinion cannot be meaningfully weighed with the remaining evidence of record. Thus, the Board finds that the opinion is inadequate for ratings purposes and gives the opinion little probative value. The Veteran testified at the RO in March 2010. The Veteran reported having tingling sensations in her hands and wrists during service and using ace wraps and Motrin. The Veteran did not recall any specific treatment, but mentioned it had been noted at her separation examination. The Veteran reported repetitive motion in her duties during service, particularly typing and sensation that became more frequent. The Veteran did not seek treatment for several years after separation, instead using over the counter remedies. The Veteran testified that she had been seen at a VA hand clinic and provided an EMG study and that the doctors had been unable to make a link between the CTS and her service-connected diabetes mellitus, type 2. She testified that she had not had repetitive motion type employment since her separation from service. The Veteran indicated continuous treatment since she began seeking treatment. The Veteran also testified before the undersigned in March 2011. She provided a similar history as at her March 2010 hearing. Unlike her prior testimony, she did report that one of the C&P doctors had told her that the CTS could be aggravated by her diabetes mellitus, type 2. She stated that the doctor had to go back and redo the paperwork, but that the doctor said at the time that the CTS was aggravated. The Veteran reported that she began seeking treatment five years before because the frequency increased and that the sensation had been intermittent and only happening on occasion. The Veteran also stated that the condition should be related to her diabetes mellitus, type 2, considering the research that had been done on herbicide exposed veterans. With respect to the Veteran's contentions that she has experienced tingling and numbness since service, the Board observes that lay evidence can be competent and sufficient to establish a diagnosis of a condition when (1) a 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. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007); see also Barr v. Nicholson, 21 Vet. App. 303 (2007) (lay testimony is competent to establish the presence of observable symptomatology). The Board notes that the Veteran's complaints at her retirement examination were of tingling in the hands, arms and feet. No neurological disorders were found at separation, despite her complaints. No neuropathy of any kind has been found in her lower extremities, despite specific testing in 2010, discussed in the February 2010 VA examination report. To the extent that the Veteran reported tingling during service, the complaint is inconsistent with the later medical diagnosis. The complaints are not supported by later medical diagnosis. The Board affords the Veteran's lay evidence little weight as the cause of tingling of the hands, arms and feet during service is not clear from the record and is not consistent with the current complaints. See Jandreau. The Veteran also testified that she had researched the relationship between diabetes mellitus, type 2 and neurological disorders. The Veteran mentioned that many other veterans with service connection for diabetes mellitus, type 2, also received service connection for associated neurological disabilities. The Veteran contended that she should be granted service connection because she has service connection for diabetes mellitus, type 2, and has developed neurological disabilities in both arms. To the extent that the Veteran offers a lay opinion regarding the association between diabetes mellitus, type 2, or hypothyroidism and CTS, the Board acknowledges that the Veteran is competent to give evidence about what she experiences. See, e.g., Layno v. Brown, 6 Vet. App. 465 (1994). She is not, however, competent to diagnose any medical disorder or render an opinion as to the cause or etiology of any current disorder because she does not have the requisite medical knowledge or training. See Rucker v. Brown, 10 Vet. App. 67, 74 (1997) (stating that competency must be distinguished from weight and credibility, which are factual determinations going to the probative value of the evidence). The facts of each case are to be judged independently of each other. The Board notes that in cases of veterans who are service-connected for diabetes mellitus, type 2, and associated neurological disabilities, a medical nexus opinion would be required to establish service connection for the neurological disabilities. See generally 38 C.F.R. § 3.303. The Board requires the same here. The medical opinions obtained are based not only on general medical principles, but on application of those principles to the particular facts of the Veteran's case. The medical opinions obtained do not, on balance, support such a relationship. Thus, the Board finds the Veteran's lay opinion without probative weight and her argument unavailing. The Veteran has submitted a large number of medical articles from the Internet in support of her claim. These articles discuss carpal tunnel syndrome, polyneuropathy, neuropathy, diabetes mellitus, type 2, hypo-thyroidism, and the likelihood of developing carpal tunnel syndrome. While these articles do show that carpal tunnel syndrome has a higher incidence in women and individuals with diabetes and hypothyroidism, there is no tailoring of that information to the specific circumstances of the Veteran's case. The Board notes that a medical article or treatise "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). The medical articles submitted by the Veteran in this case were not accompanied by the opinion of any medical expert linking her CTS to service or a service-connected disability. Instead, they discuss generally the existence of the many known causes of CTS and diabetic complications. They do not establish that CTS is caused by a particular etiology that can be compared to the facts as alleged by the Veteran. Thus, the medical articles submitted by the Veteran are insufficient to establish the medical nexus opinion required for causation. See Sacks, 11 Vet. App. at 317 (citing Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996)); see also Libertine v. Brown, 9 Vet. App. 521, 523 (1996). As such, the Board considers these articles to raise a possibility of a relationship, but do not establish a probability of such a relationship. Such evidence is insufficient to support a grant of service connection and is entitled to little probative weight. The Board looks to the medical nexus opinions of record. As discussed, the medical opinions obtained do not, on balance, support such a relationship. In light of the foregoing, the Board finds that the well-reasoned but negative May 2007, February 2010 and May 2010 VA examination opinions outweigh the positive April 2011 opinion made without rationale, the Veteran's lay evidence and the treatise articles. The Board finds that the preponderance of the evidence is against a relationship either causal or by aggravation, between the Veteran's CTS and her service-connected diabetes mellitus, type 2, or hypothyroidism. Furthermore, the Board finds that the preponderance of the evidence is against a finding that the CTS was present during service or has been continuous since service. Service connection is not warranted on direct or secondary bases. See Hickson; see also Allen. Where a veteran served continuously for 90 days or more during a period of war, or during peacetime service after December 31, 1946, and an organic disease of the nervous system become manifest to a degree of 10 percent within 1 year from date of termination of 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.A. §§ 1101, 1110, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. The Veteran complained of tingling at her separation examination in 2001, but no neurological disorder was identified. The Veteran did not seek treatment for tingling in her hands and arms until 2006. The Board finds that the CTS was not manifest during service or within the first year post-service. The Veteran cannot benefit from the presumption. As such, the Board finds that the preponderance of the evidence is against the Veteran's claim for service connection for CTS on direct, presumptive and secondary bases. Consequently, the benefit-of-the-doubt rule does not apply, and the claim must be denied. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 55 (1990). (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for bilateral carpal tunnel syndrome, to include as secondary to service-connected disabilities, is denied. ____________________________________________ THERESA M. CATINO Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs