Citation Nr: 1237176 Decision Date: 10/26/12 Archive Date: 11/09/12 DOCKET NO. 10-06 934 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Milwaukee, Wisconsin THE ISSUE Entitlement to service connection for arthritis of the left hand. REPRESENTATION Appellant represented by: Wisconsin Department of Veterans Affairs ATTORNEY FOR THE BOARD T. Sherrard, Counsel INTRODUCTION The Veteran, who is the Appellant in this case, had active service from October 1970 to August 1974, November 1978 to September 1981, and October 1984 to July 2000. This matter comes before the Board of Veterans' Appeals (BVA or Board) from a June 2004 rating decision by the above Department of Veterans Affairs (VA) Regional Office (RO). The Board remanded this claim for issuance of a Statement of the Case (SOC) in December 2009. An SOC was issued in January 2010. However, as discussed below, the Board finds that additional development is necessary prior to appellate review. The appeal is REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. REMAND The Veteran in this case contends that he developed arthritis in his left hand as a result of repeatedly doing push-ups during active service. He avers that, in the early 1990s, he developed acute pain in both wrists while doing push-ups for a physical fitness test. When his wrist pain became too severe, he started doing push-ups on his knuckles, which he says caused arthritis in the knuckles of both hands. Service connection has been granted for degenerative joint disease of the right third metacarpophalangeal joint. The Veteran's service treatment records show that in October 1990, the Veteran reported a two month history of numbness in his right index finger associated with callous formation secondary to a bump on his tennis racquet. Currently, he reported feeling an electric shock whenever he bumped his finger. Physical examination revealed a positive Tinel's sign at the base of the right index finger, and the physician diagnosed a contusion. No mention was made of left hand or finger symptoms. In January 1997, the Veteran reported shoulder pain when doing full push-ups. He sought treatment for the same problem on multiple occasions during that year, but at no time did the Veteran mention hand or wrist problems due to performing push-ups. His May 2000 retirement examination report indicates that he reported painful joints, and the examining physician assessed arthritis, although the report does not specify which joints were affected. The claims file includes an August 2005 letter from Dr. P.R., who wrote that the Veteran was well known to her as a patient during her three year medical residency at Clark Air Force Base in the Philippines. She stated that the Veteran frequently consulted her for medical advice, and that one of his primary physical complaints was pain in both hands and wrists beginning in July 1990. She stated that these symptoms occurred while the Veteran was on a combat training exercise referred to as "Red Flag," conducted by the U.S. Air Force and the Philippine Army. During this exercise, the Veteran had to build a tent city, carry heavy objects, and do extensive field training, and he initially noted pain in the knuckles and wrists. She attributed this pain to osteoarthritis of both hands and wrists. The Veteran's contentions of experiencing hand and wrist pain during active service are also supported by multiple "buddy" statements from colleagues who state that they remember the Veteran experiencing hand and wrist pain during active service, usually during or after physical training, but that he did not seek treatment for it. Following separation from service, in June 2003, VA treatment notes indicate that the Veteran reported chronic problems with arthritis in his hands, and that, over the last several months, he had noticed worsening of the pain in his hands. Specifically, he stated that the knuckle of the right middle finger had become very painful, and that he had difficulty writing because of it. A VA nurse practitioner assessed probable degenerative joint disease of the hands. However, she noted that, because of the unilateral presentation, the Veteran's rheumatoid factor should be checked. The Veteran was afforded a VA examination in May 2004 with regard to his hands. The Veteran reported pain in the left third metacarpophalangeal joint, which he believed was secondary to performing push-ups during active service. Unlike his right hand, the Veteran stated that he had not had significant pain in the left hand since he started staking Relafen the previous summer. Currently, he denied any pain, stiffness, weakness, incoordination, or fatigue. On physical examination, functional range of motion of the left third metacarpophalangeal joint was not significantly affected by pain. There was no synovitis or tenderness, and the hand and fingers had full range of motion. The VA examiner noted that radiographs of the left hand revealed no abnormalities, although the X-ray report itself indicates subluxation of the first carpometacarpal joint, which the radiologist noted could relate to ligamentous instability or laxity. The VA examiner concluded, however, that there was no obvious abnormality of the left hand, and therefore did not provide a nexus opinion. With regard to the right degenerative joint disease of the third metacarpophalangeal joint, the examiner opined that it was at least as likely as not related to repetitive trauma of doing push-ups during active service. VA treatment notes from November 2005 indicate the Veteran continued to report pain in his hands, and he requested an X-ray of the hands, stating that, if arthritis was found, he wanted to file a claim for service connection. The X-ray study showed re-demonstration of slight first carpometacarpal joint subluxation and mild spurring of the left hand. In August 2006, the Veteran requested a letter from a VA physician to support his claim for service connection for arthritis of the left hand, stating that his bilateral hand and wrist pain began in July 1990. The VA physician interviewed the Veteran via telephone and reviewed VA treatment records and examination reports. She concluded that there were no medical records to support the Veteran's claim, noting that he did not seek medical treatment for hand or wrist pain during active service. She noted that the Veteran did discuss his pain with Dr. P.R., a co-worker, when he was a nurse in a medical unit at Clark Air Force Base, and that Dr. P.R. corroborated his contention that his hand pain began in July 1990. However, due to the lack of medical records to support his claim, the doctor stated she was unable to write a letter in support of his claim for service connection. The Board finds that a new VA examination is necessary to decide this claim. The Veteran is competent to report the occurrence of hand or wrist pain during active service, and his statements are corroborated by both Dr. P.R. and several colleagues. However, the August 2006 VA physician did not consider the Veteran's statements in reaching her opinion that she could not relate the Veteran's bilateral hand and wrist pain to service. Moreover, the May 2004 VA examiner concluded that there was no current left hand disability, despite the X-ray report to the contrary. In addition, a more recent X-ray study from 2005 does show the presence of a current left hand disorder. Therefore, a new VA examination is necessary to clarify the Veteran's current left hand diagnosis and to assist in determining the etiology of any current left hand disorder. Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran a VA orthopedic examination to address the causation or etiology of any left hand disorder. Any and all indicated evaluations, studies, and tests deemed necessary by the examiner should be accomplished, and a rationale for any opinion expressed should be provided. The claims file must be made available to the examiner for review of the history in conjunction with the examination, and the examination report should reflect that such review was accomplished. a. The examiner should first identify any and all current left hand disorders, if any. b. Next, the examiner should offer an opinion as to whether it is at least as likely as not (i.e., to at least a 50/50 degree of probability) that any current left hand disorder(s) was/were incurred during or caused by active service. The examiner should specifically address whether the Veteran's left hand disorder(s) was/were at least as likely as not caused by performing repetitive push-ups during active service. For the purpose of this opinion, the examiner should assume the Veteran's contentions regarding experiencing hand pain during active service are true. In addition, reference should be made to the August 2005 letter of Dr. P.R. in this regard, as well as to the multiple "buddy" statements which support the Veteran's contention that he experienced bilateral hand pain during active service. Note: The term "at least as likely as not" does not mean merely within the realm of medical possibility, but rather that the weight of medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of causation as it is to find against it. If the opinion and/or supporting rationale cannot be provided without invoking processes relating to guesses or judgment based upon mere conjecture, the examiner should clearly and specifically so specify in the report, and explain why this is so. In this regard, if the examiner concludes that there is insufficient information to provide an etiologic opinion without result to mere speculation, the examiner should state whether the inability to provide a definitive opinion is due to a need for further information (with such needed information identified) or because the limits of medical knowledge have been exhausted regarding the etiology of the Veteran's claimed left hand disorder. 2. When the development requested has been completed, the case should again be reviewed by the RO on the basis of the additional evidence. If any benefit sought is not granted, the Veteran and his representative should be furnished a Supplemental Statement of the Case and afforded a reasonable opportunity to respond before the record is returned to the Board for further review. The appellant has the right to submit additional evidence and argument on the matter or matters the Board has remanded. Kutscherousky v. West, 12 Vet. App. 369 (1999). The Veteran is advised to appear and participate in any scheduled VA examination, as failure to do so may result in denial of the claim. See 38 C.F.R. § 3.655 (2011). This claim must be afforded expeditious treatment. The law requires that all claims that are remanded by the Board of Veterans' Appeals or by the United States Court of Appeals for Veterans Claims for additional development or other appropriate action must be handled in an expeditious manner. See 38 U.S.C.A. §§ 5109B, 7112 (West Supp. 2011). _________________________________________________ K. J. ALIBRANDO Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2002), only a decision of the Board of Veterans' Appeals is appealable to the United States Court of Appeals for Veterans Claims. 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) (2011).