Citation Nr: 1237343 Decision Date: 10/31/12 Archive Date: 11/09/12 DOCKET NO. 08-25 022 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Columbia, South Carolina THE ISSUES 1. Entitlement to service connection for residuals of a left wrist fracture 2. Entitlement to service connection for a disorder manifested by swelling of the feet or lower extremities. REPRESENTATION Appellant represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD J. Juliano, Associate Counsel INTRODUCTION The Veteran served on active duty from January 1996 to October 2005. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2006 rating decision of the Department of Veterans Affairs (VA) regional office (RO) located in Roanoke, Virginia. Jurisdiction was subsequently transferred to the RO located in Columbia, South Carolina. In April 2009, the Veteran testified at a videoconference Board hearing before a Veterans Law Judge who is no longer employed by the Board. The Veteran was therefore provided with an opportunity for another Board hearing, which was held at the central office in Washington, DC in October 2012 before the undersigned Veterans Law Judge. A transcript of the proceeding has been associated with the claims file. In July 2009 and July 2010, the Board remanded the Veteran's claims for further development. Such development has been completed and associated with the claims file, and these matters are returned to the Board for further review. 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 Left Wrist The Veteran served on active duty from January 1996 to October 2005. She claims that she has a left wrist condition involving pain, numbness, and tingling that she attributes to an in-service left wrist fracture in August 2000, or that is attributable to an undiagnosed illness due to her service in Saudi Arabia during the Persian Gulf war. See Statement, October 2010. She has also asserted that she has carpal tunnel syndrome in her left wrist that is related to service. See Board Hearing Transcript, April 2009 at 11. The Veteran's service treatment records reflect that in August 2000, while stationed in Saudi Arabia, the Veteran fractured her left wrist when she tripped and fell and extended her left arm to break her fall. X-rays showed a non-displaced intra-articular fracture of the left distal radius. An October 2000 x-ray revealed a well-healed fracture of the styloid, but that the Veteran complained of left wrist pain. The Veteran was subsequently medically discharged in October 2005 as a result of a head injury sustained in a January 2004 motor vehicle accident. Post-service VA treatment records reflect that the Veteran complained of bilateral hand tingling and numbness, see April 2006, and that EMG studies revealed right hand carpal tunnel syndrome. A May 2006 VA examination report reflects there was no left wrist pathology to render a diagnosis. A June 2007 VA examination showed no objective signs of pain and noted x-rays were normal. November 2011 x-rays relating to the recent November 2011 VA examination were also negative. The Veteran testified at the April 2009 Board hearing that she had an occupational therapy appointment scheduled at the Columbia, South Carolina VA medical center relating to her left wrist condition. The Board notes however, that there are no VA treatment records from the Columbia VA Medical Center dated after March 2009 associated with the claims file. Based thereon, a remand is necessary to obtain any outstanding VA treatment records dated in 2009 from the Columbia, South Carolina VA Medical Center relating to her claim. See 38 U.S.C.A. § 5103A (West 2002); 38 C.F.R. § 3.159 (2012). In July 2010, the Board remanded the Veteran's claim so that, among other things, the Veteran's service in the Persian Gulf could be verified (for 38 C.F.R. § 3.317 purposes). The Board acknowledges that the RO requested certain personnel records from DPRIS, and the records received include a certification that the Veteran is the recipient of an Air Force Achievement Medal relating to her service in Saudi Arabia between December 1998 and April 1999. As noted above, her service treatment records reflect that she experienced left lower extremity swelling while serving in Saudi Arabia in January 1999, later treatment records (relating to the swelling) reflect she returned to the U.S. around April 1999, that she later injured her left wrist while serving again in Saudi Arabia in August 2000, and that she returned to the U.S. later in August 2000. In light of all of the above, the Board concedes that the Veteran constitutes a Persian Gulf veteran for 38 C.F.R. § 3.317 purposes. See also 38 U.S.C.A. § 1117. The Board also remanded the Veteran's claim so that she could be provided with a new VA examinations, including to address whether there was qualifying 38 C.F.R. § 3.317 undiagnosed illness (prior VA examinations were performed in May 2006 and June 2007). The Veteran was subsequently provided with a VA examination in November 2011 relating to her left wrist claim. The November 2011 VA examiner opined that it is less likely as not that the Veteran's "left wrist impairment" was related to her in-service left wrist injury, reasoning that such was not supported by "longitudinal treatment records" in service or in near proximity from her discharge. The Board finds, however, that it is unclear whether the Veteran had any current complaints at the time of the VA examination, and if so, whether they relate to a known clinical diagnosis, and whether such diagnosis is related to her in-service injury; and if there is no current, known clinical diagnosis, whether she has any current symptomatology that may be attributed to an undiagnosed illness for 38 C.F.R. § 3.317 purposes. Also, the Board notes that the VA examiner did not address the Veteran's post-service complaints of tingling, numbness, and carpal tunnel syndrome in her left wrist. Based thereon, the Board finds that a remand for a new VA examination is required. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303 (2007). Bilateral Foot or Lower Extremity Swelling The Veteran claims that she has a bilateral foot or lower extremity condition involving swelling and pain that had its onset in service, or is attributable to an undiagnosed illness due to her Persian Gulf service. See Statement, October 2010. A January 1999 service treatment record reflects that while stationed in Saudi Arabia, the Veteran complained of bilateral foot swelling for one week, the left worse than the right. A diagnosis of left lower extremity edema secondary to left knee tendonitis was recorded. Subsequent records dated through May 1999 reflect that the Veteran continued to be followed for left lower extremity edema, noted as possibly secondary to chronic tendonitis (of the knee, as was noted in the prior January 1999 record), and later noted as idiopathic. She was referred to general surgery for a possible vascular or lymphatic cause. A May 1999 general surgery consultation reflects that she denied any trauma in Saudi Arabia, and a diagnosis of pain and swelling of the left foot secondary to prolonged standing was recorded. Post-service, VA treatment records reflect that the Veteran has been followed for complaints of leg and foot swelling. See, e.g., April 2006, April 2007, March 2011, June 2011. The Board also acknowledges that a July 2006 VA treatment record reflects that the Veteran sprained her right ankle tripping post-service. Recent VA treatment records reflect that the Veteran was seen in Rheumatology in October and December 2011, and Neurology in September 2011 and November 2011, relating to her complaints of lower extremity edema and pain. November 2011 EMG and bone scan testing were normal, and it was noted that the etiology of her complaints was unclear. The Board also acknowledges that service treatment records reflect that as a result of a January 2004 automobile accident, the Veteran was noted as experiencing closed head injury/post concussion syndrome with balance and weakness to the lower extremities, as well as fatigue, and that she was ultimately medically discharged as a result of the injury. The Board remanded the Veteran's claim so that she could be provided with a new VA examination, including to address whether there was qualifying 38 C.F.R. § 3.317 undiagnosed illness (a prior general VA examination performed in May 2006). The Veteran was subsequently provided with a VA examination in November 2011 relating to her claim. The November 2011 VA examiner noted the Veteran's history in service of left lower extremity ("foot") swelling, and that she presently complained of swelling in her entire left leg that the examiner opined needed to be addressed by a vascular or medical consultant. At the same time, however, the VA examiner opined that the Veteran had no medically determinable left foot condition. In light of the above, the Board finds that it is unclear whether the Veteran's reported symptomatology during the period on appeal is attributable to a known clinical diagnosis, and if so, whether it relates to her in-service diagnosis and treatment for edema, or if not, whether it relates to an undiagnosed illness for 38 C.F.R. § 3.317 purposes. The Board further notes that it is not clear whether the Veteran had any complaints relating to her right foot or right lower extremity at the time of the November 2011 VA examination. In light of the above, the Board finds that a remand is required for a new VA examination. See Stegall v. West, 11 Vet. App. 268 (1998); Barr v. Nicholson, 21 Vet. App. 303 (2007). Accordingly, the case is REMANDED for the following action: 1. Obtain any outstanding VA treatment records dated in 2009 from the Columbia, South Carolina VA medical center relating to the Veteran's left wrist condition and associate them with the claims file. 2. After the above development has been completed, schedule the Veteran for a new VA examination with an appropriate physician(s) to determine the current nature and the etiology of any (a) left foot or lower extremity swelling condition, (b) right foot or right lower extremity swelling condition, and (c) left wrist condition. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The complete claims folder must be provided to the examiner for review in conjunction with the examination, and the examiner must note that the claims folder has been reviewed. The examiner should indicate whether it is at least as likely as not (meaning likelihood of at least 50%) that any current left foot or left lower extremity condition, right foot or right lower extremity condition, and left wrist condition is related to service. A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. If the any current, clinically diagnosed left foot or left lower extremity condition, right foot or right lower extremity condition, or left wrist condition diagnosed on examination is not found to be related to service, please explain the rationale for such opinion. If the Veteran exhibits objective indications of a chronic disability that by history, physical examination, and any laboratory tests cannot be attributed to a current, known clinical diagnosis (i.e., an undiagnosed illness relating to service in the Persian Gulf), please explain the rationale for such conclusion in detail. Likewise, if no disability is clinically diagnosed, and there is no objective indication of a chronic disability due to an undiagnosed illness, please provide a detailed rationale. Please ask the examiner to specifically address the Veteran's post-service complaints of left wrist tingling and numbness and alleged carpal tunnel syndrome. As to any opinions expressed, it would be helpful if the examiner would use the following language, as may be appropriate: "more likely than not" (meaning likelihood greater than 50%), "at least as likely as not" (meaning likelihood of at least 50%), or "less likely than not" or "unlikely" (meaning that there is a less than 50% likelihood). The term "at least as likely as not" does not mean "within the realm of medical possibility." Rather, it means 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 that conclusion as it is to find against it. 3. Then, readjudicate the Veteran's claims. If her claims remain denied, she should be provided with a Supplemental Statement of the Case (SSOC). After the Veteran and her representative have been given the applicable time to submit additional argument, the claims should be returned to the Board for further review. Thereafter, the case should be returned to the Board, if in order. The Veteran has the right to submit additional evidence and argument on the matters that 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. 2012). _________________________________________________ DAVID L. WIGHT 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) (2012).