Citation Nr: 1307771 Decision Date: 03/08/13 Archive Date: 03/11/13 DOCKET NO. 10-41 001 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Nashville, Tennessee THE ISSUES 1. Entitlement to service connection for a right shoulder disorder. 2. Entitlement to service connection for a right wrist disorder. 3. Entitlement to service connection for a left wrist disorder. 4. Entitlement to service connection for a right hand disorder. 5. Entitlement to service connection for a left hand disorder. 6. Entitlement to service connection for a right foot disorder. 7. Entitlement to service connection for a left foot disorder. 8. Entitlement to service connection for a left knee disorder. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States of America WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD C. Fleming, Counsel INTRODUCTION The Veteran had active military service from July 1987 to August 2008. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an October 2008 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Nashville, Tennessee. This appeal was processed using the Virtual VA paperless claims processing system. Accordingly, any future consideration of this appellant's case should take into consideration the existence of this electronic record. The Veteran testified before the undersigned Veterans Law Judge in August 2010. A transcript of the hearing has been associated with the Veteran's claims file. On the day of the hearing, the Veteran appointed the Veterans of Foreign Wars of the United States of America as his representative. Hearing Transcript, p. 2. The decision below grants the Veteran service connection for carpal tunnel syndrome of the right and left wrists with ulnar neuropathy and for impingement syndrome of the right shoulder. Consideration of the remaining claims on appeal is deferred pending completion of the development sought in the remand that follows the decision. FINDINGS OF FACT 1. The Veteran has carpal tunnel syndrome with ulnar neuropathy of the right wrist that is attributable to his period of active military service. 2. The Veteran has carpal tunnel syndrome with ulnar neuropathy of the left wrist that is attributable to his period of active military service. 3. The Veteran has impingement syndrome of the right shoulder that is attributable to his period of active military service. CONCLUSIONS OF LAW 1. The Veteran has carpal tunnel syndrome with ulnar neuropathy of the right wrist that is the result of disease or injury incurred in active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 2. The Veteran has carpal tunnel syndrome with ulnar neuropathy of the left wrist that is the result of disease or injury incurred in active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). 3. The Veteran has impingement syndrome of the right shoulder that is the result of disease or injury incurred in active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.303, 3.304 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran is seeking service connection for a right wrist disorder, a left wrist disorder, and a right shoulder disorder. In its October 2008 decision, the RO denied the Veteran's claims, concluding that service connection was not warranted because the Veteran had not established a diagnosis of any disability or a nexus to his time in service. Relevant medical evidence consists of the Veteran's service treatment records and reports of his ongoing care by private treatment providers, as well as report of VA examination conducted in June 2008. The Veteran's service treatment records reflect that he was seen in April 2001 for complaints of pain in his right shoulder; at that time he was diagnosed with mild impingement syndrome in the shoulder. He was seen again in May 2001 for complaints of ongoing pain in the right shoulder; at that time, he was diagnosed with winged scapula and was referred for electromyography. However, no reports of electromyography are of record. Review of the Veteran's service treatment records further reflects that the Veteran was seen in March 2007 for complaints of pain in his wrists and hands bilaterally, as well as decreased strength in his hands. He was diagnosed at the time with "generalized osteoarthritis," but no specific joints were identified, and there is no record that radiological confirmation was obtained. The Veteran underwent electromyography study in May 2007 following ongoing complaints of hand and wrist pain. At that time, he was found to have medial neuropathies and ulnar neuropathies in the wrists bilaterally. He was diagnosed with mild carpal tunnel syndrome with ulnar neuropathy in the wrists bilaterally. This diagnosis was confirmed in June 2007. The evidence also includes records of the Veteran's ongoing private treatment, which establish that he has been seen on multiple occasions for complaints of pain, numbness, and tingling in his wrists and hands since January 2009, shortly after his separation from active duty. He has been diagnosed with myalgia and arthralgia in multiple joints, as well as with sensory neuropathy. The Veteran's private physician has not formalized a diagnosis of carpal tunnel syndrome or impingement syndrome; however, the Board notes that no electromyography studies of the Veteran's wrists or right shoulder have been conducted since he left active duty. The Veteran was also provided VA examination in June 2008. Report of that examination reflects that the examiner noted the Veteran's complaints of having been diagnosed with "winged scapula" while in service in 2001. He complained of weakness, stiffness, fatigability, and pain in the right shoulder that began in service and has continued to the present. Similarly, the Veteran stated at the VA examination that he first developed pain in his wrists in 2007, while still on active duty, and continued to experience weakness, stiffness, swelling, and fatigability in the wrists. The examiner noted that the Veteran had been diagnosed with ulnar neuropathy and carpal tunnel syndrome in the wrists while he was in service. Physical examination of the Veteran's wrists and right shoulder were normal, with no decrease in sensation, range of motion, or muscle strength. Radiological examination was also normal for the right shoulder and the left wrist. Although the examiner noted a lucency at the middle aspect of the right navicular bone on radiological study, no current disability of the wrist was noted. However, the VA examiner did not conduct electromyography study of the Veteran's right shoulder or wrists. No diagnoses were assigned for the Veteran's right shoulder or wrist complaints. The Veteran testified before the undersigned Veterans Law Judge in July 2012. At that time, the Veteran stated that he was engaged in manual labor, including heavy lifting and repetitive motions, while on active duty. He reported that he first began having problems with his wrists and his right shoulder while on active duty and that those problems have continued to the present. Service connection may be granted for disability resulting from disease or injury incurred or aggravated during active service. 38 U.S.C.A. §§ 1110, 1131 (West 2002); 38 C.F.R. § 3.303. Service connection may also be granted for any injury or disease diagnosed after service, 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). Generally, service connection requires: (1) medical evidence of a current disability; (2) medical evidence, or in certain circumstances lay testimony, of in-service incurrence or aggravation of an injury or disease; and (3) medical evidence of a nexus between the current disability and the in-service disease or injury. See Hickson v. West, 12 Vet. App. 247 (1999). Further, it is not enough that an injury or disease occurred in service; there must be chronic disability resulting from that injury or disease. In this case, the Veteran's service treatment records reflect that he was diagnosed with both impingement syndrome of the right shoulder and carpal tunnel syndrome with ulnar neuropathy of the wrists bilaterally. Although the June 2008 VA examiner did not assign diagnoses for the Veteran's complained-of right shoulder and bilateral wrist problems, the Board notes that no electromyography or other nerve conduction study was carried out to evaluate the Veteran's claims. The Veteran has stated on multiple occasions, including at his July 2012 hearing before the undersigned Veterans Law Judge, that these problems have continued from his time in service to the present. Further, private treatment providers have assessed the Veteran with problems such as myalgia and arthralgia, as well as sensory neuropathy. These findings tend to support the Veteran's contentions that he first experienced problems with his right shoulder and his wrists in service that have continued to the present. Here, the competent medical evidence has identified that while in service, the Veteran carried a diagnosis of impingement syndrome of the right shoulder and bilateral carpal tunnel syndrome with ulnar neuropathy. The Veteran has testified that the symptoms of his right shoulder impingement syndrome and bilateral carpal tunnel syndrome with ulnar neuropathy have continued from his time in service to the present. The Board thus concludes that the Veteran suffers from bilateral carpal tunnel syndrome with ulnar neuropathy and impingement syndrome of the right shoulder that began during active duty. ORDER Entitlement to service connection for carpal tunnel syndrome with ulnar neuropathy of the right wrist is granted. Entitlement to service connection for carpal tunnel syndrome with ulnar neuropathy of the left wrist is granted. Entitlement to service connection for impingement syndrome of the right shoulder is granted. REMAND The Board finds that further evidentiary development is necessary before a decision can be reached on the merits of the Veteran's claims for service connection for disorders of the left knee and the hands and feet, as well as for disabilities of the wrists other than carpal tunnel syndrome with ulnar neuropathy and a disability of the right shoulder other than impingement syndrome. The Veteran has contended that he has disorders of the left knee and the hands and feet. In addition, although the Veteran has been awarded service connection for bilateral carpal tunnel syndrome with ulnar neuropathy and impingement syndrome of the right shoulder, as his claim was made broadly for disorders of the right shoulder and the wrists, the Board finds that he may experience disorders of the wrists or right shoulder that have not been service connected and that therefore remain on appeal. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). Specifically, the Veteran alleges that he developed problems in his hands, wrists, feet, left knee, and right shoulder due to the repetitive motion and heavy lifting required by his military duties. The Veteran claims that, since his time in service, he has experienced numbness, stiffness, and pain in his hands, feet, wrists, left knee, and right shoulder. Regarding diagnosis of the Veteran's claimed disabilities, relevant medical evidence of record consists of service treatment records and records of his ongoing treatment with private treatment providers. Review of his service treatment records reveals that the Veteran complained on multiple occasions of pain and other problems with his hands, feet, wrists, left knee, and right shoulder. He was seen in May 1988 and again in September 1989 for complaints of pain in his left knee, which was diagnosed at the time as an unstable knee. He was again seen in March 1994 for complaints of experiencing subluxation in the knee; the diagnosis at the time was left knee strain. The Veteran was first seen for complaints of pain in his right shoulder in April 2001, which was diagnosed at the time as impingement syndrome. Similarly, he complained in December 2003 and January 2004 of "soft tissue pain" in his lower extremities; no diagnosis was assigned at that time. At later treatment visits in 2006, the Veteran again complained of pain in his hands, left knee, wrists, and feet. He was assigned a diagnosis of "generalized osteoarthritis" in March 2007, but no radiological study was conducted to confirm the diagnosis. Electromyography study of the right lower extremity conducted in May 2007 was normal; no study was conducted of the left lower extremity. Relevant post-service medical evidence reflects that the Veteran was seen in January 2009 and again in February 2009 for complaints of pain in his upper and lower extremities bilaterally. He was diagnosed at that time with myalgia and arthralgia, but no specific disorder or joints were identified. At later private treatment visits in 2011, he again complained of pain, stiffness, and swelling in his hands and feet for the past five years. He was diagnosed with diffuse myalgia and myofascial pain; treatment notes indicate that he was also provided "education on fibromyalgia," although no clear diagnosis of fibromyalgia was assigned. The Veteran underwent VA examination in June 2008 to address his claims for service connection. At that time, the examiner acknowledged the Veteran's report of experiencing pain, aching, burning, and swelling in his hands, wrists, and feet, as well as in his left knee and right shoulder. However, physical examination revealed no edema, effusion, or weakness, and no limitation of strength or of range of motion was noted in the Veteran's hands, wrists, feet, left knee, or right shoulder. The examiner conducted radiological study of each identified joint, which all returned normal results. Similarly, neurological study found intact sensation in the upper and lower extremities bilaterally. The examiner found the Veteran not to have any current disability of the hands, wrists, feet, left knee, or right shoulder. Once VA undertakes the effort to provide an examination when developing a claim for service connection, even if not statutorily obligated to do so, it must provide an adequate one. See Woehlaert v. Nicholson, 21 Vet. App. 456, 464 (2007), citing Barr, 21 Vet. App. at 311; see also Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence . . . is essential for a proper appellate decision"). Although it appears that the June 2008 VA examiner attempted to conduct a proper evaluation of the Veteran's physical condition at the time, the Board notes that the VA examiner did not have the opportunity to consider the opinions of the December 2011 private treatment provider, who indicated that the Veteran may be experiencing fibromyalgia. Because the VA examiner did not discuss whether, and if so to what extent, the Veteran currently experiences fibromyalgia, the Board finds that further evidentiary development is required. See 38 C.F.R. § 4.2 (2012) (providing that where an examination report does not contain sufficient detail, it is inadequate for evaluation purposes); see also Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 301 (2008) (noting that a medical examination report must contain clear conclusions with supporting data and a reasoned medical explanation connecting the two); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007) (holding that a medical opinion must be supported by an analysis that the Board can consider and weigh against contrary opinions). Accordingly, remand is required. In light of the above considerations, the Board concludes that another medical examination and opinion are needed. Under these circumstances, evidentiary development is needed to fully and fairly evaluate the Veteran's claims of service connection for disorders of the left knee and the hands and feet, as well as for disabilities of the wrists other than carpal tunnel syndrome with ulnar neuropathy and a disability of the right shoulder other than impingement syndrome. 38 U.S.C.A. § 5103A (West 2012). Specifically, the AOJ must arrange for the Veteran to undergo VA examination by a qualified health professional, who must review the Veteran's claims file and his assertions and provide clear diagnoses of all disorders the Veteran experiences of the left knee and the hands and feet, as well as for disabilities of the wrists other than carpal tunnel syndrome with ulnar neuropathy and a disability of the right shoulder other than impingement syndrome. The examiner must thoroughly discuss the December 2011 private diagnosis of diffuse myalgia and myofascial pains, as well as the notation that "education on fibromyalgia" was provided to the Veteran, and must identify whether the Veteran currently experiences fibromyalgia. If so, the examiner must specify what body parts are affected by the disorder and must discuss what other disorders the Veteran currently experiences, if his complaints regarding his joints are not fully explained by a fibromyalgia diagnosis. The examiner's opinions must be based upon consideration of the Veteran's documented medical history and assertions through review of the claims file and must include a clear and thorough explanation for all conclusions reached. 38 U.S.C.A. § 5103A. In view of the foregoing, the case is REMANDED for the following action: 1. The Veteran must be scheduled for a VA examination and notified that failure to report to any scheduled examination, without good cause, could result in a denial of his claims. See 38 C.F.R. § 3.655(b) (2012). The VA examination is necessary to determine the nature and etiology of any current disorders shown to be affecting the left knee and the hands and feet, as well as disabilities of the wrists other than carpal tunnel syndrome with ulnar neuropathy and a disability of the right shoulder other than impingement syndrome. The VA examiner must review the Veteran's claims file and medical history, examine the Veteran, provide diagnoses for each disorder the Veteran currently experiences of the left knee and the hands and feet, as well as of the wrists other than carpal tunnel syndrome with ulnar neuropathy and of the right shoulder other than impingement syndrome. The examiner must provide a thorough, well-reasoned opinion as to whether each such identified disorder is at least as likely as not (i.e., there is at least a 50 percent probability) that each such diagnosed disability is related to military service. The reviewer's attention is called to the Veteran's medical history, including in particular his in-service complaints of pain in his right shoulder, left knee, and hands, wrists, and feet, as well as his contention that he has continued to experience symptoms since that time. In addition, the examiner must thoroughly discuss the findings of the December 2011 private treatment provider, who assigned diagnoses of myalgia and myofascial pain and provided the Veteran "education on fibromyalgia." In particular, the examiner must discuss whether the Veteran has fibromyalgia and, if so, what joint or joints are affected by the disorder. The examiner must also discuss whether any diagnosed fibromyalgia accounts for all of the Veteran's symptoms. If not, the examiner must provide diagnoses for all other disorders the Veteran currently experiences, and must opine as to whether each such disorder is at least as likely as not related to service. The examiner must thoroughly review the Veteran's claims file, to include a copy of this remand. A well reasoned etiological opinion must be provided with a detailed explanation for all conclusions reached by the reviewer. Citations to the record or relevant medical principles should be included as necessary to explain the opinion, and a complete rationale should be given for all opinions and conclusions expressed. The medical reasons for accepting or rejecting the Veteran's statements as to continuity of symptoms since service should be set forth. 2. The adjudicator must ensure that the examination report(s) complies with this remand and the questions presented in the examination request. If any report is deficient, it must be returned to the examiner for necessary corrective action, as appropriate. 3. After completing the requested actions and any additional notification and/or development deemed warranted, the claims remaining on appeal must be adjudicated in light of all pertinent evidence and legal authority. If any benefit sought is not granted, the Veteran must be furnished a supplemental statement of the case (SSOC) and afforded the appropriate time period for response before the claims file is returned to the Board for further consideration. 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 case 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 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). _________________________________ MARK F. HALSEY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs