Citation Nr: 1310442 Decision Date: 03/29/13 Archive Date: 04/09/13 DOCKET NO. 07-00 970 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUES 1. Entitlement to an evaluation in excess of 20 percent for strain of the volar carpal ligament of the left (major) wrist with neuropathy of the left median nerve. 2. Entitlement to service connection for right wrist carpal tunnel syndrome. 3. Entitlement to service connection for a lumbar spine disability. 4. Entitlement to service connection for bilateral chondromalacia patellae. WITNESSES AT HEARING ON APPEAL Appellant and his spouse ATTORNEY FOR THE BOARD T. Azizi-Barcelo, Counsel INTRODUCTION The Veteran served on active duty from January 1972 to December 1973, and from January 1980 to May 1986. This case comes before the Board of Veterans' Appeals (Board) on appeal of an October 2005 decision by the Department of Veterans Affairs (VA) Regional Office (RO) in San Diego, California. The Veteran testified at video conference hearings before the undersigned Veterans Law Judge in February 2010 and November 2011. In May 2010, the Board reopened and remanded the claims for additional development. In a rating decision in October 2008, the RO denied the Veteran's claim for entitlement to a total disability rating for compensation based on individual unemployability (TDIU). While at the November 2011 hearing the Veteran testified that his service-connected left wrist condition limited his ability to perform activities of daily living, to include any physical work, he also reported that he was unemployed and in receipt of Social Security disability benefits due to nonservice-connected disabilities. In Rice v. Shinseki, 22 Vet. App. 447 (2009), the United States Court of Appeals for Veterans Claims (Court) held that a claim of entitlement to a TDIU is part of an increased rating claim when such claim is expressly raised by the Veteran or reasonably raised by the record. In this case, however, the Veteran has not attributed his unemployability to the service-connected left wrist condition and specifically noted that he was in receipt of disability benefits due to a non-service connected disability. Therefore, the Board finds that further consideration of TDIU rating is not warranted because the evidence does not infer such a claim. The evidence does not show, nor does the Veteran claim, that he is unable to secure and maintain employment due to the service-connected left wrist condition. In a VA Form 21-4138 dated in November 2011, the Veteran revoked Disabled American Veterans as his representative of record. The Veteran also indicated that he wished to be represented by L.H. However, the Veteran failed to submit a VA Form 21-22a indicating the appointment of a new representative. Accordingly, in September 2012, the Board requested clarification, furnished the appropriate form to appoint a new representative, and indicated to the Veteran that if he did not respond, it would be assumed he wished to represent himself. The appellant failed to respond and did not provide a valid authorization (VA Form 21-22 or VA Form 21-22a) signed by a representative. Therefore, the Board finds that the appellant is not represented by any organization at this time before VA. The claims of entitlement to service connection for a lumbar spine disability and bilateral chondromalacia patellae are addressed in the REMAND portion of the decision below and are REMANDED to the RO via the Appeals Management Center (AMC), in Washington, D.C. FINDINGS OF FACT 1. The Veteran's strain of the volar carpal ligament of the left (major) wrist with neuropathy of the left median nerve has been productive of, at most, moderate incomplete paralysis throughout the appeal period. 2. The evidence of record is at least in equipoise as to whether the Veteran's right wrist carpal tunnel syndrome was caused or aggravated by his service-connected strain of the volar carpal ligament of the left wrist with neuropathy of the left median nerve. CONCLUSIONS OF LAW 1. The criteria for an evaluation of 30 percent, but no higher, for volar carpal ligament of the left (major) wrist with neuropathy of the left median nerve have been met. 38 U.S.C.A. §§ 1155, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.159, 4.1, 4.3, 4.7, 4.26, 4.124a, Diagnostic Code 8615 (2012). 2. Right wrist carpal tunnel syndrome was caused or aggravated by the Veteran's service-connected strain of the volar carpal ligament of the left wrist with neuropathy of the left median nerve. 38 U.S.C.A. §§ 1110, 5107 (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duties to Notify and Assist VA has a duty to provide the Veteran notification of the information and evidence necessary to substantiate the claims submitted, the division of responsibilities in obtaining evidence, and assistance in developing evidence, pursuant to the Veterans Claims Assistance Act of 2000 (VCAA). See 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b). The notice requirements were accomplished in letters sent in May 2005, September 2006, September 2008, May 2010, and July 2010. Mayfield v. Nicholson, 444 F.3d 1328, 1333 (Fed. Cir. 2006). The letters also provided notice of the type of evidence necessary to establish a disability rating or effective date for the claimed disabilities under consideration, pursuant to Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice was timely because the claims were readjudicated in the April 2011 supplemental statements of the case. Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006). The Veteran appeared at two hearings before the Board. He presented oral testimony in support of his claims and also introduced additional documents for inclusion into the record. In Bryant v. Shinseki, 23 Vet. App. 488 (2010), the United States Court of Appeals for Veterans Claims (Court) held that 38 C.F.R. § 3.103(c)(2) requires that the Veterans Law Judge who chairs a hearing fulfill two duties to comply with the above regulation. These duties consist of (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. During the hearing, the Veterans Law Judge asked specific questions directed at identifying whether the Veteran had symptoms meeting the schedular criteria for higher ratings and service connection. Accordingly, the Veteran is not shown to be prejudiced on this basis. Finally, the Veteran has not asserted that VA failed to comply with 38 C.F.R. § 3.103(c)(2). By contrast, the hearings focused on the elements necessary to substantiate the claims, and the Veteran, through his testimony, demonstrated that he had actual knowledge of the elements necessary to substantiate his claims. As such, the Board finds that, consistent with Bryant, the Veterans Law Judge complied with the duties set forth in 38 C.F.R. § 3.103(c)(2). The Board also finds that all relevant facts have been properly developed, and that all evidence necessary for equitable resolution of the issues has been obtained. The Veteran's service treatment records, the Social Security Administration (SSA) records, Virtual VA file, and available private and VA treatment records have been obtained. In addition, he has been provided with appropriate VA examinations in connection with the claims which provide etiological opinions and sufficiently describe the manifestations of the Veteran's disabilities for rating purposes. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Moreover, the Veteran has not indicated there are any additional records that VA should seek to obtain on his behalf. Therefore, the Board concludes that all reasonable efforts were made by VA to obtain evidence necessary to substantiate the Veteran's claims, and no further assistance to develop evidence is required. Factual Background The Veteran's service treatment records disclose that, during the Veteran's second period of active military service in December 1985, he received treatment for left wrist problems, reportedly the result of a fall onto that wrist. In the process of evaluating the Veteran's left wrist pathology, the Veteran apparently also underwent evaluation, including radiographic studies, of his right wrist. December 1985 x-rays of the right hand revealed no abnormalities. A February 1986 clinical treatment note recorded an assessment of possible carpal tunnel syndrome. On VA examination in October 2003, the Veteran reported injuring his wrists during parachute jumps in service. He reported dropping objects due to pain and numbness. The Veteran rated the pain as 6/10. He denied flare-ups. He also was unable to grip objects. Motor strength was 5/5. Reflexes were 2+, and sensory examination was intact. Phalen's sign was positive on the left and Tinel's sign was negative bilaterally. X-rays of the left hand revealed old ulnar styloid trauma with no acute osseous irregularities. The examiner diagnosed strain volar carpal ligament of the left wrist and neuropathy of the left median nerve secondary to volar injuries. On VA examination in June 2005, the Veteran complained of chronic parasthesias and pain in his hands since 1989. On examination, the Veteran exhibited full range of motion of the left wrist with 80 degrees of flexion, 80 degrees of volar flexion, 25 degrees of ulnar deviation, 20 degrees of radial deviation, 90 degrees of pronation, and 90 degrees of supination. The left wrist range of motion and joint function were not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use. He had positive Tinel and Phalen signs in the left wrist. There was parasthesias of the distribution of the left hand. The examiner diagnosed left wrist status post minor fractures, healed, with associated carpal tunnel syndrome, chronic. The examiner noted mild to moderate functional impairment. On VA peripheral nerves examination in September 2006, the Veteran reported pain and parasthesias in the left hand. The Veteran was noted to be left hand dominant. He was unable to use his left hand for heavy jobs such as washing a car or hammering. He was able to write, eat, and change clothes using that hand. The Veteran also complained of right hand pain on the back of the wrist, but not on the front or left side. He denied parasthesias of the right hand and fingers. Motor examination of the upper extremities was normal with no muscle atrophy, involuntary movements or tremors. Reflexes were 2+ and sensation was normal to pinprick and vibration. Tinel's sign was positive on the left. A July 2005 MRI revealed bilateral carpal tunnel syndrome, moderate. There was also polyneuropathy in the upper extremities. VA treatment records in 2008 noted that EMG studies confirmed the presence of bilateral carpal tunnel syndrome. In correspondence dated in February 2010, a private clinician noted a diagnosis of carpal tunnel syndrome in the right hand since December 1985, following a bilateral hand injury. The clinician opined that it was more likely than not that the Veteran's carpal tunnel syndrome was related to service. The opinion was based on a December 1985 x-ray report, and an April 1986 Form 664 which documented that the Veteran's right hand was broken and required treatment with a cast, as well as treatment records in November 2001 and February 2002. The Veteran underwent an orthopedic examination in June 2010. He complained of constant pain, stiffness and weakness in the wrists, left worse than the right. The Veteran reported giving way of the wrist. He denied flare-ups of symptoms, dislocation, subluxation, locking, catching or popping. He was unable to do heavy lifting and the bilateral wrist disability reportedly impaired his ability to push and pull. On examination, there was no tenderness, muscle atrophy, asymmetry, or swelling. Sensation was normal. Dorsi-flexion was to 70 degrees, palmar flexion was to 80 degrees, supination was to 85 degrees, pronation was to 80 degrees, radial deviation was to 20 degrees, and ulnar deviation was to 45 degrees. There was no objective evidence of pain, spasms or weakness. The joint function of the left wrist was not additionally limited by pain, fatigue, weakness, or lack of endurance following repetitive use. There was no evidence of instability, crepitus or impingement. X-rays revealed an uninvited ulnar styloid fracture and mild osteoarthritis, and right wrist widening at the scapholunate interval with no evidence of fracture or dislocation. The examiner diagnosed bilateral mild wrist osteoarthritis with posttraumatic scapho-lunate disassociation on the left. With regards to the right wrist disability, the examiner noted the lack of clinical findings pertaining to that wrist in service. Following an examination of the Veteran's wrist, consideration of specific anatomic changes on available imaging studies, and based on reported history, the examiner opined that it was less likely than not that the Veteran's right wrist condition was related to service. He further determined that the right wrist disability was less likely than not proximately due to, or the result of trauma or aggravated by the left wrist disorder. The Veteran underwent a neurological examination in June 2010. He complained of continuous left wrist pain interiorly and posteriorly, as well as pain radiating to the palm of the hand. There was also numbness and tingling in the digits. He described inability to paint or hammer due to his left wrist, although he indicated that he was able to perform activities of daily living with his left hand, including writing. The Veteran reported onset of right hand pain a few years after the left hand was fractured in service. The Veteran wore volar wrist splints. On examination, there was no atrophy of the muscles. While the Veteran did not appear to be exerting maximum effort in testing of volitional strength for the muscles, the examiner was unable to find evidence of organic weakness of the hand musculature. Sensation was intact. Following an examination of the Veteran and a review of the claims file, the examiner diagnosed bilateral carpal tunnel syndrome, worse on the left than the right. The examiner opined that it was at least as likely as not that the Veteran's carpal tunnel/median neuropathy on the right hand was the result of carpal tunnel syndrome in the left hand. The examiner explained that carpal tunnel often became symptomatic in one side before affecting the extremities bilaterally, particularly where the side subsequently afflicted occurs as a result of increased use of that hand. The examiner indicated that the Veteran's major limitation of functional activity due to the carpal tunnel syndrome was sensory symptoms involving the left hand. With regards to the Veteran's complaints of pain, the examiner found that these were probably orthopedic in nature. Increased Rating for Left Wrist Carpal Tunnel Syndrome Ratings for service-connected disabilities are determined by comparing the Veteran's symptoms with criteria listed in VA's Schedule for Rating Disabilities, which is based, as far as practically can be determined, on average impairment in earning capacity. Separate diagnostic codes identify the various disabilities. 38 C.F.R. § Part 4 (2012). When rating a service-connected disability, the entire history must be borne in mind. Schafrath v. Derwinski, 1 Vet. App. 589 (1991). Where there is a question as to which of two ratings shall be applied, the higher rating will be assigned if the disability picture more nearly approximates the criteria required for that rating. Otherwise, the lower rating will be assigned. 38 C.F.R. § 4.7 (2012). The Board will also consider entitlement to staged ratings to compensate for times since filing the claim when the disability may have been more severe than at other times during the course of the claim on appeal. Fenderson v. West, 12 Vet. App. 119 (1999); Hart v. Mansfield, 21 Vet. App. 505 (2007). When evaluating joint disabilities rated on the basis of limitation of motion, VA must consider granting a higher rating in cases in which functional loss due to pain, weakness, excess fatigability, or incoordination is demonstrated, and those factors are not contemplated in the relevant rating criteria. See 38 C.F.R. §§ 4.40, 4.45, 4.59; DeLuca v. Brown, 8 Vet. App. 202 (1995). Recently, the Court clarified that although pain may be a cause or manifestation of functional loss, limitation of motion due to pain is not necessarily rated at the same level as functional loss where motion is impeded. See Mitchell v. Shinseki, 25 Vet. App. 32 (2011). Instead, the Mitchell Court explained that pursuant to 38 C.F.R. §§ 4.40 and 4.45, the possible manifestations of functional loss include decreased or abnormal excursion, strength, speed, coordination, or endurance (38 C.F.R. § 4.40), as well as less or more movement than is normal, weakened movement, excess fatigability, and pain on movement. Functional impairment also included swelling, deformity, and atrophy that affects stability, standing, and weight-bearing (38 C.F.R. § 4.45). Thus, functional loss caused by pain must be rated at the same level as if the functional loss were caused by any of the other factors cited above. Therefore, in evaluating the severity of a joint disability, VA must determine the overall functional impairment due to these factors. The provisions of 38 C.F.R. § 4.59, which relate to painful motion, are not limited to arthritis and must be considered when raised by the claimant or when reasonably raised by the record. Burton v. Shinseki, 25 Vet. App. 1 (2011). Historically, the service treatment records show that the Veteran is left hand dominant. See December 1979 Report of Medical History. It is also noted that based on symptoms noted in-service and post-service on VA examination, by a November 1986 rating decision, the RO granted service connection for strain of volar carpal ligament with neuropathy of the left medial nerve, rated as 10 percent disabling. The Veteran's claim for a higher rating was received in April 2005. In October 2005, the RO confirmed and continued the 10 percent rating, but by Statement of the Case issued in November 2006, the disability rating was increased to 20 percent pursuant to 38 C.F.R. § 4.124a, Diagnostic Code 8615. The Veteran c continued to pursue the appeal. The Veteran's carpal tunnel syndrome is rated under 38 C.F.R. § 4.124a, Diagnostic Code 8615, which pertains to neuritis of the median nerve. A 10 percent rating is appropriate for both the major and minor hand when there is mild incomplete paralysis of the median nerve. For moderate incomplete paralysis, a 30 percent rating is assigned for the major hand and a 20 percent rating is assigned for the minor hand. For severe incomplete paralysis, a 50 percent rating is assigned for the major hand and a 40 percent rating is assigned for the minor hand. A 70 percent rating is assigned for complete paralysis of the median nerve on the major side with such manifestations such as the hand inclined to the ulnar side; the index and middle fingers more extended than normal; considerable atrophy of the muscles of the thenar eminence; the thumb in the plane of the hand (ape hand); pronation incomplete and defective; absence of flexion of index finger and feeble flexion of middle finger; an inability to make a fist; the index and middle fingers remain extended; an inability to flex the distal phalanx of thumb; defective opposition and abduction of the thumb, at right angles to the palm; weakened wrist flexion; and pain with trophic disturbances. Complete paralysis of the minor hand is rated as 50 percent disabling. 38 C.F.R. § 4.124a, Diagnostic Code 8615 (2012). With respect to diseases of the peripheral nerves, the term "incomplete paralysis" indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis for a particular nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. When the involvement is bilateral, the ratings should be combined with application of the bilateral factor. 38 C.F.R. § 4.124a (2012). The evidence in this case indicates that the Veteran is left-handed. In statements and at hearings, the Veteran complained of parasthesias, constant pain, stiffness, giving way, and numbness in the left hand and wrist, as well as tingling in the fingers. He rated the pain as 6/10. He denied flare-ups of symptoms, dislocation, subluxation, locking, catching or popping. The Veteran reported dropping objects and reduction of grip strength. He was unable to use his left hand for heavy jobs such as washing a car, lifting, sweeping, or hammering, however, he was able to write, eat, and change clothes. The Veteran wore a volar wrist splint. While the aforementioned medical examination findings reveal no more than moderate functional impairment to the left median nerve, the evidence establishes that the Veteran is left-hand dominant. Thus a rating to 30 percent is warranted. As indicated however, a rating in excess of 30 percent is not warranted. No more than moderate functional impairment is present. Despite the Veteran's reports of increased functional limitations, the medical evidence of record does not show that the degree of lost or impaired function is consistent with severe incomplete paralysis of the median nerve. In this regard, the evidence shows that Phalen's sign and Tinel's sign have been noted as both positive and negative at different times throughout the period on appeal. On examination, there was parasthesias of the distribution of the left hand. Sensory examination was intact, however. Significantly, the VA examiner in June 2010 indicated that the Veteran's major limitation of functional activity due to the carpal tunnel syndrome of the left hand was sensory in nature and the Veteran's complaints of pain were probably orthopedic in origin. Further, with regards to the muscles in the left hand, on examination motor strength was 5/5 and reflexes were 2+. There was no muscle atrophy or asymmetry. No swelling, spasms, instability, crepitus, impingement, involuntary movements or tremors, were noted. Consistent with the June 2010 VA examination findings regarding the severity of the left wrist disability, in June 2005 the examiner described mild to moderate functional impairment, and the VA examiner in September 2006 characterized the Veteran's impairment due to carpal tunnel syndrome as moderate. Thus, while the Veteran complains of numbness and pain, the overall evidence is not indicative of severe incomplete paralysis. As the Veteran is left-hand dominant, and as the disability picture presented is consistent moderate incomplete paralysis of the median nerve, the Board finds that the Veteran is entitled to a 30 percent disability rating and no higher. In sum, the examination findings do not approximate the symptomatology contemplated under Diagnostic Code 8615, which must be satisfied in order to warrant the next higher rating of 50 percent. Simply stated, the Veteran's left wrist disability has not been productive of severe incomplete paralysis to warrant a higher disability rating. 38 C.F.R. § 4.124a, Diagnostic Code 8615. The Board has considered other potentially applicable diagnostic codes that provide for the assignment of separate or higher evaluations for the Veteran's disability. The Board observes however that no other diagnostic codes or provisions provide for separate or higher ratings based on the evidence of record. The provisions of 38 C.F.R. §§ 4.45 and 4.59 contemplate inquiry into whether there is limitation of motion, weakness, excess fatigability, incoordination, and impaired ability to execute skilled movements smoothly, and pain on movement, swelling, deformity, or atrophy of disuse. The Court has held that diagnostic codes predicated on limitation of motion require consideration of a higher rating based on functional loss due to pain on use or due to flare-ups. 38 C.F.R. §§ 4.40, 4.45, 4.59; Johnson v. Brown, 9 Vet. App. 7 (1997); and DeLuca v. Brown, 8 Vet. App. 202, 206 (1995). The Board has carefully considered the history of the Veteran's disability, as well as the current clinical manifestations and the effect this disability may have on the earning capacity of the Veteran. See 38 C.F.R. §§ 4.1, 4.2, 4.41 (2012). However, the Board finds that a higher evaluation based on limitation of motion is not for application in the present case. As noted, the principles delineated in the DeLuca case contemplate limitation of motion based upon joint function. The Veteran is currently rated under DC 8615; since this diagnostic code is not predicated upon loss of range of motion, but rather functional loss based on nerve impairment. 38 C.F.R. §§ 4.40 and 4.45, as interpreted in DeLuca, supra do not apply. See Johnson v. Brown, 9 Vet. App. 7, 9 (1996). While the Board acknowledges the Veteran's complaints of pain and swelling of the hand, it finds that an increased rating, based on the considerations of the DeLuca case, is not appropriate for strain of the volar carpal ligament of the left (major) wrist with neuropathy of the left median nerve. See 38 C.F.R. § 4.40, 4.45, 4.59; DeLuca, 8 Vet. App. at 204-7. Diagnostic Codes 5214, 5215. The Board has also considered whether the Veteran would be entitled to a higher evaluation under Diagnostic Code 5214, which provides for a 40 percent rating for ankylosis of the wrist, and under Diagnostic Code 5215, which provides for a 10 percent rating for limitation of motion of the wrist. See 38 C.F.R. § 4.71a, Diagnostic Codes 5214, 5215. However, he has not been shown to have ankylosis in his left wrist, and assignment of a disability rating under Diagnostic Code 5214 is therefore not for consideration. Moreover, with respect to loss of range of motion, Diagnostic Code 5215 would not allow for a higher rating. Additionally, awarding a separate evaluation under Diagnostic Codes 5214 and 5215 would constitute prohibited pyramiding by compensating the Veteran for the same disability. 38 C.F.R. § 4.14 (2012); see also Esteban v. Brown, 6 Vet. App. 259, 261-62 (1994). The Veteran is already being compensated for impaired function of the wrist under Diagnostic Code 8615. Thus, compensation for the disability under Diagnostic Code 5214 or Diagnostic Code 5215 would be duplicative since the symptomatology associated with the Veteran's strain of the volar carpal ligament of the left wrist with neuropathy of the left median nerve is already being accounted for under the appropriate diagnostic code. Accordingly, the Veteran is not entitled to higher or separate ratings under either Diagnostic Code 5214 or 5215, and no additional consideration is necessary in this regard. The medical evidence shows that the degree of lost or impaired function for strain of the volar carpal ligament of the left (major) wrist with neuropathy of the left median nerve, is consistent with, at most, moderate incomplete paralysis of the median nerve, throughout the appeal period, and as such a disability rating of 30 percent, but no higher, is granted. In exceptional cases an extraschedular rating may be provided. 38 C.F.R. § 3.321. The Court has set out a three-part test, based on the language of 38 C.F.R. § 3.321(b)(1), for determining whether a Veteran is entitled to an extraschedular rating: (1) the established schedular criteria must be inadequate to describe the severity and symptoms of the claimant's disability; (2) the case must present other indicia of an exceptional or unusual disability picture, such as marked interference with employment or frequent periods of hospitalization; and (3) the award of an extraschedular disability rating must be in the interest of justice. Thun v. Peake, 22 Vet. App. 111 (2008), aff'd, Thun v. Shinseki, 572 F.3d 1366 (Fed. Cir. 2009). Here, the rating criteria for the Veteran's service-connected strain of the volar carpal ligament of the left wrist with neuropathy of the left median nerve reasonably describe the Veteran's disability level and symptomatology, and provide for higher ratings for additional or more severe symptoms, which have not been shown. The medical evidence does not show that the Veteran's service connected left wrist disability causes unusual factors such as frequent hospitalizations or marked interference with employment beyond that contemplated by the rating schedule. The rating criteria are therefore adequate to evaluate the Veteran's strain of the volar carpal ligament of the left wrist with neuropathy of the left median nerve and referral for consideration of an extraschedular rating is not warranted. Service Connection for Right Wrist Carpal Tunnel Syndrome The Veteran claims entitlement to service connection for a right wrist condition as residuals of an in-service injury incurred when he fractured his left wrist. In the alternative, the Veteran asserts that his current right wrist disability is causally related to his service-connected left wrist disorder, in that his current right wrist disability was at least in part the result of "overuse" resulting from compensation for his dominant left wrist. Service connection may be established for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. Evidence of continuity of symptomatology from the time of service until the present is required where the chronicity of a chronic condition manifested during service either has not been established or might reasonably be questioned. 38 C.F.R. § 3.303(b). Regulations also provide that service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability was incurred in service. 38 C.F.R. § 3.303(d). In addition, a disability which is proximately due to or the result of a service-connected disease or injury shall be service-connected. 38 C.F.R. § 3.310 (2012). Secondary service connection is permitted based on aggravation. Compensation is payable for the degree of aggravation of a non-service-connected disability caused by a service-connected disability. Allen v. Brown, 7 Vet. App. 439 (1995). A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between the disability and an injury or disease incurred in service. Establishing service connection on a secondary basis essentially requires evidence sufficient to show that a current disability exists, and that the current disability was either caused or aggravated by a service-connected disability. 38 C.F.R. §§ 3.303, 3.310 (2012). Establishing service connection generally requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999); Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed. Cir. 1996) (table). The Veteran has been awarded service connection for strain of the volar carpal ligament of the left wrist with neuropathy of the left median nerve. To the extent that he associates his right wrist carpal tunnel syndrome with service or the service-connected left wrist disability, the Board acknowledges that he is competent to give evidence about what he experienced. He is competent to report that he has experienced right wrist pain and numbness. Charles v. Principi, 16 Vet. App. 370 (2002); Layno v. Brown, 6 Vet. App. 465 (1994) (competent lay evidence requires facts perceived through the use of the five senses). After a careful review of the claims folder, the Board finds that the pertinent evidence of record indicates that it is at least as likely as not that the Veteran's right carpal tunnel syndrome was caused or aggravated by the service-connected strain of the volar carpal ligament of the left wrist with neuropathy of the left median nerve. 38 C.F.R. § 3.310 (2012). The Veteran's service treatment records show that in December 1985 the Veteran injured his left wrist in service. There is some indication that he may have injured both hands and in the process of evaluating the Veteran's left wrist pathology, the Veteran apparently also underwent evaluation, including radiographic studies, of his right wrist. December 1985 x-rays of the right hand revealed no abnormalities. A February 1986 clinical treatment note recorded an assessment of possible carpal tunnel syndrome. A July 2005 MRI revealed bilateral carpal tunnel syndrome, moderate. There was also polyneuropathy in the upper extremities. VA treatment record in 2008 noted that EMG studies confirmed the presence of bilateral carpal tunnel syndrome. Significantly, on VA neurological examination in June 2010, following an examination of the Veteran and a review of the claims file, the examiner diagnosed bilateral carpal tunnel syndrome, worse on the left than the right, and opined that it was at least as likely as not that the Veteran's carpal tunnel/median neuropathy on the right hand was the result of carpal tunnel syndrome in the left hand. The examiner explained that carpal tunnel often became symptomatic in one side before affecting the extremities bilaterally, particularly where the side subsequently afflicted occurs as a result of increased use of that hand due to limitation of use of the hand that initially manifested carpal tunnel. Accordingly, the June 2010 neurological opinion supports the Veteran's claim for service connection for right wrist carpal tunnel syndrome on a secondary basis, that is, that the Veteran's currently diagnosed carpal tunnel/median neuropathy on the right hand was the result of the service-connected left wrist disability. The June 2010 physician's opinion is of great probative value. The opinion was rendered after a review of the claims file, to include the service treatment records, VA medical opinions, and post-service VA and private treatment records. The opinion is also consistent with the evidence of record and a rationale in support of the opinion was provided. For the foregoing reasons, the claim of entitlement to service connection for right wrist carpal tunnel syndrome is warranted on a secondary basis. 38 C.F.R. § 3.310. It is acknowledged that effective October 10, 2006, VA amended 38 C.F.R. § 3.310 to implement Allen v. Brown, 7 Vet. App. 439 (1995). The amendment sets a standard by which a claim based on aggravation of a nonservice-connected disability by a service-connected one is judged. That is, the rating activity must determine a baseline and current level of severity of the disability and determine the extent of aggravation by deducting the baseline level of severity, as well as any increase in severity due to the natural progress of the disease, from the current level. Although the overall intention of the amendment to 38 C.F.R. § 3.310 was to implement the Allen decision, the amended 38 C.F.R. § 3.310(b) clearly institutes additional evidentiary requirements and hurdles that must be satisfied before aggravation may be conceded and service connection granted. As 38 C.F.R. § 3.310(b) appears to place substantive evidentiary restrictions on a Veteran before aggravation may be conceded, and because the Veteran's claim was pending before the regulatory change was made, the Board will consider the version of 38 C.F.R. § 3.310 in effect before the change, which is the version that favors the claimant. See generally Kuzma v. Principi, 341 F.3d 1327 (Fed. Cir. 2003); VAOPGCPREC 7-03. Thus, as previously noted, service connection for a right wrist disability on a secondary basis is warranted. Based on the foregoing, the Board finds that the evidence supports the Veteran's claim for service connection for right wrist carpal tunnel syndrome as secondary to the service-connected strain of the volar carpal ligament of the left wrist with neuropathy of the left median nerve. As the competent medical evidence of record etiologically links the Veteran's right wrist carpal tunnel syndrome to the service-connected left wrist neurological disability, the Board finds that the evidence is at least in equipoise such that reasonable doubt may be resolved in favor of the Veteran, and service connection for right wrist carpal tunnel syndrome is granted. 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). ORDER An evaluation of 30 percent for volar carpal ligament of the left (major) wrist with neuropathy of the left median nerve is granted, subject to the law and regulations, governing the award of monetary benefits. Service connection for right wrist carpal tunnel syndrome is granted. (CONTINUED ON THE NEXT PAGE) REMAND While further delay is regrettable, the Board finds that additional development is required concerning the claims for service connection for a lumbar spine disability and bilateral chondromalacia patellae. The Veteran contends that he developed a lumbar spine disability and a bilateral knee condition as a result of multiple parachute jumps with hard landings during service. Pertinent evidence of record is to the effect that, while in service, the Veteran received the Parachutist Badge. Moreover, included in the Veteran's claims folder is a Jump Record representing 22 parachute jumps during the period from August 1980 to April 1983. The service treatment records show that in May 1982, during the Veteran's second period of active military service, the Veteran complained of pain in the knees after running. Reportedly, he wanted to have his knees evaluated in anticipation of a jump later that night. The Veteran was diagnosed and treated for bilateral chondromalacia patellae. The service treatment records did not show any lumbar spine condition. VA medical records showed a low back injury in November 2002, at which time the Veteran was working as a truck driver, for which he received Workmen's Compensation. A private treatment record in October 2003, associated with the Veteran's Worker's Compensation claim, noted that the Veteran injured his back in November 2002 when he slipped and fell while climbing down a cabin of a refuse truck. The clinician noted a lumbar strain with aggravation of degenerative disk disease at L4-5, L5-S1. In correspondence dated in September 2005, the Veteran's private physician indicated that the Veteran was currently suffering from chronic low back pain secondary to osteoarthritis, which, although fairly common in the general population, was likely to have been caused at least in part by the Veteran's prior history of repeated trauma as a paratrooper. VA clinical treatment reports in February and March 2006, noted the Veteran's report of onset of low back pain in 1980 during parachutist school in service. The Veteran underwent an orthopedic examination in June 2010. He related gradual onset of the condition in 1980 progressing with repeated parachute jumps. Following an examination of the Veteran, the examiner diagnosed lumbar spine osteoarthritis with no evidence of specific trauma. The examiner noted that a review of the claims file revealed multiple lumbar issues after 2003, following the work injury in November 2002. The examiner indicated that he could not find prior trauma that could be related to the Veteran's military service on description of his anatomic studies. Accordingly, based on examination of the Veteran, specific anatomic changes on available imaging studies, and considering the Veteran's reported history, the examiner concluded that the lumbar spine problem was less likely than not related to service. The Board finds that the VA examiner's opinion is inadequate for rating purposes. Specifically, the examiner did not discuss the Veteran's complaints of onset of low back pain due to parachute jumps in service, and his reports of recurrence of pain since that time. Moreover, the examiner did not address the September 2005 private physician's opinion that associated the Veteran's current back problems to the Veteran's in-service parachute activity, or the October 2004 evaluation report which suggests that the Veteran's lumbar spine condition preexisted the November 2002 work injury and was aggravated by it. Furthermore, although the VA examiner cited the specific bases for the opinion given, the examiner offered no explanation or rationale for the opinion. Sklar v. Brown, 5 Vet. App. 140 (1993). With regards to the Veteran's bilateral knee disorder, the June 2010 VA examiner concluded that the bilateral knee disability, diagnosed as bilateral patellofemoral and medial joint osteoarthritis, was less likely than not related to service. The examiner stated that the opinion was based on examination of the Veteran, specific anatomic changes on available imaging studies, and considering the Veteran's reported history. Specifically, the examiner indicated that the Veteran's claims file referred to no issues that could specifically be referred to the knee chondromalacia problems. However, as previously noted, the Veteran's service treatment records show that in May 1982 the Veteran was diagnosed and treated for bilateral chondromalacia patellae. Moreover, the examiner did not discuss the Veteran's complaints onset of bilateral knee problems due to parachute jumps in service, and although the examiner cited the specific bases for the opinion given, he offered no explanation or rationale for the opinion. Once VA has provided a VA examination, it is required to provide an adequate one, regardless of whether it was legally obligated to provide an examination in the first place. Barr v. Nicholson, 21 Vet. App. 303 (2007). A medical examination report must contain not only clear conclusions with supporting data, but also a reasoned medical explanation connecting the two. See Nieves- Rodriguez, supra; Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). For the reasons outlined above, the claims for service connection for a low back condition, and bilateral chondromalacia patellae, must be remanded for additional development. Finally, relevant ongoing medical records should also be obtained, to include any VA treatment records. 38 U.S.C.A. § 5103A(c) (West 2002); see also Bell v. Derwinski, 2 Vet. App. 611 (1992) (VA medical records are in constructive possession of the agency, and must be obtained if the material could be determinative of the claim). Accordingly, the case is REMANDED for the following action: 1. Notify the Veteran that he may submit lay statements from himself and from individuals that have first-hand knowledge, and/or were contemporaneously informed of his claimed disabilities and the relationship between a lumbar spine disability and bilateral chondromalacia patellae, and service. The Veteran should be provided a reasonable amount of time to submit this lay evidence. 2. Obtain, either electronically or physically, all treatment records for treatment received at the VAMC dated since March 2010. All attempts to obtain these records must be documented in the claims file. 3. Schedule the Veteran for a VA examination to ascertain the etiology of any lumbar spine or bilateral knee disability. The claims file must be reviewed by the examiner and the examination report should note that review. The examiner should provide the rationale for all opinions provided. The examiner should specifically opine as to the following: a) Diagnose all low back disabilities that may be present. b) State whether it is at least as likely as not (50 percent probability or greater) that any current low back disability is related to the Veteran's active service or to any incident of service, including the documented 22 parachute jumps during the period from August 1980 to April 1983. The examiner should consider the Veteran's statements regarding his symptoms in service and his statements of continuous symptoms after service. The examiner is also asked to consider the post-service medical evidence, to include the September 2005 private physician's opinion report and the October 2004 evaluation report which suggests that a lumbar spine condition preexisted the November 2002 work injury and was aggravated by it. c) Diagnose all right and left knee disabilities that may be present. d) State whether it is at least as likely as not (50 percent probability or greater) that any current right or left knee disability is related to the Veteran's active service or to any incident of service, including the documented 22 parachute jumps during the period from August 1980 to April 1983. The examiner should consider the Veteran's statements regarding his symptoms in service and his statements of continuous symptoms after service. The examiner is also asked to consider the May 1982 clinical treatment record that shows the Veteran was diagnosed and treated for bilateral chondromalacia patellae during the Veteran's second period of service. 4. Then, readjudicate the claims. If the decision remains adverse to the Veteran, issue a supplemental statement of the case and allow the applicable time for response. Then, return the case to the Board. 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). 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. 2012). ______________________________________________ C. CRAWFORD Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs