Citation Nr: 1311799 Decision Date: 04/09/13 Archive Date: 04/19/13 DOCKET NO. 09-23 306 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for a left hand disability. REPRESENTATION Appellant represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD T.S. Willie, Counsel INTRODUCTION The Veteran served on active duty from April 1946 to February 1948, and from June 1955 to February 1985. This case initially comes before the Board of Veterans' Appeals (Board) on appeal from a rating decision from the VA Regional Office (RO) in St. Petersburg, Florida. The Veteran testified before the undersigned at a June 2011 hearing. The case was remanded for additional development in January and December 2012. Please note this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). 38 U.S.C.A. § 7107(a)(2) (West 2002). 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 The Veteran appeals the denial of entitlement to service connection for a left hand disability manifested by numbness. In this regard, in July 1964, the Veteran was involved in an inservice motor vehicle accident and suffered a left ulna fracture. There was deceased sensation to pinprick in the left hand and left lower arm. In February 1976, the appellant suffered a second degree burn between the second and third fingers of his left hand while at the Rock Island Arsenal. In November 1982, the Veteran reported a two week history of left arm discomfort with left axillary pain that sometimes radiated down the arm with numbness and weakness in the hand. Physical examination revealed no axillary, arm, hand or cervical spine tenderness. In April 1984, the Veteran reported a history of swollen or painful joints. The examiner noted that the appellant had a history of arthritis involving the hands which was diagnosed 1977. A history of painful hand joints secondary to arthritis was also noted. Physical examination, however, revealed that the appellant's upper extremities were clinically normal. No confirmatory x-ray reports from 1984 are available. At his September 1984 separation examination a history of swollen and painful joints was reported. Physical examination revealed normal upper extremities. In August 2005, the appellant reported a history of left shoulder pain. Following a physical examination the clinical assessments included hand weakness, rule out carpal tunnel syndrome. A November 2005 upper extremity nerve conduction study revealed clinically normal findings. The Veteran complained of hand pain in May and December 2007. A March 2008 nerve conduction study conducted was abnormal with the median sensory nerve action potential amplitude. In June 2008, the Veteran argued that left hand peripheral neuropathy was directly connected to his in-service motor vehicle accident. He stated that while in service he sustained a chip fracture to his T-3 portion of his neck and his left ulna struck the steering wheel and was fractured. He asserted that he now had arthritis, as well as recurrent pain and numbness to the left hand. In May 2009, the Veteran stated that his left hand peripheral neuropathy was secondary to his service connected cervical spine spondylosis and continued to worsen. Private treatment records from Dr. Derbes from 2007 to 2009 show diagnoses of chronic neck pain syndrome and degenerative disc disease with radicular features. Following a March 2010 VA examination, the examiner found no objective evidence to support a diagnosis of neuropathy. The examiner diagnosed status post left ulnar fracture, resolved without residuals, not proximate cause of undiagnosed neuropathy. In March 2010, an assessment of bilateral hand pain, carpal tunnel syndrome was entered. In July 2011, an assessment of bilateral hand pain, osteoarthritis was entered. At his July 2011 hearing, the Veteran argued that his hand disorder was the result of lifting injuries suffered while performing his duties as a medic in service. Following a May 2012 VA examination, the VA examiner found insufficient evidence to warrant a diagnosis of neuropathy. The examiner reported that recent examination revealed no evidence of focal neuropathy, and despite the appellant's complaints, there were no objective findings to support a finding that the Veteran had neuropathy. The examiner noted that without a disability, no medical opinion could be offered to address the etiology of the appellant's complaints. When this issue was before the Board in December 2012, it was found that an addendum was necessary to address whether the Veteran had any left arm and/or hand disorder manifested by numbness which is related to his military service or to his service connected cervical spine or left ulnar disabilities. In a January 2013 VA examination report a VA examiner again found no objective medical evidence of cervical radiculopathy affecting the left upper extremity, left carpal tunnel syndrome and/or left ulnar tunnel sydrome based on three electromyopathy/nerve conduction studies results dated in November 2005, March 2008 and May 2012. The examiner did find left upper extremity numbness of uncertain etiology, but such was less likely than not caused by, related to, or aggravated by service, to include due to cervical spondylosis or residuals of a left ulnar fracture. According to the examiner, in service left arm nerve compression resolved (November 1982). The examiner also stated that September 1968 and April 1984 service treatment records were silent for left upper extremity numbness or cervical radiculopathy affecting the left upper extremity, left carpal tunnel syndrome and/or left ulnar tunnel syndrome. The examiner opined that numbness was at least as likely as not caused by and related to inconclusive left upper extremity findings of uncertain etiology, suggesting axonal sensory neuropathy noted in May 2012. The examiner could not comment on the etiology/causation of such or resolve the issue without resorting to mere speculation. The VA examiner reported reviewing the diagnoses of Dr. Derbes but found that those were based solely on the Veteran's subjective complaints. She found no objective medical evidence of cervical radiculopathy affecting the left upper extremity, left carpal tunnel syndrome and/or left ulnar tunnel syndrome based on the VA examination results of November 2005, March 2008 and May 2012. The examiner concurred with the prior, March 2010 and May 2012, VA examiners. Unfortunately, while the January 2013 VA examiner acknowledged the diagnosis of bilateral hand pain-osteroarthritis rendered by Dr. Derbes, she did not address the in service notations of hand arthritis. The Veteran alleges that he has a left hand disability to include arthritis that is attributable to service. He is service connected, inter alia, for left shoulder and elbow arthritis, as well as for residuals of a fractured left ulna. A VA examination has not been conducted to determine whether he has left hand arthritis and if so, whether such is related to service. Such development is warranted under the decision of the United States Court of Appeals for Veterans Claims in Clemons v. Shinseki, 23 Vet. App. 1 (2009). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2012). Expedited handling is requested.) 1. The RO should contact the Veteran and request that he identify any health care provider who has treated any left hand arthritis since May 2011. The Board is particularly interested in securing medical records which would link left hand arthritis to service or to a service connected disorder. Thereafter, the RO must attempt to secure all pertinent records. If the RO cannot locate all records identified by the Veteran, the RO must specifically document the attempts that were made to locate them, and explain in writing why further attempts to locate or obtain any government records would be futile. The RO must then: (a) notify the claimant of the specific records that it is unable to obtain; (b) explain the efforts VA has made to obtain that evidence; and (c) describe any further action it will take with respect to the claims. The claimant must then be given an opportunity to respond. 2. Thereafter, the RO/AMC should schedule the Veteran for a VA orthopedic examination to determine the nature and etiology of any diagnosed left hand disability. All indicated studies must be conducted. After diagnosing any pertinent disabilities, the examiner is to specifically address the following questions: (a) Is it at least as likely as not, i.e., is there a 50 percent probability or more, that any left hand arthritis was incurred during the Veteran's service? (b) Is it at least as likely as not, i.e., is there a 50 percent probability or more, that the left hand arthritis is caused and/or aggravated by service-connected disability, to include cervical spondylosis, residuals of a left ulna fracture, or arthritis that affects multiple joints to include the left shoulder and left elbow? All opinions expressed must be accompanied by a complete and full written rationale with evidence in the claims file and sound medical principles. The examiner must address the in service notations of arthritis of the hands. If left hand arthritis is not found upon examination, please explain what evidence supports this conclusion in light of diagnoses rendered by Dr. Derbes and the in service manifestations. 3. After the development requested has been completed, the RO/AMC should review the examination report to ensure that it is in complete compliance with the directives of this remand. If the report is deficient in any manner, the RO/AMC must implement corrective procedures at once. 4. The Veteran is to be notified that it is his responsibility to report for the examination and to cooperate in the development of the claim. The consequences for failure to report for a VA examination without good cause may include denial of the claim. 38 C.F.R. §§ 3.158, 3.655 (2012). 5. Upon completion of the above requested development and any additional development deemed appropriate, the RO/AMC should readjudicate the remanded issue. All applicable laws and regulations should be considered. If any benefit sought on appeal remains denied, the appellant and his representative should be provided with a supplemental statement of the case. An appropriate period of time should be allowed for response. 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). _________________________________________________ DEREK R. BROWN 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) (2012).