Citation Nr: 1313198 Decision Date: 04/19/13 Archive Date: 05/02/13 DOCKET NO. 08-15 501 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE 1. Entitlement to service connection for left carpal tunnel syndrome. 2. Entitlement to service connection for right carpal tunnel syndrome. REPRESENTATION Appellant represented by: Daniel G. Krasnegor, Attorney at Law WITNESS AT HEARING ON APPEAL Appellant ATTORNEY FOR THE BOARD C. Lawson, Counsel INTRODUCTION The Veteran served on active duty from July 1983 to October 1987 and from November 1989 to August 1993. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a December 2001 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA) denying the claim at issue. The Board confirmed the denial in September 2006, and the Veteran appealed that decision to the United States Court of Appeals for Veterans Claims (Court). The Court vacated the Board's decision in March 2008. In December 2008, June 2010, and May 2012, the Board remanded the case to the RO. The Veteran presented testimony at a Board hearing in February 2006, before a Veterans Law Judge who is no longer employed by the Board. The Veteran was offered a new hearing, but declined such in May 2008. The Board granted service connection for posttraumatic stress disorder at the time of its May 2012 decision remanding the issues currently on appeal to the RO. FINDING OF FACT The Veteran's current left and right carpal tunnel syndrome was not manifest in service or to a degree of 10 percent within one year of separation and is otherwise unrelated to service. CONCLUSIONS OF LAW 1. The criteria for service connection for left carpal tunnel syndrome are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). .2 The criteria for service connection for right carpal tunnel syndrome are not met. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1131, 1137 (West 2002); 38 C.F.R. §§ 3.303, 3.307, 3.309 (2012). REASONS AND BASES FOR FINDING AND CONCLUSIONS Upon receipt of a complete or substantially complete application, VA must notify the claimant of the information and evidence not of record that is necessary to substantiate a claim, which information and evidence VA will obtain, and which information and evidence the claimant is expected to provide. 38 U.S.C.A. § 5103(a). The notice requirements apply to all five elements of a service connection claim: 1) Veteran status; 2) existence of a disability; (3) a connection between the Veteran's service and the disability; 4) degree of disability; and 5) effective date of the disability. Dingess v. Nicholson, 19 Vet. App. 473 (2006). The notice must be provided to a claimant before the initial unfavorable adjudication by the RO. Pelegrini v. Principi, 18 Vet. App. 112 (2004). The notice requirements may be satisfied if any errors in the timing or content of such notice are not prejudicial to the claimant. Mayfield v. Nicholson, 19 Vet. App. 103 (2005), rev'd on other grounds, 444 F.3d 1328 (Fed. Cir. 2006). The RO provided the Veteran notice by letters dated in December 2003, September 2006, December 2006, and January 2009. The notification complied with the requirements of Quartuccio v. Principi, 16 Vet. App. 183 (2002), identifying the evidence necessary to substantiate a claim and the relative duties of VA and the claimant to obtain evidence; and Pelegrini v. Principi, 18 Vet. App. 112 (2004). While the notification was not provided prior to the rating decision appealed, adequate notice has been followed by subsequent adjudications, curing the timing defects. Prickett v. Nicholson, 20 Vet. App. 370 (2006). VA also has a duty to assist a claimant under the VCAA. VA has obtained service treatment records; assisted the Veteran in obtaining evidence; examined the Veteran for carpal tunnel syndrome in 2009, 2010, and 2012; and afforded the Veteran the opportunity to give testimony before the Board. The examinations are adequate as they contain sufficient information for VA to fairly decide the claim. VA examined the Veteran and obtained medical opinions. The examiner in 2012 provided an adequate rationale for the opinion. The examiner physically evaluated the Veteran, reviewed the claims file, and cited relevant medical authority and principles. This examination was therefore adequate. All known and available records relevant to the issues on appeal have been obtained and associated with the Veteran's claims file; and the Veteran has not contended otherwise. The RO complied with the Board's remand by obtaining an examination as indicated and readjudicating the claim. The representative requests another VA examination, arguing in December 2012 that there is no indication that the Board's May 2012 instruction that the examination be by a medical doctor with specialized knowledge and experience with carpal tunnel syndrome has been complied with. The representative's December 2012 report is to the effect that online research indicates that that physician's field is listed as medicine and that he specializes in internal medicine and aerospace medicine. The Board declines to find that the August 2012 VA examiner was not qualified to render an opinion. The examination report identifies the examiner as a medical doctor. The examination order document to the Medical Center includes the Board's remand directive that the examination should be conducted by a medical doctor with specialized knowledge and experience with carpal tunnel syndrome. The fact that the examiner might have a specialty in internal medicine does not per se mean that the examiner does not have specialized knowledge and experience with carpal tunnel syndrome. The Board believes that a medical doctor with a specialty in internal medicine might have a number of areas which he or she has specialized knowledge and experience in. It is stressed that the Board's remand did not direct that the examination be conducted by a particular medical specialist such as an orthopedist or neurologist. The representative's argument is recognized, but not found to be persuasive. The representative also argues that the August 2012 VA examiner failed to provide a complete opinion with an adequate rationale. The representative indicated that the internet research shows that cramping (which was reported in 1993) can be a symptom of carpal tunnel syndrome as it progresses. However, the examiner felt that the Veteran's clinical presentation in 1993 was not consistent with carpal tunnel syndrome, and he cited to a medical reference about carpal tunnel syndrome. Medical judgment is required, and the examiner exercised such judgment, having considered the symptomatology reported in 1993, disorders that are known to cause cramping, the diagnosis which was rendered in 1993, and medical literature on the cause of muscle spasm. VA has complied with the notice and assistance requirements and the Veteran is not prejudiced by a decision on the claim at this time. The issues before the Board involve claims of entitlement to service connection. Applicable law provides that service connection will be granted if it is shown that the Veteran suffers from disability resulting from an injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty, in the active military, naval, or air service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. That an injury occurred in service alone is not enough; there must be chronic disability resulting from that injury. If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Additionally, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, such as organic disease of the nervous system, are presumed to have been incurred in service if manifest to a compensable degree within one year of discharge from service. 38 U.S.C.A. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. Service connection may also be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). The Board has considered all relevant evidence of record, including that found on Virtual VA, VA's electronic data storage system. Service treatment records do not mention carpal tunnel syndrome. On service separation examination in April 1993, the Veteran reported arthritis, rheumatism, or bursitis, and he denied neuritis and paralysis. Clinically, his upper extremities and neurologic status were normal. The Veteran filed a VA compensation claim in August 1993, indicating that cramps in his hand began in July 1990. On VA examination in October 1993, the Veteran reported that he was having muscle cramps in his hands and that he had been told that he had arthritis. He reported that he used to type a lot. On examination, there was no sensory loss noted and the Veteran's nervous system was normal. X-rays of the Veteran's hands were normal. The diagnosis was muscle spasms of the feet and hands. On March 1996 VA evaluation, the Veteran reported joint pain in his hands on occasion. There is no diagnosis of carpal tunnel syndrome in any of the medical records following service discharge through the time of a VA examination in February 1999. On private neurology evaluation in February 1999, there was no drift in the Veteran's upper extremities, and strength, tone, and coordination were all normal. Sensory examination was unremarkable. On VA Persian Gulf examination in January 2000, the Veteran complained of diffuse arthralgia since 1991-1992. He also reported cramps in his hands since 1991. He complained of a sensation of his hands going to sleep and of having to wake them up by shaking them so the pins and needles go away. Nerve conduction velocity/electromyogram studies revealed slowing across the wrists in the median nerves, and bilateral carpal tunnel syndrome was diagnosed. An April 2000 letter from T.K. Ortega, M.D. states that the Veteran had signs and symptoms of carpal tunnel syndrome that he had had since 1991. A November 2007 VA medical record reports that the Veteran had a 20-year history of dorsal hand pain and forearm radiation. The symptoms were not classic for carpal tunnel syndrome. On VA examination in February 2009, the Veteran reported the onset of carpal tunnel syndrome as in service. He reported originally being told that he had arthritic pain in his hands. He was diagnosed by electromyogram/nerve conduction velocities with carpal tunnel syndrome in January 2000. He reported the onset of numbness 5-6 years ago, and of pain in his hands since the army. The Veteran's claims folder was extensively reviewed and the examiner stated that the Veteran was diagnosed with carpal tunnel syndrome in 2000 and that medical record documentation did not support carpal tunnel syndrome in service. On VA neurology consultation in April 2009, the Veteran reported that he had had numbness and tingling in the first two digits of his hands over the past decade or so. Carpal tunnel syndrome was diagnosed. On VA examination in September 2010, the examiner indicated that the claims folder was reviewed and that impingement of the median nerves has a clear etiology. Complaints of hand cramping in service were simply not suspicious for carpal tunnel syndrome in service. Therefore, the Veteran's carpal tunnel syndrome was less likely than not caused by or related to service. The Board remanded the case to the RO in May 2012, noting that there had been symptoms reported in April and October 1993. The Veteran was to be scheduled for a VA examination by a medical doctor with specialized knowledge and experience with carpal tunnel syndrome. On VA examination in August 2012, the Veteran's claims folder was reviewed. The Veteran advised the examiner that he had strained his hands in service around 1990-91 due to overuse while typing, and commenced developing cramps. He stated that he was treated with ace bandages around his wrist and anti-inflammatory. He indicated that when he was evaluated in 2000 due to multiple pains, he was diagnosed with carpal tunnel syndrome and that he had received treatment for it since. The examiner concluded that the Veteran's bilateral carpal tunnel syndrome was not caused by or related to service. It was less likely than not related to the episode of pain and cramping of the hand reported in 1993. The examiner explained that a sudden contraction of the interdigitoris muscle will case cramps and pain in the hands, and that it had no relationship to carpal tunnel. Muscle spasm, which had been the diagnosis in 1993, could be caused by multiple factors, none of which included carpal tunnel syndrome. Besides, the Veteran's clinical presentation was not consistent with a carpal tunnel syndrome diagnosis. The examiner reviewed medical literature regarding the cause of muscle spasm and noted that grasping writing instruments or household tools for prolonged periods could bring on muscle cramps in the hands and fingers. Low blood levels of potassium, calcium, or magnesium could cause muscle spasms. Muscle spasms could also be signs of more serious neuromuscular disorders such as cerebral palsy, multiple sclerosis, or amyotrophic lateral sclerosis. The examiner noted regarding carpal tunnel syndrome that the median nerve supplies sensation to the thumb, index finger, middle finger, and in most people, to part of the ring finger. Thickening of structures, inflammation, swelling, or increased fluid retention could compress the nerve, causing pain and numbness in the fingers, particularly to the thumb, index, and middle fingers, and serious hand weakness. Sensation of the palm is not affected because the branch of the median nerve to the palm does not go through the carpal tunnel. He cited a medical website as a source for information. Based on the evidence, the Board concludes that service connection is not warranted for left or right carpal tunnel syndrome. Neither was manifest in service or to a degree of 10 percent within one year of separation, neither has been related to service, and neither has continued since service. Service treatment records do not contain a diagnosis of carpal tunnel syndrome, and there were no complaints of numbness in service. To the contrary, the Veteran denied having or having had neuritis or paralysis in service on service discharge examination in April 1993, which was after the Veteran's reported symptoms in 1991-92, and he was normal on service discharge examination in April 1993. Carpal tunnel syndrome was first diagnosed in January 2000. That was after the first complaints were made of the Veteran's hands going to sleep and having pins and needles sensations. The examiner in August 2012 indicated that carpal tunnel syndrome causes pain and numbness in the thumb, index, and middle fingers, and hand weakness. This is not what the Veteran had complained of during or shortly after service. Instead, he had had arthritic complaints as well as complaints of muscle cramps in his hands, and the latter were assessed as muscle spasm with the Veteran's nervous system being normal at the time. Moreover, each of the VA examiners who have reviewed the Veteran's claims folder and rendered medical opinions concerning the claim have concluded that the Veteran's current carpal tunnel syndrome is unrelated to service. Dr. Ortega's April 2000 letter can be read as supporting the claim, but only weakly, as there is no explanation for his opinion and no indication of what relevant evidence he considered in rendering it. Accordingly, it is of little probative value and is outweighed by the opinions of the VA examiners, each of which reviewed the Veteran's claims folder and gave explanations for their opinions. See Prejean v. West, 13 Vet. App. 444 (2000) (factors for determining probative value of medical opinions include their thoroughness and detail, whether they discussed why contrary opinions were not persuasive, and the opinion-writer's access to relevant records). The representative argues in November 2011 that the April 2000 letter from Dr. Ortega demonstrates that Dr. Ortega believed that symptoms such as cramping, complained of by the Veteran since 1991, were indicative of carpal tunnel syndrome. The Board disagrees, however. Dr. Ortega's letter makes no reference to cramping, and there is no indication that he considered any of the Veteran's previous medical records (including the 1993 VA examination report which mentioned cramping). The representative also argues, in a letter received in August 2008, that Dr. Ortega had attributed muscle cramps, spasm, joint pain, and burning at the wrists to carpal tunnel syndrome. However, nothing in Dr. Ortega's letter suggests that. The specific symptoms discussed in his letter were hand weakness, pain, numbness, and a tingling sensation in the medial nerve, and none of these were mentioned in 1993 or complained of before 2000. Moreover, the Veteran had denied any neuritis and was found to be normal on service discharge examination in April 1993. Carpal tunnel syndrome was first manifest many years after service, and so the so the presumption of service connection for organic disease of the nervous system when it is manifest within one year of service separation does not permit an allowance of the claim. To address the matter of continuity since service in further detail, the Board concludes that the preponderance of the evidence indicates that the Veteran's carpal tunnel syndrome has not continued since service. It is a neurological disorder. The report on VA examination in February 2009 was of numbness of 5-6 years duration. Medical reports prior to its diagnosis in 2000 had all been neurologically normal, and no credible medical or other evidence indicates that carpal tunnel syndrome was present in service or has continued since then. The April 2000 report from Dr. Ortega, argued by the representative in August 2008 as supporting the existence of sign and symptoms of carpal tunnel syndrome since 1991, is not probative, as there is no underlying evidence supporting it. Dr. Ortega does not explain how he knew that the Veteran had had signs and symptoms of carpal tunnel syndrome since 1991, and the preponderance of the evidence indicates that the Veteran did not. Last, on VA examination in February 2009, the Veteran reported the onset of carpal tunnel syndrome in service. As a layperson, the Veteran is competent to report inservice symptoms. However, he is not competent to assign a medical diagnosis to such symptoms. See generally Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). In the present case, the record now includes opinions by medical doctors who, with full knowledge of the inservice symptoms and the Veteran's subsequent medical history, to the effect that the symptoms noted during service were not manifestations of carpal tunnel syndrome. The Board is also not competent to enter a medical opinion and must therefore rely on the opinions of medical personnel. The Board finds the opinions supported by a clear and persuasive rationale. The medical evidence in this case is simply against the Veteran's claims. ORDER Service connection for left carpal tunnel syndrome is not warranted. Service connection for right carpal tunnel syndrome is not warranted. The appeal is denied. ____________________________________________ ALAN S. PEEVY Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs