Citation Nr: 1318321 Decision Date: 06/05/13 Archive Date: 06/11/13 DOCKET NO. 01-02 698A ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Cleveland, Ohio THE ISSUE Entitlement to service connection for bilateral carpal tunnel syndrome with trigger fingers other than the right middle finger. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD D. Schechter, Counsel INTRODUCTION The Veteran served on active duty from September 1970 to November 1972 and from June 1975 to September 1995. The appeal comes before the Board of Veterans' Appeals (Board) from an April 2000 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The claim began as one for bilateral carpel tunnel syndrome with trigger fingers. However, in a November 2011 rating decision, the RO granted service connection for trigger finger of the right middle (long) finger, status post A-1 pulley release. Therefore, the claim on appeal has been characterized as noted on the cover page of this decision. The Board remanded the claim in February 2006 and September 2012 for additional development. The case now returns to the Board for further review. The appeal is REMANDED to the RO via the Appeals Management Center (AMC) in Washington, DC. VA will notify the appellant if further action is required. REMAND The Board had remanded the claim in February 2006 for a VA examination to address whether it was at least as likely as not that the Veteran's claimed bilateral carpal tunnel syndrome with trigger fingers developed in service or was otherwise causally related to service. Unfortunately, the VA examiner in November 2011 concluded that she could not, without resorting to "mere speculation" address the likelihood that the Veteran's bilateral carpal tunnel syndrome had developed in service. See Jones v. Shinseki, 23 Vet. App. 382, 390 (2010) (when an examiner concludes that an "etiology opinion is not possible without resort to speculation . . . it is not clear whether the examiner lacks the expertise to render such an opinion, or whether some additional testing or information is needed, and possibly available, that would permit such an opinion"). The November 2011 VA examiner did note that the Veteran performed clerical duties in service, that a confirmed diagnosis of bilateral carpal tunnel syndrome was made by medical professionals in August 1999, and that bilateral carpal tunnel syndrome was established by EMG testing in 1997. She further noted the Veteran's history of left carpal tunnel release surgery in 1999 and right carpal tunnel release surgery in 2001, with these surgeries reportedly well executed without recurrence of carpal tunnel syndrome as of the time of examination in November 2011. The Board remanded the claim in September 2012 because the November 2011 examiner did not note or address service treatment and examination records showing difficulties potentially associated with the bilateral carpal tunnel syndrome, including complaints over the years in service of musculoskeletal pain including hand pain, with complaints of pain in the hands upon service separation examination in June 1995. The Board then questioned whether service connection might also be secured on a secondary basis, as proximately due to service-connected left wrist fracture or other service-connected hand or wrist disabilities, including degenerative changes of the right hand and thumb, and right middle finger trigger finger. Following that remand, the Veteran was afforded another VA examination for compensation purposes in January 2013, the findings and conclusions of which were noted in three DBQ ("disability benefits questionnaire") examination reports, all authored by the same examiner, specifically, a hand and finger conditions examination, a peripheral nerves examination, and a wrist conditions examination. However, the examiner did not provide answers to the questions posed by the February 2006 and November 2011 Board remands. The January 2013 examiner did not address the etiology of the Veterans' claimed bilateral carpal tunnel syndrome (with trigger fingers other than the right middle finger), apparently concluding that because the Veteran's bilateral carpal tunnel syndrome was not symptomatic at the time of the examination, an etiology opinion of the carpal tunnel syndrome was not required. The examiner instead focused on the Veteran's current complaints of numbness and tingling in the arms and hands, which he attributed to cervical radiculopathy. The examiner noted that the Veteran had experienced cervical radiculopathy in service but also noted that past cervical radiculopathy had resolved with cervical fusion surgery. Service connection is already in effect for cervical spine degeneration, status post spinal fusion surgery, and hence an etiology opinion addressing that condition is not required. Consequently, remand is again required to address the etiology of bilateral carpal tunnel syndrome, status post bilateral carpal tunnel release surgeries, with trigger fingers other than the right middle finger. Where, as here, the VA examination does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for rating purposes. 38 C.F.R. § 4.2 (2012). Once VA provides an examination in a service connection claim, the examination must be adequate or VA must notify the Veteran why one will not or cannot be provided. Barr v. Nicholson, 21 Vet. App. 303, 311 (2007). Accordingly, the case is REMANDED for the following action: 1. Afford the Veteran the opportunity to submit additional evidence or argument in furtherance of the remanded claim. 2. With the Veteran's assistance or authorization, as appropriate, request any as yet unobtained treatment or evaluation records pertinent to the remanded claim. 3. Thereafter, afford the Veteran a new VA examination by a physician with expertise in peripheral neurological disorders of the hands including carpal tunnel syndrome. The claims folder must be made available to the examiner for review in conjunction with the examination. All necessary studies, tests, and evaluations should be performed and the results noted in the examination report. The examiner should address the following: a. The examiner should obtain a history both from the Veteran and from the clinical records. The examiner should note in particular the Veteran's documented history of complaints of hand pain in service and of findings of bilateral carpal tunnel syndrome with trigger fingers in the years post service. (Service connection for trigger finger of the right middle (long) figure has already been granted.) The examiner should note relevant service treatment records showing multiple complaints of pain in the hands, including complaints at the Veteran's June 1995 separation examination. A September 1991 service treatment report recorded a history of multi-joint arthralgia involving the bilateral elbows and hands, specifically the 2nd and 3rd metacarpophalangeal joints. The examiner should also note a December 1995 VA examination, three months following service separation, when the Veteran complained of multiple musculoskeletal pains including pain in the right hand. The examiner should note EMG testing in 1997 supporting diagnoses of bilateral carpal tunnel syndrome and carpal tunnel release surgeries performed on the left wrist in 1999 and on the right wrist in 2001. The examiner should also note a March 2007 private treatment report supporting a causal link between the Veteran's service-connected left wrist fracture and development of carpal tunnel syndrome. b. For the Veteran's left carpal tunnel syndrome status post release surgery, his right carpal tunnel syndrome status post release surgery, and any trigger finger conditions present at any time from 2000 to the present (other than the already service-connected right middle finger), the examiner should provide separate opinions for each of these conditions, addressing whether it is at least as likely as not (50 percent or greater probability) that (1) it is a condition or the residuals of a condition which developed in or persisted from service or is otherwise causally related to the Veteran's periods of service from September 1970 to November 1972 and from June 1975 to September 1995; or (2) it is a condition which was caused or aggravated (permanently increased in service) by a service-connected disability including residuals of a fractured left wrist. In providing these opinions, the examiner should carefully review service and post-service medical records, as well as lay statements and other relevant evidence as contained within the claims file. c. All opinions provided should include discussion of specific evidence of record. The examiner must provide a complete rationale for any conclusions drawn or opinions expressed. If an opinion cannot be reached without resort to mere speculation, this must be fully explained. See Jones v. Shinseki, 23 Vet. App. 382 (2010). The conclusions of the examiner should reflect review of the claims folder, and the discussion of pertinent evidence. 4. Thereafter, readjudicate the remanded service connection claim de novo. If the benefits sought by the remanded claim are not granted to the Veteran's satisfaction, provide him and his representative with a Supplemental Statement of the Case (SSOC) and an appropriate opportunity to respond. 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). _________________________________________________ KATHLEEN K. GALLAGHER 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).