Citation Nr: 1320399 Decision Date: 06/25/13 Archive Date: 07/05/13 DOCKET NO. 09-49 014 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Louis, Missouri THE ISSUE Entitlement to service connection for bilateral carpal tunnel syndrome. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD M. H. Stubbs, Counsel INTRODUCTION The Veteran served on active duty from August 1977 to August 2002. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a June 2009 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Louis, Missouri. FINDINGS OF FACT 1. The Veteran injured his right and left wrists in service. His in-service duties included administrative work from at least 1992 to 2001. 2. Bilateral carpal tunnel syndrome has not been satisfactorily disassociated from the Veteran's period of service. CONCLUSION OF LAW Resolving all reasonable doubt in favor of the Veteran, the criteria for service connection for bilateral carpal tunnel syndrome have been met. 38 U.S.C.A. §§ 1110, 1131, 5107(b) (West 2002 & Supp. 2012); 38 C.F.R. §§ 3.102, 3.303 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSION Duties to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), Pub. L. No. 106-475, 114 Stat. 2096 (Nov. 9, 2000) (codified at 38 U.S.C.A. §§ 5100, 5102, 5103, 5103A, 5106, 5107, and 5126 redefined VA's duty to assist a claimant in the development of a claim. VA regulations for the implementation of the VCAA were codified as amended at 38 C.F.R. §§ 3.102, 3.156(a), 3.159, and 3.326(a). Given the Board's favorable disposition of the claim to for service connection for bilateral carpal tunnel syndrome, the Board finds that failure to discuss VCAA compliance and duty to assist requirements will result in harmless error to the Veteran. Laws and Regulations 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 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). Establishing service connection generally requires (1) medical evidence of a current disability; (2) medical or, in certain circumstances, lay evidence of in-service incurrence or aggravation of a disease or injury; and (3) medical evidence of a nexus between the claimed in-service disease or injury and the present disability. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004); see Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd per curiam, 78 F.3d 604 (Fed.Cir.1996) (table); see also Hickson v. West, 12 Vet. App. 247, 253 (1999); 38 C.F.R. § 3.303. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Shedden/Caluza element is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post- service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. see Savage v. Gober, 10 Vet. App. 488. at 495-96 (1997); see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By "reasonable doubt" is meant one that exists because an approximate balance of positive and negative evidence which does satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. 38 C.F.R. § 3.102. See also 38 U.S.C.A. § 5107(b); Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Factual Background and Analysis The Veteran contends that he has developed bilateral carpal tunnel syndrome as a result of his 25 years of service, including injuries to both wrists in service. Service treatment records include treatment for chronic right wrist pain in January 1994. The January 1994 record noted that the Veteran complained of pain off and on since he broke his right wrist in 1978. He reported using a computer sometimes, and the record appears to note that this "isn't his primary job." His wrist pain would flare-up with woodworking. He had a positive Finkelstein's test, and was assessed with tenosynovitis. An x-ray revealed an old scaphoid fracture with non-union. In February 2002, he again complained of ongoing and progressive right wrist pain from an injury 24 years prior. On evaluation he had positive Watson's test (to detect instability between the scaphoid and lunate bones), Tinel's test (to detect irritated nerves), and Phalen's test (a diagnostic test for carpal tunnel syndrome). The evaluator's handwriting is difficult to read, but it does not appear that the Veteran was diagnosed with carpal tunnel syndrome at this time or during service. Regarding his left wrist, treatment records from January 1995 show that the Veteran injured his when he fell during basketball. He reported his left wrist "hyperextended" but that he did not hear or feel a snap, and that it did not initially swell, although he had "severe edema" of the left wrist during the evaluation. He was assessed with a wrist sprain, and the evaluator noted that x-rays were negative for fracture. In a September 2003 rating decision, the RO granted service connection for status post right wrist fracture, with a 10 percent evaluation under Diagnostic Code 5215 for limitation of movement of the wrist. In conjunction with his claim for service connection for his right wrist fracture he was provided a VA joint examination in July 2003. Physical examination of his right wrist included range of motion testing, but did not include sensory evaluation. X-rays taken in August 2003 revealed a small bony density projected over the corpus on the left which may represent a small avulsion fracture from prior trauma. The right wrist showed ununited fracture through the waist of the scaphoid on the right with 3mm separation of the fracture fragments. In a December 2003 rating decision, the Veteran was denied entitlement to service connection for a left wrist sprain. In May 2006, the Veteran reported his 1978 fracture of his right wrist and his ongoing pain. He also reported stiffness and the examiner noted he had symptoms "that seem to be purely carpal tunnel disease." He was noted to have a positive Phalen's test. In July 2006, the Veteran sought treatment for right wrist pain. The physician noted the Veteran had "some symptoms suggestive of carpal tunnel syndrome" and that nerve conduction tests confirmed that diagnosis. He was noted to be beyond the threshold for surgery with motor delay and sensory symptoms. In March 2009, the Veteran provided a statement that he injured his right wrist in 1978, and that he initially thought that he had sprained it and did not seek treatment because he did not want to be held back in training. He found out in 1994 that he had broken his wrist. He stated that in order to compensate for the pain in his right wrist, he began to use his left hand more often. He also stated that he used the computer daily during service from 1993 until retirement in 2002. He stated that using a mouse and typing aggravated his pain and caused numbness of his right wrist. He also reported weekly pain and numbness in his left wrist. He believes he was initially diagnosed with carpal tunnel syndrome in 2006. He reported that his symptoms of carpal tunnel syndrome were evident to him prior to 2006, but that he did not know that the numbness was a symptom of carpal tunnel syndrome. He thought that his numbness was just from overuse of his wrists on the computer. A May 2009 electromyography report noted the Veteran had moderately severe bilateral median neuropathies at the level of the wrist, consistent with carpal tunnel syndrome. The changes in his right wrist were slightly worse than the changes in the left. In May 2009, the Veteran was afforded a VA joint examination. The examiner diagnosed bilateral carpal tunnel syndrome. The examiner was asked to opine if the Veteran's bilateral carpal tunnel syndrome was due to his right wrist fracture. The examiner noted that he could not determine if the Veteran's bilateral carpal tunnel syndrome was due to his right wrist fracture without resorting to mere speculation. The examiner noted that the 1970s fracture should have healed, and that the Veteran was able to continue military service until 2002. The examiner then noted that the Veteran's bilateral carpal tunnel syndrome was due to repetitive bilateral wrist movement associated with his current employment. The examination report noted the Veteran worked as a clerk, and had held this employment for five to ten years. In August 2009, in response to the June 2009 rating decision and May 2009 VA examination, the Veteran provided details about his current employment. He noted that he began his current job in February 2003, and that his responsibilities include classroom training, coaching, coordinating, managing and performing different tasks for the company and computer work. He indicated that the time he spends on computer work is roughly 10 percent of his employment, and that 70 percent of his employment is classroom training. In contrast, he reported that in service, once he made Master Sergeant, 70 percent of his duties involved computer work. He provided his Enlisted Performance Reports to show his job duties in service. He argued that while he was not diagnosed with bilateral carpal tunnel syndrome in service, the repetitive use of his wrists in service for many years was a "major contributing factor" to his development of carpal tunnel syndrome. The Veteran provided Enlisted Performance Reports from 1992 to 2001. The majority of his duties from 1992 to 2001 were administrative. While the reports do not indicate how frequently the Veteran may have used a computer or used repetitive hand/wrist movements, it is easy to reason from his administrative duties that he would have spent a considerable amount of time using the computer and answering emails. In January 2011, the Veteran provided internet articles about carpal tunnel syndrome and a statement. He reported that he had surgery to alleviate his right carpal tunnel syndrome symptoms in June 2010. He indicated that he continues to have pain, numbness and difficulty picking up objects after his surgery. He stated that physicians have informed him that his broken wrist contributed to his carpal tunnel in his right wrist. He also noted that the articles from the internet support that trauma and repetitive use (such as computer use) cause carpal tunnel. The internet article provided by the Veteran is from the National Institute of Neurological Disorders and Stroke. The article notes that carpal tunnel can be due to a congenital predisposition, where the carpal tunnel is smaller than normal. "Other contributing factors include trauma or injury to the wrist that cause swelling, such as sprain or fracture...mechanical problems of the wrist joint; work stress." The article also noted that people who perform assembly line work are likely to develop carpal tunnel syndrome, and that a 2001 study by the Mayo Clinic found that heavy computer use (up to 7 hours a day) did not increase a person's risk of developing carpal tunnel syndrome." After resolving all reasonable doubt in favor of the Veteran, the Board finds service connection for bilateral carpal tunnel syndrome is warranted. As noted above, the service treatment records document that the Veteran injured his right wrist in service. While he was noted to have fractured his right wrist in service, his left wrist fracture was not diagnosed until his 2003 VA examination, and was noted to be a sprain with severe edema in service. Additionally, the Veteran has a positive Phelan's test of his right wrist in service. The internet article details that trauma is a contributing cause of carpal tunnel syndrome. The VA examiner initially indicated that he could not opine as to whether the Veteran's wrist trauma caused his carpal tunnel syndrome without resorting to mere speculation, and then noted that his carpal tunnel syndrome was more likely the result of repetitive use at his current employment. According to the Veteran his current employment involves little repetitive use of his wrists. Given that his treatment records indicate that he has difficulty doing woodworking as a hobby and his complaints of pain and numbness beginning in 2006, it seems likely that the Veteran's statements that his employment since 2003 has not involved much repetitive use of his wrists is credible. Additionally, his statements that his in-service duties from 1992 to 2001 involved significant computer use are corroborated by the Enlisted Performance Reports. Thus, the examiner's opinion that repetitive use of his wrists may have contributed to his development of carpal tunnel syndrome can be applied to both his duties in service, and less so to his duties post service. Essentially, the Veteran's current bilateral carpal tunnel syndrome cannot be satisfactorily disassociated from the Veteran's 25-year period of service that includes documentation of injuries to both wrists, and at least 10 years of administrative work. Thus, affording him the benefit of the doubt, the Board concludes that the criteria for service connection for bilateral carpal tunnel syndrome have been met. (CONTINUED ON NEXT PAGE) ORDER Entitlement to service connection for bilateral carpal tunnel syndrome is granted. ___________________________________________ DAVID L. WIGHT Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs