Citation Nr: 1323075 Decision Date: 07/19/13 Archive Date: 07/24/13 DOCKET NO. 09-12 259 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in San Diego, California THE ISSUE Entitlement to service connection for bilateral hand disability, to include as secondary to the service-connected shoulder and/or upper back disabilities. REPRESENTATION Appellant represented by: Disabled American Veterans ATTORNEY FOR THE BOARD J. Chapman, Associate Counsel INTRODUCTION The appellant is a Veteran who served on active duty from April 1968 to September 1970. This matter is before the Board of Veterans' Appeals (Board) on appeal from a July 2007 rating decision of the San Diego, California Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a Travel Board hearing; he failed to report, without good cause, for a hearing scheduled for March 2013. Accordingly, his hearing request is deemed withdrawn. See 38 C.F.R. § 20.702(d). 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 Further development is required before the Board can decide the claim. The Veteran contends that his bilateral hand disability is due to his service-connected right shoulder (right shoulder impingement syndrome) and/or upper back (multilevel cervical stenosis) disabilities. On February 2007 VA examination, diagnostic imaging showed degenerative changes consistent with osteoarthritis of bilateral hands; no evidence of fracture. The diagnosis of diffuse periarticular osteopenia of bilateral hands without specific evidence of joint degeneration. The examiner did not offer an opinion on etiology. The Veteran was afforded another VA examination in June 2012 after which thumb basilar joint arthritis was diagnosed. The examiner opined that this was less likely than not related to the Veteran's service-connected shoulder disability. The examiner stated that "hand pain in the ipsilateral extremity could be due to referred pain from another area, possibly from the scapula or from an impingement of the nerves of the brachial plexus...No imaging or radiographic findings of the patients can substantiate contralateral hand pain from scapular bursitis. [I]t is likely coming from the neck." This opinion lacks an adequate rationale. The examiner seems to conclude that hand pain could be due to the shoulder, but then states that the neck seemed to be the more likely cause, but does not provide a basis for this conclusion. An additional opinion was provided in September 2012, similarly finding that the bilateral hand disability was less likely than not due to the Veteran's service-connected shoulder disability. The examiner stated that he "is unaware of any instance of hand and wrist arthritic change as the result of impingement syndrome of the shoulder. Impingement syndrome of the shoulder has no immediate or remote effect on the wrist and hand." Here, it is unclear whether the examiner has adequately considered and addressed whether the service-connected shoulder disability has aggravated his bilateral hand disability. When adjudicating a secondary service connection claim VA must address the aggravation aspect of such claim. See Allen v. Brown, 7 Vet. App. 439, 448 (1995) (en banc) ("[I]t is a big stretch of the English language to construe the phrase "no etiological relationship between the Veteran's service connected right knee arthritis and the subsequent onset of left knee and bilateral hip arthritis as encompassing aggravation, especially considering the use of the word 'onset.'"). Neither the June 2012 or September 2012 examiner adequately addressed whether the Veteran's service-connected shoulder disability has aggravated his bilateral hand disability. In addition, neither examiner has considered whether the Veteran's bilateral hand disability may be due to or aggravated by his (now) service-connected multi-level cervical stenosis disability. See December 2006 claim; see also July 2012 rating decision. Consequently, a supplemental medical opinion to address aggravation is necessary. The Board also notes a September 1969 service treatment record (STR) indicating swelling of the right hand and wrist. Thus, the examiner should additionally opine as to whether this notation in service is in anyway related to the Veteran's current bilateral hand disability. Accordingly, the case is REMANDED for the following actions: 1. Forward the Veteran's claims file to the September 2012 VA examiner (or to another appropriate physician) for review and an advisory medical opinion regarding likely etiology of the bilateral hand disability to include whether it is caused or aggravated by the service-connected shoulder and upper back disabilities. If that examiner is unavailable or it is otherwise determined that an opinion cannot be provided without an examination, the Veteran should be scheduled for an appropriate examination. Based on review of the record (to include this remand), the consulting provider should provide an opinion that responds to the following: (a) Is it at least as likely as not (50 percent or higher degree of probability) that any current bilateral hand disability was incurred in or aggravated by service? The examiner should address the September 1969 STR noting swelling of the right hand and wrist and opine as to whether this treatment in service has any bearing on the Veteran's current bilateral hand disability. (b) Is it at least as likely as not (50 percent or higher degree of probability) that any current bilateral hand disability was caused by his service-connected right shoulder impingement syndrome or multilevel cervical stenosis? (c) Is it at least as likely as not that the Veteran's service-connected right shoulder impingement syndrome or multilevel cervical stenosis aggravated any current bilateral hand disability? The examiner is informed that aggravation is defined for legal purposes as a chronic worsening of the underlying condition versus a temporary flare-up of symptoms, beyond its natural progression. If aggravation is present, the clinician should indicate, to the extent possible, the approximate level of hand disability (i.e., a baseline) before the onset of the aggravation. The examiner must explain the rationale for all opinions, citing to supporting factual data/medical literature. 2. The RO should then readjudicate the claim. If it remains denied, the RO should issue an appropriate supplemental statement of the case and afford the Veteran and his representative the opportunity to respond. The case should then be returned to the Board, if in order, for further review. The appellant has the right to submit additional evidence and argument on the matter 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 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). _________________________________________________ M. E. LARKIN 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).