Citation Nr: 1340407 Decision Date: 12/06/13 Archive Date: 12/20/13 DOCKET NO. 07-39 662 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in St. Petersburg, Florida THE ISSUE Entitlement to service connection for bilateral wrist disability, including carpal tunnel syndrome. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD K. Neilson, Counsel INTRODUCTION The Veteran served on active duty from June 1981 to April 2006. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a March 2007 rating decision that, in pertinent part, denied service connection for carpal tunnel syndrome of both wrists. The instant matter was previously before the Board in October 2011 at which time it was remanded for further development and readjudication. After completion of the requested action, the agency of original jurisdiction (AOJ) readjudicated the matter via a September 2012 Supplemental Statement of the Case and, upon denial, returned the case to the Board for further appellate review. FINDING OF FACT The Veteran has not exhibited bilateral wrist disability, including carpal tunnel syndrome, during the claim period. CONCLUSION OF LAW The Veteran does not have bilateral wrist disability, including carpal tunnel syndrome, that was incurred in or aggravated during active military service. 38 U.S.C.A. §§ 1110, 1131, 5107 (West 2002 & Supp. 2013); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304 (2013). REASONS AND BASES FOR FINDING AND CONCLUSION I. Notice and Assistance The Veterans Claims Assistance Act of 2000 (VCAA), codified in pertinent part at 38 U.S.C.A. §§ 5103, 5103A (West 2002 & Supp. 2013), and the pertinent implementing regulation, codified at 38 C.F.R. § 3.159 (2013), provide that VA will assist a claimant in obtaining evidence necessary to substantiate a claim. They also require VA to notify the claimant and the claimant's representative of any information, and any medical or lay evidence, not previously provided to the Secretary that is necessary to substantiate the claim. As part of the notice, VA is to specifically inform the claimant and the claimant's representative of which portion, if any, of the evidence is to be provided by the claimant and which part, if any, VA will attempt to obtain on behalf of the claimant. The VCAA notice requirements apply to all five elements of a service connection claim. These are: (1) veteran status; (2) existence of a disability; (3) a connection between a 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). In May 2006, the Veteran filed an application for VA disability compensation for, among other things, bilateral carpal tunnel syndrome. That same month, she was sent a letter notifying her of the evidence required to substantiate a claim for service connection. The letter advised the Veteran of the information already in VA's possession and the evidence that VA would obtain on her behalf, as well as of the evidence that she was responsible for providing to VA, to include any records not in the possession of a Federal agency. The letter also included the notice elements required by Dingess for how VA determines disability ratings and effective dates. The Veteran has not disputed the contents of the VCAA notice in this case. Further, the Board finds that the May 2006 notice letter complies with the requirements of 38 U.S.C.A. § 5103(a), and afforded the Veteran a meaningful opportunity to participate in the development of her service connection claims. Thus, the Board finds that the duty-to-notify requirements under 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) were satisfied. Regarding the duty to assist, the Board also finds that VA has adequately fulfilled its obligation to assist the Veteran in obtaining the evidence necessary to substantiate her claim. All available relevant evidence pertaining to the Veteran's claim has been obtained. The evidence includes her service treatment records (STRs), VA examination reports, and statements from the Veteran. The Veteran has not alleged that there is any additional outstanding evidence pertinent to the matter currently before the Board and the Board is also unaware of any such evidence. Further, the Veteran was afforded two VA examinations in connection with her claim. Both examiners examined the Veteran and considered her subjective complaints related to her claimed disabilities. A December 2011 VA examiner also conducted a thorough review of the claims folder, to include the Veteran's STRs. Both examiners concluded that there was no objective evidence of carpal tunnel syndrome and the December 2011 VA examiner set forth specific reasons for why the Veteran's subjective complaints did not support such a diagnosis. The Board is satisfied that the examination reports, along with the Veteran's STRs and lay statements, contain sufficient evidence by which to evaluate her claim of service connection for bilateral carpal tunnel syndrome. Thus, the Board has properly assisted the Veteran by affording her an adequate VA examination. See Barr v. Nicholson, 21 Vet. App. 303, 311 (2007); Cox v. Nicholson, 20 Vet. App. 563 (2007). II. Analysis Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. § 1110 (West 2002); 38 C.F.R. §§ 3.303, 3.304 (2013). That an injury or disease occurred in service is not enough; there must be a disability resulting from that injury or disease. Service connection may be granted for any disease diagnosed after discharge when all evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Generally, establishing service connection requires medical or, in certain circumstances, lay evidence of (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a nexus between the claimed in-service disease or injury and the present disability. See Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009); Hickson v. West, 12 Vet. App. 247, 253 (1999). In the instant case, the Veteran is seeking service connection for a disability manifested by wrist and hand pain, numbness, and difficulty grasping objects, which she has characterizes as carpal tunnel syndrome. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009) (holding that VA must construe a claim for service connection to include any disability that may reasonably be encompassed by the claimant's description of the claim). She asserts that she was diagnosed as having carpal tunnel syndrome while in service and has, since that time, experienced similar symptoms of that disability. STRs show that the Veteran fractured her right wrist in March 1984, was assessed as having right wrist tendonitis in January 1990, was assessed as having right wrist carpal tunnel syndrome in January 1992, fell on her right hand in April 1997 and subsequently experienced wrist pain, complained of left wrist pain in May 1997, complained of stiffness in her fingers in September 2000, and complained of bilateral wrist pain in September 2002. However, as stated above, that an injury or disability existed in service is not enough. Rather, for an award of service connection to be made, there must be evidence of, among other things, a current disability. See Hickson, supra; see also McClain v. Nicholson, 21 Vet. App. 319, 321 (2007) (holding that a "current disability" includes a disability present at the time of filing or during the pendency of a claim). That evidence is lacking in this case. Pertinent to the issue of whether the Veteran has exhibited a wrist disability at any point since filing her May 2006 claim, the Veteran was afforded a VA examination in October 2006. She stated that she was diagnosed as having carpal tunnel syndrome in 1991 or 1992 and reported experiencing diffuse aching discomfort in the hands and difficulty holding things every three to four months, lasting for a period of two to three days. The Veteran indicated no precipitating factors, but stated her belief that driving and computer work created a worsening of symptoms. It was noted that the Veteran wore a cock-up splint bilaterally every night and self-massaged. The Veteran reported having an electromyogram (EMG) and stated that the results indicated that she was not a surgical candidate. She reported no medical therapy and denied numbness. Examination of the Veteran's wrists revealed a full range of motion and negative Tinel's sign and Phalen's maneuver, which is a provocative test used in the diagnosis of carpal tunnel syndrome. See Dorland's Illustrated Medical Dictionary 1117 (31st Ed. 2003). Although under "Diagnoses" the examiner listed "Bilateral carpal tunnel syndrome," the examiner stated that there were no objective findings to support a diagnosis at that time. The Veteran underwent a second VA examination December 2011. The examiner indicated that a review of the claims folder showed that the Veteran had presented in service with complaints of dysaesthesias and that the findings of various in-service examinations ranged from no findings to a positive Tinel's sign. The examiner noted the in-service diagnosis of carpal tunnel, but stated that a close review of the Veteran's STRs revealed that they did not contain sufficient evidence to support that diagnosis with any degree of certainty. The Veteran's then-current complaints were noted to consist of occasional nocturnal dysaesthesias in the hands, left greater than right and existing in the ulnar and median distribution. The Veteran denied cervical or elbow symptoms and indicated rare bilateral shoulder discomfort. The Veteran reported a tendency to drop objects and related that symptoms were more noticeable with mental stress and prolonged keyboard use. She also related a negative flick sign. Physical examination revealed no swelling or deformity, and there was a normal vascular supply, including normal radial and ulnar artery patency and capillary refill. There was also no evidence of muscular atrophy, nerve signs, or muscle weakness. The examiner noted a slightly decreased sensation to light touch in all fingers, as well as a decreased sensation in the distribution of the palmar cutaneous nerve, which the examiner stated was not involved with carpal tunnel syndrome. The Veteran exhibited equal grip strength, which was described to be good bilaterally, and had a full range of motion. Phalen's maneuver and median nerve compression test were both normal. Ultimately, the VA examiner concluded that the Veteran's reported symptoms and physical findings on examination did not fit the criteria for a diagnosis of carpal tunnel syndrome. Rather, the examiner stated that the Veteran's symptoms could be reasonably classified as consistent with a benign normal variant. The examiner noted that large epidemiologic studies revealed that 20 percent of the normal population experienced such symptoms intermittently and that 18 percent of the normal population has mildly "abnormal" electrical nerve conduction studies that could be considered consistent with carpal tunnel syndrome. The examiner also determined that the Veteran's right wrist fracture did not result in any permanent residual wrist disability, stating that if it had, it would have resulted in a strictly ulnar nerve problem stemming from the time of injury, which was not the case clinically or historically. After review of the record, the Board finds that service connection for a wrist disability, to include bilateral carpal tunnel syndrome, is not warranted. The Board emphasizes that Congress has specifically limited entitlement to service connection for disease or injury to cases where such incidents have resulted in a current disability. See 38 U.S.C.A. § 1110 (West 2002). In the instant case, although the Veteran has reported wrist-related symptoms, such as pain, numbness, abnormal sensation, and occasional decreased grip strength, the evidence of record fails to show that these symptoms are the result of any underlying pathology indicative of a chronic disability, to include carpal tunnel syndrome. Indeed, neither VA examiner found any objective evidence to support a diagnosis of carpal tunnel syndrome and the December 2011 VA examiner explained that a certain percentage of the population experiences symptoms such as those experienced by the Veteran without any underlying cause. The results of objective tests undertaken to diagnose carpal tunnel syndrome were also negative and the Veteran has presented no medical evidence evidencing a diagnosis of carpal tunnel syndrome during the relevant time period. Regarding the in-service diagnosis, the December 2011 VA examiner concluded that the objective evidence of record was insufficient to support a diagnosis of carpal tunnel syndrome or any other wrist disability. In essence, the VA examiner concluded that the in-service diagnosis was made in error. Regardless, however, of whether or not that in-service diagnosis was erroneous, the fact remains that there is no objective evidence of a current wrist disability. The VA examiner also explained why evidence of a residual disability resulting from the Veteran's in-service wrist fracture was lacking. In sum, although the Veteran had complaints of wrist symptomatology in service and she has, since that time, complained of such symptoms, as explained by the VA examiner, those complaints have not been related to underlying disability. In this regard, the Board also notes that even if the in-service diagnosis of carpal tunnel syndrome was correct, the provisions pertaining to chronicity or continuity of symptomatology are not for application in this case as carpal tunnel syndrome is not a chronic disease as defined by regulation. See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013) (38 C.F.R. § 3.303(b) only applies to the listed chronic disabilities in 38 C.F.R. § 3.309(a)). In any event, it is only the second and third elements of service connection that may be established through demonstrating chronicity or continuity of symptomatology in accordance with 38 C.F.R. § 3.303(b) and, as such, there must be evidence of a current disability for an award of service connection to be made. The Board has considered the Veteran's lay assertions regarding the presence of a current disability, but concludes that lay evidence is not sufficient evidence of a medical diagnosis in this case. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir 2007) (stating that lay evidence may be sufficient to establish a current diagnosis "when (1) a layperson is competent to identify the medical condition, (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional") In this regard, the Board finds that carpal tunnel syndrome is not a disability capable of lay diagnosis as it requires some measure of objective testing, as evidenced by the VA examination reports. Accordingly, without evidence of a currently diagnosed disability related to the Veteran's wrists or a showing that the Veteran's complained of symptoms are pathological in nature, the Board finds that the claim of service connection for carpal tunnel syndrome must be denied because a current disability has not been shown. See Gilpin v. West, 155 F.3d 1353 (Fed. Cir. 1998); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. See 38 U.S.C.A. § 5107(b) (West 2002); Gilbert v. Derwinski, 1 Vet. App. 49, 53- 56 (1990); 38 C.F.R. § 3.102 (2013). ORDER Entitlement to service connection for bilateral wrist disability, including carpal tunnel syndrome is denied. ____________________________________________ THOMAS J. DANNAHER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs