Citation Nr: 1526270 Decision Date: 06/19/15 Archive Date: 06/26/15 DOCKET NO. 13-00 220 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in New Orleans, Louisiana THE ISSUE Entitlement to service connection for a right wrist disability. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD J. J. Tang, Associate Counsel INTRODUCTION The Veteran served on active duty from September 1957 to September 1960. This case is before the Board of Veterans' Appeals (Board) on appeal from an April 2010 rating decision by a Regional Office (RO) of the Department of Veterans Affairs (VA) that declined to reopen the previously denied claim of service connection for a right wrist disability. In October 2014, the Board reopened the claim and remanded the case for further evidentiary development. The claim was denied in a supplemental statement of the case, and the case is again before the Board for further appellate proceedings. All documents on the Virtual VA paperless claims processing system and the Veterans Benefits Management System (VBMS) have been reviewed, to include a transcript of the September 2014 Board hearing presided over by the undersigned Veterans Law Judge. This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). 38 U.S.C.A. § 7107(a)(2) (West 2014). The appeal is REMANDED to the Agency of Original Jurisdiction (AOJ). VA will notify the appellant if further action is required. REMAND The Veteran contends that he has a right wrist disability, diagnosed during the current appeal period as degenerative joint disease and carpal tunnel syndrome, that had its onset in service and that has continued since service. The service treatment records show that the Veteran was treated for wrist drop manifested by symptoms of weakness of the flexors and extensors and was provided a wrist splint. See April 1959 service treatment records. Per the Board's October 2014 remand directives, the Veteran was afforded a VA examination in December 2014. The December 2014 examiner's medical opinion regarding the etiology of the Veteran's right wrist disability is inadequate, however, as the examiner evaluated the severity of the Veteran's right wrist weakness since service and did not address whether the Veteran's reported recurrent right wrist weakness since service was a manifestation of the Veteran's currently diagnosed carpal tunnel syndrome or degenerative joint disease. See also Representative's argument in the May 2015 Appellant's Post-Remand Brief. Specifically, the December 2014 examiner noted only the date of onset of carpal tunnel syndrome and that carpal tunnel tunnel syndrome is not related to weak wrist extension, but the examiner did not comment as to whether the carpal tunnel syndrome may be related to the Veteran's weakness of flexors in service. The December 2014 examiner did not comment on the Veteran's long history of wrist problems with various diagnoses and whether the carpal tunnel syndrome may be etiologically related to those various right wrist disabilities. The Board also notes that in rendering his opinion that the Veteran's arthritis is related to age, the December 2014 examiner did not reconcile his opinion that the Veteran's arthritis began in 1999 with the medical evidence in the claims file that shows treatment for and a diagnosis of arthritis as early as 1981. See August 1981 private treatment record from Dr. A. K.; May 1983 private treatment record from Dr. A. J. The Board also notes that on VA examination in April 2010, the examiner diagnosed the Veteran with carpal tunnel syndrome and noted that if the Veteran's wrist splint had extended up to the base of the palm, then it could have put some pressure over the median nerve at the wrist and possibly resulted in carpal tunnel syndrome. It remains unclear whether the Veteran's wrist splint may have extended up to the base of the palm and resulted in the Veteran's carpal tunnel syndrome. Based on this evidence, further medical inquiry is warranted to determine the etiology of the Veteran's right wrist disability. Accordingly, a VA medical opinion should be obtained to determine the same. See McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006). Accordingly, the case is REMANDED for the following action: (Please note, this appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c). Expedited handling is requested.) 1. Please obtain all outstanding relevant VA treatment records, to include records from December 2014 to present. 2. Afterwards, please obtain a VA medical opinion from a physician with appropriate medical expertise in neurology who did not render the December 2014 VA examination to determine the etiology of a right wrist disability. Make the claims file available to the examiner for review of the case. The examiner should review all records associated with the claims file (including Virtual VA and VBMS) and should note that this case review took place. a. The examiner is asked to please provide an opinion as to whether it is at least as likely as not (probability of 50 percent) that the Veteran's in-service prescribed wrist splint extended up to the base of the palm. If the examiner is unable to provide this opinion without resorting to speculation, please explain why this is the case. See e.g., April 27, 1959 service treatment record. b. The examiner is asked to please provide an opinion as to whether it is at least as likely as not (probability of 50 percent) that the Veteran's carpal tunnel syndrome manifested in service or within the first post-service year, or is otherwise etiologically related to service. For purposes of this opinion, please specifically address whether the in-service diagnosed wrist drop was an initial manifestation of the Veteran's carpal tunnel syndrome. See April 1959 service treatment records (showing symptoms to include weakness of the flexors and extensors). For purposes of this opinion, please consider the following: (a) whether the Veteran's current right wrist disability is etiologically related to a history of Keinbock's Disease, or probable avascular necrosis of the lunate, or cystic change of the lunate bone, and (b) whether a history of Keinbock's Disease, or probable avascular necrosis of the lunate, or cystic change of the lunate bone, is etiologically related to the Veteran's in-service wrist complaints. See e.g., VA treatment records dated 1984 to 1987 (noting Keinbock's Disease and probable avascular necrosis of the lunate); August 1999 VA examination and x-ray (diagnosing cystic change of the lunate bone); October 2013 VA x-ray. c. If the in-service prescribed wrist splint extended up to the base of the palm, or assuming that it extended thusly if the examiner was unable to provide an opinion as to this matter without speculation, the examiner is asked to please provide an opinion as to whether it is at least as likely as not (probability of 50 percent) that the Veteran's carpal tunnel syndrome resulted from the Veteran's in-service prescribed wrist splint. For purposes of this opinion, the examiner is asked to please comment on the April 2010 VA examiner's opinion that if the Veteran's wrist splint had extended up to the base of the palm, then it could have put some pressure over the median nerve at the wrist, thus possibly resulting in carpal tunnel syndrome. d. Regarding the Veteran's degenerative joint disease of the right wrist, please provide an opinion as to whether it is at least as likely as not (probability of 50 percent) that such arthritis manifested in service or within the first post-service year, or is otherwise etiologically related to service, to include as a result of the Veteran's in-service right wrist disability. In so doing, please reconcile the December 2014 VA examiner's opinions that the Veteran's arthritis has its onset in 1999 and is related to age, with the medical evidence in the claims file that shows treatment for and a diagnosis of arthritis as early as 1981. See August 1981 private treatment record from Dr. A. K.; May 1983 private treatment record from Dr. A. J. For purposes of these opinions, the examiner's attention is invited to the following: 1) The Veteran's reports that problems with his right hand and wrist began in service and continued since service, and that for many years his doctors were unable to diagnosis the problem. See e.g., March 1981 VA examination; June 1983 Veteran statement; March 1987 Veteran statement (reporting weakness, pain, clumsiness, and numbness since service). 2) Lay statements dated in December 1980 testifying as to their observations of the Veteran's right wrist and hand problems. 3) The Veteran's report that he did not seek further therapy for the right wrist right after receiving treatment in service because it was not severe enough and the only thing he could do for it was exercise; however, the problem never healed and therefore he returned to treatment in the 1980s. See e.g., December 1981 Form 9; November 1989 Veteran statement. The examiner is asked to explain the reasons behind any opinions expressed and conclusions reached. The examiner is reminded that the term "as likely as not" does not mean "within the realm of medical possibility," but rather that the evidence of record is so evenly divided that, in the examiner's expert opinion, it is as medically sound to find in favor of the proposition as it is to find against it. Please note that the December 2014 examiner's medical opinion regarding the etiology of the Veteran's right wrist disability is inadequate as he did not address whether the Veteran's reported recurrent right wrist weakness since service was a manifestation of the Veteran's currently diagnosed carpal tunnel syndrome or degenerative joint disease. Specifically, the December 2014 examiner noted only the date of onset of carpal tunnel syndrome and that carpal tunnel tunnel syndrome is not related to weak wrist extension, but the examiner did not comment as to whether the carpal tunnel syndrome may be related to the weakness of flexors shown in service. The December 2014 examiner also did not comment on the Veteran's long history of right wrist problems with various diagnoses and whether the carpal tunnel syndrome may be etiologically related to those various right wrist disabilities. Further, in rendering his opinion that the Veteran's arthritis is related to age, the December 2014 examiner did not reconcile his opinion that the Veteran's arthritis began in 1999 with the medical evidence in the claims file that shows treatment for and diagnosis of arthritis as early as 1981. 3. Thereafter, readjudicate the claim on appeal and furnish the Veteran and his representative a supplemental statement of the case if a matter is not resolved to the Veteran's satisfaction. Provide an opportunity to respond before the claim is returned to the Board. 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 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 2014). _________________________________________________ MICHAEL A. PAPPAS Veterans Law Judge, Board of Veterans' Appeals Under 38 U.S.C.A. § 7252 (West 2014), 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) (2014).