Citation Nr: 1610733 Decision Date: 03/16/16 Archive Date: 03/23/16 DOCKET NO. 08-26 103 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUE 1. Entitlement to service connection for hypertension, to include as secondary to service connected disabilities. 2. Entitlement to service connection for carpal tunnel syndrome of the left wrist to include as secondary to service connected disabilities. REPRESENTATION Veteran represented by: Disabled American Veterans WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. L. Burroughs, Associate Counsel INTRODUCTION The Veteran served on active duty from June 1967 to January 1989. These matters come before the Board of Veterans' Appeals (Board) on appeal of a December 2006 rating decision by the Montgomery, Alabama Department of Veterans Affairs (VA) Regional Office (RO). A hearing was conducted before an RO Decision Review Officer (DRO) in July 2011. In June 2014 and September 2015, the Board remanded these matters to the RO for additional development. The issue of entitlement to service connection for carpal tunnel syndrome of the left wrist to include as secondary to service connected disabilities is addressed in the REMAND portion of the decision below and is REMANDED to the Agency of Original Jurisdiction (AOJ). FINDING OF FACT Hypertension was not shown in service or within a year of service discharge; and the preponderance of the evidence fails to establish that the Veteran's diagnosed hypertension is etiologically related to service or a service-connected disability. CONCLUSION OF LAW The criteria for service connection for hypertension have not been met. 38 U.S.C.A §§ 1101, 1110, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309, 3.310 (2015). REASONS AND BASES FOR FINDINGS AND CONCLUSION The Board has thoroughly reviewed the Veteran's claims file. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the evidence submitted by the appellant or on his behalf. Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000) (the Board must review the entire record, but does not have to discuss each piece of evidence). The analysis below focuses on the most salient and relevant evidence and on what this evidence shows, or fails to show, on the claim. The appellant must not assume that the Board has overlooked pieces of evidence that are not explicitly discussed herein. Timberlake v. Gober, 14 Vet. App. 122 (2000) (the law requires only that the Board address its reasons for rejecting evidence favorable to the claimant). The Board must assess the credibility and weight of all evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. When all the evidence is assembled, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the appellant prevailing in either event, or whether a preponderance of the evidence is against a claim, in which case, the claim is denied. Gilbert v. Derwinski, 1 Vet. App. 49 (1990). Duty to Assist and Notify VA has a duty to notify and assist claimants in substantiating claims for VA benefits. See e.g. 38 U.S.C.A. §§ 5103, 5103A (West 2014) and 38 C.F.R. § 3.159 (2015). VA provided adequate notice in letter mailed to the Veteran in May 2006. VA also has a duty to assist the Veterans in the development of their claims. This duty includes assisting him/her in the procurement of service treatment records and pertinent treatment records and providing an examination when necessary. 38 U.S.C.A. § 5103A; 38 C.F.R. § 3.159. The Board finds that all necessary development has been accomplished, and therefore appellate review may proceed without prejudice to the Veteran. See Bernard v. Brown, 4 Vet. App. 384 (1993). The claims file includes the Veteran's service treatment records, Social Security Administration records, lay statements, submitted medical treatise and VA and private treatment medical records. The Veteran was afforded a VA examination in July 2014. An addendum opinion was obtained in December 2015. When VA undertakes to provide a VA examination, it must ensure that the examination is adequate. Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the examination, when paired with its addendum opinion, is adequate, is predicated on a full understanding of the Veteran's medical history, and provides sufficient evidentiary bases for the claim to be adjudicated. Accordingly, the Board finds that VA's duty to assist with respect to obtaining VA examinations or opinions with respect to the claim has been met. 38 C.F.R. § 3.159(c)(4). The Board acknowledges that the Veteran has not been provided a VA examination which directly addresses his most recent contentions of his hypertension being related to in-service exposure to environmental or chemical contaminants (Agent Orange and "contaminated test fuel"). Such does render the opinion inadequate. The discussion below will explain how the Veteran has failed to provide evidence of exposure or evidence suggesting a relationship between his alleged exposure and his hypertension. See McClendon v. Nicholson, 20 Vet. App. 79, 81 (2006); Waters v. Shinseki, 601 F.3d 1274 (Fed. Cir. 2010). Further, with respect to his herbicide argument, there is objective evidence against a finding that hypertension is related to herbicide exposure. With that said, this claim has previously been remanded to the RO in June 2014 and September 2015 for additional evidentiary development. This development included the RO enabling the Veteran access to view a "March 2015 SSOC," obtaining etiological opinions and readjudicating the instant claim. The Board finds that the RO has substantially complied with all the previously issued remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). As to obtaining an etiological opinion, as stated, the RO procured an adequate VA examination in July 2014 and an addendum opinion in December 2015. With regard to the "March 2015 SSOC," the Board directed that the RO provide the Veteran with access to this document as it appeared blank within the claims file. See September 2015 Board Remand. From the outset, it is acknowledged that the record no longer contains this document. Nevertheless, the Board considers its absence to be irrelevant to the current adjudication. Specifically, this blank document appears to have never contained an SSOC and thus was associated with the claims file in error. In support of this conclusion, subsequent SSOCs generated by the RO in September 2015 and January 2016, contain no indication that any adjudicative action ever occurred in March 2015. As to any argument that the Veteran sustained procedural harm, the Board finds that he did not. The record reflects that prior to the Board remanding this matter, the RO updated the claims file to include a fully effectuated SSOC dated on September 2, 2015. This September 2015 SSOC was present and viewable within the claims file during the entirety of the remand. Additionally, there is no evidence of record that indicates the Veteran did not receive this document. Thus the Board finds that the Veteran was fully apprised of the matters previously adjudicated by the RO and given substantial time to respond. Therefore, there has been substantial compliance with the previous September 2015 remand with regard to this directive. As to the remand directive of readjudication, the Veteran, by way of his representative, argues that a Stegall violation has occurred. See February 2016 Motion to Remand. Specifically, he argues that this matter was recertified to the Board prior to the issuance of an addendum opinion or SSOC. In turn, the Veteran argues that this error requires "the Board remand his case to the AOJ with instructions to comply with the previous remand directives." See February 2016 Motion to Remand. The Board acknowledges that an error did occur. See Notification Letter date on November 22, 2015. Nevertheless, the claim will not be remanded as the Board finds that the RO's actions equate to harmless error. Specifically, the record clearly establishes that since the date of recertification the Veteran has had substantial time to formulate a response to the December 2015 VA opinion and January 2016 SSOC. Notably, the Veteran has since filed a letter in support of his claim. See Correspondence received in February 2016. Notwithstanding this correspondence, at the time the Veteran filed his Motion, he had already been apprised of the contents of the SSOC for approximately a month. As a result of the foregoing, the Board finds that the remedy the Veteran seeks of remanding the claim would provide him no actual benefit. See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991) (strict adherence to requirements in the law does not dictate an unquestioning, blind adherence in the face of overwhelming evidence in support of the result in a particular case; such adherence would result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994) (remands which would only result in unnecessarily imposing additional burdens on VA with no benefit flowing to the veteran are to be avoided). Thus, the Board finds that there has been substantial compliance with all the directives of the previous remands. Finally, as noted above a Decision Review Officer Hearing was conducted by the RO in July 2011. In Bryant v. Shinseki, the U.S. Court of Appeals for Veterans Claims held that 38 C.F.R. § 3.103(c)(2) requires that the RO Decision Review Officer or VLJ who chairs a hearing to fulfill two duties: (1) the duty to fully explain the issues and (2) the duty to suggest the submission of evidence that may have been overlooked. Bryant v. Shinseki, 23 Vet. App. 488 (2010). During the hearing, the DRO identified the issues on appeal. Information was also solicited regarding the circumstances of the Veteran's claim. The testimony does not indicate that there are any outstanding medical records available that would support his claim. Additionally, the DRO questioned the Veteran as to whether he would be interested in attending VA examinations to assist with the development of his claim. Therefore, not only were the issues "explained... in terms of the scope of the claim for benefits," but "the outstanding issues material to substantiating the claim" were also fully explained. See Bryant, 23 Vet. App. at 497. The Board finds that, consistent with Bryant, the DRO complied with the duties set forth in 38 C.F.R. 3.103(c)(2) and that the Board may proceed to adjudicate the claims based on the current record. For the above reasons, the Board finds that VA has complied with the duties set forth in 38 C.F.R. §3.103(c)(2) and that the Board can adjudicate the claim based on the current record. No further notice or assistance is required to fulfill VA's duty to assist in the development of the claim. Smith v. Gober, 14 Vet. App. 227 (2000), aff'd 281 F.3d. 1384 (Fed. Cir. 2002); Dela Cruz v. Principi, 15 Vet. App. 143 (2001); see also Quartuccio v. Principi, 16 Vet. App. 183 (2002). Laws and Regulations Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C.A. §§ 1110, 1131 (West 2014). Generally, the evidence must show: (1) the existence of a present disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004); Caluza v. Brown, 7 Vet. App. 498, 505 (1995). Certain chronic diseases, including organic disease of the nervous system, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from service even though there is no evidence of such disease during the period of service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C.A. §§ 1112, 1113; 38 C.F.R. §§ 3.307(a)(3), 3.309(a). Carpal tunnel syndrome, however, is not included as a chronic disease for presumptive service connection purposes. 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 if the disability claimed qualifies as a chronic disease listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 708 F.3d 1331 Fed. Cir. 2013). As a result, service connection via the demonstration of continuity of symptomatology is potentially applicable in the present case. Regulations also provide that service connection may be granted for a disability diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disability is due to disease or injury which was incurred in or aggravated by service. 38 C.F.R. § 3.303(d). Service connection on a secondary basis requires (1) evidence of a current nonservice-connected disability; (2) evidence of a service-connected disability; and (3) evidence establishing that the service-connected disability caused or aggravated the current nonservice-connected disability. 38 C.F.R. § 3.310(a),(b); Wallin v. West, 11 Vet. App. 509, 512 (1998). Analysis The Veteran asserts that his current hypertension was caused by his service connected disabilities. See Statements in Support of Claim dated on February 1, 2006 and August 28, 2007. In the alternative, he contends that his hypertension was aggravated beyond its natural progression, as a result of medication used to treat his service connected asthma. See August 2015 Appellant's Post-Remand Brief. Additionally, he asserts that his hypertension could be the result of in-service exposure to environmental or chemical contaminants. See Veteran's correspondence received in February 15, 2015. The Board will first address the Veteran's claim for service connection on a direct basis. For VA compensation purposes, the term "hypertension" means that the diastolic blood pressure is predominantly 90mm or greater, and isolated systolic hypertension means that the systolic blood pressure is predominantly 160mm or greater with a diastolic blood pressure of less than 90mm. Multiple blood pressure readings are required to confirm the diagnosis of hypertension with two or more readings on at least three different days. 38 C.F.R. § 4.104, DC 7101, Note 1. With this in mind, the Veteran's service treatment records are negative for a diagnosis or treatment of hypertension in-service. On entrance examination in December 1966, his blood pressure was 120/68 and he had a clinically normal heart and cardiovascular system. Additionally, he denied having high blood pressure. None of the service treatment records in evidence demonstrate a diagnosis of hypertension or results which would equate to a diagnosis of hypertension for VA compensations purposes. It is noted that the Veteran's separation examination is not of record. However, shortly before separation from service in September 1988, the Veteran reported he was in good health and had never had high blood pressure. See September 8, 1988 Initial Patient Medical History. Significantly, thereafter in November 1988, his blood pressure was noted as 104/72. This reading is not considered hypertensive for VA compensation purposes. Turning to post-service records, there are no medical records immediately following his service that contain a diagnosis of hypertension. In fact, the record contains no evidence regarding hypertension for many years after service separation. Treatment records indicate the Veteran received a diagnosis of "essential hypertension" and medication for the condition in 2005. See April 4, 2005 Birmingham VAMC. An initial diagnosis of systemic hypertension did not occur until January 2006. See Blue Family Practice Clinic records. These records reflect that his condition did not manifest until well over a decade after service separation. In sum, service treatment records are negative for a diagnosis of hypertension or blood pressure levels that would equate to such a diagnosis. There is also no evidence that the Veteran was diagnosed with hypertension within one year of his separation from service. Rather, the record establishes that the first treatment for even essential hypertension did not occur until 2005. Furthermore, an actual diagnosis for systemic hypertension was not noted until 2006. As a result, the first noted diagnosis of record would be approximately seventeen years after service separation. Such an amount of time would preclude service connection on the basis of continuity of symptomology. What remains for consideration is whether there is a competent clinical medical nexus linking the Veteran's hypertension to service or to a service connected disability. There is no such evidence of record. In July 2014, the Veteran was afforded a VA examination to determine whether or not his hypertension was proximately due to or the result of his service or a service connected disability. On examination, the Veteran reported that he did not believe he was prescribed blood pressure medication while in-service. He referenced that he was possibly "told he had blood pressure problems" after being assaulted in 1973. Additionally, the Veteran reported having intermittent nosebleeds in service which he attributed to high blood pressure. He also, reported being unable to remember his date of diagnosis or when he started taking blood pressure medication. The Veteran reported no further history in regards to his condition. Following examination, the examiner opined that the Veteran's hypertension was less likely than not (less than 50% probability) incurred in or caused by the claimed in-service injury, event or illness. The examiner cited to the Veteran's service treatment records which showed no elevated blood pressure readings over his many years of service. The examiner also directly addressed the Veteran's contention that his intermittent nosebleeds in service were caused by elevated blood pressure. The examiner stated that the Veteran's contention was not supported by the objective evidence of record. In support of this determination, the examiner cited to representative blood pressure readings from the Veteran's service in 1975, 1980, 1984, 1986 and 1987. Importantly, the examiner specifically noted blood pressure tests that were conducted after the Veteran's in-service assault in 1973. These tests failed to reveal hypertension. In regards to secondary service connection, the examiner opined that his hypertension was less likely than not proximately due to or the result of a service connected disability. The examiner stated that none of the Veteran's noted service connected disabilities are known to be causative of essential hypertension. Rather the examiner believed that the Veteran's hypertension was at least as likely as not a "life event." The examiner cited to the Veteran's age of "around 60 years old" at the time of his hypertension diagnosis as evidence. Importantly, the examiner indicated that hypertension incidences increase with age. Here it is acknowledged, that the examiner indicated that the earliest documented treatment/diagnosis of the Veteran's hypertension was in 2006. As discussed above, the record reflects the Veteran was first diagnosed with essential hypertension in 2005. Although, the examiner does not specifically reference records from 2005, the examiner does note the Veteran's original diagnosis was essential hypertension. Additionally, the examination opinion was predicated on the Veteran being "around 60 years old" at the time of diagnosis. The examiner also addressed the question as to whether it was at least as likely as not that the Veteran's hypertension had been aggravated beyond its natural progression. The examiner opined that the record contained no evidence of aggravation. In support of this opinion, the examiner cited to the Veteran being diagnosed with hypertension six years prior and his use of only a single medication to control blood pressure. Moreover, the examiner explained that even with the Veteran's noted recent mildly elevated blood pressure findings, the record did not reflect aggravation of the condition. Rather, the course of the Veteran's hypertension had followed the expected natural progression of hypertension without evidence of aggravation. In December 2015 addendum opinion, the examiner determined that the Veteran's hypertension was not aggravated by his use of albuterol to treat his service connected asthma. The examiner noted that the effects of albuterol are very transient and self-limited. Specifically after use, blood pressure quickly returns to baseline and therefore there is no permanent aggravation beyond its natural progression. Even with protracted use of albuterol, "the length of the blood pressure elevations from the medication is limited." As a result, it would be less likely than not that the "use of albuterol or other b-agonist medication would change the natural progression of hypertension or aggravate the hypertension beyond its natural course." The Board finds these opinions to be highly probative, sufficiently rationalized and to be based on thorough review of the record. Specifically, the examiner incorporates the Veteran's relevant medical history and contentions into well rationalized opinions. There are no competent medical opinions to the contrary. What remains of the evidence of record are submissions made by the Veteran to establish a nexus between his hypertension and service. The Board finds these submissions carry limited probative value. In that regard, the Board has considered the internet article submitted in support of the Veteran's claim by his representative. See August 2015 Appellant's Post-Remand Brief. The article noted the effect asthma medications may have on blood pressure, because of their beta-agonist activity. See Dr. Craig Weber, M.D.'s article Do Asthma Medications Affect Blood Pressure? Notably, this article outlines many of the same factors espoused by the VA examiner in determining that the Veteran's condition was not aggravated by albuterol. Nevertheless, as a lay person, relying on a generic medical treatise, the Veteran is not qualified to render a medical opinion as to the etiology of his claimed hypertension or its relation to his asthma medication. See Wallin v. West, 11 Vet. App. 509, 514 (1998) (treatise evidence cannot simply provide speculative generic statements not relevant to the veteran's claim, but, "standing alone," must include "generic relationships with a degree of certainty such that, under the facts of a specific case, there is at least plausible causality based upon objective facts rather than on an unsubstantiated lay medical opinion" (citing Sacks v. West, 11 Vet. App. 314, 317 (1998)); see also Stadin v. Brown, 8 Vet. App. 280, 284 (1995). The document supplied by the Veteran simply provides speculative generic statements and it does not address the specific facts of the Veteran's case. As a result, the aforementioned article lacks probative value in the consideration of the Veteran's claim. Consideration has also been given to the Veteran's personal assertion that his hypertension is proximately due to his aforementioned service connected disabilities, service, or in-service exposure. To that point, the Board will now address the Veteran's contentions of in-service exposure to environmental or chemical contaminates. Specifically, the Veteran appears to make two contentions. The first of which is exposure to contaminated test fuel while working as a fireman in-service. Here, the Veteran has not provided any competent clinical medical opinion which establishes that any such exposure to contaminated test fuel in-service caused or aggravated his hypertension. Only the Veteran's own lay statements note a connection. For reasons that will be fully discussed below, the Board does not find the Veteran competent to make such an opinion. Therefore these statements carry limited probative value. The Board now turns, to the Veteran's second argument regarding potential exposure to Agent Orange. By way of correspondence, the Veteran reports being present during the removal of burned bodies "just outside of the main gate" when he was stationed at Udorn RTAFB See February 15, 2015. This letter does not specifically assert Agent Orange caused his hypertension. However, the Board addresses these statements out of an overabundance of caution. Specifically, they appear to be asserting a relationship between the Veteran's hypertension and potential exposure to Agent Orange in-service. In this regard, there have been important changes in the protocols involved with VA's development of claims based on alleged exposure to dioxin-based herbicides in Thailand. A May 2010 VA Compensation and Pension Bulletin indicated that, after reviewing documents related to herbicide use in Vietnam and Thailand, it had been determined that there was significant use of herbicides on the fenced-in perimeters of military bases in Thailand, which was intended to eliminate vegetation and ground cover for base security purposes. It was ultimately determined that special consideration of herbicide exposure cases should be extended to those veterans whose duties placed them on or near the perimeters of Thailand military bases. This allows for presumptive service connection of the diseases associated with herbicide exposure. With that said, the Board does not dispute that the Veteran was exposed to Agent Orange, however his exposure is also not conceded. Rather, the pertinent question is whether there is a relationship exists between the Veteran's herbicide exposure and his hypertension. Hypertension is not a disease for which presumptive service connection may be established based on exposure to Agent Orange during service. 38 U.S.C.A. § 1116(f)(West 2014); 38 C.F.R. §§ 3.307(a)(6)(iii) , 3.307(e) (2015). However, the availability of presumptive service connection for a disability based on exposure to herbicides does not preclude a Veteran from alternatively establishing entitlement to service connection with proof of direct causation linking his claimed disability to his military service. See Stefl v. Nicholson, 21 Vet. App. 120 (2007); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). The Veteran has provided no competent evidence establishing a link between his alleged exposure to herbicides and his hypertension. Moreover, and of significant import, the available occupational and environmental studies to date have consistently failed to detect a significant association between herbicide exposure and hypertension. Specifically, a June 2010 a Federal Register notice best addresses VA's current stance on hypertensions related to Agent Orange exposure. VA explained as follows: The available Vietnam Veteran studies have produced a mixture of positive and negative findings, as well as findings that are essentially indeterminate in that they report low-magnitude increases that are not statistically significant. The primary evidence in favor of an association is the recent study by Kang et al. Other Vietnam Veteran studies reporting a significant increased risk of hypertension are limited primarily by concern of control for confounding factors. Viewing the evidence as a whole and taking into account the considerations discussed above, the Secretary has determined that the credible evidence for an association between hypertension and herbicide exposure is not equal to nor does it outweigh the credible evidence against an association. Therefore, he has determined that a positive association does not exist. In view of the suggestive findings in the recent Kang study, VA will continue to closely monitor further developments regarding the possible association between herbicide exposure and hypertension. 75 Fed. Reg. 32540, 32549 (June 8, 2010). The Veteran has made lay statements asserting a connection between his hypertension and service, service-connected disabilities, medication and exposure to contaminants both environmental and chemical. To that point, lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011). However, as to the specific issues in this case, the etiology of hypertension falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007). Additionally, an opinion as to any etiological relationship between exposure to Agent Orange, or contaminated fuel, also falls outside of the realm of common knowledge of a lay person. Importantly, the record does not demonstrate that the Veteran has special training or acquired any medical expertise in evaluating cardiovascular disorder such as hypertension. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed.Cir.2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. Therefore, after weighing all the evidence, the Board finds greater probative value in the only pertinent competent clinical evidence of record the July 2014 and December 2015 VA examination opinions. In light of the other evidence of record, these negative nexus opinions are sufficient to satisfy the statutory requirements of producing an adequate statement of reasons and bases where the expert has fairly considered material evidence which appears to support the Veteran's position. Wray v. Brown, 7 Vet. App. 488, at 492-93 (1995). For these reasons, the Board finds that the preponderance of the evidence is against the Veteran's claim of entitlement to service connection for hypertension, to include as secondary to service-connected disabilities. In reaching this conclusion, the Board notes that under the provisions of 38 U.S.C.A. § 5107(b); 38 C.F.R. § 3.102 , a reasonable doubt is to be resolved in the claimant's favor in cases where there is an approximate balance of positive and negative evidence in regard to a material issue. However, as the preponderance of the evidence is against the Veteran's claim, that doctrine is not applicable. See Gilbert v. Derwinski, 1 Vet. App. 49 (1990). The claim is denied. ORDER Entitlement to service connection for hypertension, to include as secondary to service connected disabilities is denied. REMAND In pertinent part, the Veteran underwent a VA examination in March 2015 to determine the etiology of his CTS. In the examination report the examiner provided both an opinion as to the appropriateness of service connection on a direct and secondary basis. In regards to the direct service connection opinion, the Board finds that it is inadequate for adjudication purposes. Review of the service treatment records indicates that the Veteran sought treatment for injuries to his left hand and fingers on multiple occasions while in-service. The December 2015 examination report only discusses one instance of injury to the left hand, in 1971, while in service. Therefore a new opinion is necessary. For clarification purposes, it is noted that service treatment record include a radiographic report conducted in November 1, 1971. Although this report indicates that its findings pertain to the right wrist, the Board will consider this a typographical error. Specifically, this radiographic report corresponds with a November 1, 1971 treatment record for an injury to the Veteran's left wrist sustained while playing basketball. Importantly, under pertinent clinical history in the radiological report the physician indicated that the injury being examined resulted from basketball. Moreover, within the report it notes that an examination was requested for the "A-P, lateral [left] wrist." Moreover, this report also notes there is a question as to whether the Veteran had a "coller deformity" of the left wrist. As such, the findings of this report will be associated with the Veteran's left wrist. With that said, this radiographic record indicates the presence of "a small 8 mm. exostosis off the radial aspect of the first metacarpal distally secondary to old trauma." On remand this radiographic finding must be addressed. Accordingly, the Board finds that an addendum opinion is necessary that opines on whether the Veteran's carpal tunnel syndrome in his left wrist merits service connection on a direct basis. Accordingly, the case is REMANDED for the following action: 1. Obtain an addendum opinion, from an examiner other than the December 2014 VA examiner. The need for a new examination is left to the discretion of the examiner offering the addendum opinion. The claims file and a copy of this Remand must be made available to the reviewing examiner, and the examiner shall indicate in the addendum report that the claims file was reviewed. After reviewing the record, and conducting a thorough examination and interview of the Veteran if deemed necessary, the VA examiner should offer his/her opinion regarding whether it is at least as likely as not (50 percent or greater probability) that the Veteran's carpal tunnel syndrome in his left wrist was incurred in, caused by, or etiologically related to the Veteran's service. In so opining, the examiner is to consider whether the record shows persuasive evidence of a medically-sound basis for attributing the Veteran's carpal tunnel syndrome to service. The examiner must specifically address the Veteran's noted repeated injuries to the left hand and fingers in-service. Special attention is directed to: (a) A November 1, 1971 radiographic report now considered to be conducted on the left wrist. The examiner must specifically address the importance of this radiographic reports finding of "a small 8 mm. exostosis off the radial aspect of the first metacarpal distally secondary to old trauma." The examiner should address this finding in regards to the previous notation of a possible "coller deformity" of the left forearm. See November 1, 1971 treatment medical records. (b) The examiner must address April and May 1976 service treatment records, which indicate that the Veteran jammed his left index finger and subsequently reinjured the area. (c) The examiner must address a March 10, 1980 service treatment record which indicates the Veteran was injured in a car accident and as a result suffered from a severe left thumb sprain. The examiner must also address an adjoining May 1980 "physical profile serial report." This report indicated that as a result of the injury the Veteran was restricted from all duties requiring the use of a hand for one month. (d) The examiner must address a November 1, 1985 record indicating the Veteran reported experiencing numbness and tingling. See Occupational Health Examination Report. The examiner should provide a rationale for the conclusions reached. If the examiner believes that an opinion cannot be provided without resorting to speculation, then he/she must provide a detailed medical explanation as to why this is so. 2. Readjudicate the claim after the development requested above has been completed. If any benefits sought on appeal remain denied, the Veteran and his representative should be furnished with a supplemental statement of the case and be given the opportunity to respond thereto. The case should then be returned to the Board for further appellate consideration, if in order. 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 2014). ______________________________________________ MICHAEL A. HERMAN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs