Citation Nr: 1708131	
Decision Date: 03/16/17    Archive Date: 04/03/17

DOCKET NO.  09-27 551	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Oakland, California


THE ISSUE

Entitlement to service connection for a left wrist disorder (claimed as left wrist numbness).  


REPRESENTATION

Appellant represented by:	Eric Campbell, OIF Veteran Community


ATTORNEY FOR THE BOARD

R. Costello, Associate Counsel






INTRODUCTION

The Veteran served on active duty from October 1993 to October 1997.

This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2008 rating decision of the Oakland, California, Regional Office (RO) of the Department of Veterans Affairs (VA).

This case was previously before the Board in June 2015 and again in June 2016.  The Board finds there is compliance with the prior remands.

Subsequent to the most recent supplemental statement of the case, the Veteran submitted additional statements and contentions in support of her appeal.  No waiver of Agency of Original Jurisdiction review (AOJ) was submitted; however, the statements were duplicative of the evidence already of record.  She has simply reiterated her arguments.  Thus, no waiver is required.  See 38 C.F.R. § 20.1304 (2016).

This appeal has been advanced on the Board's docket pursuant to 38 C.F.R. § 20.900(c) (2016).  38 U.S.C.A. § 7107(a)(2) (West 2014).


FINDING OF FACT

The weight of the evidence is against the conclusion that the Veteran has a chronic neurological disability manifested by left hand numbness, tingling, or pain.


CONCLUSION OF LAW

The criteria for service connection for a left wrist disorder (claimed as left wrist numbness) have not been met.  38 U.S.C.A. § 1110 (West 2014); 38 C.F.R. § 3.303 (2016).

  REASONS AND BASES FOR FINDING AND CONCLUSION

I.  Duty to Notify and Assist

VA's duty to notify was satisfied by letter in May 2008.  See 38 U.S.C.A. §§ 5102, 5103, 5103A (West 2014); 38 C.F.R. § 3.159 (2016); see also Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015).

As to VA's duty to assist, all necessary development has been accomplished.  See Bernard v. Brown, 4 Vet. App. 384 (1993).  The Veteran's service treatment records, VA medical records, and identified private treatment records have been obtained.

Also, the Veteran was provided a VA examination of her claimed left wrist disorder.  This examination and its associated report were adequate because, along with the other evidence of record, they provided sufficient information to decide the appeal and a sound basis for a decision on the Veteran's claim.  The examination report was based on examination of the Veteran by the examiner with appropriate expertise who thoroughly reviewed the claims file.  38 C.F.R. § 3.159(c)(4); Barr v. Nicholson, 21 Vet. App. 303 (2007). 

Therefore, VA has satisfied its duties to notify and assist, and there is no prejudice to the Veteran in adjudicating this appeal.  See Soyini v. Derwinski, 1 Vet. App. 540, 546 (1991); Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). 

II. Service Connection

Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active military, naval, or air service.  38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a).  Service connection may be granted for any disease initially diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service.  38 C.F.R. § 3.303(d).  As a general matter, service connection for a disability requires evidence of: (1) the existence of a current disability; (2) the existence of the disease or injury in service, and; (3) a relationship or nexus between the current disability and any injury or disease during service.  Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004); see also Hickson v. West, 12 Vet. App. 247, 253 (1999), citing Caluza v. Brown, 7 Vet. App. 498, 506 (1995), aff'd, 78 F.3d 604 (Fed. Cir. 1996). 

In determining whether service connection is warranted for a disability, VA must determine whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied.  38 U.S.C.A. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990).  When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded to the claimant. 

The finding of an actual, quantifiable disability is a key component of a service connection claim, as VA does not generally grant service connection for symptoms alone, without an identified basis for those symptoms.  Rather, VA needs to identify a disability, not symptoms of a disability; and service connection cannot be granted for symptoms of a disability.  

The Veteran claims service connection for a left wrist disorder.  Specifically averring in her November 2007 claim that she suffered from numbness in her wrists and arms from long-term computer use.  She elaborates in an April 2016 statement that her wrist is not better and she continues to suffer from numbness, tingling, and episodes of dropping items.  Her left wrist is also "usually accompanied with severe discomfort or outright pain."  There are some days she has no hand strength and other days when she can function normally.  She never knows when her wrists will go numb and weak except during times of frequent use, like she had to do in the Navy as she was on the computer all the time.  

However, as will be discussed, despite extensive testing, no specific disability has ever been diagnosed that would address the Veteran's complaints, beyond the disabilities for which she is already service connected, including a traumatic brain injury (TBI).  To this end, the regulations provide that the evaluation of the same disability under various diagnoses (known as "pyramiding") is to be avoided.  38 C.F.R. § 4.14.

Here, the issue is not necessarily whether the Veteran is experiencing symptoms in her extremities, but whether such symptoms are attributable to a separate neurological disability. 

Service treatment records reflect that in May 1996 the Veteran complained of left wrist pain.  Specifically, a one day history of pain along the medial aspect of the left lower arm.  Pain was made worse with typing at work.  There was no history of trauma and the impression was tendonitis of the left lower arm.  She was prescribed Motrin and compressions.  Her October 1997 separation examination was normal for any upper extremity conditions.  On her October 1997 report of medical assessment she notes that her hands continually fall asleep/go numb.  

An August 2006 private treatment record notes the Veteran complained of cervical muscle spasm with numbness to both forearms that had been occurring for the past two years.  She reported two injuries to her spine.  The first was a motor vehicle accident in 1993 and the second was an 1997 injury on the USS WASP where she was struck on the right forehead by a steel door, fell backwards, and was followed up for a possible concussion.  The report notes that based on the history of the injuries, subjective complaints, and objective findings, it was "my opinion that there is a high probability that the patients complaints are directly related to the injuries she incurred in 1993, and 1997."

A May 2008 VA treatment record reflects that the Veteran complained of tension in her wrists while sleeping.  She requested a wrist splint.  

The Veteran was afforded a VA examination in June 2008, in which she reported that about seven years earlier her left hand became painful and numb from time to time.  Also it occasionally hurt to move the wrist joint.  She stated that during service in 1997 a door hit her forehead on the right side and she fell backwards.  During service she worked in administrative jobs and continued to do similar work for different employers after service.  Results of a nerve conduction test revealed normal nerves in both upper extremities and no evidence of carpal tunnel syndrome.  The examiner diagnosed the Veteran with bilateral wrist and hand numbness of unknown etiology and opined that the Veteran's bilateral wrist numbness was not caused by or a result of her wrist injury sustained in service.  The examiner explained that the Veteran reported her symptom of numbness started some seven years prior to the exam, which would be sometime in the year 2001.  Also, she had been doing administrative work and the symptoms may have started after her military service in the last seven years brought on by repetitive use of hands.   

A June 2010 VA treatment record notes the Veteran was seen for further evaluation for a TBI.  She reported that in 1996 she was hit in the head by a steel door and thrown three to four feet that struck her on the right side of the head.  She complained of tingling to numb and sometimes constant pain in her bilateral elbows to fingertips.  The report notes the Veteran had "possible neurological deficits in bilateral forearms to hands." 

A July 2010 VA treatment record notes the Veteran sought an evaluation due to concerns about possible neuropsychological sequelae of her mild head injury in-service.  She showed normal neurocognitive functioning in all areas assessed, except mild impairments in motor function involving grip strength and fine motor movements.  An October 2010 VA treatment record notes the Veteran complained of numbness in her bilateral upper extremities.  However a magnetic resonance imaging (MRI) of the Veteran's cervical spine revealed slight loss of normal cervical lordosis without other significant neuroanatomic pathology.  

The Veteran was afforded a neurological evaluation in November 2010.  The VA treatment record notes she reported numbness in her bilateral arms up to her elbow.  She could not recall the start of her numbness; however, it was about ten years ago.  It had become persistent in her bilateral arms and she had tingling in her finger tips.  The examiner noted the Veteran's complaints of numbness were not typical for small fiber neuropathy.  The report notes an explanation for the numbness could not be found at that time.  

A December 2010 VA treatment record notes the Veteran complained of bilateral numbness in her hands since at least 1994.  After a neurological examination, MRI of the cervical spine, and MRI of the brain, she was found to have bilateral wrist and hand numbness of unknown etiology.  (See Virtual VA, Capri, 12/16/10, pg. 5). 

The Veteran continued to report difficulty with paresthesias in a stocking glove pattern and sometimes dropping things.  She underwent a nerve conduction study in January 2011.  The results were normal.  She also had an electromyography (EMG) that was normal for left first dorsal interosseous and bicep muscles.  Both tests revealed no evidence of neuropathy.  

A March 2011 VA treatment record notes a neurological examination was conducted.  Although the Veteran continued to report numbness and tingling in the stocking/glove distribution, the report notes EMG testing was consistent with normal neuronal function.  The report concluded that the Veteran complained of peripheral neuropathy with no identifiable cause and no central or peripheral neuropathy pathology identifiable.  

The Veteran was afforded a VA TBI examination in April 2011.  She reported gradual onset of constant numbness in the distal four extremities that was worsened by certain movements such as turning her head to the left.  She was not sure when this started.  She was diagnosed with a TBI, but it was found that her sensory changes were not caused by the TBI.  "With the gradual onset and fluctuating symptoms, often from positional change, traumatic brain injury would be an extremely unlikely etiology." 

Although a June 2010 VA treatment record notes the Veteran had "possible neurological deficits in bilateral forearms to hands," and a July 2010 VA treatment record notes the Veteran showed mild impairments in motor function involving grip strength and fine motor movements, an MRI of the cervical spine, MRI of the brain, neurological examinations, and EMGs have all found no evidence of peripheral neuropathy or any other neurological conditions.  This is highly relevant in that while the June 2010 and July 2010 VA treatment records suggested that the Veteran had some type of peripheral polyneuropathy based on a vague and entirely subjective physical examination, the objective medical testing did not support the diagnosis of peripheral neuropathy or of any other neurological condition.

As an initial point, the Veteran, as a lay person, lacks the medical training and expertise to provide a complex medical opinion such as diagnosing a neurologic disability.  See Jandreau v. Nicholson, 492 F. 3d 1372 (Fed. Cir. 2007).  As such, her opinion is insufficient to establish the presence of a neurological disability.  However, the Veteran is considered competent to report what comes to her through her senses.  See Layno v. Brown, 6 Vet. App. 465 (1994).  As such, she may report symptoms such as tingling, numbness, and pain; as she is uniquely qualified to report how and what she feels.  The Board must then review the Veteran's statements and make a credibility determination as to her reports.  See Barr v. Nicholson, 21 Vet. App. 303 (2007).

The Board acknowledges the Veteran's complaints of left hand numbness, tingling, and pain, but finds that despite extensive investigation by medical professionals, the weight of the evidence is against the conclusion that the Veteran has a neurological disability.  In the absence of proof of a present disability, there can be no valid claim.  Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992).  Again, service connection is not granted for symptoms without an identifiable medical condition. Accordingly, the Veteran's claim of entitlement to service connection for a left wrist disorder is denied.


ORDER

Service connection for a left wrist disorder (claimed as left wrist numbness) is denied.  


____________________________________________
MICHELLE L. KANE
Veterans Law Judge, Board of Veterans' Appeals


Department of Veterans Affairs