Citation Nr: 1722489 Decision Date: 06/16/17 Archive Date: 06/29/17 DOCKET NO. 11-27 567 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Winston-Salem, North Carolina THE ISSUE Entitlement to service connection for a wrist disability, to include carpal tunnel syndrome (CTS) and tenosynovitis. REPRESENTATION Veteran represented by: Veterans of Foreign Wars of the United States WITNESS AT HEARING ON APPEAL Veteran ATTORNEY FOR THE BOARD J. Gallagher, Associate Counsel INTRODUCTION The Veteran served on active duty from February 1986 to July 2006. This appeal is before the Board of Veterans' Appeals (Board) from a November 2009 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Louisville, Kentucky. Jurisdiction has since been transferred to the RO in Winston-Salem, North Carolina. In August 2015, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript is included in the claims file. In March 2014, the Board reopened and remanded the Veteran's appeal with instruction to conduct further development, including affording the Veteran appropriate VA examinations. The RO complied with these instructions. The Veteran's appeal came before the Board again in October 2014, and the Board remanded to accommodate her request for a hearing. As described above, she testified at an August 2015 videoconference hearing. In October 2015, the Board again remanded with instruction to provide the Veteran with a VA examination that includes objective tests such as an electromyography study (EMG). She underwent such an examination in March 2016. The Board is therefore satisfied that the instructions in its remands of March 2014, October 2014, and October 2015 have been satisfactorily complied with. See Stegall v. West, 11 Vet. App. 268 (1998). FINDING OF FACT Bilateral tenosynovitis of the wrists arose in service. CONCLUSION OF LAW The criteria for service connection for bilateral tenosynovitis of the wrists have been met. 38 U.S.C.A. §§ 1101, 1110, 1131, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.303 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran claims service connection for a bilateral wrist disability, claimed as CTS. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, including organic diseases of the nervous system such as CTS, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant 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 the claimant. Service treatment records include a May 2006 separation examination at which no abnormalities of the wrist were noted. Subsequently, the Veteran sought treatment for pain in her hand joints in June 2006. It was noted that her May 2006 x-rays were normal and there was a possible diagnosis of CTS. In her original July 2006 claim, the Veteran claimed joint pain and CTS. She failed to report for her scheduled VA examination and her claim was denied in March 2007. In September 2009 she filed a claim to reopen for a bilateral wrist condition, to include CTS. The Veteran underwent a VA examination of her peripheral nerves in July 2011. She reported bilateral hand joint pain described as an aching, numbing sensation. She had been on Celebrex but had recently switched to Mobic which provided some relief. The examiner diagnosed the Veteran with bilateral CTS based on sensory examination. The examiner opined that CTS was less likely than not caused by or a result of military service. This opinion was based on the rationale that while there was evidence of in-service joint pain there was no evidence of chronicity of care during military service or post-service. The Veteran underwent a second VA examination in May 2014. The examiner found no objective evidence of a current condition of CTS, noting that no electromyography (EMG) had been performed. The Veteran underwent another VA examination in March 2016. The examination report noted review of the claims file and medical records, recounted the Veteran's history and complaints, and examiner the Veteran. The examiner noted that her symptoms were consistent with bilateral tenosynovitis of the wrists. The examiner diagnosed bilateral tenosynovitis of the writs, with approximate onset of 2005 and 2006. A subsequent EMG was negative for CTS. In a June 2016 addendum, the examiner opined that CTS was less likely than not related to service because the Veteran did not have current CTS. The Board finds that the evidence is at least in equipoise as to whether the Veteran's tenosynovitis arose in service. The March 2016 examiner opined that no CTS was present, but the examination report states both that her current symptoms are consistent with bilateral tenosynovitis of the wrists, with approximate onset during the period of active duty service. Implicit in this finding is that the Veteran's prior diagnoses of CTS were misdiagnoses of her tenosynovitis, as the CTS diagnoses were at the time unsupported by diagnostic tests and subsequently ruled out when such tests were conducted. The Veteran has consistently and credibly reported a wrist disability since her July 2006 separation from service, filing claims in July 2006 and September 2009. There is no evidence in the record to contradict her reports of wrist pain throughout the entire period since separation from service. While medical records showing treatment for her wrist disability are absent from the record, her July 2011 examination report reflects that she had been taking prescription medication for her pain. Finally, her September 2009 claim was for a wrist condition, which should be construed to include tenosynovitis. For these reasons, the Board finds the evidence at least in equipoise as to whether her current bilateral tenosynovitis of the wrists arose in service, and service connection for such is therefore granted. Because the Veteran's claim is being granted in full, VA's duties to notify and assist are deemed fully satisfied and there is no prejudice to the Veteran in proceeding to decide the issue on appeal. See 38 U.S.C.A. §§ 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.156, 3.159. ORDER Service connection for bilateral tenosynovitis of the wrists is granted. ____________________________________________ JONATHAN B. KRAMER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs