Citation Nr: 1743937 Decision Date: 09/14/17 Archive Date: 10/10/17 DOCKET NO. 13-28 572 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Muskogee, Oklahoma THE ISSUE Entitlement to service connection for a bilateral wrist disorder, to include bilateral carpal tunnel syndrome. REPRESENTATION Veteran represented by: Oklahoma Department of Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD K.C. Spragins, Associate Counsel INTRODUCTION The Veteran had active service in the United States Air Force from August 1993 to February 2001. This matter comes to the Board of Veterans' Appeal (Board) on appeal from an April 2012 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO) in Sioux Falls, South Dakota. The RO in Muskogee, Oklahoma certified the case to the Board on appeal. The Veteran testified at a Travel Board hearing before the undersigned Veterans Law Judge in June 2015. A transcript from that proceeding is associated with the Veterans Benefits Management System (VBMS) folder. In a May 2016 decision, the Board remanded the claim to the Agency of Original Jurisdiction (AOJ) for additional development and adjudication. The case has since been returned to the Board for appellate review. FINDING OF FACT The Veteran's bilateral wrist disorder, diagnosed as bilateral carpal tunnel syndrome, is related to active service. CONCLUSION OF LAW The criteria for entitlement to service connection for a bilateral wrist disorder, diagnosed as bilateral carpal tunnel syndrome, have been met. 38 U.S.C.A. § 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (West 2014); 38 C.F.R. §§ 3.102, 3.159, 3.303 (2016). REASONS AND BASES FOR FINDING AND CONCLUSION Law and Analysis Service connection will be granted for a disability resulting from injury or disease incurred in or aggravated by military service. 38 U.S.C.A. §§ 1110, 1131; 38 C.F.R. § 3.303. In order to establish service connection for a present disability, the Veteran 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). The absence of any one element will result in denial of service connection. Coburn v. Nicholson, 19 Vet. App. 247, 431 (2006). Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including organic diseases of the nervous system, are presumed to have been incurred in service if they manifested to a degree of 10 percent or more within one year from the date of separation from service. 38 U.S.C.A. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. 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. As organic diseases of the central nervous system are considered to be chronic diseases for VA compensation purposes, if chronicity in service is not established, a showing of continuity of symptoms after discharge may support the claim. 38 C.F.R. §§ 3.303 (b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran contends that he has a bilateral wrist disorder that is related to his active service. During service, the Veteran was a satellite communication technician. See June 2015 Board Hearing Transcript (Tr.), page 4-5; DD Form 214. He testified that his work in maintenance involved activities that required repetitive motions with his wrist, such as work with a screw driver. See Tr., page 6. In his last four years of service, he was also the maintenance control officer for the maintenance unit. See Tr., page 4-5. In this position, the Veteran typed on the computer all day recording maintenance for the entire squad. After considering the evidence of record, the Board finds that the Veteran's description of his repetitive activities in service is consistent with the conditions and circumstances of his service. 38 U.S.C.A. § 1154(a). The Veteran reported that he gradually began to experience wrist pain during active service. See June 2016 VA examination. He did not have a specific injury, but the pain was worse during weight lifting. While the June 2016 VA examiner reported that his pain began in 1995, the Board notes that the Veteran has most consistently asserted that it began in 1999. See October 2011 Claim; Tr., page 3. The Veteran's service treatment records (STRs) show that the Veteran was noted to go to the gym on a daily basis in May 1998. He lifted weights and used a bench press. On July 1, 1999, the Veteran reported that both of his wrists were hurting, but the pain was greater in his left wrist. The bilateral wrist problem had been present for 4 months. An examination of the wrists showed no swelling, and the range of motion was within normal limits. The assessment was wrist pain, and he was given Naprosyn. The record indicated that an x-ray was planned to determine whether the Veteran had an overuse syndrome. The same day, a left wrist x-ray was conducted. The record noted that the Veteran lifted weights five times a week, and he did not recall any trauma. The impression from the x-ray stated that the scapholunate angle was in the lower limits of normal, and the capitolunate angle was in the upper limits of normal. These findings suggested, but did not meet the diagnostic criteria for, volar intercalated segment instability (VISI). A subsequent July 13, 2013 STR noted the Veteran's report that his wrist was much better. In addition, the STR stated that an examination of the Veteran was within normal limits. The assessment was wrist pain that had resolved, and the record indicated that the Veteran could slowly begin weight lifting again. The record is silent for any additional complaints related to the Veteran's wrists until May 2006. At that time, a Family Health Center record stated that the Veteran presented with bilateral wrist tenderness and occasional numbness in his hands, with the left worse than the right. The record indicated that he lifted weights five days a week at the gym. He also had some mild low back pain. The examination revealed no point tenderness of the back, and an x-ray of the lumbar spine revealed no significant bony abnormalities. However, the Veteran had a mildly positive Phalen's sign and a negative Tinel's sign. The assessment was probable carpal tunnel and low back pain. The plan reflected that the Veteran would obtain a wrist brace for lifting, and neuropathy testing would be considered if the complaints persisted. Later in May 2011, an Osso Healthcare Network record noted that the Veteran had vague complaints of left wrist pain with occasional popping. The Veteran reported that he fell 2 to 3 months before the visit. The Veteran was also noted to work in an IT department and frequently engage in repetitive activities. The examination showed that he had a little pain over the triangular fibrocartilage complex. He also had a little popping, but good grip strength. The radiographs did not show any acute abnormalities. The record indicated that he would be given a wrist brace. In July 2011, a VA treatment record stated that the Veteran had experienced bilateral shoulder pain for many years that had occurred more frequently over time. With overuse, he had a dull ache to the deltoid/trapezium area as well as crepitus. The pain did not radiate. He also reported having left wrist pain to the trapezium area. This pain also did not radiate, and the Veteran denied having symptoms of numbness or tingling. The assessment was bilateral shoulder pain and right wrist pain. In February 2012, the Veteran underwent a left ulnar nerve release and transposition; and a left carpal tunnel release. The pre- and postoperative diagnoses were left cubital tunnel and left carpal tunnel. A subsequent July 21, 2013 record from Dr. C. at Osso Healthcare Network noted the Veteran's report that five days before the visit, he began to have symptoms of numbness in his left small finger and half of the left ring finger. The numbness traveled into the ulnar side of his left hand. The Veteran also described his skin as hyperesthetic. He reported that on the previous day, he began to have pain from the base of his left thumb into his hand. The pain sometimes traveled from the Veteran's elbow into his shoulder, but it originated in his elbow. The record noted that the Veteran typed a lot in his employment as an IT project manager. He denied any trauma to his arm, but he was noted to lift weights, and he reported having soreness in his bilateral triceps prior this episode. He also stated that his bilateral wrists were sore, and he occasionally experienced intermittent numbness in his radial digits. These symptoms usually resolved after a couple days of using a wrist brace at night. The record stated that he had never experienced this type of symptomatology before. The assessment was cubital tunnel. Also on July 21, 2013, a record from Dr. R. stated that the Veteran had a one week history of pain, numbness, and tingling that extended from the medial aspect of the left elbow into the fourth and fifth digits of the hand. The symptoms were aggravated by repetitive use of the extremity and direct pressure over the elbow. The Veteran denied experiencing cervical discomfort or radicular features to either upper extremity. The summary/interpretation from EMG and nerve conduction studies reported that the Veteran had moderate ulnar nerve entrapment neuropathy at the left elbow (cubital tunnel syndrome) and moderate median nerve entrapment neuropathy at the left wrist (carpal tunnel syndrome). In a February 1, 2013 letter, Dr. K. addressed the electrodiagnostic studies completed on January 21, 2013. Dr. K. stated that the Veteran had developed elbow discomfort and sensory changes in the medial left hand approximately three weeks ago after going to the gym. Dr. K. considered the interpretations from the electrodiagnostic studies, but he indicated that the Veteran's symptoms were more accurately characterized as left ulnar neuropathy. According to Dr. K., the study was atypical for median neuropathy across the wrist. The Board notes that the while the February 2013 letter from Dr. K. disagreed with the January 2013 findings, the subsequent treatment records reaffirmed that the Veteran has a diagnosis bilateral carpal tunnel syndrome. In March 2013, the Veteran was again assessed to have both carpal tunnel and cubital tunnel syndrome. See March 2013 Oso Healthcare Network record. In May 2013, the Veteran underwent a right ulnar nerve neurolysis with anterior transposition; and right carpal tunnel release. See May 2013 Community Hospital at St. Anthony North record. The pre- and postoperative diagnoses were right cubital tunnel and right carpal tunnel. A June 2015 letter from Dr. C additionally noted that the Veteran had bilateral carpal tunnel syndrome. As such, the Veteran has established the first element of service connection, the presence of a current disability. The Board also notes that the Veteran has received diagnoses for bilateral cubital syndrome or ulnar entrapment neuropathy during the appeal period. See June 2015 letter from Dr. C. However, the issue of entitlement to service connection for left elbow cubital tunnel syndrome was separately denied in an August 2013 rating decision; and entitlement to service connection for a bilateral elbow disorder was later denied a July 2016 rating decision. The record does not show that the Veteran appealed these decisions, and these claims are not before the Board at this time. Despite the report from the January 13, 1999 STR that the Veteran's wrist problems had resolved, the Veteran asserted that while the pain did stop after a few days, he continued to experience subsequent flare ups during service. See Tr., page 3. The Board also notes that although there is no record of any wrist complaints between 1999 and 1996; and some of the post-service treatment records indicated that the onset of the Veteran's wrist symptoms was only a short time before the visit. However, the Veteran has been consistent in reporting that he continued to have pain in his wrists after discharge. See July 2013 VA examination; Tr., page 3. The Veteran indicated that due to the fact that he usually received similar advice from medical professionals to stop lifting and to take pain medication, he stopped seeking treatment. See Tr., page 3. Instead, the Veteran self-treated by purchasing his own Motrin and refraining from certain exercise. See Tr., page 8-9. He only began to seek treatment again after service when his pain began to worsen in 2006. The Veteran is competent to give evidence about his observable symptoms. See Layno v. Brown, 6 Vet. App. 465 (1994). Furthermore, as the Veteran has provided plausible explanations for the discrepancies in the record, the Board finds that his assertions credible and as a result, evidence of in service incurrence of problems with his wrists is established. See Barr v. Nicholson, 21 Vet. App. 303, 307-08 (2007); Washington v. Nicholson, 19 Vet. App. 362, 368-69 (2005). Regarding the question of nexus, the record contains different medical opinions. In June 2015, Dr. C. provided a positive nexus opinion. Dr. C. noted that the she had treated the Veteran since January 2013. At that time, he presented with bilateral upper extremity paresthesias that were greater on the left than the right; and notable left intrinsic atrophy. Dr. C. recounted that the Veteran was diagnosed with bilateral cubital and carpal tunnel syndrome in conjunction with nerve conduction studies and a clinical examination. Dr. C. also noted that the Veteran reported performing jobs that required the use of both his arms during his service beginning in 1993; and his belief that these duties initiated the onset of his symptoms. The Veteran's symptoms ultimately progressed, and he underwent surgical intervention bilaterally to relive the compression of the medial and ulnar nerves. As a result of the significant nature of the compression on the left ulnar nerve, the Veteran still experienced residual numbness on the left small finger. Dr. C. explained that carpal tunnel is known to be associated with repetitive use activities. She added that in Oklahoma, the repetitive use activity at issue would only need to be performed for 3 months to be deemed the source of the compression. After considering the job duties that the Veteran described performing during his 18 years of active service, Dr. C. found that it was reasonable to conclude that his symptoms began during service. She indicated that the Veteran's in-service symptoms represented early manifestations of his current symptoms of bilateral carpal tunnel syndrome. The Board notes that Dr. C. demonstrated her understanding of the pertinent facts from the Veteran's medical history, she has medical expertise on which she relied to form an opinion, and she provided a complete rationale for her conclusion. In addition, Dr. C.'s rationale is supported by the evidence of record. As Dr. C. based her opinion on clinical date and other rationale, the Board finds that this opinion provides great probative value. Bloom v. West, 12 Vet. App. 185, 187 (1999). The Board acknowledges that Dr. C. incorrectly indicated that the Veteran had 18 years of active service. However, the Veteran's service actual period of active service was a little less than 8 years, and Dr. C. correctly stated that his service began in 1993. As such, the Board finds that this statement is a clerical error. Moreover, the 8 year period of repetitive activities is still consistent with Dr. C.'s rationale than any period greater than 3 months could cause the compression. The Board notes that the record also contains negative nexus opinions provided by VA examiners in July 2013 and June 2016. In support of July 2013 opinion, the VA examiner pointed to the report from the January 13, 1999 record that the Veteran's wrist pain had resolved after his visit on January 7, 1999. The examiner also emphasized that there was no medical record of related treatment between January 1999 and May 2011. In addition, the Veteran's complaints at the time of the May 2011 record indicated that he had a recent fall and worked in an IT department performing repetitive activities. In light of this information, the examiner found that there was no indication of symptomatology consistent with carpal tunnel syndrome during the Veteran's active duty. There was also no indication of a bilateral wrist injury that would result in carpal tunnel entrapment while on active duty. As such, the examiner concluded that there was no evidence of a chronic condition diagnosed on active duty and no evidence of continuity following active duty. Similar to the July 2013 VA examiner, the June 2016 VA examiner stated that the in-service bilateral wrist pain that was noted to be resolved by January 13, 1999. In addition, there were no additional complaints related to the Veteran's wrists until July 13, 2011. Moreover, the Veteran was not diagnosed with left median entrapment neuropathy of the left wrist and moderate ulnar neuropathy of the left elbow until 2013. The examiner explained that the Veteran's 2011 symptoms and mechanism of injury were not consistent with his current diagnosis of median or ulnar nerve entrapment. Consequently, the examiner found that there was no continuity of symptoms. The Board does not find that these opinions provide much probative value. Neither examiner addressed the Veteran's reports of continuous symptoms since the in-service treatment in January 1999. In addition, while both examiners partly based their conclusions on an understanding that the Veteran first sought treatment for wrist complaints in 2011, the record shows that he also received earlier treatment in May 2006. As indicated by the May 2006 record, his complaints at that time were suggestive of carpal tunnel. Thus, the June 2016 examiner's reliance on the fact that the complaints in 2011 were inconsistent with carpal tunnel is called into question by this record. The Board also notes that while the July 2013 examiner found it persuasive that the Veteran post-service employment involved repetitive activities, she appeared to be unaware that the Veteran also performed similar activities during service. Based on the foregoing, the Board finds that the most probative evidence of record shows that the Veteran's bilateral carpal tunnel syndrome is related to active service. Consequently, service connection for a bilateral wrist disorder, diagnosed as bilateral carpal tunnel syndrome, is granted. 38 U.S.C.A. §§ 1131, 5107(b); 38 C.F.R. §§ 3.102, 3.303. As the record supports a grant of direct service connection on this basis, the Board need not consider any other theory of entitlement advanced. ORDER Entitlement to service connection for a bilateral wrist disorder, diagnosed as bilateral carpal tunnel syndrome, is granted. ____________________________________________ GAYLE E. STROMMEN Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs