Citation Nr: 1800038 Decision Date: 01/02/18 Archive Date: 01/19/18 DOCKET NO. 13-10 730 ) DATE Advanced on the Docket ) ) On appeal from the Department of Veterans Affairs Regional Office in Roanoke, Virginia THE ISSUE Entitlement to service connection for a disability manifested by burning sensations in the thighs and hands, to include as due to service-connected diabetes mellitus, type II. ORDER Service connection for bilateral compression neuropathies, as due to service-connected diabetes mellitus, type II is granted. FINDING OF FACT The Veteran's bilateral compression neuropathies are caused by the service-connected diabetes mellitus, type II. CONCLUSION OF LAW The criteria for entitlement to service connection for bilateral compression neuropathies, as secondary to service-connected diabetes mellitus, type II, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.310 (2017). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from May 1954 to May 1958 and from June 1958 to June 1974. This matter is before the Board of Veterans' Appeals (Board) on appeal of a September 2010 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). The Veteran appeared at a hearing before the undersigned in March 2015. In June 2015, the Board remanded this matter for further evidentiary development. I. Service Connection 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; 38 C.F.R. § 3.303 (a). Service connection may also be granted for any disease diagnosed after discharge, 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). Alternatively, service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310 (a). In order to prevail on the issue of entitlement to secondary service connection, there must be (1) evidence of a current disability; (2) evidence of a service-connected disability; and (3) medical nexus evidence establishing a connection between the service-connected disability and the current disability. See Wallin v. West, 11 Vet. App. 509, 512 (1998). The Veteran asserts that he has developed mononeuritis multiplex as a result of military service. He claims to have experienced symptoms of pain, numbness, and burning in his bilateral upper extremities since 1967. The available service treatment records (STRs) do not show a diagnosis of mononeuritis multiplex or complaints of numbness and/or burning in the bilateral hands or fingers. However, the Board finds that the Veteran is competent and credible to describe such symptoms during active duty and since service. Post-service treatment records reflect diagnoses of carpal tunnel syndrome, neuropathy, and peripheral neuropathy in response to the Veteran's report of a long-standing complaint of numbness in his hands and fingers. An October 2003 private treatment record, written by neurologist, Dr. R. H., provided a diagnosis of mononeuritis multiplex of unknown cause. At a VA examination in September 2010, an examiner indicated that the Veteran's mononeuritis multiplex was worsened by his service-connected diabetes. In February 2013, a different VA examiner indicated that the mononeuritis multiplex of the bilateral upper extremities is of unknown etiology per neurology notes in the claims file. The September 2010 and February 2013 VA opinions are inadequate as neither are supported by a clinical rationale and neither addresses whether the Veteran's subjective complaints, which he credibly asserts had onset in service, are related to the currently diagnosed mononeuritis multiplex disorder. Thus, the Veteran was afforded a new VA examination in September 2015. During the September 2015 VA examination, the examiner acknowledged the Veteran's report that he first became aware of mononeuritis multiplex in 2003. The examiner indicated that review of the Veteran's military records does not support evidence of a mononeuritis multiplex (MNM) diagnosis. Nonetheless, the examiner also stated that review of current medical literature supports diabetes mellitus as one of the possible causes of MNM. In October 2017, an expert opinion was obtained from a VHA neurologist regarding the Veteran's claim. N. J., M.D., stated that accepting as credible the Veteran's reports of experiencing symptoms of transient burning sensations in the thighs and hands both during and after his service, it was less likely than not that his mononeuritis multiplex had onset during the Veteran's active duty service, or within the initial year after separation, or was otherwise related to service. Dr. N. J. stated that based on the Veteran's EMG/NCS in October 2003, Dr. R. H. diagnosed the Veteran with "mononeuritis multiplex of unknown cause with left more severe than right ulnar more severe than median neuropathies, ulnar on the left better localized to the olecranon groove." Dr. N. J. found that this interpretation of the EMG/NCS findings was incorrect. Instead, he stated that the Veteran's EMG/NCS findings were consistent with bilateral (left greater than right) median neuropathy at the wrist (carpal tunnel), bilateral (left greater than the right right) ulnar neuropathy across the elbow, and chronic right C8 radiculopathy. The Veteran's chronic right C8 radiculopathy was not mentioned in the "summary/interpretation". The findings of bilateral median neuropathy at the wrist (carpal tunnel) and bilateral (left greater than the right) ulnar neuropathy across the elbow indicate bilateral entrapment neuropathies at the sites of compression (e.g., compression neuropathies). Dr. N. J. stated that, as discussed by Misra and colleagues (2008), mononeuritis multiplex "refers to the involvement of multiple, separate noncontiguous peripheral nerves either simultaneously or sequentially." Preston & Shapiro (2013) further clarify that mononeuritis multiplex manifests as "an asymmetric, stepwise progression of individual cranial or peripheral neuropathies, usually of named nerves." Thus, the symptoms progress in an asymmetric, stepwise fashion. Mononeuritis multiplex typically presents either hyper acutely (within 24-72) or acutely (less than four weeks); thirty percent of cases have a subacute (four to 12 weeks) presentation. The course of symptom progression is not chronic. If mononeuritis multiplex is not diagnosed and treated with steroids and/or other immune-suppressing medications early, symptom progression may relatively quickly (within weeks to months) lead to grave disability, including inability to walk. Misra and colleagues (2008) explain that the most common causes of mononeuritis multiplex are vasculitis (especially systemic vasculitides) and leprosy. Diabetes is a less common cause of mononeuritis multiplex. Dr. N. J. opined that the Veteran's reported symptoms were less likely than not the initial manifestations of his current mononeuritis multiplex. He explained that if the Veteran's initial symptoms were early manifestations of mononeuritis multiplex, he would likely be wheel-chair bound or bed-bound at this time, as he has never been treated appropriately for mononeuritis multiplex. The Veteran has never received steroids or immune-suppressing agents, such as IVIG, mycophenolate, methotrexate, or cyclophosphamide, in the 40 years since his symptoms began. In fact, the Veteran reported improvement in his symptoms with vitamin B6 supplementation. Dr. N. J. found that the Veteran's clinical history and exam as well as the electrodiagnostic evidence do not support a diagnosis of mononeuritis multiplex. Dr. N. J. stated that the Veteran did have bilateral compression neuropathies and that it was at least as likely as not that the Veteran's diabetes mellitus caused his bilateral compression neuropathies even though the Veteran's diabetes mellitus was diagnosed in January 2006 and his EMG/NCS showing bilateral compression neuropathies was completed in 2003. He explained that diabetes and glucose intolerance (pre-diabetes) are known risk factors for compression neuropathies. The Veteran may have had glucose intolerance (pre-diabetes) prior to his diagnosis of diabetes. Without a two hour oral glucose intolerance test in 2003, a definite diagnosis of glucose intolerance cannot be made; however, glucose intolerance in 2003 or prior is possible. The Board finds the most probative evidence fails to demonstrate that the Veteran has or has had mononeuritis multiplex. In consideration of the medical and lay evidence, the Board finds that the Veteran does not have a current diagnosis of mononeuritis multiplex. The Board has weighed the conflicting evidence and accorded more probative value to the evidence against a mononeuritis multiplex diagnosis. Specifically, the Board accords great value to the October 2017 VHA opinion because it included a detailed account of the Veteran's in-service experiences and post-service symptoms, considered an accurate factual history of the claimed disability, and provided an adequate rationale to support the opinion that the Veteran does not have a diagnosis of mononeuritis multiplex. See Stefl v. Nicholson, 21 Vet. App. 120, 123 (2007). Here, the October 2017 VHA opinion includes a persuasive rationale as to why the Veteran does not have a diagnosis of mononeuritis multiplex. Dr. N. J. reviewed the October 2003 private opinion by Dr. R. H., who, based on the Veteran's October 2003 EMG/NCS, diagnosed the Veteran with "mononeuritis multiplex of unknown cause." However, upon his review, Dr. N. J. found that this interpretation of the EMG/NCS findings was incorrect. Instead, Dr. N. J. explained that the Veteran's EMG/NCS findings were consistent with bilateral median neuropathy at the wrist, bilateral ulnar neuropathy across the elbow, and chronic right C8 radiculopathy. He explained that the symptoms of mononeuritis multiplex progress in an asymmetric, stepwise fashion. If mononeuritis multiplex is not diagnosed and treated with steroids and/or other immune-suppressing medications early, symptom progression may relatively quickly lead to grave disability. Dr. N. J. further indicated that the Veteran's reported symptoms were less likely than not the initial manifestations of any mononeuritis multiplex. He explained that if the Veteran's initial symptoms were early manifestations of mononeuritis multiplex, he would likely be wheel-chair bound or bed-bound at this time, as he has never received steroids or immune-suppressing agents in the 40 years since his symptoms began. Although the Board finds that the Veteran has not been diagnosed with mononeuritis multiplex, he has been diagnosed with bilateral compression neuropathies. In Clemons v. Shinseki, 23 Vet. App. 1 (2009), the United States Court of Appeals for Veterans Claims (Court) clarified the scope of a claim on appeal by holding that when a claimant makes a claim, he/she is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled. The Court in Clemons held that that the scope of a disability claim includes any disability that may reasonably be encompassed by the Veteran's description of the claim, reported symptoms, and other information of record. Here, the Veteran is seeking service connection for symptoms of burning sensations in this thighs and hands, regardless of whether that disability is diagnosed as mononeuritis multiplex or something else. In the October 2017 VHA opinion, Dr. N. J. found that it was at least as likely as not that the Veteran's diabetes mellitus caused his bilateral compression neuropathies. He explained that diabetes and glucose intolerance are known risk factors for compression neuropathies. Service connection has been established for diabetes mellitus, type II, and in reviewing the record, Dr. N. J. explained that the Veteran has bilateral compression neuropathies that accounts for his claimed symptoms and that these bilateral compression neuropathies are caused by his service-connected diabetes mellitus, type II. Therefore, resolving all reasonable doubt in the Veteran's favor, service connection is granted for bilateral compression neuropathies secondary to the service-connected diabetes mellitus, type II. ____________________________________________ M. HYLAND Veterans Law Judge, Board of Veterans' Appeals ATTORNEY FOR THE BOARD S. Gordon, Associate Counsel Department of Veterans Affairs