Citation Nr: 1806310	
Decision Date: 01/31/18    Archive Date: 02/07/18

DOCKET NO.  08-16 483	)	DATE
	)
	)

On appeal from the
Department of Veterans Affairs Regional Office in Detroit, Michigan


THE ISSUES

1. Entitlement to service connection for bilateral wrist arthritis.

2. Entitlement to service connection for bilateral elbow arthritis.

3. Entitlement to service connection for hypertension, to include as due to exposure to an herbicide agent, and to include as secondary to service-connected posttraumatic stress disorder.


REPRESENTATION

Veteran represented by:	The American Legion


ATTORNEY FOR THE BOARD

T. C. King, Associate Counsel

INTRODUCTION

The Veteran served on active duty from July 1969 to July 1971. His decorations include the Purple Heart, the Vietnam Service Medal with two Bronze Stars, and the Army Commendation Medal with "V" device. 

This case comes before the Board of Veterans' Appeals (Board) on appeal from November 2007 and April 2009 rating decisions by the Department of Veterans Affairs (VA) Regional Office (RO) in Detroit, Michigan.  The November 2007 rating decision denied, among other issues, the claims of entitlement to service connection for hypertension and the claim of entitlement to service connection for "arthritis of the body."  The April 2009 rating decision again denied the claim of entitlement to service connection for hypertension.  

These matters were remanded by the Board in May 2014, February 2016, and April 2017, and have been returned for further appellate review. 

The claim of entitlement to service connection for arthritis of the body, other than arthritis of the hands and of the knees, is separated into the issues of entitlement to service connection for bilateral elbows and entitlement to service connection for bilateral wrists, per clarification of the Veteran's pleadings, review of prior Board decisions, and review of the medical record. See April 2017 Board Remand; May 2017 Correspondence from VA to Veteran; June 2017 Statement in Support of Claim. The Veteran specifically clarified in his June 2017 Statement in Support of Claim that when he is referring to arthritis of the entire body he is only in fact referring to arthritis of the knees, elbows and wrists. Therefore, the issues have been restated on the title page to clarify this fact.  

Also, while the Veteran did restate in June 2017 that he was seeking service connection for bilateral knee arthritis, the claim for such was already adjudicated by the February 2016 Board decision and is no longer before the Board. 

The issues of entitlement to service connection for bilateral elbow arthritis, and entitlement to service connection for hypertension, to include as due to exposure to an herbicide agent, and to include as secondary to service-connected posttraumatic stress disorder are addressed in the REMAND portion of the decision below and are REMANDED to the Agency of Original Jurisdiction (AOJ).


FINDINGS OF FACT

1.  The Veteran's left carpometacarpal CMC joint arthritis is already service-connected as part of his hand.

2.  The Veteran does not have a current bilateral wrist arthritis condition.


CONCLUSION OF LAW

The criteria for establishing entitlement to service connection for bilateral wrist arthritis have not been met. 38 U.S.C. §§ 1110, 1113, 5107 (2012); 38 C.F.R. §§ 3.303, 3.307, 3.309, 3.310, 3.365, 3.385 (2017).


REASONS AND BASES FOR FINDINGS AND CONCLUSION

I. Duties to Notify and Assist/Prior Remand Compliance

The Appellant has not raised any procedural arguments regarding the notice or assistance provided for his claim. Scott v. McDonald, 789 F.3d 1375 (Fed. Cir. 2015).

Regarding compliance with the prior remand instructions, the Board finds that there has been substantial compliance by the AOJ with the instructions relevant to the claim being disposed of, as the Veteran was contacted to clarify his claim for arthritis, and a response was received and associated with the file. See D'Aries v. Peake, 22 Vet. App. 97 (2008) (holding that only substantial, and not strict, compliance with the terms of a Board remand is required pursuant to Stegall v. West, 11 Vet. App. 268 (1998)).

II. Service Connection, Bilateral Wrist Arthritis

In this matter, the Veteran contends that he is entitled to service connection for bilateral wrist arthritis. 

Generally, to establish service connection there must be competent evidence showing: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the in-service injury incurred or aggravated during service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303; Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). 

Service connection may also be granted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). 

A claimant has the responsibility to present and support a claim for benefits. All information, lay evidence and medical evidence in a case is to be considered by the Board in deciding the claim. When there is an approximate balance of positive and negative evidence regarding any material issue, the claimant is to be given the benefit of the doubt. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 53 (1990). To deny a claim on its merits, the evidence must preponderate against the claim. Alemany v. Brown, 9 Vet. App. 518, 519 (1996), citing Gilbert, 1 Vet. App. at 54.

The Board has an obligation to provide reasons and bases supporting its decision, but there is no need to discuss, in detail, every piece of evidence of record. See Gonzales v. West, 218 F.3d 1378, 1380-81 (Fed. Cir. 2000).

In-service records and post-service records through 2015 are silent regarding any issues involving the Veteran's wrists. 

The May 2016 VA examination of the Veteran's wrists noted that the Veteran reported that his wrists were fine, that he did not think he had a wrist condition, and had never seen a doctor for his wrists or had x-rays taken of his wrists. The report noted that the Veteran denied symptoms pertaining to his wrists. Testing of range of motion on both wrists revealed normal results. The examiner noted that degenerative or traumatic arthritis of the left wrist had been documented with diagnostic testing. Two diagnostic imaging views of the right wrist from May 2016 were noted to have revealed no significant degenerative change, but condrocalcinosis of the triangular fibrocartilage complex was noted, with no radiopaque foreign body. Two diagnostic imaging views of the left wrist revealed severe osteoarthritic changes of the first carpometacarpal (CMC) joint, with chondrocalcinosis that suggested CPPD. The examiner opined that chondrocalcinosis is deposition of the calcium pyrophosphate dihidrate crystals in articular cartilage and fibrocartilage, which can lead to arthritic changes and pain, but is not related to, incurred in, or caused by service. 

With regards to the May 2016 examination, the Board finds that the examiner's diagnosis of arthritis is limited to arthritis of the left CMC joint that connects the thumb to the wrist. The affirmative response regarding arthritis of the left wrist falls under "diagnostic testing" category, and specifies only the osteoarthritis of the first carpometacarpal joint seen with the imaging performed. 

For VA evaluation purposes, the CMC joint is considered part of the hand, and not part of the wrist. Compare 38 C.F.R. §4.71a, Diagnostic Codes 5214, 5215 (ratings of the wrist), with id, Diagnostic Codes 5216 to 5230. 

As arthritis of bilateral hands was service-connected by the April 2017 Board decision, the left CMC joint arthritis noted in the May 2016 VA wrist examination is already service-connected. Service-connecting the arthritis of the left CMC joint as part of the wrist would not benefit the Veteran, as he will receive only one rating for the symptoms that this condition presents, and could not obtain additional ratings for the same symptoms under separate diagnostic codes. 38 C.F.R. § 4.14.

Review of the remainder of the record and pleadings does not reveal any other indication that the Veteran has arthritis of the wrists. Although the Veteran has contended he has arthritis of the wrists, and is considered competent to report symptoms, there is no evidence of record that he is qualified to diagnosis this medical condition. See Jandreau v. Nicholson, 492 F.3d 1372, 1374 (Fed. Cir. 2007). 

The Board notes that the May 2016 examiner noted the presence of calcium pyrophosphate dihidrate crystals, and also opined that they were not linked to service. The Board does not consider this condition to be one for which the Veteran has sought service connection, and declines to expand the claim to this condition. The Veteran has specifically stated that he is seeking service connection for arthritis secondary to an in-service event that he believes has spread throughout his body - not a condition such as calcium pyrophosphate dehydrate crystal deposition disease. If the Veteran wishes to seek service connection for this condition, he may do so by requesting such. 

As the weight of the evidence indicates that the Veteran does not have arthritis of either wrist, service connection for bilateral wrist arthritis must be denied. 38 C.F.R. § 3.303. As the evidence preponderates against the claim, the benefit-of-the-doubt rule does not apply. Gilbert, 1 Vet. App. at 54.

ORDER

The claim of entitlement to service connection for arthritis, specifically of the bilateral wrists, is denied.







	(CONTINUED ON NEXT PAGE)
REMAND

Although the additional delay is regrettable, the Board finds that remand is necessary in this case.

Regarding the Veteran's claimed bilateral elbow arthritis, there is no VA examination of record addressing this condition, and the record does not contain any other medical evidence on this issue. 

The record reflects that the Veteran suffered injuries to both hands due to a mine explosion in-service, and incurred shell fragment wounds to both hands, as well as a fracture of the distal phalanx of the left thumb. The Veteran is currently service-connected for bilateral hand disabilities, to include arthritis.

Given the particulars in this case, the Board considers the evidence of record sufficient to conclude that the Veteran may have recurrent symptoms of a disability, that there is sufficient competent evidence that the disability may be associated with the claimant's active service, and the record does not contain sufficient medical evidence to reach a decision on the claim. See 38 U.S.C. § 5103A(d). Accordingly, a VA examination of the Veteran's elbows is warranted. 

Regarding the Veteran's claim for hypertension, it appears that the July 2017 VA examination addressing the condition is incomplete and did not fully comply with the April 2017 Board remand, as the examiner did not specifically address, with a complete rationale, whether the Veteran's hypertension is related to his exposure to an herbicidal agent in the Republic of Vietnam. Therefore, the case must be returned for an addendum opinion.

Accordingly, the case is REMANDED for the following action:

1.  The AOJ should obtain a medical opinion from an appropriate examiner to determine whether the Veteran has arthritis of the elbows, and provide an opinion on the nature and etiology thereof. The evidentiary record, including a copy of this remand, must be made available to and reviewed by the examiner. The medical opinion must include a notation that this record review took place. 

After reviewing the evidentiary record, the examiner is asked to offer his/her opinion with supporting rationale as to the following inquiries:

**Please identify all diagnoses pertaining to the Veteran's elbows. 

**For any diagnosed elbow condition, is it at least as likely as not (i.e. probability of 50 percent or greater) that it was either incurred in, or is otherwise related to, the Veteran's active duty service?

**For any diagnosed elbow condition, is it at least as likely as not (i.e. probability of 50 percent or greater) that it was caused by or aggravated by any other service-connected condition? 

Aggravation is a worsening of the underlying condition. If aggravation is determined, the examiner should attempt to quantify the extent of additional disability resulting from the aggravation.

2.  The AOJ should return the file to the examiner who provided the July 2017 VA examination regarding the Veteran's hypertension, or any other qualified examiner, for an addendum opinion or new examination, if the AOJ deems necessary to answer this question. 

**The examiner must address whether it is at least as likely as not (i.e. probability of 50 percent or greater) that the Veteran's current hypertension was either incurred in, or is otherwise related to, the Veteran's active duty service.

**Please note: the examiner should specifically address the Veteran's contention that his current hypertension is related to his exposure to Agent Orange during his Vietnam service. The examiner should specifically note that service connection can be established on a direct basis for diseases, such as hypertension, even if they have not been shown to warrant a regulatory presumption of service connection due to herbicide exposure.

The complete rationale for all opinions should be set forth. The examiner is advised that the Veteran is competent to report his symptoms and history. Such reports, including those of continuity of symptomatology, must be acknowledged and considered in formulating any opinion. If the examiner rejects the Veteran's reports, the examiner must provide an explanation for such rejection.

3.  After the above development has been completed, re-adjudicate the claims. If any benefit sought remains denied, provide the Veteran and his representative with a supplemental statement of the case, and return the case to the Board.

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. §§ 5109B, 7112.



______________________________________________
B. MULLINS
Veterans Law Judge, Board of Veterans' Appeals




Department of Veterans Affairs