Citation Nr: 18144925 Decision Date: 10/25/18 Archive Date: 10/25/18 DOCKET NO. 18-47 384 DATE: October 25, 2018 REMANDED The claim of entitlement to service connection for right wrist carpal tunnel syndrome is remanded. REASONS FOR REMAND The Veteran had honorable active duty service with the United States Marine Corps from February 1979 to July 1979, March 1982 to May 1998, and March 2003 to March 2007, including three combat tours in Iraq. For his meritorious service, the Veteran was awarded (among other decorations) the Combat Action Ribbon, the Navy and Marine Corps Commendation Medal, and the Iraq Campaign Medal. 1. The claim of entitlement to service connection for right wrist carpal tunnel syndrome is remanded. The Board cannot make a fully informed decision regarding the claim of entitlement to service connection for carpal tunnel syndrome of the right wrist as the medical opinion of record is inadequate. The Veteran’s service treatment records reflect reports of numbness or tingling of the hands or feet following three separate deployments to Iraq. The Veteran’s October 2006 separation examination endorses numbness or tingling, as well as a painful shoulder, elbow or wrist. In October 2016, VA treatment records reflect right shoulder pain, tingling and numbness caused by multiple surgeries, residuals of which are presently service connected. In this treatment, the Veteran reported that tingling and numbness radiated down to his elbow, and a subsequent treatment record from the same month reported chronic numbness in his right arm and hand. In December 2016, the Veteran was diagnosed with bilateral carpal tunnel syndrome, right greater than left, affecting the myelin of sensory and motor fibers with evidence of complete bilateral sensory conduction block. In February 2017, the Veteran reported numbness in his bilateral upper extremities originating in his shoulders and radiating down his arms. He also awakened with numbness in his hands. In March 2018, the Veteran underwent a VA examination to assess his bilateral carpal tunnel syndrome. In the examination, the Veteran reported that symptoms of numbness or tingling in his hands began in 2003 while deployed to Iraq. The Veteran stated that the symptoms were ongoing and worsened over time. The examiner endorsed a nexus between left carpal tunnel syndrome and active duty service, primarily relying on a diagnosis of left carpal tunnel in 2008. The examiner also reported that the Veteran’s right wrist carpal tunnel syndrome was less likely than not related to active duty service as he was not diagnosed until 2016, almost 10 years after his retirement. Unfortunately, this opinion is inadequate for adjudicative purposes as it does not consider the Veteran’s lay reports of continuous and worsening symptomatology from 2003 to present day. VA examination opinions must provide an adequate rationale for any conclusions drawn, and must consider competent lay evidence of symptoms associated with a disability. Accordingly, an addendum opinion is necessary on remand in order to obtain a thorough medical opinion regarding the Veteran’s right wrist carpal tunnel syndrome. Additionally, the medical evidence of record indicates that the Veteran’s right wrist symptoms may be associated with his service-connected right shoulder disability. The Board has an obligation to consider all reasonably raised theories of entitlement to service connection, even if not specifically raised by the claimant. See Douglas v. Derwinski, 2 Vet. App. 435 (1992) (evidence reasonably raising a service-connection theory not specifically raised by the claimant must be considered in adjudicating a claim); Robinson v. Mansfield, 21 Vet. App. 545, 553 (2008). In the context of a service connection claim, theories of entitlement such as direct service connection, secondary service connection and presumptive service connection are deemed as part of the appeal regardless of when the issue has been raised in the record. Bingham v. Nicholson, 421 F.3d 1346, 1349 (2005). Accordingly, an opinion regarding secondary service connection must be obtained on remand. The matter is REMANDED for the following action: 1. Contact the Veteran and his representative in order to identify any outstanding non-VA treatment records regarding the issues on appeal. If non-VA providers are identified, obtain releases for those records. Make all reasonable attempts to obtain the non-VA treatment records and associate them with the claims file. If such records cannot be obtained, inform the Veteran and his representative, and afford an opportunity for him to provide these outstanding records. 2. Obtain any relevant, outstanding VA treatment records that are not already associated with the claims file. If no records are available, the claims folder must indicate this fact and the Veteran should be notified in accordance with 38 C.F.R. § 3.159(e). All attempts to contact the Veteran should be documented in the record. 3. Once the aforementioned development is complete, obtain a medical opinion regarding the etiology of the Veteran’s right wrist carpal tunnel syndrome. A new examination may be scheduled if the examiner deems it necessary. A complete copy of the claims file must be made available to the examiner. The examiner must consider the Veteran’s competent reports of ongoing symptomatology, including onset of symptoms in 2003 while deployed to Iraq, as well as the post-deployment assessments in his service treatment records. After a thorough review of the medical and lay evidence of record, the examiner should opine as to the following: (a.) Is it at least as likely as not (i.e. a probability of 50 percent or more) that the Veteran’s right wrist carpal tunnel syndrome had its onset during active service or within one year of separation from service, or, otherwise resulted from his active service? (b.) If not, is it at least as likely as not (50 percent or greater probability) that the Veteran’s right wrist carpal tunnel syndrome was caused by or aggravated by his service-connected disabilities, to include his right shoulder disability? (c.) If aggravation of the carpal tunnel syndrome is found to have occurred as a result of a service-connected disability, state if there is medical evidence created prior to the aggravation, or at any time between the onset of aggravation and the current level of disability that shows a baseline for the carpal tunnel syndrome prior to aggravation. Note: The term “aggravation” in the above context refers to a permanent worsening of the underlying condition, as contrasted to temporary or intermittent flare-ups of symptomatology which resolve with return to the baseline level of disability. The examination report should specifically state that a review of the record was conducted. The examiner should provide a complete rationale for all opinions provided. If an opinion cannot be provided without to resorting to mere speculation, the examiner should identify all medical and lay evidence considered in this conclusion, fully explain why this is the case and identify what additional evidence (if any) would allow for a more definitive opinion. Evan M. Deichert Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD H. Fisher, Associate Counsel