Citation Nr: 18148667 Decision Date: 11/08/18 Archive Date: 11/07/18 DOCKET NO. 14-08 125 DATE: November 8, 2018 ORDER Entitlement to service connection for a right wrist disorder, to include osteoarthritis and carpal instability status post anterior and posterior interosseous neurectomies of the right wrist, is denied. FINDING OF FACT 1. The Veteran’s osteoarthritis and carpal instability status post anterior and posterior interosseous neurectomies of the right wrist is not shown to manifested during military service or for many years thereafter. 2. The evidence of record does not demonstrate that the Veteran’s current right wrist disorder began in or was otherwise the result of military service, to include facture of his right fifth metacarpal therein. CONCLUSION OF LAW The criteria for service connection for a right wrist disorder, to include osteoarthritis and carpal instability status post anterior and posterior interosseous neurectomies of the right wrist, are not met. 38 U.S.C. §§ 1110, 1112, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from December 1987 to December 1992. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a November 2012 rating decision. The Board previously remanded this case in October 2015 and November 2017. Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. See 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). “To establish a right to compensation for a present disability, a 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”—the so-called “nexus” requirement.” Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2010) (quoting Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases, including arthritis, may be presumed to have been incurred in or aggravated by service if manifest to a compensable degree within one year of discharge from service, even though there is no evidence of such disease during service. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309(a). The Veteran contends that his current right wrist disorder is the result of military service, to specifically include a fifth metacarpal fracture of the right hand suffered during service. The Veteran’s service treatment records do not contain any complaints of, treatment for, or diagnosis of any right wrist problems during military service. The Board reflects that the Veteran’s right upper extremity was noted to be normal during the separation examination in October 1992; the Veteran denied any arthritis, rheumatism, or bursitis, bone or joint deformity, neuritis, or paralysis in his report of medical history at that time. The Veteran, however, did report that he had broken bones during military service; the examiner noted that the Veteran had fractured his right fifth metacarpal (little finger) in 1990, although there were no residuals of that fracture noted at that time. The Board reflects that there are no treatment records related to any right fifth metacarpal fracture found in the Veteran’s service treatment records. The first instance of any right wrist problems noted in the record is in March 2012 VA orthopedic consultation, in which the Veteran reported progressive weakness of grip in his right hand. The Veteran denied any recent trauma, although he reported that he suffered a right fifth metacarpal fracture that healed during military service. He stated that he was then deployed and “really did not have much problem with the hand for quite some time.” X-rays noted right scapholunate diastases with some slight dorsal intercalated segment instability and early degenerative changes of the radioscaphoid joint. He was diagnosed with residuals of scapholunate ligament tear with diastases and early osteoarthritis with loss of motion, weakness, and pain. Subsequent VA treatment records demonstrate continued treatment for his right wrist problems throughout the appeal period. The Veteran underwent a VA examination of his right wrist in October 2012, at which time he was diagnosed with a boxer fracture of the right fifth metacarpal during service, although no other right wrist disorders were noted. During the examination, the Veteran reported he first began to have problems with his right wrist in the last 3 years, when he noticed problems lifting, shaking hands and with other activities. He noted that before that he “always had a little tingle in the radial aspect” of the right wrist. The Veteran also reported that he had a fracture of the right fifth metacarpal (ulnar aspect of the hand) during military service in 1990, and that he wore a splint followed by a cast to his elbow; he was then deployed and did not have any other treatment during military service. He also stated that the “area did not really bother him after the case was removed,” and that he did not have any problems in the 1990’s or 2000’s. He further denied any further injuries, although he reported having a cyst removed from the ventral radial aspect of his wrist about 5 years ago. He additionally was noted to have had a neurectomy of the anterior and posterior interosseous nerves of the right wrist in September 2012; since that time he has had a decrease in pain and has had full range of motion and his handshake was fine. After the examination, the examiner opined that the Veteran’s right wrist disorder was less likely than not related to his boxer’s fracture in service, as the Veteran’s VA surgical physicians noted that the current wrist complaints “would have been caused by some other, more recent, injury to the wrist itself.” The Veteran underwent another VA examination of his right wrist in March 2016, at which time he was noted to have right carpel instability status post anterior and posterior interosseous neurectomies in 2012. During that examination, the Veteran again reported an injury during a training exercise during service when he “hit something” and his right hand and wrist were swollen. He was initially treated with a bulky soft dressing and then a cast from his hand to his elbow when the swelling went down. He continued his duties without problems after the cast was removed. The examiner additionally noted that he had a cyst removed from his right wrist about 10 years ago, and the Veteran denied any trauma to the right wrist after that. The examiner also noted that the Veteran had right wrist surgery in 2012 that was helpful to reduce his pain for a while, although his grip weakness and pain were beginning to return at that time. After examination, the examiner opined that it was less likely than not that the right carpel instability was related to service to include the right fifth metacarpal fracture noted on his separation examination. She noted that the Veteran’s current right wrist condition was a separate condition with different symptoms and examination findings than a right fifth metacarpal fracture. She also noted that the Veteran reported in his 2012 VA treatment records that he did not have any problems with his hand and wrist for some time and that the examination at that time found tenderness in the scapholunate area; she also noted that the Veteran reported onset of symptoms in the 2012 VA examination in the last 3 years. She concluded that it was more likely that the current right wrist carpal instability had onset following service. The March 2016 examiner additionally rendered an addendum opinion in December 2017. She opined again that it was less likely than not that the right fifth metacarpal fracture in service developed into the current right wrist disorder. She stated as follows: [Service treatment records] from the date of injury in 1990 are not available to review[. H]owever at separation fracture right little finger metacarpal [in] 1990 [was] reported. Therefore there is no objective evidence of treatment for the current right wrist condition in service. The Veteran did not file a claim for a right hand or wrist condition in 1995 or in 1997. 2012 [VA treatment records the Veteran] reports progressive weakness however also reports he really [did not] have much problem with the hand for quite some time. Early osteoarthritic change[s] are reported in the 2012 [VA records]. In my opinion it is less likely than not that these early osteoarthriti[c] changes [of the] radioscaphoid joint are related to an injury more than 20 years prior to the diagnosis of arthritis. It is noted that in 2012 the Veteran reported a three-year history of wrist problems with regard to lifting, shaking hands and other activities. In my opinion a three-year history of wrist problems reported in 2012 is less likely related to an injury in 1990. It is noted that the Veteran reported he always had a little tingle in the radial aspect of the wrist and pain [of] the radial [and] dorsal wrist when weather would change. These are as likely as not symptoms of the current right wrist condition based on the location of symptoms however it would be speculation to determine time of onset of these symptoms based on the information available. The Veteran reports treatment for a right wrist condition, surgery for cyst 5 years prior to [the 2012 VA examination], however medical treatment records for this condition are not [of record]. When the Veteran established [VA medical care] in 2012 he reported past treatment in the community for medical condition however treatment records are not available to review [in the record]. Therefore [there is] no medical evidence of a chronic wrist condition prior to treatment [at VA] in 2012. Based on the foregoing evidence, the Board finds that service connection for a right wrist disorder must be denied at this time. Initially, the Board reflects that the Veteran is shown to have osteoarthritis and carpal instability status post anterior and posterior interosseous neurectomies of the right wrist. The first element of service connection is therefore met. The Board reflects that the Veteran is not shown to have a diagnosis of arthritis either during or within one year of discharge from military service in this case. Accordingly, service connection on a presumptive basis must be denied at this time. See 38 C.F.R. §§ 3.307, 3.309. Next, the Board reflects that there is no evidence of any right wrist problems during military service. Nevertheless, although there is no evidence of any treatment of the right fifth metacarpal fracture shown in the Veteran’s service treatment records, such was noted on his separation examination as occurring during military service in 1990. Accordingly, by resolving reasonable doubt in his favor, the Board finds that the second element—an in-service injury—is present and has been in this case. This case therefore turns on whether there is a nexus to military service; the Board finds that the evidence of record does not support a finding of a nexus in this case. Initially, the Board acknowledges the Veteran’s statements and assertions that his current right wrist disorder is related to military service, particularly his right fifth metacarpal fracture therein. The Board, however, reflects that the Veteran—although competent to state the symptoms he experienced—is not competent to render a medical opinion as to a nexus in this case, as he lacks the requisite medical knowledge and expertise. See Jandreau v. Nicholson, 492 F.3d 1372, 1376-77 (Fed. Cir. 2007) (noting general competence to testify as to symptoms but not to provide medical diagnosis); see also Jones v. West, 12 Vet. App. 383, 385 (1999) (where the determinative issue is one of medical causation or a diagnosis, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issue). The other evidence of record demonstrates that, on separation from military service, the Veteran’s right wrist was normal and he denied any right wrist symptoms at that time. Furthermore, the first evidence of any right wrist disorder is shown in the record to manifest many years after military service. See Maxson v. West, 12 Vet. App. 453 (1999), aff'd, 230 F.3d 1330 (Fed. Cir. 2000) (a significant lapse in time between service and post-service medical treatment may be considered as part of the analysis of a service connection claim, which weighs against the claim). Even when factoring in the Veteran’s reports of symptoms in the 2012 records, the Veteran’s own statements at that time indicate that he began having onset of symptoms approximately 3 years prior to treatment. Such is again noted as being many years after military service. See Maxson, supra. Furthermore, such onset of symptoms in this case are shown, again by the Veteran’s own statements, to have began after cyst removal of the right wrist, an intervening injury of the right wrist since his discharge from service. Finally, the Board notes that both the October 2012 and the March 2016 VA examiners have reviewed the documents in the claims file and contemplated the Veteran’s medical history and assertions in this case. Those examiners both found that the Veteran’s current right wrist disorder was not related to his right fifth metacarpal fracture that occurred during military service. Such opinions are not refuted by any other evidence in the record and are found by the Board to be the most probative evidence in the claims file. Accordingly, as there is no nexus to military service in this case, service connection for osteoarthritis and carpal instability status post anterior and posterior interosseous neurectomies of the right wrist is not warranted based on the evidence of record at this time, and the Veteran’s claim must be denied at this time. See 38 C.F.R. § 3.303. In reaching the above conclusions, the Board has considered the applicability of the benefit of the doubt doctrine. However, as the preponderance of the evidence is against the Veteran’s claims, that doctrine is not applicable in the instant appeal. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. MARTIN B. PETERS Acting Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D. Pitman, Associate Counsel