Citation Nr: 18152775 Decision Date: 11/27/18 Archive Date: 11/26/18 DOCKET NO. 16-52 715 DATE: November 27, 2018 REMANDED Entitlement to service connection for carpal tunnel syndrome of the right upper extremity is remanded. Entitlement to service connection for a right shoulder disorder, to include as secondary to carpal tunnel syndrome of the right upper extremity, is remanded. REASONS FOR REMAND The Veteran had active duty service from February 1986 to February 1989 and from February 1993 to August 1993. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a November 2014 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in St. Paul, Minnesota. The Board notes that the Veteran’s appeal had originally included the issue of entitlement to service connection for carpal tunnel syndrome of the left upper extremity. However, the Veteran did not submit a substantive appeal for that particular issue following the issuance of the September 2016 statement of the case. Instead, he limited his appeal to the issues of entitlement to service connection for a right shoulder disorder and carpal tunnel syndrome of the right upper extremity. See September 2016 VA Form 9. Therefore, that issue no longer remains in appellate status, and no further consideration is required. Carpal Tunnel Syndrome of the Right Upper Extremity The Veteran was diagnosed with mild carpal tunnel syndrome with demyelination in May 2014 following an electrodiagnostic study. There was no evidence of cervical radiculopathy. The Veteran was afforded a VA examination in May 2016 during which the examiner noted his diagnosis of median neuropathy due to bilateral carpal tunnel syndrome in 2014, as well as a history of a 1993 back injury in service. However, the examiner found that the Veteran’s carpal tunnel syndrome is less likely as not due to, a result of, or aggravated by his service-connected back disability. He explained that there is no medical evidence or consensus to support the claim that the Veteran’s thoracic spine degenerative joint disease could have caused his mild bilateral carpal tunnel syndrome. However, the examiner did not address the aggravation prong of secondary service connection or the Veteran’s contention that his military duties caused his carpal tunnel syndrome. See January 2015 statement in support of claim; September 2016 VA Form 9. Therefore, the Board finds that an additional VA medical opinion is needed to determine the etiology of his carpal tunnel syndrome of the right upper extremity. Right Shoulder The Veteran was afforded a VA examination in December 2015 during which his right shoulder was found to be normal. Specifically, x-rays were within normal limits, and the range of motion was normal with no pain noted on examination, including with repetitive use. There was also no pain on palpation and no crepitus, and the Veteran’s muscle strength was 5/5 with no instability or rotator cuff condition suspected. There were also no reported flare-ups, functional loss, or functional impairment. The examiner determined that, despite the Veteran’s subjective complaints of shoulder pain, the examination was normal, and no diagnosis was rendered. Nevertheless, an October 2016 VA treatment record subsequently noted that there was limited and mildly painful active range of motion of the right shoulder with rotator cuff weakness. As such, more recent evidence suggests that there may be some functional impairment. Pain alone, without a specific diagnosis or identifiable disease, may cause a functional impairment and therefore qualify as a disability for VA purposes. See Saunders v. Wilkie, 886 F.3d 1356, 1362 (Fed. Cir. 2018). Therefore, the Board finds than an additional VA examination and medical opinion are needed to determine the nature and etiology of any right shoulder disorder that may be present. The matter is REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request the Veteran provide the names and addresses of any and all healthcare providers who have provided treatment for his right upper extremity and shoulder that are not already of record. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. The AOJ should also secure any outstanding VA treatment records. 2. After completing the preceding development, the Veteran should be afforded a VA examination to determine the nature and etiology of any carpal tunnel syndrome that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should opine as to whether it is at least as likely as not that the Veteran has carpal tunnel syndrome of the right upper extremity that is causally or etiologically related to his military service, including his duties and any symptomatology therein. The Veteran has claimed that he developed the disorder in service as a result of repetitive stress from his military duties, including using manual screwdrivers and removing rivets by hand. The examiner should also state whether it is at least as likely as not that the Veteran has carpal tunnel syndrome of the right upper extremity that is either caused by or aggravated by his service-connected thoracic spine disability. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 3. After completing the preceding development, the Veteran should be afforded a VA examination to determine the nature and etiology of any right shoulder that may be present. Any and all studies, tests, and evaluations deemed necessary by the examiner should be performed. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and assertions. The examiner should note that the Veteran is competent to attest to factual matters of which he had first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should identify any right shoulder disorder that has been present during the appeal period or within close proximity thereto. If the Veteran does not have a current diagnosis associated with his symptoms, the examiner should state this with a fully reasoned explanation. The examiner should also state whether there is any functional impairment caused by any right shoulder pain. Evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes. For each diagnosis identified or any functional impairment resulting from pain, the examiner should opine as to whether it is at least as likely as not that the disorder is causally or etiologically related to the Veteran’s military service, including his duties and any symptomatology therein. The examiner should also state whether it is at least as likely as not that the disorder is either caused by or aggravated by carpal tunnel syndrome of the right upper extremity and/or his service-connected thoracic spine disability. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a certain conclusion is so evenly divided that it is as medically sound to find in favor of such a conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. Because it is important “that each disability be viewed in relation to its history[,]” 38 C.F.R. § 4.1, copies of all pertinent records in the appellant’s claims file, or in the alternative, the claims file, must be made available to the examiner for review. 4. The AOJ should review the examination reports to ensure that they are in compliance with this remand. If a report is deficient in any manner, the AOJ should implement corrective procedures. 5. After completing the above actions and any other development as may be indicated as a consequence of the actions taken in the preceding paragraphs, the case should be reviewed by the AOJ on the basis of additional evidence. J.W. ZISSIMOS Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD D.S. Chilcote, Associate Counsel