Citation Nr: 18157411 Decision Date: 12/12/18 Archive Date: 12/12/18 DOCKET NO. 10-13 542A DATE: December 12, 2018 ORDER Entitlement to service connection for arthritis of the left wrist as a residual of left wrist ganglion cyst is granted. Entitlement to service connection for ulnar neuropathy of the left upper extremity, to include as a residual of left wrist ganglion cyst, is denied. FINDINGS OF FACT 1. The evidence is at least in equipoise as to whether the Veteran’s left wrist arthritis is a result of the left wrist ganglion cyst treated in service. 2. The weight of the evidence is against a finding that the Veteran’s ulnar neuropathy is related to his left wrist ganglion cyst in service or other incidence of service. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for arthritis of the left wrist have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. 2. The criteria for entitlement to service connection for ulnar neuropathy of the left upper extremity, to include as a residual of left wrist ganglion cyst in service, have not been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran had active duty military service from February 1981 to June 1992. In February 2016, the Board sought an expert medical opinion through the Veterans’ Health Administration (VHA) with respect to the question of whether the Veteran’s left wrist disability resulted from his military service. The opinion was received in April 2016. The Board requested a supplemental opinion, which was inadvertently delayed, finally being dispatched in April 2018. The opinion was received in July 2018. The Veteran was provided an opportunity to respond to the opinion obtained and a response was furnished in September 2018. Entitlement to service connection for a left wrist disability Generally, to establish a right to compensation for a present disability, a Veteran must show: (1) a present disability; (2) an 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. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). All three elements must be established by competent and credible evidence in order that service connection may be granted. The Veteran seeks service connection for a left wrist disability, which he asserts is the result of a ganglion cyst that manifested in and was treated during service. The Veteran’s service treatment records show that he was treated in September 1991 for knots on his wrists, worse on the left wrist. The left wrist was shown to have a non-mobile ganglion cyst on physical examination, which was subsequently aspirated. In June 2009, a VA evaluation of the Veteran’s hands and arms showed evidence of congenital malformations in each arm, as well as changes of distal and maximal carpal tunnels. The Veteran reported that he had weakness in both wrists, for which he wore wrist splints while working at the post office. He reported having shooting pains down his arms and into the center of each palm, and dropping things from his left hand. A December 2009 treatment note described the Veteran’s symptoms of bilateral wrist pain, dropping objects, and numbness and tingling in his fingers. An MRI of the wrists had shown bilateral ulnar nerve neuropathy across the elbows, as well as a small cystic mass on the left wrist. He had full range of motion in the wrists and elbows. The provider diagnosed bilateral cubital tunnel syndrome and noted that the mass on the left wrist was not related to this diagnosis or the mild degenerative changes shown in that area. In his VA Form 9 submitted in April 2010, the Veteran asserted that the draining of the ganglion cyst in his left wrist in service had not resolved the problem. He reported that even at the time he had complained of pain with pressure and lifting, as well as weakness. He noted that the VA doctor wanted to operate on both his right and left arms to correct a problem that the Veteran believed had begun even before his treatment in service in 1991. The record shows that the Veteran underwent ulnar nerve release surgery on both arms for cubital tunnel syndrome in 2010. In a statement submitted in June 2010, the Veteran stated that the VA provider had told him that the problems in his hands were related to nerve damage in his elbow, the extent of which was not known. An August 2010 VA examination was conducted with a focus on the right wrist and hand. The examiner noted the treatment for left wrist ganglion cyst in September 1991 and a diagnosis of bilateral ulnar nerve neuropathy in December 2009. A February 2015 VA examination noted the diagnosis of left wrist ganglion cyst in 1991 and of bilateral ulnar nerve neuropathy in 2009. The Veteran stated that the aspiration of the cyst in service had helped the pain and the cyst had not returned. He complained of bilateral wrist pain and discomfort since service and said he had started dropping items and having trouble putting mail into slots. He had undergone ulnar releases at the elbows in 2010 but this had not relieved the numbness. The examiner described the Veteran’s peripheral nerve symptoms as constant mild pain, paresthesias, and numbness in both arms, with mild atrophy of the left hypothenar eminence. The examiner provided the opinion that the Veteran’s ulnar neuropathy produced numbness and pain in his hands and limited his ability to perform his job as a mail carrier, but this was not related to the left wrist ganglion cyst in service. The basis for this opinion was that the ganglion cyst did not occur in the region where the ulnar nerve is located, and that the ulnar releases were performed at the elbows, as opposed to the cyst which was located on the palmar side of the wrist. At the October 2015 Board hearing, the Veteran testified that he had done physical work all his life prior to service but did not have any problem with his wrists or arms prior to service. In 1991 he sought treatment at sick call after he had knots pop up on both wrists and was diagnosed with a left ganglion cyst. He had refused an additional examination after the treatment for the cyst because he had been approved for early release from service and requesting an additional examination would have delayed his release. In 2009, he had sought treatment again for problems with his hands and arms and examination had shown the same ganglion cyst and deformities shown in service. The provider had determined that the Veteran was suffering from ulnar neuropathy in both arms and surgery on both elbows was eventually performed. He felt that the ulnar neuropathy was related to the problems he had experienced in service. In 2016, the Board sought an expert medical opinion through VHA in order to address concerns about inadequacies in the prior VA opinion. The expert was specifically asked to address the history of the Veteran’s symptoms as described in his Board hearing The expert’s March 2016 opinion was that the Veteran’s bilateral ulnar nerve neuropathy was not related to his left wrist ganglion cyst in service. The opinion was based on the fact that there was no evidence of symptoms related to ulnar nerve neuropathy in the Veteran’s service treatment records. The expert also noted that the Veteran had apparent congenital malformations in the wrists, as well as the ganglion cyst and the ulnar nerve neuropathy, but stated that these malformations were likewise not related to his ganglion cyst. In a statement submitted in October 2017, the Veteran asserted that his claim with respect to the ulnar neuropathy was based on the diagnosis by the VA provider in 2009. He noted that he had been given service connection for arthritis in other parts of his body and did not believe his left wrist pain was due to a pre-existing congenital condition. The Board sought clarification of the March 2016 VHA expert medical opinion, specifically requesting an explanation in lay terms of the medical diagnoses and language in the opinion and consideration of the Veteran’s history of symptoms regardless of the evidence of any treatment or diagnosis in service. The opinion received in April 2018 defined the diagnosis of mild degenerative changes in the scaphoid, trapezium, first, and second metacarpal bases as arthritis, most likely manifested by mild pain, possible stiffness, and loss of range of motion. The expert stated that this was not related to the ulnar neuropathy but might be related to the Veteran’s ganglion cyst. The Veteran’s history of pain in his left wrist could be related to the arthritis; the problem of dropping things was likely due to his ulnar neuropathy. The expert noted that imaging studies had shown bilateral congenital issues and bilateral ulnar neuropathy, with arthritic changes shown in the left wrist only. After considering all of the evidence of record, with specific attention to the documents discussed above, the Board finds that service connection is warranted for the residuals of the left wrist ganglion cyst manifested in service. Moreover, the evidence is at least in equipoise; that is, evenly balanced, as to whether the Veteran’s left wrist arthritis is the result of his ganglion cyst. The Veteran has reported ongoing pain and stiffness in his left wrist since service and the 2018 expert opinion stated that the arthritis might be related to the ganglion cyst. In addition, the evidence shows that the Veteran has arthritis in his left wrist but not his right, just as he had a ganglion cyst in the left wrist but not the right. For these reasons, the Board finds that the benefit-of-the-doubt standard supports service connection for the arthritis in the Veteran’s left wrist. 38 U.S.C. § 5107(b). In contrast, the Board finds that the ulnar neuropathy in the Veteran’s left arm is not a residual of his left wrist ganglion cyst. Specifically, the evidence shows that the ganglion cyst was on the Veteran’s left wrist and his ulnar neuropathy affected both his right and left arms, at the elbow. In addition, the ganglion cyst was located on the opposite side of his wrist from the connection point for the ulnar nerve. The VA examination and the VHA opinion are both against a finding that the Veteran’s ulnar neuropathy had its onset in service or was related to his ganglion cyst, in large part because of the fact that both arms are affected to the same degree. The Veteran has not provided any competent medical evidence to the contrary. Therefore, service connection for ulnar neuropathy is denied. 38 C.F.R. § 3.304. Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals ATTORNEY FOR THE BOARD Cheryl E. Handy, Counsel