Citation Nr: 1818019 Decision Date: 03/22/18 Archive Date: 04/03/18 DOCKET NO. 14-27 862 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Philadelphia, Pennsylvania THE ISSUE Entitlement to service connection for residuals of a right wrist ganglion cyst (other than the post-operative scar). REPRESENTATION Appellant represented by: Pennsylvania Department of Military and Veterans Affairs WITNESS AT HEARING ON APPEAL The Veteran ATTORNEY FOR THE BOARD W. R. Stephens, Associate Counsel INTRODUCTION The Veteran served on active duty from July 1986 to September 1994. These matters come before the Board of Veterans' Appeals (Board) on appeal from a June 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) in Philadelphia, Pennsylvania. The Board previously remanded this matter in December 2015 to schedule the Veteran for a Board hearing. In March 2017, the Veteran testified before the undersigned Veterans Law Judge at a videoconference hearing. A copy of the transcript is associated with the file. FINDINGS OF FACT 1. The in-service right wrist ganglion cyst was treated. Service connection for a post-operative scar has been granted. 2. Another right wrist disorder was not manifest during service. Arthritis and carpal tunnel syndrome were not manifest within one year of separation. A right wrist disorder (other than scar) is unrelated to service. 3. Arthritis and carpal tunnel syndrome of the right wrist are unrelated (causation or aggravation) to service connected disease or injury. CONCLUSIONS OF LAW 1. A right wrist disorder (other than a ganglion cyst) was not incurred in or aggravated by active service and arthritis and carpal tunnel syndrome may not be presumed to have been incurred therein. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 5103, 5103A, 5107 (2012); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309 (2017). 2. Arthritis and carpal tunnel syndrome are not proximately due to, the result of or aggravated by service connected disease or injury. 38 C.F.R. § 3.310 (2017) REASONS AND BASES FOR FINDINGS AND CONCLUSIONS I. Duty to Notify and Assist Neither the Veteran nor his representative has raised any issues with the duty to notify or duty to assist. See Scott v McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015) (holding that "the Board's obligation to read filings in a liberal manner does not require the Board . . . to search the record and address procedural arguments when the veteran fails to raise them before the Board."); Dickens v. McDonald, 814 F.3d 1359, 1361 (Fed. Cir. 2016) (applying Scott to duty to assist argument). II. Service Connection Veterans are entitled to compensation if they develop a disability "resulting from personal injury suffered or disease contracted in line of duty, or for aggravation of a preexisting injury suffered or disease contracted in line of duty." 38 U.S.C. § 1110 (wartime service), 1131 (peacetime service). To establish entitlement to service-connected compensation benefits, 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." Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may be granted for any disease diagnosed after discharge, when all the evidence, including that pertinent to service establishes that the disability was incurred in service. 38 C.F.R. § 3.303 (d). The determination as to whether these requirements are met is based on an analysis of all the evidence of record and the evaluation of its credibility and probative value. See Baldwin v. West, 13 Vet. App. 1, 8 (1999). The Veteran has been diagnosed with arthritis and carpal tunnel syndrome of the right wrist. Arthritis and organic diseases of the nervous system (carpal tunnel) are identified as a "chronic diseases" under 38 USCA 1101 and 38 C.F.R. § 3.309 (a). "For the showing of chronic disease in service there is required a combination of manifestations sufficient to identify the disease entity, and sufficient observation to establish chronicity at the time, as distinguished from merely isolated findings or a diagnosis including the word "Chronic." When the disease identity is established (leprosy, tuberculosis, multiple sclerosis, etc.), there is no requirement of evidentiary showing of continuity. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim." 38 C.F.R. 3.303 (b). The Veteran contends that he has a residual disorder of the right wrist from a ganglion cyst incurred in service. Notably, the Veteran has not asserted that he incurred a specific injury to his right wrist in service. Specifically, the Veteran has testified that he experiences pain and loss of strength in the right wrist. He relates this to the post-service removal of his right wrist ganglion cyst. Service treatment records document a ganglion cyst of the right wrist in 1988. Private treatment records document that the Veteran had the ganglion cyst removed in 1997. At an August 1994 report of medical history upon separation, the Veteran denied swollen or painful joints, arthritis, rheumatism, or bursitis, and bone, joint or other deformity. There is no separation examination of record. Service treatment records do not document any other relevant treatment, symptoms, complaints, or diagnoses. At a September 2012 VA examination, the Veteran was diagnosed with osteopenia and mild degenerative joint disease of the right wrist. In a January 2013 addendum medical opinion, the examiner concluded that the Veteran's osteopenia and mild degenerative joint disease are not a result of the ganglion cyst removal. The examiner did note that the Veteran's hand pain may be the result of nerve damage caused by the right wrist ganglion cyst. In a March 2014 VA sensory-motor examination to clarify the September 2012 examiner's statement, the Veteran was diagnosed with carpal tunnel syndrome. The examiner concluded that the Veteran's right hand pain is a "natural progression as a result of the Veteran's dominant hand and the type of work that he has done for a living for several years and NOT a result of the ganglion cyst and its subsequent removal from the right wrist." In adjudicating a claim, the Board is charged with the duty to assess the credibility and weight given to evidence. See Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997). Competency of evidence differs from weight and credibility. The former is a legal concept determining whether testimony may be heard and considered by the trier of fact, while the latter is a factual determination going to the probative value of the evidence to be made after the evidence has been admitted. Rucker v. Brown, 10 Vet. App. 67, 74 (1997). The probative value of a medical opinion primarily comes from its reasoning; threshold considerations are whether a person opining is suitably qualified and sufficiently informed. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). In this case, the Board accepts the September 2012 and March 2014 VA examiners' opinions that the Veteran's right wrist disorders are less likely than not related to his service, specifically his ganglion cyst, as highly probative medical evidence on this point. The Board notes that the examiners rendered their opinions after thoroughly reviewing the claims file and relevant medical records. The examiners noted the Veteran's pertinent history and provided a reasoned analysis of the case. See Hernandez-Toyens, 11 Vet. App. at 383; Gabrielson v. Brown, 7 Vet. App. 36, 40 (1994) (the probative value of a physician's opinion depends in part on the reasoning employed by the physician and whether or not (or the extent to which) he reviewed prior clinical records and other evidence). Here, it is important to note that the Veteran had a ganglion cyst during service and that service connection has been established for a post-operative scar. The issues before the Board are whether there is a relationship between the carpal tunnel syndrome and arthritis and service, or in the alternative a relationship to the residuals of the ganglion cyst. Specific to the potential link between neurological symptoms and the Veteran's ganglion cyst, the Board finds the March 2014 VA opinion to be of greater probative value than the September 2012 opinion. The March 2014 VA examiner specifically addresses the potential link between the Veteran's carpal tunnel syndrome and his ganglion cyst and provides a supporting rationale, whereas the September 2012 examiner's reference to a potential link is not supported by a rationale. The Board has also considered the lay statements of record, to include the Veteran's assertions of a link between his ganglion cyst and his current right wrist disorder. To the degree that the Veteran has reported that he has experienced a continuity of symptoms, or at least since separation from service, he is competent to report his observations and relate what he was told by medical professionals. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Of note, the Veteran has not indicated that a medical professional provided him with a diagnosis of either arthritis, carpal tunnel syndrome, or osteopenia during service or immediately thereafter. Id. The Veteran's lay evidence of onset and continuity is far less probative than the opinions of the VA professionals, as the VA medical opinions are far more detailed and reasoned; thus warranting a greater probative value. The Board finds that the probative value of the general lay assertions are outweighed by the clinical evidence of record. Service treatment records do not document any relevant symptoms, complaints, treatment, or diagnoses, and the Veteran has not indicated as much, other than the aforementioned ganglion cyst. The medical evidence of record is afforded greater probative value than the more general lay assertions of the Veteran. In sum, there is no reliable evidence linking the Veteran's post service right wrist arthritis and carpal tunnel syndrome to service, or the ganglion cyst and post-service status of the ganglion cyst. The contemporaneous records establish that there were no documented manifestations of right wrist arthritis or carpal tunnel syndrome in service and the Veteran specifically denied any relevant symptoms or manifestations upon separation, and there were no manifestations of arthritis or carpal tunnel syndrome within one year of separation. Rather arthritis and carpal tunnel syndrome were first manifest many years after separation. The Board finds the contemporaneous records to be far more probative and credible than the Veteran's report of onset and continuity and treatment. Here, chronic disease of the right wrist was not "noted" during service within the meaning of section 3.303(b). The Board finds that the service treatment records do not show a combination of right wrist manifestations sufficient to identify the disease entity of either arthritis or carpal tunnel syndrome, and sufficient observation to establish chronicity at the time. Furthermore, the evidence does not establish that arthritis or carpal tunnel syndrome of the right wrist was manifest to a compensable degree within one year of separation. 38 C.F.R. §§ 3.307; 3.309. The evidence of record shows that the disorders were manifest many years after service, are not related to the documented ganglion cyst and its subsequent recision, and are more likely related to a post-service event. Furthermore, there is no showing of continuity. The Veteran was not shown to have arthritis or carpal tunnel syndrome, or any relevant chronic right wrist disorder in service and did not have characteristic manifestations of such a disorder until multiple years after discharge. In essence, the evidence establishes that the right wrist was normal throughout service, with the exception of the unrelated ganglion cyst, and the onset of arthritis and carpal tunnel syndrome occurred many years after service. The Board finds that the contemporaneous in-service and post-service treatment records are entitled to greater probative weight and credibility than the lay statements of the Veteran. The more probative evidence establishes that he did not have a chronic right wrist disorder during service or within one year of separation, and that current disorders are not residuals of the ganglion cyst and subsequent recision. Furthermore, the evidence establishes that the remote onset of right wrist disorders are unrelated to service. The Board finds that the preponderance of the evidence is against the claim and the claim must be denied. ORDER Entitlement to service connection for right wrist arthritis or carpal tunnel syndrome is denied. ____________________________________________ H. N. SCHWARTZ Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs