Citation Nr: 20005051 Decision Date: 01/22/20 Archive Date: 01/22/20 DOCKET NO. 14-22 577 DATE: January 22, 2020 ORDER Entitlement to service connection for a right hand disability, to include arthritis and carpal tunnel syndrome, is denied. Entitlement to service connection for a left hand disability, to include arthritis and carpal tunnel syndrome, is denied. FINDINGS OF FACT 1. The Veteran’s right hand arthritis and carpal tunnel syndrome were not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established, and the disability is not otherwise etiologically related to an in-service injury or disease. 2. The Veteran’s left hand arthritis and carpal tunnel syndrome were not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established, and the disability is not otherwise etiologically related to an in-service injury or disease. CONCLUSIONS OF LAW 1. The criteria for service connection for right hand arthritis and carpal tunnel syndrome are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. 2. The criteria for service connection for left hand arthritis and carpal tunnel syndrome are not met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from January 1978 to July 1997. Service Connection 1. A right hand disability, to include arthritis and carpal tunnel syndrome 2. A left hand disability, to include arthritis and carpal tunnel syndrome The Veteran contends that his bilateral hand condition—diagnosed as arthritis and carpel tunnel syndrome—was caused by his service. Specifically, he asserts that he experienced bilateral hand fractures in service due to his military duties. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. Service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). Certain chronic diseases, such as arthritis, are subject to presumptive service connection if manifest to a compensable degree within one year from separation from active service. This presumption is rebuttable by affirmative evidence to the contrary. 38 U.S.C. §§ 1112, 1113; 38 C.F.R. §§ 3.307 (a)(3), 3.309(a). The question for the Board is whether the Veteran has a current disability of either hand that began during service or is at least as likely as not related to an in-service injury, event, or disease. In this regard, the Board concludes that, while the Veteran has a current diagnosis of arthritis and carpal tunnel of each hand, the evidence shows that the Veteran did not experience a bilateral hand fracture during service. The preponderance of the evidence weighs against finding that the Veteran’s diagnosed arthritis and carpal tunnel of his hands began during service, within the first year after separation from service, or is otherwise related to an in-service injury, event, or disease. A review of the Veteran’s service treatment records shows that, in September 1981, he was treated for a small abrasion of his right hand on the dorsal area secondary to an assault. The Veteran was cleaned with a scrub, and dressing was applied. A December 1992 medical examination showed that the Veteran did not self-report any bilateral hand condition or injury. The report of his July 1997 retirement examination showed a summary of defects and diagnosis, which included previous fractures of the hands. The examiner noted bilateral hand fractures during service. Private treatment records in August 2012 show that the Veteran reported bilateral arthritis of his extremities. A December 2012 private treatment record shows that he reported swollen and stiff hands and fingers, as well as trouble with typing. A January 2014 private treatment note from the Veteran’s physician shows that the Veteran had osteoarthritis, most likely related to service. The physician stated that the Veteran had continuous bilateral hand pain, and he was referred to a rheumatologist for management of symptoms. At an August 2019 VA examination, the examiner noted, after reviewing the evidence of record and conducting a physical examination of the Veteran, that it was less likely than not that a bilateral hand condition (to include arthritis and carpal tunnel) was related to active service. The examiner noted that the Veteran was first diagnosed with arthritis of the left hand by X rays in June 2013 and for the right hand in August 2019. The examiner noted that there was no diagnosis of bilateral hand fractures prior to these findings despite the Veteran reporting bilateral hand fractures in-service. The examiner acknowledged that the July 1997 separation examination report showed a history of bilateral hand fractures but noted that this notation was based on the Veteran’s self-reports. The examiner opined that the current arthritis of the Veteran’s hands was most likely due to the natural aging processes for a 60-year-old patient. Accordingly, after a review of the evidence of record, the Board finds that the preponderance of the evidence is against the Veteran’s claim for a bilateral hand disability because such a condition did not onset during service or within the first year after separation from service. Initially, VA and private treatment records show the Veteran was not diagnosed with any bilateral hand conditions until 2012, which is more than 25 years after separation from service. While the Veteran and his spouse are competent to report that he experienced symptoms of hand pain since service, they are not competent to provide a diagnosis in this case or to determine that these symptoms are manifestations of an alleged in-service bilateral hand fracture. The issue is medically complex, as it requires knowledge of the musculoskeletal system and interpretation of diagnostic medical testing. Jandreau v. Nicholson, 492 F.3d 1372, 1377, 1377 n.4 (Fed. Cir. 2007). Additionally, while the Veteran reports that he experienced a bilateral hand fracture during service and while he claimed to have a history of a bilateral hand fracture on his 1997 separation examination, the evidence indicates that no such injury occurred. A review of the Veteran’s extensive service treatment record indicates that there are no assessments of a bilateral hand fracture. While the Veteran asserts that the hands were fractured in 1981, treatment records only confirmed an injury consistent with an abrasion. Additionally, the Veteran did not report a bilateral hand condition during his entire period of service until 1997, despite reporting numerous other musculoskeletal conditions affecting the back, feet, and arms. Further, while the physician conducting the separation examination in 1997 noted a history of bilateral hand fractures, no X-rays of the hand were undertaken, and it is apparent that the diagnosis was made entirely on the Veteran’s self-reports of symptoms. As such, the Board finds that the evidence does not support that the Veteran’s contentions that he sustained a bilateral hand fracture in-service. Furthermore, the August 2019 VA examiner opined that the Veteran’s bilateral hand disability is not at least as likely as not related to an in-service injury, event, or disease (including his reports of a bilateral hand fracture during service). The rationale was that the service treatment records showed no indications of a hand fracture and that post-service medical records do not provide a diagnosis of a hand condition until many years after separation from service. The examiner’s opinion is probative, because it is based on an accurate medical history and provides an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). The Board acknowledges that the record contains a conflicting medical opinion as to whether the Veteran’s bilateral hand disability is at least as likely as not related to an in-service injury, event, or disease. Specifically, in a January 2014 letter, the Veteran private physician acknowledged that the Veteran was diagnosed with osteoarthritis and bilateral hand pain and opined that this condition was most likely related to service. This opinion is, however, less probative than the VA examiner’s opinion. There is no indication that the private physician reviewed pertinent medical evidence in the claims file. Instead, the opinion appears to be based on the Veteran’s self-reported medical history, which is inconsistent with VA and private treatment records that show no hand fractures during service and no diagnosis of the condition until many years after separation from service. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008); Reonal v. Brown, 5 Vet. App. 458, 460-61 (1993). Consequently, the Board gives more probative weight to the August 2019 VA examiner’s opinion. The record also shows that VA has fulfilled its obligation to assist the Veteran in developing the claim. In a September 2019 statement submitted by the Veteran, he questioned why the VA examination conducted by a nurse practitioner was worth more than the word of a physician. The Board finds that the Veteran has been afforded an adequate examination. The VA examination was conducted by a nurse practitioner and was based on review of claims file, solicitation of history and symptoms from the Veteran, and a thorough examination of him. To the extent that the Veteran’s representative has challenged the adequacy of the VA examiner based upon the examiner’s qualifications as a nurse practitioner, the United States Court of Appeals for Veterans Claims (Court) has held that VA satisfied its duty to assist in a case where a nurse practitioner performed the VA examination, as a nurse practitioner is competent to provide medical evidence. Cox v. Nicholson, 20 Vet. App. 563, 569 (2007). The Board finds that the August 2019 VA examination and medical opinion are adequate to decide the Veteran’s claim because they were based on a thorough examination, appropriate diagnostic tests, and review of his relevant medical history. The examination report and medical opinion are accurate and fully descriptive. Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2008); Barr v. Nicholson, 21 Vet. App. 303, 312 (2007). The Board finds that the duties to notify and assist the Veteran have been met, such that no further notice or assistance to the Veteran is required to fulfill VA’s duty to assist in the development of the claim. The Veteran and his spouse believe his bilateral hand conditions are related to his active service. However, the Veteran and his spouse are not competent to report that he incurred a bilateral hand fracture during service or that his current disability is related to active service. The issue is medically complex, as it requires knowledge of the musculoskeletal system and interpretation of complicated diagnostic medical testing. It is thus outside the competence of the Veteran and his spouse in this case because the record does not show that they have the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); Kahana v. Shinseki, 24. Vet. App. 428 (2011). Thus, the Board gives more probative weight to the competent and probative medical evidence of record. These service connection claims must be denied. THERESA M. CATINO Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J. Dworkin, Counsel The Board’s decision in this case is binding only with respect to the instant matter decided. This decision is not precedential, and does not establish VA policies or interpretations of general applicability. 38 C.F.R. § 20.1303.