Citation Nr: 20046622 Decision Date: 07/13/20 Archive Date: 07/13/20 DOCKET NO. 15-24 399 DATE: July 13, 2020 ORDER Entitlement to service connection for bilateral carpal tunnel syndrome, to include as secondary to service-connected diabetes mellitus is denied. FINDING OF FACT The record does not establish that the Veteran has a current bilateral carpal tunnel syndrome disability separate from bilateral peripheral neuropathy, for which he is already service connected. CONCLUSION OF LAW The criteria for service connection for bilateral carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1110 , 5107(b) (2012); 38 C.F.R. § 3.303 (a) (2019). REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty in the U.S. Army from July 1970 to January 1972, including service in the Republic of Vietnam. He was awarded the Purple Heart Medal and Combat Infantryman’s Badge. This matter comes before the Board of Veteran’s Appeals (Board) on appeal from a February 2013 rating decision by the Regional Office (RO). The Veteran testified at a Board videoconference hearing before the undersigned Veterans Law Judge in February 2018; a transcript is associated with the claims file. The Board has previously remanded the claim in September 2019 for a medical examination and opinion. The Board finds that the subsequent December 2019 VA examination is adequate and in compliance with the Board’s remand instructions. As such, the Board finds there has been substantial compliance with the prior Board remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998) (noting the Board’s duty to “insure [the RO’s] compliance” with the terms of its remand orders); D’Aries v. Peake, 22 Vet. App. 97 (2008). Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury suffered or disease contracted in active military, naval, or air service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service injury or disease; and (3) a relationship between the two. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Entitlement to service connection for bilateral carpal tunnel syndrome, to include as secondary to service-connected diabetes mellitus The Veteran contends that he has bilateral carpal tunnel syndrome (CTS) due to his active service, or as secondary to his service-connected diabetes mellitus. The Board finds that the Veteran’s claim must be denied, both due to the Veteran failing to meet the requirements of the first element of service connection, and also because a grant of benefits would constitute pyramiding. This denial of benefits will be discussed in greater detail below. In June 2010 a VA EMG test was ordered but was cancelled one day later. See February 2019 CAPRI. Subsequently, a nerve conduction study was performed later in June 2010. There, the examiner stated that there was “no clear indication to justify EMG/NCS studies at this time per review of last consultant’s note since PE was normal.” See February 2019 CAPRI, p. 1. The Veteran subsequently submitted an October 2010 private EMG test in which bilateral carpal tunnel syndrome was diagnosed. The October 2010 report stated: “the above is an abnormal nerve conduction EMG evaluation consistent with mild bilateral carpal tunnel syndrome, grade 2/4.” See November 2010 Medical Treatment Record – Non – Government Facility. However, in October 2012, a VA examiner concurred that the Veteran had carpal tunnel syndrome, while stating that it was not caused by military service. Specifically, the VA examiner stated: “CTS less likely than not due to DM, reasoning CTS is not caused or aggravated by DM. Rather, it is an anatomical condition caused by compression of the median nerve by the ligamentous structures of the wrist. It is made worse by repetitive motions. The veteran does not have symptoms consistent with diabetic neuropathy of the upper extremities.” See October 2012 VA Examination. In December 2013, the Veteran underwent another electrodiagnostic study of the upper extremities that was evaluated as essentially normal. Then, in October 2018 a neurology consultation report reported that the Veteran did not have carpal tunnel syndrome, explaining: “The patient indicates that numbness and tingling was present in the hands by around 2010. The patient was evaluated by Dr. C, neurology in Waco Texas with nerve conduction studies that were read consistent with mild carpal tunnel syndrome in 2010. A more extensive nerve conduction study was performed in 2013. This study was read as essentially normal. Dr. TJ has performed a current nerve conduction study. This reveals mild axonal sensorimotor peripheral neuropathy in the legs and mild axonal loss with mild slowing in the upper extremities as well. There is some mild slowing at the right ulnar nerve at the cubital tunnel. The patient had no involvement of the median nerves on either side and therefore no findings that would support carpal tunnel syndrome. No cervical radiculopathy findings were seen on EMG.” Id at 92 (emphasis added by Board). During the February 2018 Board hearing, the Veteran testified that he first noticed the onset of carpal tunnel syndrome while handling mail in his job at the Post Office in about 2010. He stated that he was diagnosed by a private clinician based on the results of testing and diagnosed with peripheral neuropathy at about the same time. The pain and numbness started at mid-bicep and goes down the arm. The Board cited “inconsistent and credible evidence [on] whether the Veteran had or now has CTS” and issued a remand in September 2019 for an addendum opinion. The ordered addendum opinion was provided in December 2019. The VA examiner opined that the Veteran did not have carpal tunnel syndrome but rather had sensorimotor peripheral neuropathy. The VA examiner explained: “After physical exam and review of above records, I concur with Dr B’s 3/2019 finding that claimant does not have carpal tunnel syndrome. Per Dr. M’s neurology consult 10/16/2018, a 2010 nerve conduction study indicated carpal tunnel, then a "more extensive nerve conduction study" in 2013 was normal, then a 2018 study indicated mild axonal sensorimotor peripheral neuropathy. Claimant’s current description of the numbness and being in his hands and arms weighs against carpal tunnel, as in carpal tunnel symptoms are in the wrist and hand, not the arm. Additionally he failed to improve with use of carpal tunnel splints. These would weigh against a carpal tunnel diagnosis. On the other hand, the 2018 conduction study and the 15 year history of diabetes would support the finding of sensorimotor peripheral neuropathy.” See December 2019 C&P Exam. The Board assigns significant probative value to the findings of the December 2019 VA examiner, as the VA examiner conducted an in-person examination, reviewed the Veteran’s record, considered his lay statements, and provided a detailed rationale supported by the record. In reaching this conclusion, the Board notes that the examiner’s statements regarding the Veteran’s splints is supported by the record. The Veteran used his prescription of splints as evidence of his carpal tunnel syndrome. See August 2019 VA 21-4138. However, the October 2018 neurology consultation notes stated “the patient in the past was given wrist splints which were not helpful. Given the absence of findings consistent with carpal tunnel syndrome this is not surprising. The patient describes pain in his thumbs. This is reproduced by palpation of the base of the first metacarpal ventrally but in no other location. The patient has no pain on manipulation of the ulnar nerves at the cubital tunnel. There is no Tinel on manipulation of the ulnar nerves. There is no Phalen on compression of the nerves. The patient does have a positive Tinel on percussion of the median nerve especially on the right side. There is no fixed sensory deficit of either the median or ulnar nerve distribution. There is no atrophy and no weakness.” See February 2019 CAPRI, p. 92. The Board acknowledges that the Veteran initially stated that he had numbness in this wrist area. See April 2008 VA 21-4138. However, a careful review of the Veteran’s records shows that the Veteran consistently complained of numbness in the thumbs, see December 2019 CAPRI, hands, see February 2019 CAPRI, and feet, see November 2019 CAPRI. A careful review of the record does not reveal any claimed numbness of the wrist, aside from the Veteran’s single April 2008 statement. As such, the Board finds that the December 2019 VA examiner’s medical opinion is supported by the record and is thus adequate. Therefore, the Board finds that the Veteran does not have a current diagnosis of bilateral carpal tunnel syndrome, and as such the claim must be denied. Finally, the Board notes that the Veteran has been already granted service-connection for bilateral upper peripheral neuropathy of the musculospiral nerve, median nerve and ulnar nerve. The Veteran’s grant of benefits was based on a March 2017 VA examination, in which the VA examiner stated: “Veteran had a EMG in October 2018 with a Neurologist. EMG was negative for carpal tunnel syndrome but did show mild axonal sensorimotor peripheral neuropathy. Opinion is given per neurologist that the likely cause of veteran's neuropathy is his diabetes mellitus. Veteran has not had continual treatment for neuropathy in the past as it was recently just noted on current EMG. It is opinioned by Neurologist in October that is more likely than not due to diabetes caused by herbicide exposure. I agree with this opinion.” See March 2017 C&P Exam. The reported manifestations of peripheral neuropathy were based on the same statements made by the Veteran, examinations and evidence put forward by the Veteran for carpal tunnel syndrome. The critical element in this case is that the symptomatology for carpal tunnel syndrome was duplicative of or overlapping with the symptomatology of peripheral neuropathy, for which compensation has been awarded See Esteban v. Brown, 6 Vet. App. 259, 261 (1994). (continued next page) In sum, the Board finds that service connection for carpal tunnel syndrome must be denied, as the Veteran does not have a current disability of carpal tunnel syndrome and that the manifestations a loss of function are contemplated in service-connected peripheral neuropathy. As such, the benefit-of-the doubt doctrine is not for application, and the claims for service connection for a carpal tunnel syndrome must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). J.W. FRANCIS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. Abels, Associate 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.