Citation Nr: 21001106 Decision Date: 01/07/21 Archive Date: 01/07/21 DOCKET NO. 16-15 011 DATE: January 7, 2021 ORDER Entitlement to service connection for a right wrist disorder, diagnosed as degenerative arthritis, is granted. FINDING OF FACT The Veteran’s right wrist disorder, diagnosed as degenerative arthritis, is at least as likely as not related to active service. CONCLUSION OF LAW The requirements to establish entitlement to service connection for a right wrist disorder, diagnosed as degenerative arthritis, have been met. 38 U.S.C. §§ 1110, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the United States Air Force from March 1962 to March 1966. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2015 rating decision. In February 2019, the Veteran testified at a Board hearing before the undersigned Veterans Law Judge. A transcript from that proceeding is associated with the claims file. In a May 2019 decision, the Board remanded the case to the agency of original jurisdiction (AOJ) for additional development and adjudication. The case has since been returned to the Board for appellate review. The Board finds that the AOJ substantially complied with prior remand directives, to the extent possible, and no further action in this regard is warranted. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (concluding that a remand is not required under Stegall v. West, 11 Vet. App. 268 (1998) where there was substantial compliance with the Board's remand instructions). 1. Entitlement to service connection for a right wrist disorder. Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, 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. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 38 F.3d 1163, 1167 (Fed. Cir. 2004)). The absence of any one element will result in denial of service connection. Service connection may also be granted for any disease initially diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In addition, for Veterans who have served 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis, are presumed to have been incurred in service if they manifested to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1131, 1137; 38 C.F.R. §§ 3.307, 3.309. For the showing of a 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. If chronicity in service is not established, a showing of continuity of symptoms after discharge is required to support the claim. 38 C.F.R. §§ 3.303(b), 3.309; Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The Veteran contends that he has a right wrist disorder that his related to active service. The Veteran testified that his right wrist problems began during active service when he first sustained an injury in 1964 after a maintenance stand collapsed on his arm. See February 2019 Board Hearing Transcript. The Veteran indicated that part of the machine was raised to its full height of 15 feet before it slammed down on his arm. The Veteran theorized that his arthritis began to develop at this time, and although he sustained some post-service injuries, including when he hit a knot while working with a drill, these injuries only served to aggravate the arthritis that was already present and took years to develop. The Veteran has also indicated that he experienced continued symptoms after the in-service injury, reporting that his right wrist disorder began in 1964, and his wrist has always been hurting. See February 2010 VA Form 21-526; March 2015 Notice of Disagreement. At the time of the Veteran's enlistment in March 1962, the Veteran reported a history of swollen or painful joints in the Report of Medical History. However, the physician's summary only noted usual childhood diseases with no sequalae as well as a history of a right tympanic membrane (TM) injury. The summary added that no other significant abnormalities were present. The Veteran's March 1962 enlistment examination indicated that a scar was present in the right wrist area. The Board notes that the Veteran later clarified in a July 2014 statement that this scar was related to a cut from glass he sustained as a child. In addition, the examination reported that the upper extremities were normal and no abnormalities related to the right wrist joint were noted. The Veteran's upper extremities were still marked as normal in a subsequent March 1964 service examination, and there were no relevant complaints in the associated Report of Medical History. On December 30, 1964, a service treatment record (STR) from 6045th United States Air Force Hospital at Osan Air Force Base, Korea noted that the Veteran was diagnosed with a contusion to the right forearm with tenderness over the distal radioulnar joint. No fracture was seen on x-ray. The record indicated that the Veteran was instructed to ice the injury for 24 hours, followed by the application of heat. The record also indicated that he should return to care in 7 days. Following this entry, service examinations dated in July 1965 and November 1965 noted that the Veteran’s upper extremities were normal. The Veteran also did not report any relevant problems in a July 1965 Report of Medical History. The Veteran's March 1966 discharge examination continued to note a one-inch scar on the palmar aspect of the right wrist. However, the report added that the scar was well-healed and non-symptomatic. The upper extremities were still marked as normal in the clinical evaluation, and no right wrist joint abnormalities were noted. The Veteran did not report any complaints related to the right wrist in the March 1966 Report of Medical History. After service, Dr. H. noted in a February 1998 private treatment record that the Veteran was a right-handed construction worker who came in with x-rays showing moderate degenerative arthritis in the right wrist and electrical tests showing a severe carpal tunnel syndrome on the right side with moderate carpal tunnel syndrome on the left and normal ulnar nerve conduction tests. The Veteran denied any significant past history of difficulty with his wrist or hand. He had also performed heavy construction work on a seasonal basis, working for approximately five months out of the year. The Veteran's work involved heavy shoveling, raking, running jack hammers, swinging sledgehammers, and so forth. The record noted that his difficulty began in December 1997 when he was engaged in road paving. The Veteran described the process as paving over manholes, locating the manholes with a metal detector, and using a sledgehammer, jack hammer, or a similar tool to break up the cement over a manhole cover. In performing this task, he developed rather severe numbness in his bilateral upper extremities that was greater on the right side. The difficulty began at the end of November, and he was having so much numbness by the end of December that he had not been able to return to work. Right wrist x-rays showed no evidence of acute injury, but they did show moderate scapholunate collapse with substantial degenerative change in the radial scaphoid joint, a wide scapholunate gap, and considerable osteophyte formation on the tubercle of the scaphoid. The Veteran was subsequently noted to have a substantial amount of numbness, and he was referred to Dr. C. for nerve conduction tests. These tests revealed severe right carpal tunnel syndrome involving both sensory and motor fibers with a complete electrophysiological block at the wrist and evidence of axon degeneration. There was moderate carpal tunnel compression of both sensory and motor fibers on the left side, and no evidence of ulnar, sensory, or motor entrapment at the wrist or elbow. In the discussion section of the record, Dr. H. noted that although the Veteran had two significant problems with carpal tunnel and moderate scapholunate advanced collapse, the provider thought that a very high percentage of his symptoms were coming from carpal tunnel. The provider also observed that the Veteran had experienced degenerative change in his wrist for a long time and functioned at a very high level. In a subsequent March 1998 private treatment record, Dr. B. noted that the Veteran had developed acute carpal tunnel syndrome following an event at work in the latter part of November/early December. He also had a significant degree of traumatic arthritis involving the wrist and the scaphoid navicular where he had a prominent osteophyte with a lot of thinning of the articular surface, and a very prominent radial styloid. Dr. B. indicated that the Veteran's symptoms of persistent paresthesias, numbness, and pain consistent with carpal tunnel syndrome were related to the activity at work in November, but also related to probable hypertrophy of the capsule and issues and osteophytes at the wrist. A plan was made for the Veteran to undergo a carpal tunnel release, and Dr. B. later noted in an April 1998 private treatment record that the Veteran was postoperative carpal tunnel release, synovectomy and excision of a loose fragment from the radiocarpal joint and osteophytes. The record stated that he also had a radial styloid-ectomy. In August 1998, Dr. B., summarized that prior to the surgery, electrodiagnostic studies showed carpal tunnel syndrome, but radiographs showed advanced changes of the radial carpal joint, including osteophyte formation. At the time of the surgery, the Veteran was additionally found to have a loose body in the radial carpal joint along with the osteophytes. Therefore, Dr. B.'s impression was that the Veteran had long-term underlying degenerative changes of the wrist related to multiple events. Dr. B. further indicated that at that point, Dr. B. could not pinpoint the etiology of these changes with any degree of certainty. The carpal tunnel syndrome also fit in that pattern of long-term overuse and repetitive use that gradually thickened the synovial sheath and increased the intracranial volume to the point where carpal tunnel syndrome developed. The Veteran's latest employment with a construction company was somewhat different than his previous work as it required a marked repetitive overuse with a sledgehammer. It appeared that this was the event that unmasked the problems with his wrist and led to the need for surgery. It would not surprise Dr. B. if this repetitive ulnar stress with a sledgehammer broke loose an osteophyte that created the loose fragment or loose body that was found in the radial carpal joint at the time of the surgery. Therefore, while some radiographic changes of arthritis in the wrist, and some thickening of the synovium in the sheath of the flexor tendons contributing to the carpal tunnel syndrome may have been preexisting, it would appear historically, and on the basis of this different activity, that the most likely source of the unmasking of his problems that led to surgery was his most recent employment. In March 2000, Dr. B. indicated that an x-ray impression for the right wrist noted significant collapse of the first row of carpal bones and changes of the distal radius with traumatic arthritis. In April 2001, Dr. B. noted that the Veteran came in for a followup regarding his right wrist. Dr. B. stated that he had been following the Veteran for many months with the sprain of his wrist superimposed on underlying changes, with dissociation of the scapholunate as well as traumatic arthritis. In November 2001, Dr. B. noted that the Veteran presented for follow-up of his wrists and expressed concern about a recent independent medical examination he attended. Dr. B. reviewed the examination report and indicated that he disagreed with the interpretation that the Veteran had no ratable impairment. Dr. B. then appeared to reference the 1997 injury discussed in February 1998, stating that although he realized that the Veteran did have some preexisting arthritis of the wrist radiographically, the episode of injury related to the Veteran's claim was a significant injury in which he knocked loose a loose fragment in the wrist that required a styloid-ostectomy or partial styloid-ectomy and debridement of the joint and removal of the loose body. This event had left the Veteran with increased problems of traumatic arthritis that should have been taken into consideration. In December 2001, Dr. B. again noted that the recent independent medical examination was totally wrong as the Veteran had significant traumatic arthritis. The Veteran had undergone a radial styloid-ectomy and removal of loose bodies which had been the result of trauma that occurred on top of preexisting arthritis of the wrist. In January 2009, a private treatment record authored by Dr. N. indicated that the Veteran was a new patient who sought a consultation related to his right wrist. Dr. N. noted that the Veteran's history dated back to 1997 when he injured his wrist at work. The Veteran had two surgeries in 1999, but he refused to have a fusion that was offered at that time. The Veteran was thereafter disabled and experienced intermittent swelling. The previous June, the Veteran injured his right wrist chopping wood. He denied having any significant problems in his left wrist. The Veteran also had a history of gout many years ago in his toes. A right wrist x-ray showed severe degenerative changes and obliteration of the radial carpal joint. He also had significant chondrocalcinosis. The impression noted osteoarthritis as well as right wrist pain that appeared to be secondary to calcium pyrophosphate disease. In February 2009, the impression was pseudogout and osteoarthritis. In January 2010, Dr. N. noted that the Veteran reported increasing pain in his right wrist in the past three weeks. The impression was inflammatory polyarthritis, possible calcium pyrophosphate deposition disease (CPPD). In May 2010, Dr. N. stated that the Veteran had continued pain and swelling in the right wrist. An x-ray showed severe degenerative changes and chondrocalcinosis of the wrist. The impression was calcium pyrophosphate disease and osteoarthritis. In June 2010, Dr. N. recommended that the Veteran receive a possible fusion of the right wrist at VA sooner than mid-December. In August 2010, a VA treatment record noted the Veteran's complaint of right wrist pain and noted that he injured his wrist in 1964 while on active duty in Korea. He sustained a crush injury when a maintenance cart collapsed on it. The Veteran was told at that time that there was no fracture, and he wore a sling. Although the Veteran thought his wrist was back to normal, the record indicated that the Veteran later discovered he had arthritis. The impression was posttraumatic arthropathy of the right wrist, very symptomatic and activity-limiting pain. In September 2010 VA treatment record noted that the Veteran complained of right wrist pain. He was pre-operative for a right wrist total fusion. The Veteran described having pain, inflammation, and swelling all the time. He reported sustaining trauma during service in 1964 when a maintenance stand collapsed onto his arm and sandwiched the arm between posts. The Veteran was placed in a sling for several weeks as treatment. The record also noted that the Veteran had a bone chip removed 9 years ago, and he had received treatment for pseudogout. An x-ray of the bilateral wrists yielded an impression of bilateral scapholunate advanced collapse (SLAC). In an October 2010, a VA operative note reported that the Veteran underwent a total wrist fusion. The pre- and postoperative diagnoses were right wrist arthritis. The operative report noted that the Veteran had a long history of significant wrist pain. He had a diagnosis of degenerative arthritis as well as gout and pseudogout. In October 2014, Dr. N. noted that the Veteran's right wrist had improved after his fusion. Dr. N. observed that the Veteran was seen in 2010 and noted to have possible calcium pyrophosphate disease with intermittent flare of pseudogout. The Veteran was concerned that his wrist problems dated back to 1964 when he in the military service and a hydraulic fell on his arm. Dr. N. indicated that the injury was described as a contusion that had him in a sling for approximately 2 to 4 weeks before the Veteran returned back to work. However, Dr. N. noted that when the Veteran was initially seen in Dr. N.'s office in January 2009, he described pain dating back to 1997 when he injured his wrists at work. Therefore, it was difficult to determine the exact date of onset of his problems. The impression was osteoarthritis, multiple regions, including the spine, knees, and wrists. In February 2019, a private treatment record noted that the Veteran requested a nexus letter stating that his wrist arthritis was due to an injury that occurred 50 years ago in the Air Force. The Veteran reported that during all the surgeries he had on his wrist, he did not recall this injury. However, he had since remembered that hydraulic scaffolding fell on his arm. The record also noted that a maintenance tank collapsed on the right arm, wrist, and hand in 1964. The Veteran's prior surgeries had been performed at other institutions, and based on the Veteran's scars, they included a trapezoid-ectomy with ligament reconstruction and tendon interposition followed by a total wrist arthrodesis. The assessment was right wrist pain and posttraumatic osteoarthritis of the right wrist. The provider noted that given the lack of medical records and inconsistencies, he was unable to provide a nexus letter stating that on a more probable basis than not, the forearm contusion resulted in his wrist arthritis. The Veteran was later provided with a VA examination related to his claim in February 2020. The diagnosis section of the report noted right degenerative arthritis and status post right wrist fusion. The Veteran reported that the condition started in 1964 when he a maintenance stand collapsed onto his right arm/hand in Korea. The February 2020 VA examiner provided a negative nexus opinion. The examiner stated that the Veteran's right wrist arthritis/fusion/strain was less likely due to service. Despite the Veteran's reported wrist injury in 1964, the examiner noted that he did not report any problems in his right wrist towards the end of his service. The Veteran's yearly examinations in 1964 and his exit examination in 1965 reported that he did not have any wrist problems. There was also evidence that the Veteran was a construction worker after leaving service, and his February 1998 private treatment record reported wrist pain from arthritis and carpal tunnel syndrome. The examiner noted that the Veteran's work as a construction worker involved heavy shoveling, raking, running jack hammers, swinging and swinging sledgehammers. The examiner opined that the Veteran's current wrist disorder was at least as likely related to the Veteran working in construction. Regarding the Veteran's report that he has experienced symptoms of right wrist pain since the December 1964 injury noted in his STRs, the Board notes that the Veteran is competent to attest to observable symptomatology and events that he experienced. 38 U.S.C. § 1153(a); 38 C.F.R. § 3.303(a); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). While the Veteran did not report right wrist complaints in the reports of medical history that followed the 1964 injury, the Board nevertheless finds the Veteran's reported history to be credible in light of the fact that the record indicates that the right wrist pain did not cause him significant problems until 1997. The Board also does not find that the Veteran’s denial of a history of significant wrist problems in February 1998 contradicts the report from the March 2015 notice of disagreement indicating that some symptoms of pain have been present since the 1964 injury. Indeed, Dr. H. further noted in February 1998 that despite the fact that the Veteran had experienced degenerative change in his wrist for a long time, he had been able to function at a high level prior to the 1997 work injury. In addition, the Veteran’s theory from the February 2019 Board hearing indicating that his arthritis began to develop as a result of his 1964 injury and was present for many years before it was aggravated by post-service injuries is consistent with the conclusions of Dr. H. and Dr. B. in 1998 and 2001. As noted above, Dr. H. found in February 1998 that the Veteran had experienced degenerative change in his wrist for a long time. Dr. B.’s August 1998 opinion similarly suggested that the severity of arthritis shown on x-rays at that time was consistent with longterm underlying degenerative changes of the wrist. Dr. H. also indicated in November 2001 and December 2001 that the Veteran had preexisting arthritis in his wrist at the time of the 1997 post-service injury, and the 1997 trauma caused increased problems of traumatic arthritis. Although Dr. B. stated in August 1998 that he was unable to pinpoint the exact etiology of the arthritis, Dr. B. did not attribute the disorder to any one event or activity. Dr. B. instead indicated that it was possible that the disorder could be related to multiple events from the Veteran’s medical history. The Board finds that this determination is probative as it was based on Dr. B.’s understanding of the Veteran’s medical history and consideration of clinical findings. In this regard, the Veteran has identified the 1964 injury as the event that preceded his continued symptoms of right wrist pain. There is also no indication from the record that he experienced any interim injuries between this in-service event and the 1997 work injury that revealed the presence of longterm arthritis. Although the Board acknowledges the negative opinion provided by the February 2020 VA examiner regarding the Veteran's service connection claim for a right wrist disorder, the Board finds that the opinion has minimal probative value as the examiner appeared to disregard the Veteran’s competent and credible reports of right wrist pain since his in-service injury in light of the lack of in-service evidence of right wrist complaints in the STRs after the injury occurred. In addition, the examiner highlighted the Veteran’s diagnosis of arthritis in February 1998 without discussing the potential significance of Dr. H.’s finding from that record that the degenerative changes had been present for a long time. After considering the Veteran's competent and credible reports of right wrist pain since it began after his documented in-service injury in 1964, and Dr. B.'s opinion indicating the Veteran had longterm arthritis by the time of his post-service injury in 1997 that could be related to multiple events from his medical history, the Board finds that the most probative evidence establishes a nexus between active service and the Veteran's current right wrist disorder. 38 C.F.R. § 3.303(a) (service connection must be considered on the basis of the places, types, and circumstances of his service as shown by his service records, the official history of each organization in which he served, his medical records, and all pertinent medical and lay evidence); see also Buchanan v. Nicholson, 451 F.3d 1331, 1335 (Fed. Cir. 2006) ("[N]othing in the regulatory or statutory provisions [relating to evidence to be considered] require both medical and competent lay evidence; rather, they make clear that competent lay evidence can be sufficient in and of itself"). As such, service connection is granted for the Veteran’s diagnosed degenerative arthritis. GAYLE STROMMEN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.C. Spragins, 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.