Citation Nr: 21002028 Decision Date: 01/12/21 Archive Date: 01/12/21 DOCKET NO. 15-22 995 DATE: January 12, 2021 REMANDED Entitlement to service connection for a bilateral upper extremity disability is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1949 to May 1952 and from March 1958 to March 1964. This matter is before the Board of Veterans’ Appeals (Board) on appeal from a May 2013 rating decision. The Board previously considered this matter in June 2018, August 2019, and December 2019, when it remanded for further development. As noted in the Board’s 2019 remand, the Veteran is deemed to be representing himself regarding the above issue due to limitation of scope or representation by the Veteran’s private attorney as stated in box 15 of the VA 21-22a signed by the Veteran and the attorney in 2014. 07/31/2014 Power of Attorney. Entitlement to service connection for a bilateral upper extremity disability is remanded. The Veteran seeks service connection for a bilateral upper extremity disability. He asserts that this disability is secondary to his service-connected dizziness, as the latter causes him to fall and he catches himself with his hands. 03/09/2012, Statement in Support of Claim; 07/30/2012, VA 21-0820 Report of General Information. Service connection is already in effect for residuals of an in-service right thumb fracture with postoperative excision of exostosis. Private treatment records show that the Veteran sought treatment for soreness on his left hand in October 2009. It was recommended that the Veteran undergo an EMG to determine whether he had carpal tunnel syndrome (CTS). A subsequent July 2010 note, documenting treatment for the right shoulder, shows a diagnosis of CTS. 07/12/2012, Buddy/Lay Statement, at 1-2. VA and private treatment records reference a long history of hand and arm surgeries since 1995. 03/07/2017, CAPRI, at 1; 10/15/2018, Medical Treatment Record - Non-Government Facility, at 7, 10-12 & 15. More recently, in April 2014, the Veteran reported that he underwent surgery for his right hand in February 2014. 04/07/2014, NOD. An October 2012 VA examination, however, is silent regarding CTS. Rather, the examination report shows diagnoses of osteoarthritis of the right hand and right index trigger finger. 10/11/2012, C&P Exam. Regarding the right index trigger finger, it was noted that this condition began in March 2011, after a fall caused by dizziness. The examiner, however, opined that the right index trigger finger was not related to service; rather, it was related to the Veteran’s diffuse interphalangeal (IP) degenerative joint disease throughout the right hand due to age. In contrast, a March 2019 VA examination shows a diagnosis of right CTS status post carpal tunnel release. The report was silent regarding the left upper extremity. The VA examiner opined that the diagnosed condition was less likely as not directly related to service or secondary to the Veteran’s vertigo. The rationales for these opinions were that there was no evidence of CTS in service or right after service and that the medical literature does not support a nexus between vertigo and CTS. As explained in the Board’s December 2019 remand, this opinion does not show adequate consideration of the relevant evidence, is not supported by a medical rationale, and is therefore incomplete. For these reasons, the Board remanded for a new VA examination to determine the nature and etiology of any current or recurrent bilateral upper extremity. For any current or recurrent disability, the examiner was to provide an opinion whether it is related to service or secondary to a service-connected disability, to include stress placed on the Veteran’s hand by multiple falls caused by now service-connected dizziness. Pursuant to the Board’s December 2019 remand, the Veteran underwent a VA examination in October 2020. 11/04/2020, C&P Exam. For the reasons explained below, the Board finds that the October 2020 VA examination is inadequate. At the outset, the Board notes that the VA examiner completed only one disability benefits questionnaire (DBQ), the one pertaining to peripheral nerves conditions. This DBQ shows a single diagnosis of “paralysis of the median nerve, right CTS.” The DBQ does not address the Veteran’s other diagnoses, particularly his diagnoses of osteoarthritis of the right hand and right index trigger finger. Additionally, there is no discussion of whether the Veteran has a left upper extremity disability. Furthermore, the October 2020 VA examiner did not provide a medical rationale for any of his opinions. In detail, the examiner opined that the Veteran’s “long history of treatment for upper extremity issues, to include CTS and trigger finger, as well as evidence showing a diagnosis of arthritis” was less likely than not related to service. The examiner’s rationale was simply that service treatment records are silent regarding the claimed condition. This rationale is inadequate because it relies on the absence of corroborating evidence to rule out nexus. Additionally, it does not show adequate consideration of the relevant evidence. As mentioned, the Veteran is service-connected for an in-service right thumb fracture. The examiner also opined that the Veteran’s right upper extremity disabilities were less likely than not due to or the result of stress placed on his hands by multiple falls caused by his service-connected dizziness. The examiner’s sole rationale was that “based on [his] general medical knowledge, there is no link between CTS and trigger finger, as well as evidence showing a diagnosis of arthritis, and stress placed on his hands by multiple falls caused by his service-connected dizziness.” This conclusion requires an explanation, one that also shows adequate consideration of the relevant evidence, such as the indication that the Veteran’s right index trigger finger began in March 2011, after a fall caused by dizziness. As mentioned above, this was noted in an October 2012 VA examination. Finally, the October 2020 VA examiner opined that the Veteran’s right upper extremity disabilities were less likely than not aggravated by a service-connected condition. The examiner’s rationale was simply that “[a]rthritis is a common side effect of long history of treatment for upper extremity issues, to include CTS and trigger.” This rationale raises the question of whether the Veteran’s arthritis is secondary to his service-connected residuals of a right thumb fracture. No VA examiner has considered this aspect, which is encompassed by the Veteran’s claim. As summarized above, the medical evidence references a long history of bilateral upper extremity issues, to include surgeries for CTS and trigger finger. The Veteran asserts that these issues are secondary to falls caused by his now service-connected dizziness. In October 2018, he submitted a statement detailing a significant history of falls. 10/15/2018, Correspondence, at 9-10. On remand, VA is to schedule the Veteran for a VA examination to determine the nature and etiology of any current or recurrent bilateral upper extremity. For any current disability, the examiner is to provide an opinion whether it is related to service or secondary to a service-connected disability, to include the service connection right thumb fracture and any stress placed on the Veteran’s hand by multiple falls caused by now service-connected dizziness. As noted in the Board’s December 2019 remand, the Veteran has indicated that he underwent surgery for his right hand in February 2014. Medical records suggest that this surgery was conducted at a non-VA facility. The Board has reviewed the evidence of record but has not found any treatment records specifically related to this procedure. The Board’s December 2019 remand instructed the AOJ to take appropriate action to obtain any outstanding and relevant records. The record shows that, in April 2020, the AOJ sent a letter to the Veteran, asking him to identify and authorize the release of any relevant treatment records. No response, however, was received. Since the Veteran’s appeal is being remanded for different reasons, and considering disruptions related to the COVID-19 pandemic, the Board finds that the AOJ should give the Veteran another opportunity to identify and authorize the release of any relevant private treatment records. This matter is REMANDED for the following actions: 1. Take appropriate action to obtain any outstanding, relevant private treatment records, to include records of the February 2014 right hand surgery referenced by the Veteran in his April 2014 notice of disagreement. 2. After completing #1, schedule the Veteran for an examination by an appropriate clinician to determine the nature and etiology of any current bilateral upper extremity disability (to include his documented diagnoses of CTS, trigger finger, and arthritis). The examiner must identify all upper extremity diagnoses experienced by the Veteran during the period on appeal (since March 2012) and should complete all DBQs relevant to these diagnoses. While the evidence of record mostly focuses on the Veteran’s right upper extremity, the examiner should clearly indicate whether the Veteran also has a current left upper extremity disability. The examiner should also be aware that the Veteran is already service-connected for an in-service right thumb fracture with postoperative excision of exostosis. For each relevant diagnosis, the examiner must opine: (a.) Whether it is at least as likely as not related to an in-service injury, event, or disease. **The Veteran is service-connected for an in-service right thumb fracture with postoperative excision of exostosis.** (b.) Whether it is at least as likely as not (1) proximately due to service-connected disability, OR (2) aggravated beyond its natural progression by a service-connected disability, to include the Veteran’s right thumb fracture and his dizziness. **The examiner must address the Veteran’s contention that his bilateral upper extremity disability is related to stress placed on his hand by multiple falls caused by his service-connected dizziness. In this regard, an October 2012 VA examination indicates that the Veteran’s right index trigger finger began in March 2011, after a fall caused by dizziness.** (c.) For arthritis: whether it at least as likely as not (1) began during active service, (2) manifested within one year after discharge from service, or (3) was noted during service with continuity of the same symptomatology since service. A comprehensive rationale for all opinions is to be provided. All pertinent evidence, including both lay and medical, should be considered. (Continued on the next page)   If an opinion cannot be given without resorting to speculation, the examiner should explain why and state whether the need to speculate is due to a deficiency in the state of general medical knowledge (no one could respond given medical science and the known facts), the record (additional facts are required), or the examiner (does not have the knowledge or training). Paul Sorisio Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board P. López 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.