Citation Nr: 21002380 Decision Date: 01/13/21 Archive Date: 01/13/21 DOCKET NO. 18-10 800 DATE: January 13, 2021 ORDER Entitlement to service connection for residuals of a left upper extremity injury, diagnosed as left ulnar neuropathy at the elbow and left labral tear, including superior labral anterior-posterior lesion (SLAP), is granted. FINDING OF FACT The Veteran’s diagnosed left ulnar neuropathy at the elbow and left labral tear, including SLAP, are at least as likely as not related to the left upper extremity injury the Veteran sustained during active service. CONCLUSION OF LAW The criteria to establish entitlement to service connection for residuals of a left upper extremity injury, diagnosed as left ulnar neuropathy at the elbow and left labral tear, including SLAP, have been met. 38 U.S.C. §§ 1101, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty service in the United States Army from August 1959 to August 1962. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a May 2017 rating decision. The Veteran testified at a Board hearing before the undersigned Veterans Law Judge in November 2019. A transcript from the proceeding is associated with the claims file. In a January 2020 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). Although the Veteran’s service connection claim was previously characterized as entitlement to service connection for a left arm condition, the record reflects that the he has received diagnoses of left ulnar neuropathy at the elbow and left labral tear, including SLAP, in connection with his left arm complaints. See October 2020 VA examination. As the Veteran’s service connection claim encompasses all disorders that are reasonably raised by the record, and in consideration of the Veteran’s contentions discussed below, the Board has recharacterized the issue as entitlement to service connection for residuals of a left upper extremity injury. See Clemons v. Shinseki, 23 Vet. App. 1 (2009). 1. Entitlement to service connection for residuals of a left upper extremity injury. 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 and other organic diseases of the nervous system, 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 current residuals, to include arthritis and peripheral neuropathy, from a left upper extremity injury he sustained during active duty service. During the November 2019 Board hearing, the Veteran indicated that he was in a missile unit at Fort Tilden, New York in 1961 or 1962, and he barracked a mile away. The Veteran reported that he had to walk back and forth four times a day. During one such day in the winter when there was snow, the Veteran went "over and down," breaking his left forearm. Rather than receiving treatment on base, the Veteran was taken to St. Alban's Hospital in New York. The Veteran recalled that he received an x-ray and was informed that he had a crack or tears. He remembered that his arm was placed in a cast. The Veteran reported that he stayed at St. Alban's Hospital for 6 months, but he also clarified that the cast was only on his arm for maybe one month. The Veteran recalled that when he was placed back on active duty, he did not receive a profile or light duty. The Veteran indicated that although he did not receive any subsequent hospital treatment for this injury, he did seek treatment from a medic and received aspirin. The Veteran indicated that he was numb all the time and continuously had problems with his left arm after the injury. Following the Veteran's separation from active service, he first sought private treatment from a general practitioner in 1963, and he was advised to take ibuprofen. The Veteran indicated that this doctor was now deceased, and no records were available. The Veteran also testified that his current symptoms included pain as well as loss of sensation and grip strength. The Veteran also indicated that he worked after service as a police officer and a Xerox technician. The Veteran remembered that he did have a problem with a small fracture in his employment as a police officer, but he could not recall whether it was his left or right arm. A Health Record - Abstract of Service in the Veteran's service treatment records (STRs) as well as his Record of Assignments in his military personnel records reflect that he had service at Fort Tilden from November 1959 to August 1962. The Veteran's DD 214 also identified his last duty assignment and major command as Battery B, 3rd Missile Battalion, 51st Artillery, Fort Tilden, New York. The Veteran's July 1959 enlistment examination noted that the Veteran's upper extremities were normal upon clinical evaluation. In addition, the Veteran did not report any relevant complaints in the July 1959 Report of Medical History. In November 1960, an STR indicated that the Veteran caught a finger from his right hand in a door and dislocated the proximal interphalangeal (PIP) joint before he snapped it back into place. There was moderate limitation of motion and swelling, but no x-ray was indicated. The impression was post dislocated PIP joint. Subsequent entries indicate that the Veteran continued to seek treatment for this injury in November 1960 and December 1960 before a consultation was requested. The December 1960 consultation report stated that the x-ray was negative for fracture. In April 1961, an STR indicated that a piece of metal became embedded into the Veteran's left palm at Fort Tilden. The Veteran pulled some metal out and received emergency treatment at Fort Tilden as well as a tetanus shot. Later in April 1961, an STR reported that the wound looked very good and was healing with no symptoms of edema. It was minimally painful. On February 11, 1962, an STR from the United States Naval Hospital, St. Albans, New York, noted that the Veteran had right hand swelling. The entry reported that the Veteran fell on the ice that day and struck his right thumb and wrist. The impression was probable navicular fracture, and the record indicated that a plan was made to obtain an x-ray. A separate x-ray report for the right wrist from the same day was negative. On February 13, 1962 a Statement of Medical Examination and Duty Status in the Veteran's military personnel records noted that the Veteran had been admitted to the United States Naval Hospital, St. Albans, Long Island, New York on February 12, 1962 for an injury that occurred on February 11, 1962 at Fort Tilden, New York. The injury was noted to be a "DU" fracture navicular. The record stated that the Veteran reported sustaining his injury when he slipped and fell on the ice at Fort Tilden. The accident was found to be incurred in the line of duty. On June 8, 1962, an STR stated that the Veteran had closed the door on his left hand. An associated June 8, 1962 x-ray report noted that the x-ray had been requested due to a possible fracture in the left hand. The x-ray report noted that no abnormality was visualized. The STR also noted that the x-ray revealed that there was no fracture. However, the physical examination showed soft tissue swelling and tenderness over the dorsum of the left hand. The record indicated that the injured hand was wrapped with an ace bandage, and the Veteran was also meant to treat the injury with hot soaks. A plan was made to check the injury the following Monday morning. On June 13, 1962, an STR stated that the although the swelling had decreased, there was still some tenderness. The record indicated that the Veteran was advised to ice his hand as needed. In the subsequent July 1962 Report of Medical History, the Veteran did not report any relevant complaints. The physician's summary stated that there was no significant history of illness. In the July 1962 Separation Exam, the upper extremities continued to be marked as normal. The Veteran was provided with VA examinations in connection with his claim in October 2020. The Veteran reported driving in a jeep that overturned on the ice in 1961 or 1962. After exiting the jeep, he slipped and fell on the ice. The Veteran reported having neck pain and left arm pain at that time. He also described having persistent neck pain with pain radiating into the left upper extremity over the years, and he identified the injury as occurring during service. He also complained of left arm weakness and numbness in the ring finger and small fingertips. The condition had progressed/worsened since its onset. The examiner competed Disability Benefits Questionnaires (DBQs) specific to shoulder and arm conditions as well as peripheral nerve conditions, and the examiner noted diagnoses of left ulnar neuropathy at the elbow and left labral tear, including SLAP. The examiner provided a negative nexus opinion. In the rationale, the examiner noted that the Veteran's medical service records were lacking in documentation of a left upper extremity condition. Although no arthritis was diagnosed during the examination, the examiner also noted that there was also no documentation of arthritis of the left shoulder. The examiner further noted that there were no service or post-service outpatient medical records to indicate shoulder pathology. Therefore, it was less likely than not that the left shoulder ulnar neuropathy/labral tear were incurred in service during the slip and fall event. Regarding the Veteran’s contention that he was treated for a left arm fracture at the United States Naval Hospital, St. Albans, while in service in conjunction with a fall during the winter, the record does not reflect that this event occurred exactly as he remembered during the November 2019 Board hearing. It appears that the Veteran might have been recalling the instances when his service providers sought to rule out a right navicular fracture in February 1962, or a left-hand fracture in June 1962. Nevertheless, the February 1962 STR does support the Veteran’s testimony that he fell on ice during his service at Fort Tilden. Although only the right wrist and hand symptomatology was noted in the associated February 1962 STRs that immediately followed this event, the Veteran has asserted that he also sustained a left upper extremity injury in the course of the fall that resulted in symptoms of pain in his left forearm as well as numbness and reduction of grip strength in his left hand. The Veteran’s Board hearing testimony also provided an explanation for the lack of documentation of in-service treatment as the Veteran indicated that he only received aspirin from a medic for these symptoms after the February 1962 treatment at St. Albans. While no relevant complaints were noted in the July 1962 Report of Medical History, the Veteran maintained that these symptoms have persisted since service such that he was obliged to seek private treatment soon after his discharge in 1963. As indicated above, the Veteran has reported that records of the 1963 treatment are unavailable. The October 2020 VA examination also indicates that the symptoms have progressively worsened since that time. Although the Board acknowledges the Veteran’s report from the Board hearing that he could not recall whether he fractured his left or right arm during his employment after service as a police officer, he has provided competent evidence that his symptoms preceded any post-service injury. In this regard, the Board notes that the Veteran is competent to report observable in-service events and his perceived symptoms of pain and numbness in his left arm since service. Layno v. Brown, 6 Vet. App. 465 (1994); Buchanan v. Nicholson, 451 F.3d 1331 (Fed. Cir. 2006); Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). Based on the foregoing discussion, the Board also finds the Veteran’s reported history to be credible. As noted above, the October 2020 VA examination reflects that the Veteran’s complaints are associated with the diagnoses of left ulnar neuropathy at the elbow and left labral tear, including SLAP. Consequently, the Board finds that the Veteran has provided probative evidence of symptoms of these disorders that continued to be present after discharge. Although the Board has considered the October 2020 VA examiner’s negative opinion, the Board finds that it has reduced probative value as the examiner's opinion that these disorders not due to service appears to discount the Veteran's competent and credible report of symptoms that began during service. In summary, the Veteran has provided competent and credible reports that his symptoms of left ulnar neuropathy at the elbow and left labral tear, including SLAP, have been continuously present since his left upper extremity injury during active service. The October 2020 VA examiner's negative opinion does not carry greater probative weight in this case than the Veteran's reported history of continuous symptoms. The Board consequently finds that the most probative evidence establishes a nexus between active service and the Veteran's current left ulnar neuropathy at the elbow and left labral tear, including SLAP. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. As such, service connection is granted for these disorders. See 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"). 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.