Citation Nr: 21003338 Decision Date: 01/21/21 Archive Date: 01/21/21 DOCKET NO. 17-56 072A DATE: January 21, 2021 ORDER Entitlement to service connection for a left arm disorder is denied. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s left arm began during active service, or is otherwise related to an in-service injury or disease. CONCLUSION OF LAW The criteria for service connection for a left arm disorder are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from February 1969 to February 1971. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a May 2015 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In April 2017, the Veteran testified at a RO hearing before a Decision Review Officer (DRO). A transcript is of record. In December 2018 and September 2020, the Board remanded the appeal for further development. There has been substantial compliance with the remand directives. See Stegall v. West, 11 Vet. App. 268 (1998). This appeal has been advanced on the Board’s docket pursuant to 38 C.F.R. § 20.900 (c). Service Connection 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. The three-element test for 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). Service connection may also be granted for certain diseases based on presumed exposure to certain herbicide agents, even though there is no record of such disease during service. 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307, 3.309(e). A veteran who, during active military, naval, or air service, served in the Republic of Vietnam during the Vietnam era is presumed to have been exposed to herbicides during that service. 38 U.S.C. § 1116; 38 C.F.R. § 3.307. The presumptive provisions of 38 C.F.R. § 3.307 are limited to enumerated chronic diseases listed in 38 C.F.R. § 3.309 (e). The provisions for presumptive service connection do not preclude a claimant from establishing service connection with proof of actual direct causation, on the basis that exposure to herbicide agents led to the development of the claimed disability after service. See Combee v. Brown, 34 F.3d 1039, 1044 (Fed. Cir. 1994). 1. Entitlement to service connection for a left arm disorder is denied. The Veteran asserts that he got pricked by a thorn and developed a knot in his left forearm while stationed in Vietnam. He asserts that he still has pain, stiffness, and tenderness in that area ever since, even after undergoing a surgery for the injury in 1972. As a preliminary matter, the Board notes that service connection on a presumptive basis is not warranted. The Veteran’s military personnel records note service in Vietnam from August 1969 to August 1970. His Form DD-214 also shows Vietnam Service Medal and Republic of Vietnam Campaign Medal. Therefore, he is presumed to have been exposed to herbicide agents in service. However, the Veteran’s currently diagnosed conditions of chronic left wrist sprain and status-post surgery of left forearm with multiple phleboliths are not listed under 38 C.F.R. § 3.309 (e). Thus, service connection due to herbicide agent exposure is not presumed. Nonetheless, the provisions for presumptive service connection do not preclude a claimant from establishing service connection on a direct basis. The question for the Board is whether the Veteran has a current disability that began during service or is at least as likely as not related to an in-service injury, event, or disease. The Board concludes that, while the Veteran has current diagnoses of chronic left wrist sprain and status-post surgery of left forearm with multiple phleboliths, the preponderance of the evidence weighs against finding that the Veteran’s diagnosed disabilities began during service or is otherwise related to an in-service injury, event, or disease. Turning to the records, the Veteran’s September 1968 pre-induction exam did not indicate any forearm or wrist condition. In the February 1971 report of medical history, the Veteran answered “Yes” for the question on whether he had consulted or been treated by a clinic or a doctor in the past 5 years. The Veteran noted, “Finger clinic hospital Marion, S.C. swollen wrist.” The physician’s summary also noted “swollen wrist.” The Veteran’s upper extremities were found normal at his February 1971 separation exam, and he noted “I am in good health.” The Veteran’s service treatment records (STRs) are otherwise silent for any complaint or treatment for a forearm or a wrist condition. The Veteran underwent a VA Agent Orange examination in November 2006. The Veteran reported he had a small hemangioma removed from his left arm in 1972. The exam did not reveal any left forearm condition. In an October 2009 VA treatment note, the Veteran complained of pain in the left forearm and wrist area. The Veteran reported he had a knot caused by a plant that pierced his wrist area while serving in Thailand. He reported he had a surgery in 1972. Physical examination noted, “s/p surgical scars on ventral aspect radial and ulnar sides measuring @ 18cm.” An October 2009 MRI for left upper extremity noted, “very large hyperintense serpiginous mass in the ventral aspect of the forearm, which most likely represents a slow venous vascular malformation.” It noted correlation with prior study is recommended for complete evaluation. In a January 2015 VA treatment note, the Veteran reported ongoing left arm pain secondary to having a “type of melanoma” removed in 1972 in PG County Hospital. The clinician noted, “no records of surgery and unsure of the extent of surgery” and “old linear scar visible.” For impression, the clinician noted left arm pain and stiffness status-post surgery in 1972. In a January 2015 VA Form 21-4138, the Veteran stated he had surgical procedure done on his forearm for hemangiomas, angiosarcomas, and vascular malformation. He stated he had surgery on his left forearm at Prince Georges Hospital in Cheverly, Maryland, in 1972. He stated he served in Vietnam on land and in air. In a February 2015 VA Form 21-4138, the Veteran noted that he contacted the Prince Georges Hospital in Cheverly Maryland to obtain his medical records for the 1972 surgery, but was told that the hospital did not retain records after 10 years. In an April 2016 VA treatment note, the Veteran complained of left elbow swelling. The Veteran reported he had a hemangioma removed years ago. In another April 2016 VA treatment note, the Veteran reported that an old left forearm surgery still caused tingling and numbness. The clinician noted no record of surgery in the system. The impression included neuropathy in the left forearm status-post surgery and gout/hyperuricemia. At the April 2017 DRO hearing, the Veteran stated that his turn came for perimeter guard shortly after deployment in Vietnam, and that he had to walk through a wooded area to get to the guard station. He stated there was a plant that looked like a snake plant with needle along the path. He stated he bumped into the plant and a ‘notch’ started to develop later. He stated he went to get treated once in Vietnam around September 1969, and once in Udon Thailand Air Force base around December 1969. He stated the injury led to a surgery in 1972 which removed the knot. A May 2017 VA Form 21-8020 noted that VA contacted the Prince George Hospital for the Veteran’s 1972 surgery records. It noted that the hospital was unable to honor the request as the records were past the retention period. A June 2017 private radiology report noted that anterior/posterior and lateral views of the left forearm showed distal forearm soft tissue calcifications. It noted no evidence for fracture or other significant bone, joint, or soft tissue abnormality. The report also noted that anterior/posterior, oblique, and lateral views of the left wrist showed soft tissue calcifications. It noted no evidence for fracture or other significant bone or soft tissue abnormality. The Veteran underwent a VA examination for elbow and forearm conditions in June 2017. The Veteran was diagnosed with status-post surgery left forearm. He reported the forearm condition had onset in Vietnam in 1969 when he bumped into a bush with thorns, which stuck in the left wrist and developed a mass. He reported he was given a shot, and was given another shot when he went to Thailand. He reported he had surgery for the forearm in 1972. He complained of swelling, tingling, and pain in the left forearm and left wrist. The examiner noted a 12cm x 0.3cm scar on the radial aspect of the forearm, and a 13cm scar on the ulnar aspect. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that there are no medical records indicating an in-service injury or treatment to the left forearm. The examiner however also noted that swelling with moderate pain and tenderness to palpation is consistent with surgical scars, indicating prior injury or trauma to extremity. The Veteran also underwent a VA examination for wrist conditions in June 2017. The Veteran was diagnosed with chronic wrist sprain. The Veteran reported his left wrist condition had onset in 1969 when he was stuck with thorns, causing tingling and mass to form. He reported he had surgery for hematoma. The examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner explained that there are no medical records indicating an in-service injury or treatment to the left forearm. The examiner also noted that swelling noted on exam with moderate pain and tenderness to palpation can account for range of motion pain of wrist due to proximity. An August 2017 VA treatment noted that both elbows displayed effusion. Impression was noted as bilateral elbow effusion/gout managed by Allopurinol. A February 2018 VA treatment record noted chronic pain in the left arm. The clinician noted that the Veteran maintained an acceptable pain level of 4/10 during the admission. In December 2018, the Board remanded the appeal for a VA exam and opinion. The Veteran underwent a VA examination in October 2019. And the examiner provided an unfavorable nexus opinion. The Veteran was diagnosed with status-post surgery left forearm with multiple phleboliths. The Veteran reported the condition started around 1969 when he was stuck by a thorn bush, and had itching of the arm. He stated he was seen several times at a hospital for bump on left hand and given injections. He stated he separated from service in 1971 and received no treatment as it was not on his mind. He stated it started hurting in 1972, was seen by a primary care provider in 1972 for swelling of left hand and left wrist, and had x-rays done. He stated that at some point in 1972, he had surgery to remove the mass on the forearm. He stated that swelling worsened after the surgery, but pain was manageable. He reported the condition got worse due to more frequent pain, limited range of motion with fingers, and tingling and sharp pain in the left wrist. The examiner noted a 14cm x 1cm scar on the lateral aspect of the forearm, and a 12.5cm x 1cm scar on the medial aspect of the forearm. The examiner opined that the conditions were less likely than not incurred in or caused by the claimed in-service injury, event, or illness. An October 2019 private radiology report noted that anterior/posterior and lateral views of the left forearm showed multiple phleboliths Volar soft tissues distal left forearm. It noted that this appearance may be normal or associated with a hemangioma or multiple varicose veins. In September 2020, the Board remanded the appeal for a supplemental opinion due to deficiencies in the October 2019 VA opinion. In November 2020, VA received an addendum medical opinion. The examiner, who reviewed the claims file, opined that the current condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner noted that there is no documentation of a thorn-stick injury in service, and even if it occurred, it has nothing to do with the hemangioma as hemangiomas are superficial blood vessel growths. The examiner also noted that the hemangioma has been described as small, and it is unlikely to have had any residuals of note. The examiner noted that the June 2017 and October 2019 VA exam reports show two scars that measured at least 12.5cm, up to 18cm at the maximum. The examiner noted that it is unlikely that the scars are related to the excision of a small hemangioma, but rather represent some other surgery that occurred post-service. The examiner also noted that it is less likely than not that any wrist condition is due to the thorn-stick during service or the hemangioma excision. The examiner noted that the diagnosis of chronic wrist sprain in 2017 did not make [clinical] sense, as it was inconsistent with the Veteran’s given history, claim, and documented history. The examiner noted the wrist condition is more likely than not a new condition. He noted that the wrist sprain did not occur in service, and that it is possible that the wrist sprain is related to the Veteran’s gout in the elbow or to the events leading to the two major scars. The examiner noted that gout is a disorder associated with uric acid metabolism, leading to arthritic changes in the involved joints. The examiner noted that it is highly unlikely excision of a small hemangioma in 1972 would cause any of the noted complaints, decades later. The examiner noted that none of the claimed conditions bears any relationship to exposure to Agent Orange. The examiner noted this is accepted medical knowledge. The examiner also commented that phleboliths are simply tiny calcifications arising in vessels naturally, post-trauma or post-surgery, and that they are considered inconsequential and do not represent a condition. Given the foregoing, the preponderance of the evidence weighs against finding that the Veteran’s left arm disorder began during service or is otherwise related to an in-service injury, event, or disease. Taken together, the Board finds the VA medical opinions of record (excluding the October 2019 VA opinion) are probative and persuasive. The examiners reviewed the Veteran’s service and post-service records, and they explained the reasons for their conclusions. Especially, the November 2020 opinion provided an extensive rationale that contained clear conclusions and supporting data. Thus, these opinions are entitled to substantial probative weight. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning; threshold considerations are whether the person opining is suitably qualified and sufficiently informed). There is no competent medical opinion to the contrary. The available medical evidence does not include findings of a nexus between the Veteran’s military service, to include presumed herbicide agent exposure therein, and the current left arm disorder. Thus, service connection is not warranted on a direct basis. 38 C.F.R. § 3.303. The Veteran believes his left arm (which includes his wrist) disorder is related to service. The Veteran in this case is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of the interaction between multiple organ systems in the body and interpretation of complicated diagnostic medical testing. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA examiners’ opinions. As the preponderance of evidence is against the claim, there is no reasonable doubt to be resolved. Service connection for a left arm disorder is not warranted. 38 U.S.C. § 5107 (b); Gilbert v. Derwinski, 1 Vet. App. 49 (1990). D. JOHNSON Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board B. Jake Choi, 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.