Citation Nr: 21061321 Decision Date: 10/01/21 Archive Date: 10/01/21 DOCKET NO. 16-42 244 DATE: October 1, 2021 REMANDED Entitlement to a rating higher than 0 percent for residuals of lacerations of the left middle, ring, and little fingers is remanded. REASONS FOR REMAND The Veteran served on active duty in the United States Navy from July 1973 to April 1975. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2016 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). In a November 2018 decision, the Board denied a higher rating for the Veteran's residuals of laceration injuries to the left middle, ring, and little fingers. In a June 2020 memorandum decision, the United States Court of Appeals for Veterans Claims (Court) vacated the Board's decision and remanded the matter for further development and readjudication. In May 2021, the Board remanded the matter to the agency of original jurisdiction. (Continued on following page) Entitlement to a rating higher than 0 percent for residuals of lacerations of the left middle, ring, and little fingers is remanded. The Board sincerely regrets the delay in issuing a decision in this matter, but finds that another remand is necessary to ensure a fully informed decision, for the reasons that follow. The Board's November 2018 decision denied a higher rating for the Veteran's left hand condition in part based on the findings in January 2016 and May 2016 VA examination reports that his symptoms of pain and numbness in the fingertips were caused by nonservice-connected carpal tunnel syndrome (CTS), which was surgically treated in 2013. In its May 2021 decision, the Court found the examination reports to be inadequate. It observed that CTS involves the median nerve (as stated in the January 2016 VA examination report) and that it did not appear that this would affect the little finger. The VA examiner's finding that the Veteran's symptoms were caused by CTS did not account for that fact. Moreover, the Veteran has reported experiencing pain and numbness in his fingertips ever since service, years prior to the diagnosis of carpal tunnel syndrome, as noted by the Court. See December 2015 VA Form 21-4138 (Statement in Support of Claim). The Court further noted that the Veteran's symptoms persisted after the carpal tunnel surgery. The Board finds that the record is still insufficient on the issue of whether, and to what extent, the Veteran's left hand symptoms and associated functional impairment are manifestations of his service-connected disability. Pursuant to the Court's remand, the Board remanded the claim for a new VA examination. A VA hand examination was performed in June 2021. In the examination report, the examiner found that due to degenerative arthritis in the right hand and scars on the digits of his left hand (as described in the report), the Veteran could not use his left hand to drive for long periods of time, tolerate cold weather, push and/or pull objects, grip objects, or tolerate repetitive movements. The examiner was unable to "distinguish which diagnosis impacts function." The examination report reflects that the Veteran related having a constantly achy left hand with sharp pain along the palmar aspect. On range-of-motion-testing, all fingers of the left hand exhibited reduced range of motion at the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints. The examiner stated that there was a gap of 4 centimeters between the long finger and the proximal transverse crease of the hand on maximal finger flexion. The record remains unclear as to whether the Veteran's symptoms and reduced range of motion of the middle (or long), ring, and little fingers is attributable to his service-connected residuals of laceration injuries, and whether his weakened grip and difficulties driving for long periods of time, pushing and pulling objects, gripping objects, and tolerating repetitive movements represent functional impairment attributable to his service-connected disability. The VA examiner's stated inability to determine which "diagnosis impacts function" is not supported by an explanation, and is confusing in its reference to degenerative arthritis of the right hand, when the issue here concerns the Veteran's left hand. With regard to the fact that the Veteran has continued to experience symptoms in the left hand after the 2013 CTS surgery was performedas observed in the Court's memorandum decisionthe Board notes that VA treatment records reflect findings that he may continue to have CTS. In this regard, an August 2020 VA treatment record reflects that the Veteran reported having numbness in his left hand involving the pinky, ring, and middle fingers, and some weakness in the hand. On examination, he was found to have reduced sensation in the palmar aspect of the third, fourth, and fifth fingers. Pain was reproduced with palpation at the medial elbow. He also had left wrist pain with reduced active motion in flexion and extension of the wrist. He was referred for a surgery consultation. The September 2020 surgery consultation record notes that the Veteran complained of pain and numbness in a left median nerve distribution. He also had some radicular-like symptoms intermittently. He had positive Tinel's and carpal compression tests. The assessment was persistent symptoms of left carpal tunnel syndrome. It was noted that the etiology could be compression at the carpal tunnel versus a more proximal nerve compression In short, notwithstanding his history of CTS surgery, the medical evidence shows that the Veteran's continuing symptoms in the left hand have been assessed as being persistent symptoms of CTS or more proximal nerve compression. (An electromyography (EMG) study has been advised for further diagnostic workup, but he has declined one so far, as reflected in an April 2021 VA treatment record.) No treating clinician has expressed a belief that these symptoms may be manifestations of his service-connected laceration residuals. Significantly, since the Board's May 2021 remand, additional VA treatment records have been added to the file dating back to 1995, while previously the records in the file only dated back to about 2013. The newly added records provide new information regarding the history of the Veteran's left hand symptoms. Specifically, they reflect that in October 1996 he fractured his left wrist. A computerized tomography (CT) scan revealed a comminuted displaced fracture of the distal radius with intra-articular extension. It also showed decreased volar angulation of the distal radius. An October 2003 VA treatment record reflects that he stated he had fractured his left hand some years ago, and since that time had numbness and tingling ("N/T") in the fingers. He stated that these symptoms were only in the fingers, and were progressive in nature. He also had experienced a throbbing like pain in his left hand for a few days. An August 2005 VA treatment record states that the Veteran reported constant paresthesias in the fingers of his left hand involving the index, long, ring, and little fingers. These symptoms had been present for the last several years. He stated they began after a remote trauma to the left wrist involving a fracture to the distal left radius. The symptoms principally involved the distal fingertips at all times, and were exacerbated by cold temperatures. The symptoms extended proximally along the palm of his hand as far as proximal to the wrist. An X-ray report showed evidence of an old distal radius fracture. In short, even if the Veteran's CTS does not account for all his symptoms, the above VA treatment recordshitherto not consideredindicate that his left hand symptoms may also be related to the October 1996 left wrist fracture, which occurred after service, since these earlier records show his report that the symptoms began following that injury. The Board notes that a March 2021 report authored by G. Leslie, D.O., which is based on a review of the Veteran's medical records and other pertinent records in the claims file, concludes that his left hand symptoms are due to his scarring from the service-connected laceration injuries and/or neuropathy from those injuries. However, Dr. Leslie did not considerbecause they were not available at the time the earlier VA treatment records discussed above showing an October 1996 post-service left wrist fracture and the Veteran's report that he began experiencing symptoms of numbness and tingling (also referred to as paresthesias) in the index, long, ring, and little fingers after that injury. Accordingly, the Board is unable to rely on the conclusions in Dr. Leslie's report, since they do not take into account that history. In addition, the March 2021 private report by Dr. Leslie notes the Veteran's history of CTS in the left hand which "complicated the clinical picture" because CTS and peripheral neuropathy are "very similar," but finds that the pain and numbness in the fourth and fifth fingers cannot be accounted for by the CTS. That statement continues to leave open the question of whether the symptoms in the Veteran's long finger are due to CTS. Moreover, even if the Veteran's symptoms in the fourth and fifth fingers may not be due to CTS according to Dr. Lesliealthough the VA treatment records reflect findings that they are either due to CTS or more proximal nerve compression his history of the October 1996 left wrist fracture and subsequent development of symptoms in the fingers of his left hand must still be taken into consideration. Accordingly, on remand, a new VA medical opinion must be obtained that considers the complete medical history, and which to the extent possible identifies the symptoms and functional impairment, if any, attributable to the Veteran's service-connected laceration injury residuals as distinguished from any symptoms and functional impairment related to CTS and the October 1996 left wrist fracture. On remand, the AOJ should also determine whether any archived VA treatment records from the 1990's and earlier may exist. While the computer-generated records are in the file, there may be earlier records, including handwritten or typed records, that remain outstanding. If so, appropriate efforts must be made to obtain them. The matters are REMANDED for the following action: 1. Add to the claims file any VA treatment records pertaining to the Veteran dated since August 2021. 2. Determine whether archived VA treatment records pertaining to the Veteran from the 1990's and earlier may exist. If so, appropriate efforts must be made to obtain them and add them to the claims file. 3. Then, after completing the above actions, obtain a new VA medical opinion regarding the nature and etiology of the Veteran's left hand symptoms (as thoroughly described in the June 2021 VA examination reports). The examiner is asked to clearly identify, to the extent possible, the symptoms and functional impairment, if any, attributable to the Veteran's service-connected residuals of laceration injuries to the middle, ring, and little fingers, which were caused by a door slamming his hand, and which were surgically treated, as described in the November 1973 service treatment records. To that end, the examiner should address the symptoms in each affected finger, including the limited range of motion. For example, the March 2021 report by Dr. Leslie states that symptoms in the little and ring finger would not be due to CTS, which does not rule out CTS as a cause of the symptoms in the long finger. In making this determination, the examiner must consider the fact that the Veteran sustained a left wrist fracture in October 1996. A 1996 CT scan revealed a revealed a comminuted displaced fracture of the distal radius with intra-articular extension. It also showed decreased volar angulation of the distal radius. VA treatment records dated in 2003 and 2005 show he reported that his numbness and tingling in the middle (long), ring, and little fingers (as well as the index finger at that time), began after that injury. He stated in an October 2003 VA treatment record that he had experienced throbbing pain in his left hand the last few days. The examiner must also consider that while the Veteran had carpal tunnel surgery in 2013, VA treatment records dated in 2020 reflect an assessment that his current symptoms may be persistent symptoms of CTS or a "more proximal nerve compression." The examiner must provide a complete explanation in support of the conclusion reached. If the examiner is unable to distinguish symptoms and functional impairment attributable to the service-connected versus the nonservice-connected conditions, the examiner should so state and explain whether this is due to missing information, the limits of medical knowledge in general, or limits in the examiner's own expertise in this area. P.M. DILORENZO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Rutkin, 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.