Citation Nr: 21062265 Decision Date: 10/06/21 Archive Date: 10/06/21 DOCKET NO. 17-17 175A DATE: October 6, 2021 ORDER 1. Entitlement to service connection for right carpal tunnel syndrome (claimed as a right upper extremity disorder) is granted. 2. Entitlement to service connection for a right wrist disorder other than carpal tunnel is denied. 3. Entitlement to service connection for a right knee disorder is denied. FINDINGS OF FACT 1. The Veteran has a diagnosis of right carpal tunnel syndrome that is shown by competent medical evidence to have been due to an in-service injury. 2. The Veteran is not shown to have a chronic right wrist disorder other than right carpal tunnel syndrome. 3. The preponderance of the evidence is against a finding that any right knee disorder is etiologically related to the Veteran's active service. CONCLUSIONS OF LAW 1. Service connection for right carpal tunnel syndrome is warranted. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. 2. Service connection for a right wrist disorder other than carpal tunnel syndrome, is not warranted. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304. 3. Service connection for a right knee disorder is not warranted. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. §§ 3.303, 3.304, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The appellant is a Veteran who had active service from July 1980 to September 2001. This case is before the Board of Veterans' Appeals (Board) on appeal from Department of Veterans Affairs (VA) rating decisions that denied service connection for a right upper extremity, right wrist, and right knee disabilities. In March 2019 the case was remanded for additional development. A November 2020 rating decision granted service connection for a left shoulder disability, resolving the appeal in that matter. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). Service Connection Service connection is warranted for disability due to disease or injury incurred in or aggravated by active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To substantiate a claim of service connection there must be competent evidence showing: (1) the existence of a claimed disability; (2) incurrence or aggravation of a disease or injury in service; and (3) a causal relationship between the present claimed disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Certain chronic diseases (to include arthritis) may be presumed to be service-connected if manifested as chronic in service or to a compensable degree within a specified period after service (one year for arthritis). 38 U.S.C. §§ 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). For chronic disease listed in 38 C.F.R. § 3.309(a) service connection may be established by showing continuity of symptomatology. See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Secondary service connection may be established for a disability which is proximately due to, or the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310. To substantiate a claim of secondary service connection, the record must show (1) a current disability (for which secondary service connection is sought); (2) an already service-connected disability; and (3) that the already service-connected disability caused or aggravated the disability for which service connection is sought. Wallin v. West, 11 Vet. App. 509 (1998). Right carpal tunnel syndrome and a right wrist disability other than carpal tunnel syndrome) The Veteran has asserted that he has a right wrist disability and right carpal tunnel syndrome disorder that were incurred in service or are secondary to a service-connected disability. The Veteran's STRs show that on a January 1980 medical questionnaire, he did not report any upper extremity or wrist symptoms. On a September 1985 examination, his upper extremities were normal on clinical evaluation. In September 1990, the Veteran injured his right wrist; an x-ray was interpreted as suspicious for a hair-line fracture. On May 1992 examination, his upper extremities were normal on clinical evaluation. In a May 1992 medical questionnaire, he denied having any broken bones, any bone, joint, or other deformity, or any neuritis or paralysis. On April 1994 examination, his upper extremities were normal on clinical evaluation. In September 1998, he injured his right wrist playing football. A suspicious lucency was noted in the right wrist at the scaphoid; no other abnormalities were seen. On a June 2001 medical questionnaire, he denied having a painful wrist, numbness or tingling, impaired use of a hand, or swollen or painful joints. On August 2001 service separation examination, his upper extremities were normal on clinical evaluation. In an August 2001 Report of Medical Assessment, he reported there were no changes since a June 2001 examination. The Veteran's postservice medical records do not show any treatment for residuals of a right wrist fracture or diagnosis for a right wrist disorder other than carpal tunnel syndrome. On March 2013 VA examination, the Veteran reported that he fractured his right wrist during active service and has continued to have right wrist pain. Upon review of the Veteran's claims file, and interview and examination of the Veteran, the diagnosis was resolved right wrist ligament sprain; it was noted that no related complaints were noted on the Veteran's service separation examination report. The examiner opined that any right wrist disorder was less likely than not due to his active service, and noted that there was no evidence of a chronic right wrist disability related to the Veteran's active service. On July 2014 VA examination, the examiner indicated that the Veteran did not have a diagnosis of a right arm disorder (apart from right shoulder arthritis. It was noted that right wrist x-rays were normal. On August 2015 VA examination, the Veteran reported that after he injured his right shoulder in service, he noticed occasional right arm pain, numbness, tingling, and burning; right upper extremity median nerve neuropathy was diagnosed. Upon review of the Veteran's claims file, and interview and examination of the Veteran, the examiner opined that the Veteran's right median neuropathy was at least as likely as not proximately due to or the result of the Veteran's right shoulder disability. The examiner reported that the Veteran's right shoulder disability could cause arthritic changes that impinge on the median nerve. On March 2017 VA examination, upon review of the Veteran's claim file, and interview and examination of the Veteran, the diagnosis was right carpal tunnel syndrome. The examiner noted that EMG/NCS results were consistent with carpal tunnel syndrome. The examiner opined that any right carpal tunnel syndrome was less likely than not incurred in or caused by the Veteran's service-connected right shoulder disability. The examiner explained that the Veteran's right carpal tunnel syndrome is a stand-alone entity, that was neither due to nor aggravated by the Veteran's active service or his service-connected right shoulder disability, and that carpal tunnel syndrome occurs when the median nerve is pressed or squeezed at the wrist. On August 2019 VA examination, upon review of the Veteran's claim file, and interview and examination of the Veteran, the diagnosis was right carpal tunnel syndrome. The examiner stated that the Veteran did not have any right upper extremity peripheral neuropathy other than right carpal tunnel syndrome. The examiner noted that the Veterans upper extremities were normal on August 2001 service separation examination. On November 2019 VA examination, the Veteran denied ever receiving a diagnosis of a chronic right wrist disorder or receiving care for an acute or chronic right wrist disorder. The examiner noted that the claims file did not show the Veteran has a diagnosis of right median neuropathy but shows a diagnosis of right carpal tunnel syndrome. On October 2020 VA examination, upon review of the Veteran's claims file, and interview and examination of the Veteran, the diagnosis was right carpal tunnel syndrome. The examiner opined that the Veteran's right carpal tunnel syndrome was at least as likely as not due to the right wrist trauma he experienced during his active service. The diagnosis and etiology of a disease such as carpal tunnel syndrome are medical questions. Regarding the etiology of the Veteran's right carpal tunnel syndrome, the Board finds most probative of medical evidence in the record to be the opinion by the October 2020 VA examiner indicating that it is due to wrist trauma the Veteran sustained in service. The Board finds no reason to question the expertise of VA's own consulting medical professional, or the validity of the opinion offered. The provider indicated that the claims file was reviewed (and the conclusion reached is assumed to be based on the provider's interpretation of what the factual evidence in the record shows). The provider is a medical professional who included rationale that cites to factual data. Therefore, the Board finds that opinion persuasive. Considering the foregoing, all the requirements for substantiating a claim for service connection are met, and service connection for right carpal tunnel syndrome is warranted. Regarding the claim of service connection for a chronic right wrist disorder other than carpal tunnel syndrome), the Veteran has not submitted any competent (medical evidence) supporting that he has such a disability. His medical records do not show a current diagnosis of a chronic right wrist disability, and VA examiners have all found that he did not have a chronic right wrist disorder. On November 2019 VA examination, the Veteran denied ever having a chronic right wrist disorder. The diagnosis of a chronic right wrist disorder is a complex medical question, it requires medical expertise, informed by clinical testing, and cannot be diagnosed by lay observation alone. The Veteran is a layperson and does not profess to have any medical expertise. He does not cite to supporting clinical data or medical opinion or treatise evidence, and his own opinion that he has a right wrist disorder other than carpal tunnel syndrome has no probative value. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). A threshold requirement for substantiating a claim of service connection is that there must be competent evidence of the disability for which service connection is sought. In the absence of proof of a current disability, there is no valid claim for service connection. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). As it is not shown by competent (medical) evidence that the Veteran has, or at any time during the pendency of the instant claim has had, a chronic right wrist disability other than carpal tunnel, that threshold requirement is not met with respect to the instant claim. Therefore, the preponderance of the evidence is against the service connection claim for a right wrist disorder other than right carpal tunnel syndrome, and the appeal in the matter must be denied. Right knee disability The Veteran asserts that he has a right knee disability that was incurred in service. He states that he injured his right knee in service and has continued to have right knee pain since. The Veteran's wife has reported that the Veteran was an athlete and a runner during his active service. She reported that he complains of knee pain, stiffness, and swelling. The Veteran's STRs show that in January 1980, he denied having any knee symptoms. On September 1985 and May 1992 examinations, his lower extremities were normal on clinical evaluation; on a May 1992 questionnaire he denied having any knee symptoms. In June 1993, he complained of right knee pain and the assessment was right knee strain. On April 1994 examination, his lower extremities were normal on clinical evaluation. On a June 2001 medical questionnaire, he denied having any knee symptoms. On August 2001 service separation examination, his lower extremities were normal on clinical evaluation. In an August 2001 Report of Medical Assessment, he reported there were no changes since his last physical. Postservice medical records do not show any right knee complaints, symptoms, or treatment prior to a March 2013 VA examination. On March 2013 VA examination, the Veteran's right knee was normal on clinical evaluation. Right knee x-rays showed spurring of the right medial femoral condyle and the inferior patella and mild calcification posterior to the distal femur; degenerative spurring was diagnosed. Upon review of the Veteran's claims file, and interview and examination of the Veteran, the examiner opine that the Veteran's right knee disorder is less likely than not due to his active service. The examiner explained that there is no evidence of a chronic right knee disorder related to his right knee strain in service. In July 2013, the Veteran reported right knee pain that started the previous weekend but was not deployment related. In October 2014, he was again seen for right knee pain. A February 2015 right knee x-ray showed a small exostosis (a benign bone growth). A November 2016 treatment record notes a diagnosis of right knee arthritis; however, the Veteran's medical records do not include any notations of clinical findings or diagnostic studies supporting a diagnosis of arthritis. On November 2019 VA examination of the Veteran, residuals of a right knee sprain in 1993 and right bony outgrowth off the medial aspect of the medial femoral condyle were diagnosed. Right knee x-rays did not show arthritis, did not show an acute bony abnormality, and were within normal limits for age. Upon review of the Veteran's claims file, and interview and examination of the Veteran, the examiner opined that the Veteran's right knee disorder was less likely than not due to his active service. The examiner explained that the Veteran was treated conservatively for a right knee sprain in 1993 during his active service, and that right knee sprain was acute and resolved without residuals as the evidence did not show any other right knee treatment for a chronic condition. The examiner noted that the Veteran's August 2001 separation physical did not note treatment for or diagnosis of a chronic right knee disorder, and his lower extremities were normal on examination. It was noted that the Veteran specifically denied having knee trouble or any bone, joint, or other deformity. The examiner observed that a bony outgrowth was not diagnosed until the March 2013 VA examination, and that a bony outgrowth is not a disease process but represents a normal residual finding from a healed acute injury, such as a knee sprain. The examiner stated that medical literature is silent for any mechanism by which a right knee sprain might cause or aggravate degenerative spurring. While the Veteran's STRs show that he seen and treated for a right knee strain, they reflect that such was an acute injury that resolved with treatment. A chronic right knee disability in service is not shown. While he has been found to have degenerative spurring at the knee, such pathology was not shown prior to 2013, nearly a dozen years after the Veteran's separation from active-duty service. Therefore, presumptive service connection for arthritis of the knee (as a chronic disease under 38 U.S.C. § 1112) or service connection based on continuity of manifestations of knee arthritis), is not warranted. What remains for consideration is whether the Veteran's current right knee disability is otherwise shown by competent evidence to be etiologically related to his service and the documented injury therein. Whether a current right knee disability (to include the degenerative spurring now shown) is, or may be, related to remote service and an acute injury therein is a medical question. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). The Veteran has not submitted any competent medical (opinion or treatise) evidence indicating that his current right knee disability might be related to his active service and the acute knee injury therein. To assist the Veteran, VA has obtained medical opinions that address that question. Of these, the Board finds most probative the November 2019 VA examiner's opinion that the Veteran's right knee disorder is less likely than not due to his active service, explaining that a right knee bony outgrowth is not a disease process but represents a normal residual finding, and is not considered a chronic right knee disorder. The opinion includes a detailed explanation of rationale, noting that a chronic right knee disorder was not shown in service and that medical literature does not identify any mechanism by which current degenerative spurring might be etiologically related to an acute sprain in remote service. The provider is a medical professional and is competent to offer the opinion given. The opinion includes rationale that indicates the claims file was reviewed and all evidence was considered and cites to supporting factual data, and medical principles. The Board finds it to be probative evidence in this matter. The assertions of the Veteran and his wife that his right knee disorder disability is related to an injury in service are not competent evidence in the matter. While they are competent to report knee symptoms he has and has had, they are laypersons, and lack the medical expertise to establish by their own opinion that the current right knee disability is related to an injury during the Veteran's active service. The matter of a nexus between a current disability and remote service is a question beyond the scope of common knowledge or capability of resolution by lay observation. And because they are laypersons, they are not competent to establish by their own opinions that the Veteran has had a diagnosis of right knee arthritis or continuity of right knee arthritis manifestations ever since service (to support a chronic disease presumptive or continuity theory of entitlement). Considering the foregoing, the Board finds that the preponderance of the evidence is against this claim. Therefore, the appeal in the matter must be denied. GEORGE R. SENYK Veterans Law Judge Board of Veterans' Appeals Attorney for the Board T. Berryman, 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.