Citation Nr: 21062579 Decision Date: 10/08/21 Archive Date: 10/08/21 DOCKET NO. 17-01 887 DATE: October 8, 2021 REMANDED Entitlement to service connection for a left hand and finger disability is remanded. REASONS FOR REMAND The Veteran served on active duty from March 1967 to January 1970. In April 2019, the Veteran testified at a Board hearing via videoconference before the undersigned Veterans Law Judge of the Board. A transcript of the hearing is associated with the record. In July 2019, the Board remanded the case for further development by the originating agency. The case has been returned to the Board for further appellate action. Entitlement to service connection for a left hand and finger disability is remanded. The Veteran contends that he has a current left hand and finger disability related to an in-service injury. Specifically, he asserts that service treatment records incorrectly document a right hand and finger injury in service, and that he actually injured his left hand and finger in service when a pipe fell on it. See Hearing Transcript at 3. Specifically, the Veteran pointed to a service treatment record dated May 10, 1968, reflecting "injury to the distal end of the right fourth finger due to a dropped pipe on the hand while working in the field. X-rays were done and confirmed that there was a chip fracture of the distal phalangeal fourth finger of the right hand." Id. Further, he testified that service treatment record of June 7, 1968 makes reference to a right finger injury and light duty. Lastly, the Veteran asserts that he did in fact injure his left hand, but a mistake could have been made by the doctor at the time, where he recorded right versus left, which is common during combat operations during that era. Id. at 4. The Veteran has reportedly experienced a continuity of left hand and finger symptomatology in the years since service, but there is some evidence to the contrary. For example, there were no left or right hand or finger problems found at discharge in December 1969, and the first post-service clinical evidence of left hand and finger problems is not for several years following his separation from service. Furthermore, during private treatment in 2012, the Veteran reported that he woke up in late August 2012 with inability to extend his left wrist or fingers. He denied any injury, and he did not report an in-service injury to the left hand or finger at that time. He was diagnosed at that time with left radial nerve palsy, chronic. Post-service, VA and private treatment records also show the Veteran suffered a stroke in 2013, which left him with left-hand weakness and numbness. A VA hand and finger conditions examination was conducted in November 2019, to assess the nature and etiology of any current left hand and finger disability and the Veteran was diagnosed with residuals of stroke with left hand weakness and numbness. The examiner noted that although the Veteran reported that he sustained left 4th and 5th fingertip fractures around 1968 and developed left hand numbness during service, no left hand fractures or numbness were documented in the service treatment records, and medical records show that he suffered a right 4th fingertip fracture in June 1968. The examiner opined that it is less likely as not that the Veteran has a diagnosis of a left hand and finger condition that is caused by the left hand and finger condition during service. In rendering his rationale, the examiner noted that according to service records, the Veteran did not suffer a left hand injury during service. Rather, he sustained a right hand ring finger distal phalanx tip fracture in May 1968, which healed without complications. He noted further that during his separation examination in December 1969, the Veteran was not diagnosed with any left hand chronic condition or neurological damage (numbness); there is no evidence of a left hand/finger condition within one year of separation; and there is no evidence of chronicity. The examiner also noted that the stroke in 2013 that left the Veteran with left-hand weakness and numbness has nothing to do with military service. The Board finds the November 2019 opinion insufficient because it is predominantly based on a lack of objective clinical evidence of treatment for left hand and finger problems in the Veteran's service treatment records. The opinion discounts, without explanation, the Veteran's reports that although service treatment records document a right hand and finger injury, he actually injured his left hand and finger during service. In this regard, a medical opinion is inadequate if it is based solely on the absence of documentation in the record and does not take into account the Veteran's reports of symptoms and history (even if recorded in the course of the examination). Dalton v. Peake, 21 Vet. App. 23 (2007). Furthermore, the examiner failed to discuss the etiology of the chronic left radial nerve palsy noted in the 2012 private treatment records, which the Board notes was diagnosed prior to the Veteran's stroke and subsequent left-hand weakness and numbness in 2013. As such, the opinion is incomplete and therefore, inadequate for evaluation purposes. Therefore, a remand for a new examination and medical opinion as to the etiology of any current left hand and finger disability is necessary. Barr v. Nicholson, 21 Vet. App. 303 (2007); 38 C.F.R. § 4.2 (2019). The Board, by this remand, makes no determination, expressed or implied, concerning the credibility of any statements on file. The matters are REMANDED for the following action: 1. Updated treatment records should be obtained and added to the claims folder/efolder. 2. Following completion of the above, afford the Veteran a VA examination to determine the etiology of any currently diagnosed left hand and finger disability. The examiner should review the claims folder and acknowledge such review in the examination report, and any indicated studies should be performed. The examiner should provide an opinion as to whether it is at least as likely as not (50 percent probability or greater) that any left hand and finger disability diagnosed in the course of the appeal, to specifically include chronic left radial nerve palsy and residuals of stroke with left hand weakness and numbness, is etiologically related to active service. For purposes of this opinion, the examiner should presume that the Veteran's reports of a left hand and finger injury in service due to a pipe falling on the left hand are accurate. A complete rationale should be given for all opinions and conclusions expressed. If the examiner cannot provide an opinion without resort to speculation, the examiner should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. (Continued on the next page) 3. Then readjudicate the Veteran's claim for service connection for a left hand and finger disability. If the benefit sought on appeal is not granted, the AOJ should issue a supplemental statement of the case and provide the appropriate opportunity to respond, before returning the case to the Board, if otherwise in order. KELLI A. KORDICH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board F. Yankey, 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.