Citation Nr: 21063899 Decision Date: 10/18/21 Archive Date: 10/18/21 DOCKET NO. 11-17 727 DATE: October 18, 2021 REMANDED Service connection for a left hand injury, to include as secondary to service-connected left shoulder strain, is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1973 to September 1993. This matter comes to the Board of Veterans' Appeals (Board) on appeal from an August 2010 rating decision issued by the Department of Veterans' Affairs (VA) Regional Office (RO) in Cleveland, Ohio. The Board has previously remanded this claim in October 2018, April 2020, January 2021, and June 2021 for additional development. Unfortunately, as will be discussed in more detail below, remand is again necessary to ensure substantial compliance with the June 2021 remand directives and that the Veteran is afforded an adequate VA examination. See Stegall v. West, 11 Vet. App. 268, 271 (1998). The Board regrets further delay but wants to ensure the Veteran receives any benefits to which he may be entitled. Service connection for a left hand injury, to include as secondary to service-connected left shoulder strain, is remanded. The Veteran contends he has a left hand injury that was caused by or incurred during service or, in the alternative, is secondary to service-connected left shoulder strain. The Board finds the evidence of record is insufficient to resolve his claim. The Veteran has been afforded four VA examinations to determine the nature and etiology of any left hand injury. The examinations occurred in October 2019, June 2020, February 2021, and July 2021. Following each VA examination, remand has been necessary to ensure the Veteran receives an adequate examination. In April 2020, the claim was remanded for consideration by a VA examiner of the Veteran's service treatment records (STRs) noting numbness in the last two fingers of the left hand and thumb injuries during service. Thereafter, the Board again remanded in January 2021 for consideration of the Veteran's STRs noting that the previous examiner stated she was unable to locate the documents referenced. Most recently in June 2021, the Board again remanded the claim for consideration of the Veteran's STRs and a secondary causation opinion. Specifically, the Board directed consideration of the Veteran's STRs noting numbness in the last two fingers of the left hand and the Veteran's service-connected shoulder disability prior to rendering an opinion regarding direct and secondary service connection. Unfortunately, the July 2021 VA examination was again unresponsive to the Board's June 2021 remand directives. The July 2021 VA examiner opined that it was not at least as likely as not the Veteran's left hand disorder was caused by or incurred during service because the February 1993 separation examination was silent regarding the left hand and arthritic changes of the thumb are likely incidental. The Board, however, specifically directed consideration of the Veteran's STRs noting left finger numbness during service in 1978. Further, there are multiple complaints of thumb pain and hand injuries during service with symptoms following separation which remain unaddressed. As such, remand is necessary for consideration of the Veteran's STRs as previously directed. Additionally, the July 2021 VA examiner opined that it was not at least as likely as not the Veteran's left hand disorder was caused or aggravated by service-connected left shoulder strain reasoning that there is no etiological association between left shoulder strain seen and treated several times in 1978 and subjective complaints noted currently at the left wrist or arthritic changes of the left thumb. The examiner, however, failed to reconcile the Veteran's 1978 STRs noting complaints of numbness in the last two fingers of the left hand in relation to medical care for pain in the left shoulder. Additionally, the opinion failed to address whether the Veteran's left hand disorder is aggravated by his service-connected left shoulder strain. See El-Amin v. Shinseki, 26 Vet. App. 136, 140 (2013). In an effort to avoid further remands, the Board notes the Veteran's STRs contain complaints of pain in the left shoulder with numbness in the last two fingers of the left hand in May 1978; a left hand laceration in June 1978; a left hand or index finger injury in January 1979; sutures for the left thumb in November 1979; and a left thumb injury involving a nail in May 1980. In October 1991, STRs noted imaging requested of the left wrist to rule out rheumatoid arthritis versus probable tendinitis in the left wrist with complaints of wrist pain. Additionally, within months following service, the Veteran complained of experiencing left hand numbness after sleeping on it in December 1993. Consideration should be given to these STRs on remand prior to the VA examiner rendering an opinion. Thus, this claim is remanded to afford the Veteran another VA examination to ensure substantial compliance with both the February 2021 and July 2021 Board decisions and ensure the Veteran receives an adequate VA examination regarding both direct and secondary service connection. The matters are REMANDED for the following action: 1. Schedule the Veteran for a VA examination for his left hand disability. The examiner must review the entire claims file and this remand prior to rendering an opinion. The examiner shall provide an opinion, including rationale, addressing the following: - Note any and all left-hand disabilities for VA purposes found (this includes diagnosis or pain causing functional impairment of earning capacity) Consideration should be given to the Veteran's previous diagnosis noted in the VA examinations of record as well as the Veteran's treatment records. - For each left-hand disability found, is the disability (a) at least as likely as not related to service, including the documented left hand and thumb injuries and symptoms during service, (b) proximately due to his service-connected left shoulder strain, or (c) aggravated, i.e., worsened beyond its natural progression, by service-connected left shoulder strain? In so opining, the examiner is specifically directed to address and consider the Veteran's STRs noting complaints of pain in the left shoulder with numbness in the last two fingers of the left hand in May 1978; a left hand laceration in June 1978; a left hand or index finger injury in January 1979; sutures for the left thumb in November 1979; a left thumb injury involving a nail in May 1980; and October 1991 notes requesting imaging of the left wrist to rule out rheumatoid arthritis versus probable tendinitis in the left wrist with complaints of wrist pain. The VA examiner is cautioned that the term "aggravated," as used in 38 C.F.R. § 3.310(b), does not require that there be "permanent worsening" of the nonservice-connected disability. Instead, secondary service connection is warranted for "any incremental increase in disability and any additional impairment of earning capacity in nonservice-connected disabilities resulting from service-connected conditions, above the degree of disability existing before the increase regardless of its permanence." See Ward v. Wilkie, 31 Vet. App. 233, 239 (2019). - For any arthritis condition of the left hand, including the wrist or thumb, is it at least as likely as not that it (a) began during active service, (b) manifested within a year after discharge from service, or (c) was noted during service with continuity of the same symptomatology since service? In so opining, the examiner is directed to specifically address and consider the Veteran's complaints of experiencing left hand numbness after sleeping on it in December 1993 in the months following service. The examiner must provide a complete rationale for any opinion expressed, based on the examiner's clinical and medical expertise; established medical principles; and references to the evidence of record, as appropriate. If any opinion cannot be expressed without resort to speculation, ensure that the examiner so indicates and discusses why an opinion is not possible, to include whether there is additional evidence that could enable an opinion to be provided, or whether the inability to provide the opinion is based on the limits of medical knowledge. (Continued on the next page) 2. After the above development, and any other development deemed necessary, readjudicate the claims. SHEREEN M. MARCUS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A.C. Allen, 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.