Citation Nr: 21066108 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 15-21 165 DATE: October 28, 2021 ORDER Entitlement to service connection for a right upper extremity disability other than right hand arthritis, to include right wrist arthritis and right upper extremity carpal tunnel syndrome, and to include as secondary to a right hand disability, is denied. Entitlement to service connection for a left upper extremity disability, to include left wrist arthritis and left upper extremity carpal tunnel syndrome, and to include as secondary to a right upper extremity disability, is denied. FINDINGS OF FACT 1. The Veteran's right upper extremity disability other than right hand arthritis, to include right wrist arthritis and right upper extremity carpal tunnel syndrome, did not manifest to a compensable degree within one year of separation from service; continuity of symptomatology is not established; the disability is not otherwise etiologically related to an in-service injury, disease, or event; and the disability is not proximately due to or aggravated by a right hand disability. 2. The Veteran's left upper extremity disability, to include left wrist arthritis and left upper extremity carpal tunnel syndrome, did not manifest to a compensable degree within one year of separation from service; continuity of symptomatology is not established; the disability is not otherwise etiologically related to an in-service injury, disease, or event; and the disability is not proximately due to or aggravated by a right upper extremity disability. CONCLUSIONS OF LAW 1. The criteria for service connection for a right upper extremity disability other than right hand arthritis, to include right wrist arthritis and right upper extremity carpal tunnel syndrome, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. 2. The criteria for service connection for a left upper extremity disability, to include left wrist arthritis and left upper extremity carpal tunnel syndrome, are not met. 38 U.S.C. §§ 1101, 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Army from February 1990 to November 1996. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2013 rating decision of an Agency of Original Jurisdiction (AOJ) of the Department of Veterans Affairs (VA), as that decision never became final and the Veteran subsequently filed a timely Notice of Disagreement (NOD). In June 2018, the Veteran testified at a videoconference hearing before the undersigned. In August 2018, July 2020, and May 2021, the Board remanded this matter for additional development. Substantial Compliance There has been substantial compliance with the Board's prior remand directives. In this regard, the Board has secured a medical opinion that is adequate to decide the appeal. The Board acknowledges that the July 2020 Board remand directed the examiner to accept as true the Veteran's statements that his right wrist pain continued after his ganglion cyst was drained in service, and to consider the Veteran's competent and credible reports of compensating with his left hand in response to a right hand disability. See July 2020 Board Remand at 3-4. The Board also invited the examiner to opine as to whether the Veteran's disability is medically consistent with his reported symptomatology. Id. at 4. In the May 2021 remand, the Board notified the Veteran that it was seeking an opinion as to whether the Veteran's report of continuity symptomatology following his October 1995 aspiration is medically consistent or inconsistent with the examination findings of record, and that if the response states that the findings are inconsistent then the Board may rely on this evidence in making an adverse credibility determination. The Board invited the Veteran to submit additional statements or other evidence in support of his claim for Board consideration. See May 2021 Board Remand at 2. Thus, as the Veteran was notified that the Board was developing new evidence that might result in a finding that the Veteran's statements were not credible, he has been afforded fair process in this appeal. Service Connection Service connection may be granted for a disability resulting from a disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. To establish entitlement to direct service connection, a veteran must show (1) a present disability; (2) an in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the present disability and the disease or injury incurred or aggravated during service. Shedden v. Principi, 381 F.3d 1163 (Fed. Cir. 2004). For veterans who have served continuously for 90 days or more of active service during a war period or after December 31, 1946, certain chronic disabilities, including arthritis and organic diseases of the nervous syndrome such as carpal tunnel syndrome, are presumed to have been incurred in service if manifest to a compensable degree within one year of separation from service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309. If symptoms of a chronic disease are noted in service but chronicity in service is not adequately supported, a showing of continuity of symptomatology after separation is required to presumptively establish service connection. 38 C.F.R. § 3.303. However, the presumption of service connection may be rebutted where there is evidence of an intercurrent injury or disease. 38 U.S.C. §§ 1113, 1137; 38 C.F.R. § 3.307(d). Secondary service connection may be granted for a disability that is proximately due to or aggravated by a service-connected disability. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.310. 1. Entitlement to service connection for a right upper extremity disability other than right hand arthritis, to include right wrist arthritis and right upper extremity carpal tunnel syndrome, and to include as secondary to a right hand disability, is denied. 2. Entitlement to service connection for a left upper extremity disability, to include left wrist arthritis and left upper extremity carpal tunnel syndrome, and to include as secondary to a right upper extremity disability, is denied. The Veteran asserts that his right upper extremity symptoms began in service and have continued to the present. He notes medical treatment in service, such as cortisone shots, and states that his current symptoms are severe. He attributes these symptoms to an in-service skiing accident, or alternatively to the impact of his military duties such as pushups, lifting heavy objects, and weapons firing. Alternately, he attributes his bilateral wrist symptoms to compensating for his service-connected right hand disability during activities. See, e.g., June 2018 Board Hearing Transcript; January 2015 NOD. Here, the Veteran has current diagnoses of right and left wrist arthritis (degenerative joint disease) and right and left upper extremity carpal tunnel syndrome. See, e.g., July 2020 Peripheral Nerves Examination Report; August 26, 2014 VA Treatment Note. The Veteran's service treatment records (STRs) show recurrent treatment in service for a ganglion cyst. See STRs. Thus, the first two elements of direct service connection are met, and the key question is whether there is a nexus linking his current disabilities to his symptoms in service. The evidence weighs against a nexus establishing direct service connection. A VA examiner provided a September 2020 medical opinion, as well as October 2020 and July 2021 addendum opinions. As discussed below, these opinions are highly probative evidence. The examiner is competent to offer a medical opinion and the opinions are based on an accurate facts and include thorough rationales. The probative value of this evidence outweighs the probative value of the Veteran's lay statements as to continuity of symptomatology, which is not credible. With respect to direct service connection for the Veteran's right wrist disability, the examiner opined that the Veteran's right wrist arthritis was less likely than not due to service. The examiner explained that November 2013 X-rays, taken 17 years after the Veteran's service, were negative for arthritis of both wrists, and instead, arthritis was first shown on January 2014 X-rays. Thus, the November 2013 X-rays are affirmative evidence that right wrist arthritis was not present at separation or for many years afterwards. See September 2020 Medical Opinion. Moreover, the examiner opined that the Veteran's right and left wrist carpal tunnel syndrome was less likely than not due to service. The examiner noted that the Veteran was diagnosed with mild sensory carpal tunnel syndrome by electromyograph (EMG) in 2016, nearly 20 years after separation. The examiner attributed the Veteran's symptoms in service to an intercurrent cause his right wrist ganglion cyst which resolved decades ago. See October 2020 Medical Opinion. The examiner explained that the Veteran's reports of increased pain and numbness during extreme extension such as pushups is inconsistent with carpal tunnel syndrome, as carpal tunnel symptoms manifest on flexion. See July 2021 Medical Opinion. Thus, the examiner explained, the examination findings were medically inconsistent with the Veteran's reported symptoms in service. The examiner opined that it was at least as likely as not that the Veteran's carpal tunnel syndrome was due to post-service work activities. See id. This rationale is readily comprehensible, based on an accurate factual basis, does not rely on the absence of evidence, and establishes that the Veteran's right wrist arthritis and carpal tunnel syndrome are not etiologically related to service and that continuity of symptomatology is not established. With respect to direct service connection for the Veteran's left wrist disability, the examiner opined that the Veteran's left wrist arthritis was less likely than not due to service. The examiner explained that the evidence shows that left wrist arthritis developed concurrently with his right wrist arthritis, as it is symmetric, and thus is consistent with post-service aging. See October 2020 Medical Opinion. Moreover, the examiner noted that the Veteran's left upper extremity carpal tunnel syndrome is unrelated to service and is due to post-service maintenance work. See id. As this opinion links the Veteran's left wrist arthritis to post-service causes, it demonstrates that the disability is not due to any in-service etiology, to include his reported skiing accident. This rationale is readily comprehensible, based on an accurate factual basis, does not rely on the absence of evidence, and establishes that the Veteran's left wrist arthritis and carpal tunnel syndrome are not etiologically related to service and that continuity of symptomatology is not established. With respect to secondary service connection, the Veteran has current right and left upper extremities disabilities and he is in receipt of service connection for a right hand disability. Thus, the first two elements of secondary service connection are met, and the key question is whether his current disabilities are proximately due to or aggravated by his service-connected right hand disability. The examiner opined that the Veteran's right and left wrist disabilities were less likely than not due to or aggravated by his service-connected right hand disability. The examiner stated that the Veteran's carpal tunnel syndrome was due to his post-service work as a maintenance worker and his arthritis was due to aging, and that these disabilities had not been worsened beyond their natural progression by his right hand disability. The examiner explained if the Veteran's arthritis or carpal tunnel syndrome was proximately due to or aggravated by the Veteran compensating for his service-connected right hand disability, then his bilateral wrist arthritis would be asymmetric, which is not the case. See October 2020 Medical Opinion. This rationale is readily comprehensible, based on an accurate factual basis, does not rely on the absence of evidence. The Board acknowledges that it previously directed examiners to accept his testimony of post-service pain as true, and moreover it found his testimony of increased pain during push-ups to be competent and credible. However, the examiner explained that the examination findings are medically inconsistent with arthritis or carpal tunnel syndrome having manifested in service and persisted to the present. The VA examiner is competent to provide a medical opinion and the opinion is based on an accurate factual basis, well-reasoned, and is probative. The examiner attributed the Veteran's competent and credible reports of pain during push-ups to a cause that resolved decades ago. Moreover, as the competent medical evidence of record shows that the Veteran's reports of continuous symptoms since service are medically inconsistent with the examination findings of record, the Board finds that the Veteran's report of continuity of symptomatology since service is not credible. Additionally, the Board acknowledges the Veteran's opinion that his right and left wrist disabilities are etiologically related to his military service. However, the Veteran is not shown to have the experience and training necessary to provide a medical opinion regarding the etiology of his arthritis and carpal tunnel syndrome. In this regard, while a layman is competent to report to presence and location of pain, numbness, and other sensations, an understanding of the etiology and pathological process that causes these symptoms is not lay knowledge. Moreover, the Veteran's reported continuity of symptomatology since service is not credible, and the most probative evidence of record attributes his documented symptoms in service to his resolved ganglion cyst. Finally, the Board observes that the June 2015 VA-contracted examiner opined that the Veteran's right hand disability was service-connected. However, the Board finds this statement nonprobative, given the other evidence of record. Specifically, the examiner who authored the September 2020, October 2020, and July 2021 medical opinions explained that the June 2015 examiner's opinion was clearly and unmistakably erroneous and pointed to errors in the June 2015 examiner's reasoning and the nonexistence of evidence that the June 2015 examiner purported to rely upon, to include an in-service hand and wrist x-ray that did not occur. Nonetheless, and as discussed above, the Board has considered whether the Veteran's bilateral wrist disabilities are proximately due to or secondary to the Veteran's erroneously service-connected right hand disability. However, the Board assigns no probative weight to the general background set forth by the June 2015 examiner, as the June 2015 examiner's opinion is not based on an accurate factual basis. Thus, the evidence of record against the claim consists of highly probative medical opinions authored by a VA examiner in September 2020, October 2020, and July 2021. The evidence of record against the claim consists of the Veteran's competent and credible statements of in-service symptomatology, which was been attributed to a resolved ganglion cyst, and his report of post-service continuity of symptomatology, which is not credible. The weight of the evidence of record is against the claim, and thus the benefit of the doubt doctrine is not for application and the appeal is denied. S. BUSH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board D.M. Badaczewski, 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.