Citation Nr: 21066169 Decision Date: 10/28/21 Archive Date: 10/28/21 DOCKET NO. 17-50 323 DATE: October 28, 2021 ORDER Entitlement to service connection for an acquired psychiatric disorder, defined as other specified trauma, a stressor related disorder, and major depressive disorder, is granted. Prior to February 16, 2017 and from April 1, 2017, entitlement to an initial rating in excess of 20 percent for carpal tunnel syndrome of the left wrist is denied. Prior to September 1, 2016 and from November 1, 2016, entitlement to an initial rating in excess of 30 percent for carpal tunnel syndrome of right wrist is denied. FINDINGS OF FACT 1. The evidence is in relative equipoise regarding whether the Veteran's psychiatric condition was related to in-service events. 2. The Veteran's bilateral wrist carpal tunnel syndrome has been manifested by no more than moderate incomplete paralysis. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for an acquired psychiatric disorder, characterized as other specified trauma, a stressor related disorder, and major depressive disorder, have been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.102, 3.303. 2. Prior to February 16, 2017 and from April 1, 2017, the criteria for entitlement to a rating in excess of 20 percent for carpal tunnel syndrome of the left wrist have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.124a, Diagnostic Codes 8515, 8516. 3. Prior to September 1, 2016 and from November 1, 2016, the criteria for entitlement to a rating in excess of 30 percent for carpal tunnel syndrome of right wrist have not been met. 38 U.S.C. § 1155, 5103, 5103A, 5107(b); 38 C.F.R. §§ 3.102, 3.159, 3.321, 4.1, 4.7, 4.124a, Diagnostic Code 8515, 8516. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from September 1981 to September 1985. In June 2019, the Board of Veterans' Appeals (Board) remanded this appeal for further evidentiary development. Service connection for an acquired psychiatric disorder The Veteran seeks service connection for an acquired psychiatric disorder. The evidence of record establishes that he has been clinically diagnosed with other specified trauma, a stressor related disorder, and major depressive disorder. A veteran is granted service connection where evidence shows that an injury or disease that results in a current disability was incurred during service or was aggravated by service. 38 U.S.C. § 1131; 38 C.F.R. §3.303(a). To be entitled to service connection, the evidence must support (1) a current disability; (2) an in-service injury or event; and (3) a nexus between the current disability and the in-service injury or event. 38 C.F.R. §3.303(a). Review of the record shows that a diagnosis of posttraumatic stress disorder (PTSD) was rendered by a licensed clinical social worker (LCSW) and a licensed professional clinical counselor (LPCC). VA regulations require that a medical diagnosis be competent. 38 C.F.R. § 3.159(a). Competent medical evidence means evidence provided by a person who is qualified through education, training, or experience to offer the medical diagnosis. Id. The VA Clinician's Guide provides guidance on who is qualified to diagnose PTSD. VA Clinician's Guide § 14.7 (Mar. 2002). It provides in pertinent part: Professionals qualified to perform PTSD examinations should have doctoral-level training in psychopathology, diagnostic methods, and clinical interview methods. They should have a working knowledge of DSM, as well as extensive clinical experience in diagnosing and treating veterans with PTSD. Ideally, examiners should be proficient in the use of structured clinical interview schedules for assessing PTSD and other disorders, as well as psychometric methods for assessing PTSD. Board certified psychiatrists and licensed psychologists have the requisite professional qualifications to conduct compensation and pension examinations for PTSD. Psychiatric residents and psychology interns are also qualified to perform these examinations, under close supervision of attending psychiatrists or psychologists. In order to conduct an INITIAL examination for mental disorders, the examiner must meet one of the following criteria: a board-certified or board-eligible psychiatrist; a licensed doctorate-level psychologist; a doctorate-level mental health provider under the close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; a psychiatry resident under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist; or a clinical or counseling psychologist completing a one-year internship or residency (for purposes of a doctorate-level degree) under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist. A licensed clinical social worker (LCSW), under close supervision of a board-certified or board-eligible psychiatrist or licensed doctorate-level psychologist can perform REVIEW examinations for PTSD. VA Clinician's Guide § 14.7 (Mar. 2002). The evidence does not show that the LCSW or LPCC was under the supervision of a board-certified or board-eligible psychiatrist or a licensed doctorate-level psychologist. It is noted that LCSWs are competent to conduct REVIEW examinations for PTSD but are not competent to conduct an INITIAL examination in which the disorder would be diagnosed. Accordingly, the diagnoses of PTSD provided by the LCSW or LPCC are not competent. Furthermore, the January 2020 VA Examiner, who is a licensed psychologist, found that the Veteran did not meet the full criteria for a PTSD diagnosis in accordance with the DSM criteria. Regarding an in-service injury or event, the Veteran shared that, while training in Georgia during a road march, he fell into a hole and got trampled on. As a result, he had torn tendons in his "left leg." He expressed feeling more anxious and depressed after this event. Also, he stated that he had a difficult time dealing with the possibility of sterility when he was diagnosed with varicole scrotum in service. Service treatment records show that the Veteran injured his right ankle while marching and stepping in a hole. Records document his left knee complaints and being treated for varicole repair. See January 2002 Service Treatment Records. Further, the January 2020 VA examiner opined that it was less likely than not that the Veteran's current psychiatric condition was due to his service. The examiner stated that the Veteran reported experiencing multiple traumas prior to service, during service, and post-service. The military trauma in 1982 caused "leg injuries and sleep disturbances, anxiety, panic attacks, isolating behaviors, and excessive drinking." The examiner further explained that maintaining security clearance in service made the Veteran feel as though he was constantly being watched and followed. The examiner explained that, with multiple traumatic events occurring pre-military, military, and post military, in addition to the Veteran's report of childhood depression, it is less likely than not that his current depression and trauma related symptoms were either incurred in, or otherwise related to, his active duty service. The examiner concluded that there is no way to differentiate the impact of service related events on the Veteran's psychiatric conditions. Preliminarily, the Board will address the examiner's indication of a pre-existing psychiatric condition. Although the Veteran is competent to report pre-service psychiatric symptoms that he experienced first-hand, a mere history provided by a Veteran of the pre-service existence of disorders does not, in itself, constitute a notation of a preexisting disorder. 38 C.F.R. § 3.304 (b)(1); Paulson v. Brown, 7 Vet. App. 466, 470 (1995); Crowe v. Brown, 7 Vet. App. 238, 246 (1995). The United States Court of Appeals for Veterans Claims has held that the presumption of soundness upon entry into service may not be rebutted without "contemporaneous clinical evidence or recorded history" in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Although the examiner acknowledged the Veteran's report of experiencing psychiatric symptoms prior to service, there is no clear and unmistakable evidence presented, such as contemporaneous clinical evidence, regarding any pre-service psychiatric condition, to rebut the presumption of soundness. Therefore, the Board determines that, pertaining to a psychiatric condition, the Veteran entered service in sound condition. After a thorough consideration of the evidence of the record, the Board finds that the evidence is in at least relative equipoise as to whether the Veteran's current psychiatric condition is due to his service. Although the examiner noted that it would be hard to differentiate the impact of pre-service, in-service, and post-service, the examiner did note that the military events, specifically his fall, caused psychiatric symptoms. Considering what has been proffered in the opinion, taken with the available evidence of the record, there is enough competent evidence to raise a reasonable doubt regarding the onset of the Veteran's psychiatric disorder. Therefore, resolving this reasonable doubt in favor of the Veteran, the Board finds that nexus has been established between his diagnosed psychiatric condition and his service. The criteria for service connection for an acquired psychiatric disorder have been met. Prior to February 16, 2017 and from April 1, 2017, entitlement to a rating in excess of 20 percent for carpal tunnel syndrome of the left wrist Prior to September 1, 2016 and from November 1, 2016, entitlement to a rating in excess of 30 percent for carpal tunnel syndrome of right wrist The Veteran seeks a higher rating for his bilateral carpal tunnel syndrome. This condition has been evaluated under Diagnostic Codes 8515 and 8516. The Board notes that the Veteran was awarded temporary total evaluations for his carpal tunnel syndrome in accordance with 38 C.F.R. § 4.30, for surgical treatment necessitating convalescence from February 16, 2017 to March 31, 2017 for his left wrist and from September 1, 2016 to October 31, 2016 for right wrist. Diagnostic Code 8515 evaluates paralysis of the median nerve. Mild incomplete paralysis is rated 10 percent disabling on the major side and 10 percent on the minor side. Moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side. Severe incomplete paralysis is rated 50 percent disabling on the major side and 40 percent on the minor side. Complete paralysis of the median nerve, with the hand inclined to the ulnar side, the index and middle fingers more extended than normally, considerable atrophy of the muscles of the thenar eminence, the thumb in the plane of the hand (ape hand); pronation incomplete and defective, absence of flexion of index finger and feeble flexion of middle finger, cannot make a fist, index and middle fingers remain extended; cannot flex distal phalanx of thumb, defective opposition and abduction of the thumb at right angles to palm; flexion of wrist weakened; pain with trophic disturbances, is rated 70 percent disabling on the major side and 60 percent on the minor side. Diagnostic Code 8516 evaluates paralysis of the ulnar nerve. Mild incomplete paralysis is rated 10 percent disabling on the major side and 10 percent on the minor side. Moderate incomplete paralysis is rated 30 percent disabling on the major side and 20 percent on the minor side. Severe incomplete paralysis is rated 40 percent disabling on the major side and 30 percent on the minor side. Complete paralysis of the ulnar nerve, the "griffin claw" deformity, due to flexor contraction of ring and little fingers, atrophy very marked in dorsal interspace and thenar and hypothenar eminences; loss of extension of ring and little fingers, cannot spread the fingers (or reverse), cannot adduct the thumb; flexion of wrist weakened, is rated 60 percent disabling on the major side and 50 percent on the minor side. The term "incomplete paralysis" with this and other peripheral nerve injuries indicates a degree of lost or impaired function substantially less than the type pictured for complete paralysis given with each nerve, whether due to varied level of the nerve lesion or to partial regeneration. When the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The Veteran in the current appeal is right handed. Therefore, his major side is his right, and his minor side is his left. Turning now to the relevant evidence of the record, the Board notes that, at the August 2013 VA Examination, it was reported that the Veteran experienced significantly decreased left hand strength, compared to his right hand. The Veteran reported radiating pain towards both shoulders. At night, the pain was intense. He explained that splints and ice did not always help his symptoms. He was studying interior design and stated that he had exacerbations of his symptoms when trying to do detailed work. Regarding the severity of his symptoms, he experienced moderate intermittent pain, moderate paresthesias/dysesthesias, and moderate numbness. Muscle strength testing and reflexes were normal. Tactile sensations on the left hand and wrist were altered. There were no trophic changes. Positive Phalen's sign and Tinel's sign tests were reported for the Veteran's left hand. The severity of the Veteran's condition was noted as moderate incomplete paralysis of the median nerve. Functional impact was described as the Veteran having to take more breaks during school and taking longer to complete the tasks. The quality of his penmanship decreased as well. In November 2015, the Veteran shared that he experienced flare-ups during the course of the week. He woke up to numbness in both arms and tingling in the fingers of his left hand. He reported losing sleep due to his pain. See November 2015 Correspondence. At the December 2015 VA Examination, the Veteran reporting experiencing mild intermittent pain, mild paresthesias, and mild numbness. Muscle strength testing was normal, and he did not have muscle atrophy. The severity of his condition was noted as mild incomplete paralysis of the median nerve. He used braces and wrist splints regularly for wrist support. VA Medical Treatment Records documented the Veteran's complaints and treatment of his bilateral wrist carpal tunnel syndrome. He reported experiencing pain and numbness. He wore wrist splints at night to alleviate his symptoms. On the January 2020 VA Examination, the Veteran's current symptoms included not having full coordination of his hands, pulling pain, and difficulties in printing, writing, and painting. He expressed that his left hand is worse than his right. Regarding the severity of the Veteran's symptoms, he experienced severe intermittent pain in the right, moderate intermittent pain in the left, moderate paresthesias in the right, and moderate numbness in the left. Muscle strength was normal, and no muscle atrophy was present. Reflexes were hypoactive. Sensations were decreased in the hands/fingers. The Veteran had mild incomplete paralysis of the median nerve in his right wrist and moderate incomplete paralysis in the median nerve in his left wrist. Functional impact was noted as difficulty with fine motor, writing, typing, buttoning shirts, sewing, and difficulty with using the computer and mouse. The Veteran's employer provided him with ergonomic tools for assistance. After a thorough consideration of the evidence, the Board finds that severity of the Veteran's bilateral wrist carpal tunnel syndrome is adequately contemplated by the ratings indicative of moderate incomplete paralysis. Therefore, entitlement to higher ratings is not warranted in this matter. At most, the Veteran has experienced moderate numbness and paresthesias in his wrists. His muscle strength has been noted to be normal, and he did not present with muscle atrophy. At the most, his reflexes were noted to be hypoactive, and he experienced decreased sensations. There were no trophic changes noted. The Board acknowledges that the Veteran has described constant pain to some degree as well as intermittent severe pain. As instructed, when the involvement is wholly sensory, the rating should be for the mild, or at most, the moderate degree. The Board also acknowledges the Veteran's assertion that he has lost sleep due to his bilateral wrist pain. Pain, and its severity level, is a symptom contemplated by the diagnostic codes evaluating nerve paralysis, as noted on the examinations (symptoms of constant or intermittent pain). His difficulties sleeping have been attributed to the severity level of his pain. Therefore, any interferences caused by his radiating pain is contemplated by the assigned diagnostic code and does not exhibit an exceptional disability picture. As such, no referral for extraschedular consideration is warranted. Thun v. Peake, 22 Vet. App. 111, 115-16 (2008). The Board is sympathetic to the Veteran's assertions that higher ratings are warranted for his service-connected bilateral carpal tunnel syndrome. However, the preponderance of the evidence is against the assignment of higher ratings for these disabilities. THERESA M. CATINO Veterans Law Judge Board of Veterans' Appeals Attorney for the Board S. Middleton, 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.