Citation Nr: 21066371 Decision Date: 10/29/21 Archive Date: 10/29/21 DOCKET NO. 15-12 654 DATE: October 29, 2021 REMANDED Service connection for a right wrist disability (claimed as carpal tunnel syndrome) is remanded. Service connection for a left wrist disability (claimed as carpal tunnel syndrome) is remanded. REASONS FOR REMAND The Veteran served on active duty from June 1993 to August 2013. These claims are on appeal to the Board of Veterans' Appeals (Board) from a January 2014 rating decision. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a January 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In a September 2019 decision, the Board denied all the claims. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2020 Order, the Court granted a Joint Motion for Remand (Joint Motion) filed by the parties to vacate and remand the September 2019 Board decision. The case has since been returned to the Board for appellate review. In the Joint Motion, the parties agreed the Board provided an inadequate reasons and bases and did not discuss relevant evidence. It was also agreed the Board's findings were inconsistent with the record. Ultimately, the Court noted that there were likely outstanding records that the Board did not address, that the Board relied on an inadequate January 2014 VA examination, and that it did not including findings regarding functional impairment consistent with Saunders v. Wilkie, 886 F. 3d 1356 (Fed. Cir. 2018). The case was remanded by the Board in February 2021. 1. Service connection for a right wrist disability (claimed as carpal tunnel syndrome) is remanded. 2. Service connection for a left wrist disability (claimed as carpal tunnel syndrome) is remanded. The Veteran is claiming service connection for bilateral carpal tunnel syndrome (CTS), which he believes began during and is related to his active duty service. See September 2013 FDC. In his February 2014 Notice of Disagreement, he stated he had been treated for these conditions, in addition to bilateral foot pain, during service. In his April 2015 Substantive Appeal, he indicated that his bilateral hands at times lock up and fall asleep momentarily and that he believes this is due to the typing he performed while on active duty. He indicated that it "might be considered carpal tunnel syndrome" but that it is a continual problem he has had for many years after entering active duty. Service treatment records reveal the Veteran was treated for bilateral hand/wrist pain in service. Two October 1994 treatment records note the Veteran experienced right-hand pain with signs of possible overuse and stiffness in his righthand. The doctor noted the Veteran did a lot of typing. Ultimately, the assessment was noted as overuse versus early signs of carpal tunnel syndrome. An October 1996 treatment record shows the Veteran continued to experience pain from typing. Service treatment records from 1997-1999 indicate the Veteran injured his right wrist and underwent several procedures related to that. An April 1998 record notes the Veteran was evaluated for left wrist pain that was assessed as overuse syndrome or carpal tunnel syndrome. A June 1999 record notes the Veteran had bilateral hand pain from typing that was worse in the left than right. It is also noted that he experienced swelling, weakness, and intermittent forearm pain that was likely carpal tunnel syndrome. A Tinel's sign and Phalen test was also conducted. A September 2006 record indicated the Veteran could not do push-ups because of his wrist pain. A May 2010 record shows the Veteran experienced left wrist pain following a fall. In November 2011, the Veteran was evaluated for swelling in his left wrist. A review of 2013 treatment records show the Veteran underwent surgery related to his right wrist after it was broken. In September 2019, the Board denied service connection for bilateral carpal tunnel syndrome, finding that the Veteran did not have any current diagnoses. The Veteran appealed those denials to the Court of Appeals for Veterans Claims (Court), and in a September 2020 Joint Motion for Remand (JMR), the parties vacated and remanded the claims back to the Board. First, the parties to the JMR agreed that the Board's findings were reasons and bases were inadequate because the Board did not discuss the Veteran's lay statements and several treatment records documenting his bilateral wrist impairment. See September 2020 JMR, pp. 1-4. The parties also agreed that the Board relied on inadequate January 2014 VA wrist and peripheral nerve examinations. With respect to the wrist exam, the examiner noted functional impairment in the wrists, and found no diagnosis of bilateral carpal tunnel syndrome, yet failed to explain why this did not constitute a disability under Saunders v. Wilkie, 886 F.3d 1356 (Fed. Cir. 2018). Finally, the Board found the examiner failed to discuss pertinent medical evidence (June 1999 treatment record documenting "likely CTS") and also failed to address the Veteran's lay statements. In February 2021, the Board remanded the Veteran's claims. Initially, the Board directed the Agency of Original Jurisdiction (AOJ) to contact the Veteran and request the names and addresses of any and all medical professionals who have provided treatment for his bilateral wrist pain, to include, but not limited to, treatment from a private physician in 2003. See April 2015 Substantive Appeal. The AOJ sent the Veteran a March 2021 letter requesting this information, and the record contains a March 2021 report of contact wherein the Veteran informed a VA employee that he had sent us all his records from 2003 to the present. The Board also remanded these claims for additional development and readjudication consistent with the September 2020 JMR. Following a June 2021 peripheral nerves examination, the Veteran reported gradual onset of CTS beginning in 1994 or 1995 and indicated initial symptoms included cramping and his hands fell asleep. He reported using a brace in the past and that his condition affects his ability to type for prolonged periods of time. The examiner found that although there were subjective symptoms noted on the examination pertaining to the bilateral wrist, there were no objective findings to warrant diagnosis of CTS at this time. The examiner determined it was less likely than not (less than a 50 percent probability) that the Veteran's right wrist condition was related to service noting that Tinel's and Phalen's signs as well as an electromyography (EMG) were all negative. The examiner also concluded it was less likely than not (less than a 50 percent probability) that the Veteran's left wrist condition was related to service indicating that the records had limited evidence of left wrist pain, numbness, or carpel tunnel, and that Tinel's and Phalen's signs as well as an EMG were all negative. At a June 2021 wrist examination, the examiner diagnosed a bilateral wrist sprain; however, there is no opinion which considers this diagnosis. In an August 2021 addendum opinion, the medical provider noted that Tinel's and Phalen's signs were negative at the June 2021 examination making it less likely that there was impingement of the ulnar, radial, and median nerves, and therefore, less likely his symptoms were due to CTS. However, the provider also noted that there was "lack of evidence of a nerve conduction study done objectively identifying a specific nerve involvement to explain the Veteran's bilateral wrist symptoms, making it difficult to ascertain at this time whether or not the Veteran's current right wrist symptoms were due to median nerve impingement pathognomonic of [CTS]." Another August 2021 addendum opinion pertaining to the left wrist is also negative. An addendum August 2021 opinion indicates that the Veteran does not have a diagnosis of CTS currently, and therefore, it is less likely than not related to his service, to include any symptomatology therein. The Board finds that there has not been substantial compliance with its prior remand directives, and therefore, a remand is required. First, no opinions were provided regarding the diagnoses of bilateral wrist sprain, as noted in the June 2021 examination report. Finally, the Board finds that the August 2021 provider's statement that nerve conduction studies had not been performed to determine whether there is median nerve impingement, indicative of CTS, requires that nerve conduction studies be performed on remand. The Veteran and his representative have the right to submit additional evidence and argument on the matters the Board has remanded. See Kutscherousky v. West, 12 Vet. App. 369 (1999). The matters are REMANDED for the following action: 1. Provide the Veteran the appropriate examination(s) to determine the etiology of any bilateral wrist conditions found. Nerve conduction studies must be performed, in addition to any other diagnostic testing the examiner finds is necessary. Following a review of the evidence and an examination, the examiner should provide the following information: (a) Does the Veteran have a diagnosis of CTS in either wrist; why or why not? Does the Veteran have functional impairment of either wrist, disregarding the outcome of the objective testing? In responding to this question, the examiner must discuss the significance, or lack thereof, of objective testing, to include nerve conduction studies. (b) Regardless of the response to (a), is it at least as likely as not (50 percent probability or higher) that the Veteran's right wrist CTS symptoms (or diagnosis, if applicable) began during or are etiologically related to his active service, to include as due to prolonged typing? Why or why not? (c) Regardless of the response to (a), is it at least as likely as not (50 percent probability or higher) that the Veteran's left wrist CTS symptoms (or diagnosis, if applicable) began during or are etiologically related to his active service, to include as due to prolonged typing? Why or why not? (d) Is it at least as likely as not (50 percent probability or higher) that the Veteran's right wrist sprain (diagnosed at the June 2021 examination) began during or is etiologically related to his active service, to include as due to prolonged typing? Why or why not? (e) Is it at least as likely as not (50 percent probability or higher) that the Veteran's left wrist sprain (diagnosed at the June 2021 examination) began during or is etiologically related to his active service, to include as due to prolonged typing? Why or why not? The examiner is informed of the following: The examiner must consider and address the Veteran's assertions that his problems began in service, have continued since then, and are related to typing and administrative duties during service. The examiner should also consider and address the numerous service treatment records that show the Veteran was evaluated for bilateral wrist pain in service-including assessments of overuse versus CTS. See Service Treatment Records dated 1993 to 2013. The examiner should refer to the remand portion above for an exhaustive list of the Veteran's in-service treatment for bilateral hand/wrist symptoms. An opinion which fails to consider the Veteran's competent and credible lay statements, and one that is negative based on lack of treatment, will be considered inadequate. A complete rationale for each opinion is required. If the examiner is unable to provide any opinion without resorting to speculation, he or she must explain why this is so. If the reason for not being able to provide a more definitive opinion is that additional medical testing and/or evaluation is required, this must be performed. Jennifer White Veterans Law Judge Board of Veterans' Appeals Attorney for the Board O'Connell, Jessica L. 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.