Citation Nr: 21066456 Decision Date: 11/01/21 Archive Date: 11/01/21 DOCKET NO. 13-05 212 DATE: November 1, 2021 ORDER Entitlement to service connection for median neuropathy carpal tunnel syndrome (claimed as a right-hand disability), to include as secondary to de Quervain's tenosynovitis of the right wrist, is denied. FINDINGS OF FACT 1. The Veteran's right-hand symptoms have been attributed to a diagnosis of median neuropathy carpal tunnel syndrome. 2. The Veteran's median neuropathy carpal tunnel syndrome, claimed as a right-hand disability, is not causally or etiologically due to service, did not have an onset within one year from discharge and is not proximately due to or aggravated by service-connected de Quervain's tenosynovitis. CONCLUSION OF LAW The criteria for service connection for median neuropathy carpal tunnel syndrome, claimed as a right-hand disability, to include as secondary to de Quervain's tenosynovitis, are not met. 38 U.S.C. §§ 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 CONCLUSION The Veteran had active service from August 1998 to August 2004. This matter comes before the Board of Veterans' Appeals (BVA or Board) from an August 2011 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO). The Veteran requested a hearing before the Board. The requested hearing was conducted in August 2016 by the undersigned Veterans Law Judge. A transcript is associated with the claims file. In a September 2017 decision, the Board denied the issue on appeal. The Veteran appealed the Board decision to the United States Court of Appeals for Veterans Claims (Court). An October 2018 Joint Motion for Partial Remand vacated the Board's decision for the issues of entitlement to service connection for right wrist and right-hand disabilities and remanded the claims to the Board for readjudication. In April 2019, the Board denied entitlement to service connection for a right wrist disability and remanded the issue of entitlement to service connection for a right-hand disability; however, additional evidence was added to the claims file, resulting in a grant of service connection for de Quervain's tenosynovitis (right wrist disability) in a January 2021 rating decision. In April 2021, the Board remanded this claim for additional development. That development having been completed; the claim is now ready for appellate review. Entitlement to service connection for a right-hand disability. The Veteran seeks entitlement to service connection for a right-hand disability. Under the relevant laws and regulations, service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303 (a). In general, service connection requires competent evidence showing: (1) the existence of a present disability; (2) 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, 1167 (Fed. Cir. 2004). Alternatively, service connection may be established under 38 C.F.R. § 3.303 (b) by (a) evidence of (i) the existence of a chronic disease in service or during an applicable presumption period under 38 C.F.R. § 3.307 and (ii) present manifestations of the same chronic disease, or (b) when a chronic disease is not present during service, evidence of continuity of symptomatology. The theory of continuity of symptomatology is an alternative route to establish service connection for specific chronic diseases and can only be used in cases involving those conditions explicitly recognized as chronic under 38 C.F.R. § 3.309 (a). See Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013.) Service connection may be granted on a secondary basis for disability that is proximately due to, the result of, or aggravated by a service-connected disability. 38 C.F.R. § 3.310 (a) and (b). See Allen v. Brown, 7 Vet. App. 439, 448 (1995). In order to establish entitlement to service connection on a secondary basis, there must be evidence sufficient to show: (1) that a current disability exists; and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. Id. The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence that it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618(1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991); Gilbert v. Derwinski, 1 Vet. App. 49(1990). Equal weight is not necessarily accorded to each piece of evidence contained in the record; not every item of evidence necessarily has the same probative value. Furthermore, in determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the Veteran prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination of matter, the benefit of the doubt will be given to the Veteran. 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102. The Board notes that it has thoroughly reviewed the record in conjunction with this case. Although the Board has an obligation to provide reasons and bases supporting this decision, there is no need to discuss, in detail, the extensive evidence submitted by the Veteran or on her behalf. Gonzales v. West, 218 F.3d 1378, 1380-81(Fed. Cir. 2000) (the Board must review the entire record but does not have to discuss each piece of evidence). Rather, the Board's analysis below will focus specifically on what the evidence shows, or fails to show, on the claim. See Timberlake v. Gober, 14 Vet. App. 122, 129 (2000) (noting that the Board must analyze the credibility and probative value of the evidence, account for the evidence which it finds to be persuasive or unpersuasive and provide the reasons for its rejection of any material evidence favorable to the claimant). First, the Board notes that the Veteran's reported right-hand symptoms and functional impairment have been attributed to a diagnosis of median neuropathy carpal tunnel syndrome. See e.g., November 2020 VA examination. As such, Shedden element (1), current diagnosis, is met. As for the second requirement for service connection, that a disease or injury was incurred or aggravated during service, the Veteran testified in August 2016 that she woke up one morning in service and her wrist hurt and her hand was swollen. The Board notes that although service treatment records document the Veteran had right wrist symptoms during service, there is no mention of right-hand symptoms. See November 2003 service treatment note. Additionally, on the May 2004 Report of Medical History for separation, the Veteran denied having or currently having impaired use of the hands, swollen or painful joints, numbness, or tingling. Similarly, the May 2004 Report of Medical Examination for separation noted a normal neurologic system and normal upper extremities. Therefore, the Board finds that Shedden element (2) is not met. Also, Shedden element (3), nexus, is not met. The Veteran was afforded a VA examination in November 2020. The examiner opined that the Veteran's right wrist symptoms during service in November 2003 are consistent with her current symptoms and diagnosis of tenosynovitis; however, treatment records do not contain any diagnosis of a right-hand disorder and there were no documented symptoms of the right hand at the time of her right wrist evaluation during service. The examiner opined that the Veteran's current right-hand symptoms are less likely than not related to the wrist symptoms experienced during service as her current hand symptoms are more consistent with a neuropathic etiology and there were no neuropathic complaints during service. The examiner stated that the Veteran's right wrist symptoms are a separate, primary diagnosis from her right-hand symptoms. Therefore, Shedden element (3) is not met. The Board finds the VA opinion probative because the examiner had the appropriate training, expertise, and knowledge to evaluate the claimed disorder. The examiner also reviewed the records, performed a clinical examination, and considered the Veteran's statements regarding the nature and history of her condition. In addition, the Veteran's right-hand symptoms have not been continuous since service and did not have an onset within one year of service separation. As noted, there were no reported hand symptoms documented during service and the medical evidence of record does not support any hand symptoms within a year after service. It was not until 2011 that the Veteran reported any related symptoms, and at that time, it was noted she experienced sharp pain in the right wrist. No hand symptoms were noted. See September 2011 VA treatment note. Then, it was not until May 2014 that she reported "carpal tunnel symptoms" and an electromyogram (EMG) was ordered. The EMG in November 2014 was negative; however, the November 2020 VA examiner explained that mild pathology can often yield normal EMG results. Thus, resolving all reasonable doubt in her favor, the first persuasive credible evidence of median neuropathy carpal tunnel was not demonstrated until 2011, many years after service. See Maxson v. Gober, 230 F.3d 1330 (Fed. Cir. 2000) (a lengthy period without complaint or treatment is evidence that there has not been a continuity of symptomatology and can weigh against the claim). As noted, the Veteran's service treatment records weigh against a finding of continuity of right median neuropathy carpal tunnel since service, as no hand symptoms were reported in service. Service connection based on continuity of symptomatology pursuant to 38 C.F.R. § 3.303 (b) is therefore not warranted. In addition, for the reasons expressed above, the Veteran's median neuropathy carpal tunnel did not manifest to a compensable degree during the first post-service year. Accordingly, there is no basis for presumptive service connection. 38 C.F.R. §§ 3.307, 3.309. Regarding secondary service connection, the Board notes that during the course of this appeal service connection was granted for the Veteran's claimed right wrist condition, diagnosed as de Quervain's tenosynovitis. Although the Veteran's right-hand symptoms have been attributed to a diagnosis of median neuropathy carpal tunnel syndrome and she is service connected for de Quervain's tenosynovitis, there is no probative, persuasive evidence indicating a relationship between the two disorders, either through causation or aggravation. The November 2020 VA examiner explained that there is no anatomical or pathological relationship between the Veteran's right wrist condition and her current right-hand symptoms; her service-connected wrist condition is musculoskeletal in etiology and the hand symptoms are neuropathic. In a July 2021 addendum, the VA examiner opined that it was not at least as likely as not that the Veteran's service-connected de Quervain's aggravated her current hand disorder and explained that the median nerve is located on the inside of the wrist and the tendons that result in de Quervain's tenosynovitis are on the opposite side of the wrist and the lateral side of the thumb. The examiner stated these tendons do not come in contact with the median nerve, there is no connection with carpal tunnel and de Quervain's. They are two independent conditions that have no effect on each other. Significantly, the Veteran has not provided documented evidence of a medical opinion that directly contradicts the conclusions reached by the examiners. The only evidence of record which relates the Veteran's claimed hand disorder to her active military service, or her service-connected wrist disability are her own statements. The Veteran's statements are competent evidence as to observable symptomatology, including numbness and pain. See Barr, 21 Vet. App. at 307. However, the Veteran's statements that her current disorder is due to service or is secondary to a service-connected disability is a medical conclusion which the Veteran is not qualified to make. Although lay statements are competent evidence to provide opinions on some medical issues, the etiology of the Veteran's claimed right-hand disability falls outside the realm of common knowledge of a lay person due to the complexity of the nexus question presented. See Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011); see also Jandreau, 492 F.3d at 1377. Moreover, the VA examiners considered the Veteran's statements when providing the aforementioned medical examination reports and concluded that her disorder is not likely due to her time in service or is secondary to a service-connected disability. Accordingly, service connection for a right-hand disability is not warranted. In arriving at the decision to deny the claim, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, that doctrine is not applicable. TANYA SMITH Veterans Law Judge Board of Veterans' Appeals Attorney for the Board L. Andersen, 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.