Citation Nr: 21074813 Decision Date: 12/16/21 Archive Date: 12/16/21 DOCKET NO. 17-67 389 DATE: December 16, 2021 ORDER Entitlement to service connection for a left wrist condition is denied. FINDING OF FACT The Veteran's left wrist arthritis was not shown as chronic in service and did not manifest to a compensable degree within the applicable presumptive period; continuity of symptomatology is not established; and the preponderance of the evidence does not establish a nexus between any left wrist condition, to include neither left wrist arthritis or Kienbock's disease, and any incident of service. CONCLUSION OF LAW The criteria for entitlement to service connection for a left wrist condition have not been met. 38 U.S.C. §§ 1110, 1112, 1113, 1131, 1137, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from July 1974 to August 1978 with additional service in Reserves. This matter comes to the Board of Veterans' Appeals (Board) on appeal from a May 2016 rating decision issued by the Department of Veterans' Affairs (VA) Regional Office (RO) in Portland, Oregon. The Board previously remanded this claim in June 2021 along with the Veteran's service connection claim for bilateral hearing loss. While in remand status, service connection for bilateral hearing loss was granted, which constitutes a full grant of the service connection benefit sought; thus, that issue is no longer before the Board. Grantham v. Brown, 114 F.3d 1156, 1158-59 (1997). The Board has limited the discussion below to the relevant evidence required to support its finding of fact and conclusion of law, as well as to the specific contentions regarding the case as raised directly by the Veteran and those reasonably raised by the record. See Scott v. McDonald, 789 F.3d 1375, 1381 (Fed. Cir. 2015); Robinson v. Peake, 21 Vet. App. 545, 552 (2008). Entitlement to service connection for a left wrist condition is denied. The Veteran seeks service connection for a left wrist condition. The Board finds service connection is not warranted. Service connection may be granted for a disability resulting from personal injury suffered or disease contracted in the line of duty, or for the aggravation of a pre-existing injury or disease in the line of duty. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Certain chronic diseases, including arthritis, will be presumed related to service, absent an intercurrent cause, if they were shown as chronic in service; or, if they manifested to a compensable degree within a presumptive period following separation from service; or, if they were noted in service (or within an applicable presumptive period) with continuity of symptomatology since service that is attributable to the chronic disease. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.303, 3.307, 3.309. Walker v. Shinseki, 708 F.3d 1331, 1338 (Fed. Cir. 2013). When service connection cannot be established on a presumptive basis, the Court has held that the claim must nevertheless be reviewed to determine whether service connection can be established on a direct basis. See Combee v. Brown, 34 F.3d 1039 (1994). The elements of direct service connection are: "(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," also known as the nexus element. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Lay evidence can be competent and sufficient to establish a diagnosis of a condition when: (1) a layperson is competent to identify the medical condition, (e.g., a broken leg, separated shoulder, pes planus (flat feet), varicose veins, tinnitus (ringing in the ears), etc.), (2) the layperson is reporting a contemporaneous medical diagnosis, or (3) lay testimony describing symptoms at the time supports a later diagnosis by a medical professional. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). Turning to the relevant evidence of record, upon entrance the Veteran was clinically evaluated as normal for the upper extremities. See June 1974 entrance examination. Service treatment records (STRs) lack any mention of symptoms, treatment, or diagnosis related to the left wrist. During a February 1977 examination, the Veteran's upper extremities were again clinically evaluated as normal. In November 1977, the upper extremities clinical evaluation section was left blank without any notations referencing the upper extremities in the notes section. At separation, the Veteran's upper extremities were clinically evaluated as normal. In the corresponding report of medical history, the Veteran declined experiencing a bone, joint, or other deformity and the provider noted "no continuing medical complaints." See July 1978 separation examination. In November 1982, the Veteran underwent a re-enlistment examination for the Reserves where his upper extremities were clinically evaluated as normal. See November 1982 entrance examination. In the corresponding report of medical history, the Veteran denied experiencing a bone, joint, or other deformity and stated that he was in good health. In June 1987, the Veteran injured his left wrist and complained of pain. See June 1987 treatment records. Imaging in June 1987 for the left wrist was unremarkable. See June 1987 VA treatment records. A wrist splint was ordered. In August 1987, treatment records note the Veteran landed on his left wrist while playing baseball in May and his left wrist was "not getting well." Continued use of a brace was recommended. See August 1987 treatment records. In 2010, the Veteran reported that he injured his left wrist when he landed on his outstretched left hand during a repelling fall during service. See May 2010 VA treatment records. He stated that he treated himself and did not recall getting imaging. He conveyed that in 2009, he was exercising when both wrists began to have pain with the left wrist being worse than the right. His right wrist recovered, but the left wrist still had pain. Imaging in 2010 was absent for arthritic processes. See May 2010 VA treatment records. In 2012, the Veteran had a left wrist injury at work when he fell against a shelf while trying to get out of the way and used his left hand to keep the shelf from falling. Upon examination, he reported that he had prior problems in both areas, but they had been well controlled until this incident happened. See September 2012 treatment records. The Veteran was noted to have a sprain of the left wrist that was acute. Imaging revealed mild degenerative changes in the left wrist. See November 2012 treatment records. In 2013, the Veteran complained of left wrist pain "for years." See September 2013 VA treatment records. In 2015, the Veteran was diagnosed with stage IV Kienbock disease in the left wrist. See March 2015 VA treatment records. In 2017, a private provider reported that the Veteran has a diagnosis of Kienbock's disease of the left wrist, which is degeneration of the bones of the wrist and is a "chronic condition." See November 2017 treatment records. The provider explained that it can be caused by trauma to the wrist, such as trauma from a fall. Symptom onset and bone degeneration can be delayed "for years." In correspondence of record and as part of the December 2020 hearing, the Veteran testified that he injured his left wrist in-service while he was repelling down a rope from a helicopter when he had to jump because ropes were tangled, and he had nothing to break his fall. See May 2017 NOD; see December 2020 hearing transcript. He stated that he was holding the rope with his right hand, leaving only his left arm to brace the fall. See December 2017 correspondence. During the same incident, he injured his right ankle, for which service-connection has already been granted. The Veteran stated that he fell to the ground injuring his left wrist during the incident. He stated that he was treated by a corpsman attached to his unit and given a wrist brace that was used for approximately 2-3 weeks. He acknowledged there was no record of the injury. He conveyed experiencing pain and limited mobility in the left wrist. The Veteran stated that he thought his left wrist was normal at separation. In further support, the Veteran submitted photographs of ropes and the helicopter from which he was repelling. Also of record is a buddy statement from a fellow service member explaining that the Veteran had conveyed he was hurt during a repelling demonstration in 1976 or 1977. See May 2017 buddy statement. The Veteran reported that when he repelled down from the helicopter, the rope malfunctioned, and he hit the ground causing him to bounce three times. The Veteran told the other service member that he experienced pain and had bruises and contusions "all the way up past his knees." The service member stated that in his opinion, the Veteran injured his left wrist during the incident because the Veteran did not tell him everything and instinctively, if you fall you would catch yourself with your arm to break the fall. A July 2012 provider opined that the Veteran had a diagnosis of post-traumatic arthritis of the radiocarpal joint that the provider believes "relates to an unrecognized and ignored trauma of long ago." See July 2012 VA treatment records. The provider referenced back to a May 2010 treatment record during which the Veteran reported a repelling fall where the Veteran landed on his outstretched hand. In December 2020, another private provider opined that the Veteran has a chronic left wrist injury, which in his medical opinion, more likely than not occurred as an impact injury during the same 1977 military repelling exercise in which he injured his right ankle. See December 2020 treatment records. The Veteran was afforded a VA examination in June 2021 to determine the nature and etiology of any left wrist condition. The examiner noted a diagnosis of left wrist Kienbock's disease status post fusion. See June 2021 VA examination. The Veteran stated that he was in a repelling accident in 1977 and felt pain immediately prompting use of a wrist brace and light duty for 6-8 weeks. See June 2021 VA examination. He stated that his left arm was black and blue. He did not recall if the pain was continuous since the fall. He stated that a provider in 2009 attributed his left wrist to the trauma during service. The examiner opined that the Veteran's Kienbock's disease was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. See June 2021 VA examination. The examiner explained the Kienbock's disease is a relatively rare condition that occurs when the blood supply to the lunate is interrupted and the symptoms take several months to years to manifest themselves and begin with pain, stiffness, and swelling that progresses and worsens leading to abnormal stress and wear on the bones inside of the wrist. Eventually, the bone starts to fragment and collapse, damaging the surrounding bones and causing arthritis. The examiner reasoned that the etiology appears to be multifactorial including congenital abnormalities of the blood supply, lack of venous drainage, and trauma and skeletal variations of unusually shaped lunate bone. Once the process has started, continued use can keep the process going. The examiner reasoned, in summary, that the Veteran reported a repelling injury in 1977, but re-enlistment documentation from 1982 to 1983 is absent or negative for wrist pain. Then in 1987, he was evaluated for left wrist pain and imaging was negative without an associated history. When asked about the 1987 injury, the Veteran stated that he had forgotten about it. He was evaluated in 2010 reporting left wrist pain with an onset in 2009. In 2012, he had a left wrist work-place injury. The Veteran recalled falling on the wrist in 2012, however, he explained that the left wrist pain pre-existed that fall. The examiner acknowledged records do show that he was evaluated in 2010 for wrist pain with a reported onset of one year ago. Throughout all of this time, the Veteran continued to lift weights and exercise including push-ups and bench presses which can be contributing factors leading to Kienbock's disease as resting the wrist is a treatment. Finally, in 2014, a fusion was completed limiting range of motion and producing pain. Arthritic changes were noted on imaging. The overall fact pattern more strongly suggests that the injury in 1987 is more likely the proximate cause of the Kienbock's disease and it is less likely the repelling injury that occurred while in service. The examiner reasoned that essentially, the longer the time lapse between the injury and the onset of symptoms, the less likely a particular injury is a causative factor. Here, the examiner opined that the baseball injury and weightlifting are more proximate to the onset of left wrist pain leading to the fusion with the 2012 fall probably accelerating the process. The examiner further opined that it was less likely than not the Veteran's left wrist arthritis began during service, manifested within one year of discharge, or was noted during service with the same symptomatology since separation. See June 2021 VA examination. The examiner reasoned that the report of wrist pain was intermittent and was not consistent in the overall records indicating a gap of several decades from when he was discharged in 1978. The current pain seemed to have started around 2009, which is the best date based on the review of records. It is undisputed from the record that the Veteran has a current diagnosis of Kienbock's disease and arthritis. Imaging notes left wrist arthritis, and this was confirmed and referenced by the June 2021 VA examiner. Arthritis is an enumerated condition under 38 C.F.R. § 3.309. The Veteran's left wrist arthritis, however, was not shown as chronic in service, did not manifest to a compensable degree within a presumptive period, and was not noted in service with attributable continuity of symptomatology. Treatment records show that the Veteran was not diagnosed with arthritis until 2012 via imaging, decades after service and decades outside the presumptive period. In fact, in 2010, the Veteran was evaluated for suspected arthritis, but imaging was negative. While the Veteran is competent to report having experienced symptoms of left wrist pain, the record lacks evidence of persistent symptoms since service and is inconsistent. Indeed, STRs are negative for any reference to the left wrist. The Veteran was clinically evaluated as normal at separation and less than five years later during a re-enlistment examination for the Reserves, the Veteran reported he was in good health and was clinically evaluated as normal regarding the upper extremities. The Board acknowledges the Veteran stated that his STRs lacked reference to a left wrist injury because he reported it to the unit's attached corpsman. Even assuming that is the case, the Veteran did not report any continued symptoms following this injury at separation which undermines the claim of continuity of symptomatology since service. Further, and of great significance, the Veteran's own admissions go against any finding of continuity of symptoms. The Board, as the fact-finder, is required to evaluate the credibility of evidence. See Buchanan v. Nicholson, 451 F3.d 1331, 1336-37 (2006). The credibility of a witness can be impeached by a showing of interest, bias, inconsistent statements, or, to a certain extent, bad character. See Caluza v. Brown, 7 Vet. App. 498, 511 (1995), aff'd per curiam, 78 F.3d 604 (1996). Regarding arthritis, to the extent the Veteran has contended he experienced symptoms since service, the Board finds these statements not credible in light of the inconsistencies of record. Indeed, the Veteran himself acknowledged through his testimony that his left wrist was normal at separation. As part of the June 2021 VA examination, the Veteran stated that he did not recall if the pain was continuous since the fall. Further, treatment records from 2010 reference an onset of left wrist pain in 2009. The Board acknowledges the 2012 report that the Veteran experienced problems related to the left wrist prior to the 2012 work-related injury, but notes it is otherwise unclear from the statement or corresponding treatment records what prior history the Veteran is referencing, for example, the 1987 baseball injury. While the record contains numerous lay statements from the Veteran and a buddy statement in support, none of the statements contend the Veteran experienced symptoms that began during service and continued since separation. Rather, the contention has been that the in-service repelling injury caused or is related to the Veteran's Kienbock's diagnosis. As outlined above, the Veteran's statements regarding persistent symptoms are inconsistent; thus, the Board finds that the Veteran is not entitled to service connection for arthritis on a presumptive basis. There is no evidence in his STRs suggesting that left wrist arthritis was shown as such in service. Nor is there any evidence that left wrist arthritis manifested to a compensable degree within one year of service. The first reference to left wrist arthritis in treatment records occurred in 2012, multiple decades after separation and multiple decades outside the presumptive period. While treatment records reference symptoms in 2009, this still remains decades outside of separation and beyond the presumptive period. Further, the Board finds highly probative, the June 2021 VA examiner's opinion that it was less likely than not the Veteran's left wrist arthritis began during service, manifested within one year of discharge, or was noted during service with the same symptomatology since separation as it is corroborated by the evidence of record. Accordingly, service connection for arthritis of the left wrist on a presumptive basis is not warranted. Service connection for arthritis may still be granted on a direct basis, however, the preponderance of the evidence is against finding that a medical nexus exists between the Veteran's arthritis and an in-service injury, event, or disease. As previously mentioned, the Board acknowledges the Veteran has a diagnosis of arthritis and Kienbock's disease. The Veteran has consistently stated that he suffered a left wrist injury following a repelling incident during service. Of note, the Veteran has already been granted service connection for a right ankle disability in relation to this in-service incident. While STRs are silent for any injuries from a 1977 repelling fall, the Board finds the Veteran competently and credibly reported this in-service event. Regarding a nexus to service as it pertains to arthritis, the Board finds most probative the June 2021 VA examiner's opinion that the Veteran's arthritis was less likely than not related to service. Indeed, it was based on a review of the record and was offered following a physical evaluation of the Veteran. Moreover, it was accompanied by a clear rationale, and no other competent evidence of record refutes that opinion. While the record contains two private provider's opinions, they address Kienbock's disease which is discussed in more detail below. Further, while the Veteran believes his arthritis is related to an in-service injury, event, or disease, the Veteran is not competent to provide a nexus opinion regarding this issue. Jandreau, 492 F.3d 1377. Consequently, the Board gives more probative weight to the June 2021 VA examiner's opinion. Regarding Kienbock's disease, the Board finds most probative the June 2021 VA examiner's opinion that it is less likely than not related to service. Indeed, it was based on a review of the record and was offered following a physical evaluation of the Veteran. Moreover, it was accompanied by a clear rationale, and no other competent evidence of record refutes that opinion. While the record contains two private provider opinions, neither is adequate to establish service connection. The July 2012 provider stated that the Veteran's left wrist condition relates to an unrecognized and ignored trauma of long ago while referring back to the Veteran's repelling fall during service. The provider, however, failed to consider the entirety of the Veteran's treatment records, especially the Veteran's 1987 left wrist injury without a reported history. Similarly, the December 2020 private provider failed to address or reconcile the multiple injuries to the left wrist following separation. Thus, the Board finds most probative the June 2021 VA examination and corresponding opinion. While the Veteran and the buddy statement of record both contend the Veteran's in-service repelling injury caused the Veteran's Kienbock's disease, neither are competent to provide a nexus opinion in this case. This issue requires specialized medical knowledge and training. Jandreau, 492 F.3d 1377. Consequently, the Board gives more probative weight to the competent medical evidence. For these reasons, the Board finds the preponderance of the evidence is against an award of service connection for arthritis and / or Kienbock's disease. As such, the benefit-of-the-doubt doctrine is not for application and the claim must be denied. 38 U.S.C. § 5107; see also Gilbert v. Derwinski, 1 Vet. App. 49, 57 (1990). 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.