Citation Nr: 21076126 Decision Date: 12/22/21 Archive Date: 12/22/21 DOCKET NO. 18-14 823 DATE: December 22, 2021 REMANDED Entitlement to service connection for residuals of right hand injury, other than right wrist strain, is remanded. Entitlement to service connection for a left hand disorder, claimed as secondary to the residuals of right hand injury, is remanded. REASONS FOR REMAND The Veteran served on active duty from October 2009 to September 2010, with service in Southwest Asia during the Persian Gulf War (he served in Kuwait/Iraq in support of Operation Iraqi Freedom). He also had a period of active duty for training (ACDUTRA) with the Army National Guard of Texas from March 2008 to June 2008. This matter is before the Board of Veterans' Appeals (Board) on appeal of an August 2016 rating decision of a Regional Office (RO) of the Department of Veterans Affairs (VA). In July 2021, the Veteran testified at a Board before the undersigned Veterans Law Judge. A transcript of that hearing is of record. The Veteran waived RO consideration of any additional evidence added to his claims file. The record was held open for 90 days following the Veteran's Board hearing to allow him the opportunity to submit evidence in support of his appeal. As of the date of this decision, no additional evidence has been received and the Veteran has not submitted a request to continue to leave the record open. As more than 90 days have elapsed since the hearing, the Board will proceed with adjudication. The Veteran claims service connection for right and left hand disabilities. Notably, although an August 2011 rating decision granted service for right wrist strain (claimed as right thumb injury) based on limitation of right wrist motion, the Veteran now claims service connection for right hand disability due to injury sustained in service and left hand disability due to overuse secondary to the right hand disability. See July 2021 Board hearing transcript. The Veteran's service treatment records (STRs) include a June 2010 Statement of Medical Examination and Duty Status which shows that the Veteran sustained a "crushing injury finger" on February 23, 2010 while "clearing barrels [at] Camp Bucca." It is noted that the Veteran stated "he was putting the RHINO down on the HUMV, when he caught his thumb on the hinge when the RHINO slipped and came down on his thumb." He removed his glove and noticed blood gushing, was provided 1st aid at the scene and rushed to Bucca TMC (troop medical clinic) for further care, where he received 4 stitches for a 1 inch cut from the base of the nail to the IP (interphalangeal) joint on the right thumb. These records show no bony injury was noted and follow-up X-ray (taken by dental) showed no bony fractures. Post service treatment records show right and left hand impairment. Specifically, VA treatment records include a September 2015 report of right hand X-ray study which shows findings of "[r]emote medial, fifth metacarpal fracture"; September 2015 examination finding of "slight TTP [tenderness to palpation] of 1st MCP [metacarpal phalangeal] joint;" March 2016 treatment report noting the Veteran's complaint of right hand swelling with over use and bilateral hand numbness noticeable at night; June 2017 treatment note that the Veteran had seen rheumatology with diagnosis of possible CRPS (complex regional pain syndrome); and June 2017 and March 2018 findings of chronic right hand/wrist pain. A July 2016 VA hand and finger conditions examination report shows the diagnosis of status post fracture of right fifth metacarpal bone and notes the date of onset as 2010 based on the Veteran's report of right hand crush injury in service. However, the examination report shows the Veteran's claims file was not reviewed by the examiner in connection with the examination. As such, the examiner was not familiar with the Veteran's medical history, including the details of his February 2010 inservice right hand injury. Regarding the Veteran's left hand, the examiner provided no diagnosis "because there is no pathology to render a diagnosis." The examiner remarked that the Veteran "gave history of multiple joint pain and the only trauma was to right hand. Requested a rheumatoid panel but was denied. Strongly suggest that condition be explored to confirm or deny rheumatic condition which the claimant may be pre-disposed and that is not service connected but it would be prudent to establishment, otherwise this man will be back with same or similar complaint in the future." Accordingly, as the record shows right and left hand symptoms during the appeal period, the July 2016 examination report includes the recommendation for additional testing and examination for a rheumatic condition, and in light of the Veteran's service in Southwest Asia during the Persian Gulf War; remand is necessary to accomplish the development recommended by the July 2016 examiner and obtain an opinion as to the nature and etiology of any right and/or left hand disorder. The matters are REMANDED for the following action: 1. Secure for the record copies of complete updated clinical records (any not already of record) of all VA and/or private treatment the Veteran has received for symptoms related to his hands. 2. After the development in paragraph 1 has been completed to the extent possible, please schedule the Veteran for a VA examination to determine the nature and likely etiology of any right and/or left hand disorder. As recommended by the July 2016 VA examiner, the examination should include exploration, including obtaining a rheumatoid panel, to confirm or deny a rheumatic condition. After interview and examination of the Veteran and review of his claims file, the examiner should respond to the following: a) Identify all current right and left hand disorders, other than right wrist strain, found to be present during the appeal period since receipt of the Veteran's March 2016 claim for service connection. b) As to each right and/or left hand disorder identified, other than right wrist strain, and including fifth metacarpal fracture, the examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent or greater probability) related to service, to include right thumb crush injury in February 2010. c) As to each right and/or left hand disorder identified, is it at least as likely as not (a 50 percent or greater probability) (i) caused or (ii) aggravated by the Veteran's service-connected right wrist strain? d) If, and only if, the Veteran is found to have a diagnosis of a right hand disorder, other than right wrist strain, is it at least as likely as not (a 50 percent or greater probability) that this right hand disorder (i) caused or (ii) aggravated any diagnosed left hand disorder? The examiner is informed that aggravation here is defined as any increase in disability. If any right and/or left hand disorder, other than right wrist strain, is aggravated by a service-connected disability, the clinician should indicate, to the extent possible, the approximate level of disability (baseline) before the onset of the aggravation. e) Do examination findings or other evidence objectively demonstrate signs or symptoms of a medically unexplained multisymptom illness that includes right and/or left hand signs and symptoms (in the context of the Veteran's stablished right wrist strain resulting from right hand injury in service and symptoms of other systems including medically unexplained neurological impairment), that cannot be attributed to known medical diagnoses? Are the Veteran's symptoms out of proportion to physical findings? (In answering this, please indicate whether there is evidence of any signs or symptoms of a disorder beyond what is explained by the medical diagnoses found for this Veteran.) In providing the requested opinions, in addition to reviewing the Veteran's claims file and considering his competent statements, the examiner should consider and address as necessary the following: STRs which show that, in February 2010, the Veteran "was putting the RHINO down on the HUMV, when he caught his thumb on the hinge when the RHINO slipped and came down on his thumb." He received 4 stitches for a 1 inch cut from the base of the nail to the IP (interphalangeal) joint on the right thumb, no bony injury was noted and follow-up X-ray (taken by dental) showed no bony fractures; Post service VA treatment reports including a September 2015 right hand X-ray study showing findings of "[r]emote medial, fifth metacarpal fracture," September 2015 finding of "slight TTP [tenderness to palpation] of 1st MCP [metacarpal phalangeal] joint," March 2016 treatment report noting the Veteran's complaint of right hand swelling with over use and bilateral hand numbness noticeable at night, June 2017 treatment note that the Veteran had seen rheumatology with diagnosis of possible CRPS (complex regional pain syndrome), and June 2017 and March 2018 findings of chronic right hand/wrist pain; and The July 2016 VA hand and finger conditions examination report showing the diagnosis of status post fracture of right fifth metacarpal bone, noting no diagnosis of a left hand disorder "because there is no pathology to render a diagnosis," and recommending a rheumatoid panel and further exploration to confirm or deny a rheumatic condition. The examiner is advised that the Veteran is competent to report his symptoms/history and that such reports must be acknowledged and considered in formulating any opinion. If his reports are discounted, the examiner should provide a reason for doing so. The examiner must explain the rationale for all opinions in detail, citing to supporting clinical data and/or medical literature, as appropriate. The clinician should take into consideration that the Veteran is competent to report in service and post-service symptom experiences; other witnesses are competent to report observable symptoms. If the clinician cannot provide an opinion without resorting to speculation, the clinician should provide an explanation as to why this is so and note what, if any, additional evidence would permit such an opinion to be made. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board K Hughes 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.