Citation Nr: 21077007 Decision Date: 12/28/21 Archive Date: 12/28/21 DOCKET NO. 16-27 409A DATE: December 28, 2021 ORDER Entitlement to service connection for right thumb metacarpal phalangeal joints and rheumatoid arthritis (right hand disability) is granted. Entitlement to service connection for left thumb metacarpal phalangeal joints and rheumatoid arthritis (left hand disability) is granted. FINDING OF FACT The evidence is at least evenly balanced as to whether the Veteran's left and right hand disabilities had their onset in service. CONCLUSIONS OF LAW 1. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for right hand disability have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. With reasonable doubt resolved in favor of the Veteran, the criteria for service connection for left hand disability have been met. 38 U.S.C. §§ 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSIONS The Veteran served on active duty from July 1994 to December 1994, November 2004 to May 2005, and June 2009 to July 2011. This case initially came before the Board of Veterans' Appeals (Board) on appeal from an October 2013 rating decision by the Department of Veterans Affairs (VA) Regional Office (RO) which, among other things, denied service connection for right and left hand finger conditions. In October 2014 the Veteran filed a Notice of Disagreement (NOD) and in May 2016 the RO issued a statement of the case (SOC). In June 2016 the Veteran timely filed a substantive appeal (via VA Form 9). In November 2018 and again in May 2021 the Board remanded the Veteran's claim to determine the etiology of his right and left hand disabilities. As the benefit sought is being granted in full, consideration of whether the agency of original jurisdiction complied with the Board's remand instructions is unnecessary. Service Connection Service connection will be granted if the evidence demonstrates that current disability resulted from an injury or disease incurred in active military service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Establishing service connection generally requires competent evidence of three things: (1) current disability; (2) in-service incurrence of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Saunders v. Wilkie, 886 F.3d 1356, 1361 (Fed. Cir. 2018). Consistent with this framework, service connection is warranted for a disease first diagnosed after service when all of the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). 1. Right and left hand disabilities An April 2017 VA physician diagnosed the Veteran with mild degenerative changes of bilateral thumb metacarpal phalangeal joints. A January 2019 VA physician noted that the Veteran was diagnosed with seronegative rheumatoid by his private physician. A November 2019 VA examiner diagnosed the Veteran with rheumatoid arthritis of both hands. Thus, current right and left hand disabilities have been demonstrated. An August 2003 service treatment record (STR) indicates that the Veteran reported a broken fingertip, though, did not specify which hand. In a November 2012 letter, the Veteran's spouse stated that he complained of bilateral hand pain dating back to his time on active duty. The Veteran, as a lay person, is competent to report problems with his feet during service and continuous foot problems since military service. See Clyburn v. West, 12 Vet. App. 296, 301 (1999) (a veteran is competent to testify regarding continuous pain since service). Taken together, the August 2003 STR and the November 2012 statement satisfies the in-service injury or disease requirement. The remaining question is whether a nexus exists between the Veteran's current right and left hand disabilities and an in-service injury; or whether he exhibited continuous symptoms since service which were early manifestations of his subsequently diagnosed left and right hand disabilities. A January 2012 private treatment note indicates that the Veteran's left and right hand were unremarkable. The private physician noted that there is no evidence of a fracture or destructive lesion and the joint spaces were well maintained. In a November 2012 letter, the Veteran's spouse, speaking as a family practice physician, stated that she noticed the Veteran complain of painful swollen and stiff fingers almost every morning for the past several years. The Veteran's spouse stated that although the January 2012 x-rays were unremarkable, she believes he has early symptoms of arthritis due to his family history and the degenerative changes in his cervical and shoulder joints. The Veteran's spouse is competent to provide statements relating to symptoms or facts of events that she has observed and are within the realm of her personal knowledge. Jandreau v. Nicholson, 492 F.3d 1372, (Fed. Cir. 2007). Further, as a Doctor of Osteopathic Medicine (D.O.), her statements constitute a medical opinion, and she is also competent to provide a diagnosis or determine that the Veteran's symptoms were early manifestations of arthritis. Although a private physician concurrently evaluated the Veteran's hands as "unremarkable," the subsequent diagnoses of rheumatoid arthritis and mild degenerative changes of bilateral thumb indicate the Veteran's spouse accurately assessed his left and right hand disabilities. Therefore, although the Veteran's spouse's rationale was not extensive, reading the opinion as a whole and in the context of the evidence of record, it is entitled to some probative weight. See Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012) (the fact that the rationale provided by an examiner "did not explicitly lay out the examiner's journey from the facts to a conclusion," did not render the examination inadequate); Acevedo v. Shinseki, 25 Vet. App. 286, 294 (2012) (medical reports must be read as a whole and in the context of the evidence of record). A November 2019 VA examiner opined that the Veteran's right and left hand disabilities were less likely than not related to an in-service injury, event, or disease. The VA examiner explained that there is no objective evidence in the Veteran's STRs associated with his right and left hand disabilities and he was diagnosed with these disabilities in 2019. The November 2019 VA opinion is inadequate as it relied on the Veteran's lack of medical treatment for his left and right hand disabilities in and since service without considering the Veteran's lay statements regarding continuous hand pain symptoms both in and since separation from service. Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006) (VA's examiner's opinion, which relied on the absence of contemporaneous medical evidence, "failed to consider whether the lay statements presented sufficient evidence of the etiology of [the veteran's] disability such that his claim for service connection could be proven without contemporaneous medical evidence"). A June 2021 VA nurse practitioner opined that the Veteran's right and left hand disabilities were less likely than not related to an in-service injury, event, or disease. The VA nurse practitioner explained the Veteran's STRs do not include any medical evaluations, treatment, or a diagnosis of a chronic right hand condition. The VA nurse practitioner noted that in January 2012 the Veteran's right and left hands were evaluated as normal and that the earliest diagnoses of record were made in April 2017 and January 2019. The VA nurse practitioner acknowledged that the Veteran is competent to provide a history of his symptoms and stated she considered the lay statements from the Veteran's spouse. Although the VA nurse practitioner stated she considered the Veteran's spouse's statements, she provided no rationale as to whether the Veteran's left and right hand pain could be construed as early manifestations of his subsequently diagnosed left and right hand disabilities. Therefore, the June 2021 VA opinion is inadequate as it did not properly address the Veteran's spouse's statements in her capacity as a physician. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (most of the probative value of a medical opinion comes from its reasoning). Given the positive nexus opinion and the flawed negative nexus opinions, the evidence is at least evenly balanced as to whether the Veteran's left and right hand disabilities are related to his service. As the reasonable doubt created by this relative equipoise in the evidence must be resolved in favor of the Veteran, entitlement to service connection for right and left hand disabilities is warranted. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. Jonathan Hager Veterans Law Judge Board of Veterans' Appeals Attorney for the Board James R. Miller, 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.