Citation Nr: 21005940 Decision Date: 02/02/21 Archive Date: 02/02/21 DOCKET NO. 17-55 869 DATE: February 2, 2021 ORDER Entitlement to service connection for lumbosacral strain is granted. REMANDED Entitlement to service connection for a right wrist condition is remanded. Entitlement to service connection for a left wrist condition is remanded. FINDING OF FACT The most competent and probative evidence of record is at least in relative equipoise as to whether the Veteran’s lumbosacral strain is etiologically related to his active duty service. CONCLUSION OF LAW The criteria for entitlement to service connection for lumbosacral strain have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.304, 3.307, 3.309. Introduction The Veteran served honorably on active duty in combat in the United States Army during the Gulf War Era, from July 2008 to September 2012, and is the recipient of, inter alia, the Bronze Star Medal. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2016 Rating Decision issued by the Department of Veterans Affairs (VA) Regional Office (RO) in Cleveland, Ohio. In January 2021, the Veteran testified before the undersigned Veterans Law Judge (VLJ) at a virtual hearing. A transcript of the hearing will be associated with the claims file. REASONS AND BASES FOR FINDING AND CONCLUSION Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110; 1131; 38 C.F.R. § 3.303(a). Generally, service connection requires: (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, the so-called “nexus” requirement. Holton v. Shinseki, 557 F.3d 1362, 1366 (Fed. Cir. 2009) (quoting Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004)). When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303(b). Service connection may also be granted for any disease diagnosed after discharge when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). In making all determinations, the Board must fully consider the lay assertions of record. Lay evidence can be competent and sufficient to establish a diagnosis when a layperson is: (1) competent to identify the medical condition; (2) reporting a contemporaneous medical diagnosis; or, (3) describing symptoms at the time that support a later diagnosis by a medical professional. Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). 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; 38 C.F.R. § 3.102; 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, the benefit of the doubt is afforded to the Veteran. See Gilbert, 1 Vet. App. at 53. The Board has considered the entire record, but only evidence pertinent to the determination of service connection for the claimed conditions will be discussed. See Gonzales v. West, 218 F. 3d 1378 (Fed. Cir. 2000). Entitlement to service connection for lumbosacral strain is granted. The Veteran seeks entitlement to service connection for a “back condition.” Service treatment records (STRs) dated March and April 2011 report that, “[the Veteran] also notes some upper back discomfort with wearing body armor,” as well as, “[b]ack pain and swelling localized to one or more joints.” Further, the STR indicates “low back numbness … and tingling” for six months and reportedly exacerbated by weight-bearing. The Veteran was assessed with “upper back pain (between shoulder blades) [l]ikely due to muscular instability.” In April 2012, the Veteran’s “[c]hronic” problems included “[u]pper back pain.” The Veteran reported to a VA examiner in December 2015 that, “in 2009 he started to have numbness and tingling on [sic] the back, particularly after prolonged standing or sitting.” During his hearing testimony in January 2021, the Veteran testified to serving in both Iraq and Afghanistan, as well as, injuring his back from wearing heavy gear and body armor for extended periods. According to the Veteran, his back would tingle and hurt wearing the gear, armor, and carrying a firearm. He further testified to beginning chiropractic treatment in 2013. As noted above, in December 2015 the Veteran underwent a VA medical examination at which time the VA examiner reported a diagnosis of lumbosacral strain diagnosed in “2009.” The Veteran’s range of motion (ROM) was noted as abnormal, and his back condition reportedly interfered with sitting and standing and caused difficulty lifting with arms outstretched. Nevertheless, according to the VA examiner, the Veteran’s thoracolumbar spine condition “was less likely than not … incurred in or caused by the claimed in-service injury, event, or illness.” By way of rationale, the examiner opined that, “current complaints are consistent with wear and tear, but not any specific service related [sic] events.” The Board assigns little probative weight to the VA examiner’s report in this matter. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 302-04 (2008). The VA examiner’s rationale, consisting of a single sentence, is conclusory and lacks adequate specificity for purposes of determining entitlement to service connection. The Board finds the rationale vague, heavily generalized, and fails to identify with any degree of specificity which medical evidence of record, or scientific literature, was relied upon in rendering the negative medical nexus opinion. Further, the VA examiner’s rationale is rather contradictory, as it acknowledges the Veteran’s “current complaints are consistent with wear and tear,” which the Veteran contends is the cause of his back condition; yet, summarily concludes they are not consistent with “any specific service related [sic] events.” Finally, the VA examiner did not address the above-referenced STRs or reconcile the reported diagnosis date of “2009,” at which time the Veteran was on active duty, with the negative medical nexus opinion. As such, the Board is not persuaded by the VA examiner’s opinion that the Veteran’s thoracolumbar spine condition is in no way etiologically related to his active duty service. Based upon the Veteran’s STRs evidencing back complaints during active duty service, and his competent and credible testimony showing continuity until present, of his back condition, the Board is satisfied that the evidence supporting a nexus between the Veteran’s thoracolumbar spine condition and his active duty service is at least in relative equipoise with the evidence against such a nexus. See Gilbert, 1 Vet. App. at 53. Therefore, the Veteran is entitled to service connection for his thoracolumbar spine condition. REASONS FOR REMAND Entitlement to service connection for a right wrist condition is remanded. Entitlement to service connection for a left wrist condition is remanded. The Veteran’s STRs report a right wrist sprain in May 2012. At the time, the Veteran presented “with intermittent right dorsal wrist pain” existing for one year. Further, the Veteran was noted to do “frequent typing” on his job. During his hearing testimony in January 2021, the Veteran testified to doing extensive typing As noted above, the Veteran underwent a VA medical examination in December 2015, at which time the VA examiner reported a diagnosis of bilateral chronic wrist sprain diagnosed in “2008.” According to the examiner, the “Veteran reports that in 2008 or so … he noticed increasing pain in the wrists with activity.” Nevertheless, according to the VA examiner, the Veteran’s bilateral wrist condition was “less likely than not … incurred in or caused by the claimed in-service injury, event, or illness.” By way of rationale, the examiner opined that, “current findings are consistent with chronic wear and tear but not due to any particular service related [sic] event, no records to document an injury accountable for current diagnosis.” For the following reasons, the Board finds the VA examiner’s report inadequate. See Barr v. Nicholson, 21 Vet. App. 303 (2007). First, the VA examiner’s rationale, consisting of a single sentence, is conclusory and lacks adequate specificity for purposes of determining entitlement to service connection. The Board finds the rationale vague, generalized, absent sound reasoning, and fails to identify with any degree of specificity which medical evidence of record, or scientific literature, was relied upon in rendering the negative medical nexus opinion. Further, the VA examiner’s rationale is rather contradictory, as it acknowledges the Veteran’s “current findings are consistent with wear and tear,” which the Veteran contends is the cause of his bilateral wrist condition; yet, summarily concludes they are not consistent with “any specific service related [sic] events.” Finally, the VA examiner did not address the above-referenced STRs or reconcile the reported diagnosis date of “2008,” part of which time the Veteran was on active duty, with the negative medical nexus opinion. As such, the Board finds that remand is required to afford the Veteran an adequate VA medical examination that offers a fully articulated medical nexus opinion based upon sound reasoning in relation to all pertinent evidence of record. Accordingly, these matters are REMANDED for the following action: 1. Schedule the Veteran for a VA medical examination with a physician, other than Dr. J.L.C., possessing the necessary expertise to fully assess and provide an opinion regarding the nature, severity, and etiology of the Veteran’s claimed bilateral wrist condition(s). The examiner must obtain a full history from the Veteran. It should be noted the Veteran is competent to attest to factual matters of which he has first-hand knowledge, such as observable symptomology. All pertinent symptomology, including any continuity of symptomology since military service, throughout the period on appeal must be reported in detail. All indicated studies should be performed (e.g., x-rays, EMG/NCV, etc.). Based upon a review of all pertinent documents in the Veteran’s claims file, including medical records, lay statements, and the examination results, the examiner must report all wrist conditions and opine as to the following: (a.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s left and/or right wrist condition(s) manifested during active duty service; or, if chronic conditions including, but not limited to, arthritis or carpal tunnel syndrome are present, to a compensable degree within one year of military discharge. (b.) Whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran’s left and/or right wrist condition(s) is due to, related to, or otherwise etiologically associated with an in-service injury, event, or disease. In offering the above opinion(s), the examiner must consider and discuss as necessary all pertinent lay and medical evidence of record including, but not limited to: (a.) STRs dated May 15, 2012, reporting “intermittent right dorsal wrist pain” for one year and assessing right wrist sprain; and (b.) the Veteran’s testimony regarding in-service wrist complaints he associates with extensive hours of computer usage and typing and which have continued to present. A complete and thorough rationale for any opinion(s) expressed must be provided. T. REYNOLDS Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E. Worsham, Attorney Advisor 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.