Citation Nr: 21007457 Decision Date: 02/09/21 Archive Date: 02/09/21 DOCKET NO. 14-32 333 DATE: February 9, 2021 ORDER Entitlement to service connection for left wrist tendonitis and pain is granted. REMANDED Entitlement to a rating in excess of 10 percent for lumbar degenerative disc disease and intervertebral disc syndrome is remanded. Entitlement to a compensable rating for allergic rhinitis is remanded. FINDING OF FACT The evidence is in relative equipoise as the whether the Veteran’s left wrist tendonitis and pain had its onset in service. CONCLUSION OF LAW The criteria for service connection for a left wrist tendonitis and pain have been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active duty from July 1989 to February 2011 and received a Southwest Asia Service Medal. The Board denied the Veteran’s increased rating claims for a lumbar spine condition and allergic rhinitis in an October 2019 decision. The Veteran appealed the decision to the Court of Appeals for Veterans Claims (Court). In a May 2020 order, the Court remanded the claim for development consistent with the parties’ May 2020 joint motion for remand (JMR). 1. Entitlement to service connection for a left wrist disability. To establish service connection for a disability, the evidence must show: (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 (Fed. Cir. 2004). Service connection may also be established on a presumptive basis for a Persian Gulf Veteran who exhibits objective indications of chronic disability resulting from an undiagnosed illness that became manifest either during active service in the Southwest Asia theater of operations during the Persian Gulf War, or to a degree of 10 percent or more not later than December 31, 2021, and which by history, physical examination, and laboratory tests cannot be attributed to any known clinical diagnosis. 38 U.S.C. § 1117; 38 C.F.R. § 3.317(a)(1). In claims based on undiagnosed illness, unlike those for “direct service connection,” there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Notably, laypersons are competent to report objective signs of illness. Id. A “qualifying chronic disability” for purposes of 38 U.S.C. § 1117 is a chronic disability resulting from (A) an undiagnosed illness, (B) a medically unexplained chronic multi-symptom illness (such as chronic fatigue syndrome, fibromyalgia, or a functional gastrointestinal disorder) that is defined by a cluster of signs or symptoms, or (C) any diagnosed illness that the Secretary determines in regulation prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(2); 38 C.F.R. § 3.317(a)(2)(i)(B). Irritable bowel syndrome is a qualifying chronic disability for purposes of 38 U.S.C. § 1117. See 38 C.F.R. § 3.317 (a)(2)(i)(B)(3). The term medically unexplained chronic multi-symptom illness (MUCMI) means a diagnosed illness without conclusive pathophysiology or etiology, that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, or disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. 38 C.F.R. § 3.317 (a)(2)(ii); Stewart v. Wilkie, 30 Vet. App. 383, 391 (2018) (holding that an illness is a medically unexplained chronic multi-symptom illness where either the etiology or the pathophysiology of the illness is inconclusive). Therefore, even if a multi-symptom illness has a diagnosis, consideration should still be given as to whether the disability has no known etiology, or has a known, partially understood etiology. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology, such as diabetes and multiple sclerosis, will not be considered medically unexplained. Id. The determination of whether a condition is an MUCMI must be based on an individual Veteran’s circumstances rather than the illness as it is understood in the general public. Stewart, 30 Vet. App. at 391. In the present case, the Veteran served in the Southwest Asia Theater of Operations during the Gulf War as shown by service personnel records. Thus, the Board finds that the Veteran is a “Persian Gulf Veteran” for the purposes of 38 C.F.R. § 3.317. See 38 C.F.R. § 3.317(e)(1). The Veteran asserts that his left wrist disability is related to his responsibilities as a combat medic in service. The February 2019 VA examination report indicates that the Veteran has a current diagnosis of left wrist tendonitis. As the Veteran has a current diagnosis, the issue that remains disputed is whether the Veterans left wrist condition is related to service to include Gulf War service. The Board finds the evidence in relative equipoise. Service treatment records show numerous complaints of left wrist pain. A February 1990 service treatment note indicates the Veteran complained of a knot on the left wrist. The diagnostic assessment was ganglion cyst. A June 2005 service treatment note indicates the Veteran complained of pain in both wrists over the scaphoid and lunate. He reported the pain was non traumatic. A radiology report was normal. July 2005 and August 2005 service treatment notes also show complaints of localized wrist pain. The Veteran denied history of trauma. On physical examination there was no swelling or redness. It was noted the Veteran experienced wrist trauma from repetitive motion from overuse with weightlifting and computer use. A December 2006 service treatment note shows the Veteran complained of pain in the ulnar aspect of the left wrist. The Veteran denied injury or excessive work with use of the wrist. There was tenderness to palpation on the ulnar aspect of the wrist. Pain was elicited by motion. Tests for neurological dysfunction of the right wrist were performed. Appearance of the wrist was normal. A radiologic examination report showed no fracture, dislocation, or other acute osseous or joint abnormality. The Veteran was provided a prescription for a splint. An October 2007, November 2007, and April 2010 service treatment notes indicate the Veteran complained of joint pain localized in the wrist. The Veteran was afforded VA examination in November 2010. The Veteran reported being diagnosed with carpal tunnel in 1990. He reported he currently experiences swelling, giving way, tenderness and pain. He also reported flare-ups as often as three times each month lasting for an hour, and difficulty typing on the computer keyboard. The examiner indicated that multiple views of the Veteran’s left wrist were normal with no fractures, destructive lesions or dislocation. In a May 2018 latter, private physician V.R. from D.K.P.G. stated, “I have concluded and it is my opinion that it is more than not likely that the Veteran’s current condition of the left wrist was caused by events during the time of the military service.” Dr. V.R. did not provide a rationale for the opinion and treatment records from D.M.P.G. are not associated with the Veteran’s claims file. A September 2018 VA treatment note shows complaints of left wrist pain. The Veteran was afforded an additional VA examination in February 2019. During the examination, the Veteran reported that he had gradual onset of left wrist pain during the course of duty due to repetitive overuse injuries carrying patients as a combat medic. He reported he was treated conservatively with progressively increasing pain ever since. The examiner opined that the Veteran’s left wrist disability has a specific and clear etiology – “wear and tear over time.” Thus, his left wrist was not related to Gulf War environmental toxins. The examiner further explained that the Veteran’s left wrist condition is a common orthopedic condition with no rationale to support toxic exposure as its etiology. In an addendum opinion, the examiner opined that the Veteran’s wrist treatment in service were self-limiting episodes. In an October 2019 decision, the Board remanded the claim for an additional medical opinion because the examiner failed to address the May 2018 private medical opinion. The Board also noted the Veteran’s contention that the examiner did not account for wear and tear in service as a medic and only considered post service wear and tear. In a December 2019 addendum opinion, the examiner noted that a December 2006 service treatment record indicates the Veteran reported left wrist pain at an intensity of 5 out of 10. The Veteran denied any injury or excessive workout with use of wrist. A physical examination showed finger had abnormalities spreading against resistance cause pain in the ulnar area of the left wrist. Pain was elicited by motion of the left wrist. The Veteran was given a split and oral pain medication. An x-ray of the left wrist showed no acute osseous abnormality with negative finding. The examiner concluded that the Veteran’s wrist condition had likely resolved as he was seen by the clinic for other medical conditions but did not note any chronic left wrist pain. The examiner further noted that a November 2010 medical note from Dr. D.B. in orthopedics reports normal physical objective findings of the left wrist. The provider noted no diagnosis as there was no noted pathology. Medical records from 2010 to 2017 – seven years later are silent for complaints of any chronic left wrist condition. In addition, the examiner noted there is limited objective medical evidence to show any chronic left wrist disability, thus a nexus cannot be established at this time. The examiner noted that the February 2019 Disability Benefits Questionnaire showed full functional range of motion of the left wrist. Therefore, the examiner concluded that the Veteran’s left wrist disability is less likely than not related to wear and tear as a combat medic. Notably, the examiner did not address the May 2018 private medical opinion and did not address the Veteran’s statements regarding continuity of symptoms in reaching a conclusion. The evidence as to whether the Veteran’s left wrist condition had its onset in service is in relative equipoise. Service treatment records show numerous complaints of wrist pain over a 22-year period of service. The February 2019 VA examiner’s statement that the Veteran’s wrist disability is related to “wear and tear over time” was given in the context of whether the Veteran’s condition was related to Gulf War environmental exposure. The examiner failed to adequately address whether such wear in tear occurred during his service as a combat medic. In addition, while the December 2019 examiner gives a detailed rationale for the negative nexus opinion, the examiner does not adequately address the statements that wrist pain had its onset in service and continued since. Resolving reasonable doubt in the Veteran’s favor, service connection for a left wrist condition is granted. REASONS FOR REMAND 1. Entitlement to a rating in excess of 10 percent for lumbar degenerative disc disease and intervertebral disc syndrome is remanded. The Veteran was afforded VA spine examinations in January 2019 and February 2019. The examination report indicates that the Veteran suffers additional functional loss during flare-ups due to pain, but the examiner did not indicate whether it is feasible to describe such functional loss in terms of the degree of additional range of motion loss due to pain during flare-ups. Thus, a remand for a new examination that adequately addresses the Veteran’s functional loss during flare-ups is warranted. See May 2020 JMR. 2. Entitlement to a compensable rating for allergic rhinitis is remanded. The Veteran was afforded a VA examination in January 2019. However, the examiner did not address whether there is additional functional loss during the Veteran’s reported flare-ups. See Sharp v. Shulkin, 29 Vet. App. 26 (2017); see also Ardison v. Brown, 6 Vet. App. 405 (1994); Voerth v. West, 13 Vet. App. 117 (1999). Thus, a remand for a new VA examination is warranted. The matters are REMANDED for the following action: 1. Obtain any outstanding VA treatment records from November 2019 to present. 2. After completion of the above development, the Veteran should be afforded a VA examination to determine the current nature and severity of his service-connected lumbar spine disability. 3. Arrange for the Veteran to be afforded a VA examination to determine the current nature and severity of his service-connected rhinitis. R. FEINBERG Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board J.A. Williams, 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.