Citation Nr: 21008040 Decision Date: 02/11/21 Archive Date: 02/11/21 DOCKET NO. 16-41 128 DATE: February 11, 2021 ORDER Service connection for a chronic left wrist disorder is denied. FINDING OF FACT The weight of the evidence is against finding that any left wrist disorder is due to or the result of the Veteran’s active service. CONCLUSION OF LAW The criteria for service connection for a chronic left wrist disorder have not been met. 38 U.S.C. § 1131; 38 C.F.R. §§ 3.303, 3.304. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from October 1985 to September 1989. In connection with this appeal, the Veteran testified at a hearing before the undersigned Veterans Law Judge in January 2020. A transcript of that hearing is of record. In April 2020, the Board remanded the claim for further development. In November 2020, the RO granted service connection for a right knee disability and venereal warts with tinea versicolor. This represents a complete grant of his appeal in regard to these claims. See Grantham v. Brown, 114 F.3d 1156 (Fed. Cir. 1997). These issues are no longer before the Board. Service Connection Service connection will be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred in or aggravated by active military service. 38 U.S.C. § 1131; 38 C.F.R. § 3.303. Service connection requires competent evidence showing: (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, 1167 (Fed. Cir. 2004). Service connection may also be established under 38 C.F.R. § 3.303(b), where a condition in service is noted but is not, in fact, chronic, or where a diagnosis of chronicity may be legitimately questioned. The continuity of symptomatology provision of 38 C.F.R. § 3.303(b) has been interpreted as an alternative to service connection only for the specific chronic diseases listed in 38 C.F.R. § 3.309(a). See Walker v. Shinseki, 718 F.3d 1331 (Fed. Cir. 2013). Service connection may also be established with certain chronic diseases based upon a legal presumption by showing that the disorder manifested itself to a degree of 10 percent disabling or more within one year from the date of separation from service. Such disease shall be presumed to have been incurred in service, even though there is no evidence of such disease during the period of service. 38 U.S.C. §§ 1101, 1112, 1113, 1137; 38 C.F.R. §§ 3.307, 3.309(a). While the disease need not be diagnosed within the presumption period, it must be shown, by acceptable lay or medical evidence, that there were characteristic manifestations of the disease to the required degree during that time. The Veteran filed a service connection claim for a left wrist disorder, which was denied by December 2014 and August 2015 rating decisions. He asserts that he has a left wrist disorder due to his active service. Specifically, at the November 2020 Board hearing, he testified that he injured his left wrist in service while working on a vehicle. He testified that he injured his left wrist while playing rugby during active service. He testified that he continued to have left wrist pain since his active service. The Veteran’s STRs show that at his January 1985 entrance physical, he had a normal examination of his upper extremities. In June 1989, he reported injuring his left hand two weeks previously. The physician diagnosed the Veteran with trauma to the left hand metacarpal area, not the wrist. At his July 1989 separation physical, he had a normal examination of his upper extremities and specifically denied having any joint symptoms. He also reported that he was in “excellent physical” condition. He did not report any left wrist symptoms or injury. As such, the Veteran’s STRs do not show any complaints, treatment, or diagnosis of a chronic left wrist disorder. After the Veteran’s separation from active service, his medical records show the he first reported left wrist tingling during the previous two to three months in March 2015. In July 2015, the Veteran was afforded a VA examination. He reported that he injured his hand while performing repairs on a military vehicle during his active service. He also reported that his left hand was stepped on while playing rugby. After reviewing the Veteran’s claims file, interviewing the Veteran, and conducting an examination, the examiner opined that any left wrist disorder was less likely than not due to his active service. In September 2017, the Veteran’s physician reported that the Veteran was first seen for complaints of hand pain. His physician reported that he reviewed the Veteran’s past military history, which included injuries to the left hand while working on military vehicles. His physician reported that the Veteran’s persisting complaints were consistent with his complaints during his active service. In October 2020, the Veteran’s physician reported that the Veteran’s diagnosis was constant left wrist pain. His physician reported that he again reviewed the Veteran’s military medical history and personal medical records. His physician reported that the Veteran used improper tools resulting in injuries during his active service. His physician reported that the Veteran’s military medical history showed he experienced injures as a rugby player that continued to cause pain on a daily basis. In November 2020, the Veteran was afforded a VA examination. He reported that he injured his left wrist while repairing a military vehicle and playing rugby during his active service. After reviewing the Veteran’s claims file, interviewing the Veteran, and conducting an examination, the examiner diagnosed the Veteran with a left wrist strain. The examiner opined that the Veteran’s left wrist disorder was less likely than not due to his active service. The examiner reported that the July 2015 VA examiner addressed the Veteran’s left hand and not his left wrist. The examiner reported that there was no evidence of a left wrist disorder at the Veteran’s entrance physical, during his active service, or at the Veteran’s separation physical. The examiner reported that the Veteran work after his separation from active service would require much use of the left wrist and amply opportunity for musculoskeletal injuries. The examiner noted that the Veteran first reported left wrist tingling, but not pain, during the previous two to three months at an treatment visit after a waterskiing crash, which could have been an opportunity for a left wrist injury. The examiner reported that while there was a documented left hand injury during the Veteran’s active service, there was no left wrist injury or complaints. The examiner reported that the Veteran did not start reporting left wrist symptoms until 26 years after his separation from active service. Here several medical opinions are of record, all of which were provided by medical professionals who are presumed to have the training and expertise to opine on an orthopedic condition. As such, each opinion is considered to constitute both competent and credible evidence, which is deemed to be probative. However, the Board must determine what evidence is the most probative. Furthermore, an assessment or opinion by a health care provider is never conclusive and is not entitled to absolute deference. For example, a bare conclusion, even one reached by a health care professional, is not probative without a factual predicate in the record. Miller v. West, 11 Vet. App. 345, 348 (1998). Additionally, a bare transcription of lay history, unenhanced by additional comment by the transcriber, is not competent medical evidence merely because the transcriber is a health care professional. LeShore v. Brown, 8 Vet. App. 406, 409 (1995). A medical opinion based on speculation, without supporting clinical data or other rationale, does not provide the required degree of medical certainty. Bloom v. West, 12 Vet. App. 185, 187 (1999). Also, a medical opinion is inadequate when unsupported by clinical evidence. Black v. Brown, 5 Vet. App. 177, 180 (1995). In sum, the weight to be accorded the various items of medical evidence in this case must be determined by the quality of the evidence and not necessarily by its quantity or source. After weighing all the evidence, the Board finds the greatest probative value in the November 2020 VA examiner’s opinion, which considered the elements necessary to substantiate a service connection claim. The Veteran’s physician diagnosed the Veteran with left wrist pain that was consistent with the Veteran’s complaints during his active service. However, the physician provided no rationale for his opinions and did not refer to any medical evidence within the Veteran’s claims file that led him to his conclusions. Instead, the Veteran’s physician merely recited the Veteran’s reported injuries during his active service, which are not reflected in the claims file. This appears to be highly relevant as the Veteran’s STRs showed no treatment for any left wrist condition and he specifically denied having any joint symptoms at his July 1989 separation physical. In addition, he had a normal examination of his upper extremities, he reported he was in excellent physical condition, and he did not report any left wrist symptoms. Furthermore, the Veteran’s physician did not explain the Veteran’s normal examination of his upper extremities and his specific denial of any joint symptoms at his separation physical. His physician did not explain the absence of any complaints or treatment for any left wrist symptoms for 26 years after his active service. While the Veteran reported that he injured his left wrist during his active service while working on vehicles and playing rugby, the first evidence of any current left wrist symptoms is not until March 2015, 26 years after his active service, when he reported left wrist tingling after a waterskiing accident. As such, the Board finds that the opinions of the Veteran’s physician are based on the Veteran’s own self reports and not on any objective medical evidence, which undermines the probative value of the opinions. Conversely, the November 2020 VA examiner concluded that the Veteran’s left wrist disorder was less likely than not due to his active service and specifically explained why. The November 2020 VA examiner is shown to have conducted a thorough examination, reviewed and considered the pertinent evidence of record, and provided adequate rationale for her opinion. The Veteran’s reported history was adequately considered. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). The Board appreciates the opinions of the Veteran’s physician. However, ultimately, the November 2020 VA examiner’s opinion is given greater weight. The November 2020 VA examiner’s opinion was fully grounded in the medical evidence. The November 2020 examiner was fully apprised of the Veteran’s reported in-service left wrist injuries. The November 2020 examiner clearly explained why the Veteran’s left wrist disorder was less likely than not due to his active service. Here, the support provided by the November 2020 VA examiner for her opinion is found to be greatly superior to the opinions of the Veteran’s physician, which failed to address the lack of evidence of any left wrist complaints during the Veteran’s active service, the Veteran’s normal examination of his upper extremities at his separation physical, and his denial of joint symptoms at his separation physical. Given its grounding in the medical evidence in this case, the opinion of the November 2020 VA examiner is found to be the most probative evidence in this case, and therefore is afforded the greatest weight. Consideration has been given to the assertions of the Veteran that a left wrist disorder was due to his active service. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), the specific issue in this case, namely the etiology of a left wrist disorder, falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 (Fed. Cir. 2007). A chronic wrist disability is not the type of condition that is readily amenable to mere lay diagnosis or probative comment regarding etiology, as the evidence shows that physical examinations that include objective medical tests, such as x-rays or MRIs, are needed to properly assess and diagnose the disorder. See Davidson v. Shinseki, 581 F.3d 1313 (Fed. Cir. 2009); Jandreau, 492 F.3d 1372, 1377; Woehlaert v. Nicholson, 21 Vet. App. 456, 462 (2007). That is, although the Board readily acknowledges that the Veteran is competent to report left wrist symptoms, such as pain, to the extent they are identifiable by observation, he has not been shown to possess the requisite medical training, expertise, or credentials needed to render a diagnosis or a competent opinion as to medical causation. Nothing in the record demonstrates that he received any special training or acquired any medical expertise in evaluating musculoskeletal disorders. See King v. Shinseki, 700 F.3d 1339, 1345 (Fed. Cir. 2012). Accordingly, this lay evidence does not constitute competent medical evidence and lacks probative value. The record does not contain evidence of a diagnosis of a continuously ongoing chronic left wrist disorder from the Veteran’s active service to the present, as the record does not contain evidence of a chronic left wrist disorder, such as arthritis. In addition, at the Veteran’s separation physical, he had a normal examination of his upper extremities and denied having any joint symptoms. As such, the Board does not find that the evidence of record shows continuous knee symptomatology. The Board also notes that the Veteran is not entitled to presumptive service connection for a chronic left wrist disorder. The record contains no objective medical diagnosis of a chronic left wrist disorder as he was only diagnosed with left wrist pain by his physician and a left wrist strain by the November 2020 VA examiner. Therefore, the presumption of service connection has not been triggered. (Continued on the next page)   Accordingly, the criteria for service connection have not been met for a chronic left wrist disorder. That is, the evidence does not show that a chronic left wrist disorder was diagnosed during the Veteran’s active service or within a year of separation from active service, the weight of the evidence is against a finding that a chronic left wrist disorder has existed continuously since his active service, and the weight of the evidence is against a finding that the Veteran’s left wrist disorder is due to his active service. As such, the criteria for service connection for a chronic left wrist disorder have not been met, and the claim is denied. Thomas H. O'Shay Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board T. Berryman, 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.