Citation Nr: 21010092 Decision Date: 02/24/21 Archive Date: 02/24/21 DOCKET NO. 15-12 654 DATE: February 24, 2021 REMANDED Entitlement to service connection for right wrist pain, including carpal tunnel syndrome, is remanded. Entitlement to service connection for left wrist pain, including carpal tunnel syndrome, is remanded. Entitlement to service connection for left foot disorder, including pain and numbness, is remanded. Entitlement to service connection for right foot, disorder, including pain and numbness, is remanded. REASONS FOR REMAND The Veteran served active duty in the United States Air Force from June 1993 to August 2013. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a January 2014 rating decision from the Department of Veterans Affairs (VA) Regional Office (RO). In a September 2019 decision, the Board denied all the claims. The Veteran appealed the decision to the United States Court of Appeals for Veterans Claims (Court). In a September 2020 Order, the Court granted a Joint Motion for Remand (Joint Motion) filed by the parties to vacate and remand the September 2019 Board decision. The case has since been returned to the Board for appellate review. In the Joint Motion, the parties agreed the Board provided an inadequate reasons and bases and did not discuss relevant evidence. It was also agreed the Board’s findings were inconsistent with the record. Ultimately, the Court noted that there were likely outstanding records that the Board did not address, that the Board relied on an inadequate January 2014 VA examination, and that it did not including findings regarding functional impairment consistent with Saunders v. Wilkie, 886 F.3d 1356 (Fed.Cir. 2018). Since being remanded by the Court, the Board has recharacterized the Veteran’s service connection claims for carpal tunnel syndrome and service connection claims for left and right foot pain and numbness to more accurately reflect the evidence of record, and broadly address the Veteran’s symptoms. The Board notes that during service, the Veteran injured his right wrist and was treated several times for the injury, including several surgical repair procedures in 1997 and 1998. The Veteran is currently service-connected with a 10 percent evaluation for a right wrist fracture, status post open reduction, and internal fixation. Entitlement to service connection for right wrist pain, including carpal tunnel syndrome, is remanded. Entitlement to service connection for left wrist pain, including carpal tunnel syndrome, is remanded. The Veteran asserts that his problems began in service and have continued since that time. Specifically, the Veteran stated that his wrist pain, possibly carpal tunnel syndrome, is due to his administrative duties in service, including typing. In his April 2015 VA Form 9, the Veteran indicated that while the pain continued throughout service, he did not seek treatment because he would lose time at work and have to make it up, and that he did not want to be medically released from the military, also known as, med boarded. He noted that the pain continued after service and even worsened. In the VA Form 9, the Veteran indicated that both his hands lock up and fall asleep at times, which is caused by his typing in service. In an August 2019 informal hearing presentation, the Veteran’s representative stated that he experiences daily wrist pain that causes physical limitations that make it difficult for him to work. Service treatment records reveal the Veteran was treated for bilateral hand/wrist pain in service. Two October 1994 treatment records note the Veteran experienced right-hand pain with signs of possible overuse and stiffness in his right hand. The doctor noted the Veteran did a lot of typing. Ultimately, the assessment was noted as overuse versus early signs of carpal tunnel syndrome. An October 1996 treatment record shows the Veteran continued to experience pain from typing. Service treatment records from 1997-1999 indicate the Veteran injured his right wrist and underwent several procedures related to that. An April 1998 record notes the Veteran was evaluated for left wrist pain that was assessed as overuse syndrome or carpal tunnel syndrome. A June 1999 record notes the Veteran had bilateral hand pain from typing that was worse in the left than right. It is also noted that he experienced swelling, weakness, and intermittent forearm pain that was likely carpal tunnel syndrome. A Tinel’s sign and Phalen test was also conducted. A September 2006 record indicated the Veteran could not do push-ups because of his wrist pain. A May 2010 record shows the Veteran experienced left wrist pain following a fall. In November 2011, the Veteran was evaluated for swelling in his left wrist. A review of 2013 treatment records show the Veteran underwent surgery related to his right wrist after it was broken. In a January 2014 peripheral neuropathy VA examination report, the examiner noted the Veteran was being evaluated for carpal tunnel syndrome in both of his wrists. The examiner mentioned the Veteran’s treatment for right wrist pain but found no evidence documenting left hand carpal tunnel. After the evaluation, the examiner concluded the Veteran did not have bilateral carpal tunnel syndrome and there was no evidence of flareups. The examiner did not provide an opinion related to functional loss and loss of additional range of motion. As noted in the September 2020 Court Order, the examination is considered inadequate as the examiner did not include a discussion related to pain and functional impairment in compliance with Saunders, which indicates that pain in the absence of a presently-diagnosed condition can cause functional impairment, which may qualify as a disability for VA purpose. The Court also pointed out that the Veteran’s lay statements were not addressed and relevant evidence regarding possible carpal tunnel syndrome was not discussed. In a December 2015 addendum, the examiner noted there was no evidence of flareups of the right wrist. Therefore, there was no functional loss or additional limitation of ranger of motion. Lastly, the examiner indicated an opinion could not be rendered related to repeated use over time as it was not a practical or possible option for a VA examination. For the reasons above, remand of the claims for wrist pain, including carpal tunnel syndrome must be remanded. Entitlement to service connection for left foot disorder, including pain and numbness, is remanded. Entitlement to service connection for right foot, disorder, including pain and numbness, is remanded. The Veteran contends that his foot pain is related to service, specifically, the activities of his training. In his April 2015 VA Form 9, the Veteran stated that the ball of his feet hurt from training activities while in service. He stated that he currently experiences numbness in the toes of his left foot, and because of his pain, he has to wear shoes or sandals in the house on a daily basis. He further indicated that the pain affects the type of job he can perform because he cannot hold a job that requires him to stand on his feet all the time. Lastly, he stated that a doctor that treated him in 2003 indicated that he may need surgery if the problem continued. In an August 2019 informal hearing presentation, the Veteran’s representative indicated that he has difficulty finding work because of the physical limitations his feet present. Service treatment records from October and November 2003 show the Veteran was treated for bilateral foot pain, with the possible intermetatarsal neuroma. In December 2003, the Veteran was evaluated for left foot pain that had he had been experiencing for two months. The physician noted the pain was located on the ball of the foot between the first and second toes. Treatment records from 2004 indicate the Veteran continued to have foot pain and it is noted in a January record that he may have a problem that requires surgery. In March 2006, he was treated for radiculopathy in the left foot. Treatment records from 2011 through 2012 show the Veteran’s foot pain worsened and included numbness in his left foot. During a January 2014 VA examination, the examiner noted the Veteran did not have evidence of bilateral foot pain or numbness. However, post-service treatment records continue to show the Veteran has bilateral foot pain. In 2018, the Veteran was evaluated several times for foot pain. The records note he was diagnosed with a history of idiopathic neuropathy and metatarsalgia, and, during the evaluation, with bilateral neuroma third intermetatarsal space. He was being treated with cortisone shots and surgery was recommended. An October 2018 record indicated that the Veteran had undergone a foot procedure and still had pain at the bottom of his feet. He also experienced numbness, pain, discomfort, and diminished sensation. Most recently, in November 2020, the Veteran was evaluated for bilateral foot pain that he stated was a level 7 on a 0 to 10 scale. He was found to have tenderness, some hyperhidrosis, and persistent numbness in the forefoot. The January 2014 examiner failed to address all of the relevant evidence. Additionally, it does not appear the Veteran has been afforded a VA examination that adequately addresses his claimed conditions, including bilateral foot pain. For the reasons stated above, the claims for foot pain must be remanded. Lastly, as noted in the September 2020 Court Order, it appears that outstanding private treatment records from 2003 have not been obtained and associated with the claims file. Therefore, it is necessary to remand the claims for the RO to attempt to retrieve the records. The matters are REMANDED for the following action: 1. The Agency of Original Jurisdiction (AOJ) should request that the Veteran provide the names and addresses of any and all health care providers who have provided treatment for his bilateral wrist and bilateral foot pain. After acquiring this information and obtaining any necessary authorization, the AOJ should obtain and associate these records with the claims file. A specific request should be made for any treatment records from a private physician the Veteran was evaluated and treated by in 2003. See April 2015 VA Form 9. The AOJ should also secure any outstanding VA medical records. 2. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any bilateral carpal tunnel syndrome or bilateral wrist pain that may be present. The examiner should be provided with a complete copy of this remand and all directives. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay assertions. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether it is at least as likely as not that the Veteran currently has right or left carpal tunnel syndrome that manifested in service or is otherwise causally or etiologically related to his military service, to include any symptomatology therein. If the Veteran does not have a current diagnosis associated with his reported symptoms, the examiner should state this with a fully reasoned explanation. The examiner should also state whether there is any functional impairment caused by the Veteran’s reported pain. Evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes. The examiner should consider and address the Veteran’s assertions that his problems began in service and have continued since that time, and are related to his typing and administrative duties while in service. The Veteran has indicated that both his hands lock up and fall asleep at times, which is caused by his typing in service. He also contends that he experiences daily wrist pain that cause physical limitations that make it difficult for him to work. The examiner should also consider and address the numerous service treatment records that show the Veteran was evaluated for bilateral wrist pain in service, including assessments of overuse versus carpal tunnel syndrome. See service treatment records from 1993 to 2014. The examiner should refer to the remand portion of the decision for an exhaustive list of the Veteran’s treatment for bilateral hand/wrist pain while in service. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. 3. After completing the foregoing development, the Veteran should be afforded a VA examination to determine the nature and etiology of any left or right foot disorder, including pain and numbness. The examiner should be provided with a complete copy of this remand and all directives. The examiner is requested to review all pertinent records associated with the claims file, including the Veteran’s service treatment records, post-service medical records, and lay assertions. It should be noted that the Veteran is competent to attest to matters of which he has first-hand knowledge, including observable symptomatology. If there is a medical basis to support or doubt the history provided by the Veteran, the examiner should provide a fully reasoned explanation. The examiner should state whether it is at least as likely as not that the Veteran currently has a right or left foot disorder that manifested in service or is otherwise causally or etiologically related to his military service, to include any symptomatology therein. If the Veteran does not have a current diagnosis associated with his reported symptoms, the examiner should state this with a fully reasoned explanation. The examiner should also state whether there is any functional impairment caused by the Veteran’s reported pain. Evidence of pain alone that causes functional impairment, even without a specific diagnosis or identifiable disease, may constitute a disability for VA purposes. The examiner should consider and address the Veteran’s assertions that his problems began in service and have continued since that time, and are related to his training and activities in service. The Veteran contends that he experiences daily foot pain that cause physical limitations that make it difficult for him to work at a job where he was to stand all the time. The examiner should also consider and address the numerous service and post-service treatment records that show the Veteran was evaluated and treated for bilateral foot pain in service and thereafter See 2003 treatment records that show he was evaluated for bilateral foot pain, diagnosed with the possible intermetatarsal neuroma. See also 2004 through 2012 records that show the Veteran was treated for foot pain, radiculopathy, and foot numbness. 2018 records note the Veteran has history of idiopathic neuropathy, metatarsalgia, and bilateral neuroma third intermetatarsal space. The records also show treatment with cortisone shots and surgical procedure. A November 2020 record shows the Veteran was evaluated for bilateral foot pain that he stated was a level 7 on a 0 to 10 scale. He was found to have tenderness, some hyperhidrosis, and persistent numbness in the forefoot. (The term “at least as likely as not” does not mean within the realm of medical possibility, but rather that the medical evidence both for and against a conclusion is so evenly divided that it is as medically sound to find in favor of conclusion as it is to find against it.) A clear rationale for all opinions would be helpful and a discussion of the facts and medical principles involved would be of considerable assistance to the Board. LESLEY A. REIN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K.M. Walker 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.