Citation Nr: 21011341 Decision Date: 03/01/21 Archive Date: 03/01/21 DOCKET NO. 14-43 800 DATE: March 1, 2021 ORDER Entitlement to service connection for left wrist tendonitis is denied. Entitlement to service connection for left thumb tendonitis is denied. REMANDED Entitlement to service connection for right ankle disability is remanded. FINDINGS OF FACT 1. The Veteran does not have a current left wrist disability that was incurred during or is otherwise related to service. 2. The preponderance of the evidence is against finding that a left thumb disability began during active service or is otherwise related to an in-service injury, disease, or service-connected disability. CONCLUSIONS OF LAW 1. The criteria for entitlement to service connection for left wrist tendonitis have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. § 3.303. 2. The criteria for entitlement to service connection for left thumb tendonitis have not been met. 38 U.S.C. §§ 1110, 1112, 1131, 5107; 38 C.F.R. §§ 3.303, 3.310. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from April 1982 to September 1989. This matter comes before the Board on appeal from October 2011 and June 2012 Regional Office (RO) rating decisions. In May 2018, the Veteran testified at a hearing before the undersigned Veterans Law Judge. The Board notes that its October 2018 decision denied entitlement to service connection for a ganglion cyst of the left wrist. Thus, this issue is not before the Board. Service Connection Service connection is warranted where the evidence of record establishes that an injury or disease resulting in disability was incurred in the line of duty in the active military service or, if pre-existing such service, was aggravated thereby. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). To establish a right to compensation for a present disability, a veteran 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, or nexus, 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). A disability that is proximately due to, or results from, a service-connected disease or injury shall be considered a part of the original condition. 38 C.F.R. § 3.310(a). Secondary service connection on the basis of aggravation is permitted. 38 C.F.R. § 3.310(b). Compensation is payable for that degree of aggravation of a non-service-connected disability caused by a service-connected disability and not due to the natural progress of the nonservice-connected disease. Allen v. Brown, 7 Vet. App. 439 (1995). 1. Entitlement to service connection for left wrist tendonitis is denied. The Veteran contends that she has “tendonitis also of both wrists and they call it De Quervain’s. I was diagnosed with that in the military. When I went to DCH hand therapy for both of my wrists, they also diagnosed me with that same tendonitis of both wrists.” (See Board hearing transcript, pages 9-10.) Service treatment records reflect that the Veteran’s upper extremities were clinically normal at the times of her August 1981 entrance and June 1989 separation examinations. Her June 1989 separation medical history report notes “Tendonitis to left wrist and thumb, first noted May 89, treated with medication and wrist brace, with some results.” May 1989 service treatment records reflect that the Veteran was treated for tendonitis of the left wrist and was put on profile for tendonitis of the left arm. (Service treatment records also reflect that she sought left wrist treatment in October 1982, but that record pertains to the left wrist ganglion cyst.) The earliest post-service indications of left wrist tendonitis appear in a November 2010 private medical record. This record notes that the Veteran reported that she sought treatment for left wrist pain and that she was issued a thumb spica for her left thumb secondary to increased wrist pain. She continued to receive treatment in subsequent months. A January 2011 private medical record notes that the Veteran “was evaluated initially [in November 2010] after approximately a 15 year history of deQuervain’s tenosynovitis.” The Veteran underwent a VA examination in November 2017 in which the examiner diagnosed de Quervain’s syndrome of the left wrist and lists a date of diagnosis of 2010. The examiner did not diagnose tendinitis or tendinosis of the left wrist. In terms of history, the examiner noted that the Veteran began having left wrist pain and was diagnosed with wrist tendonitis and fitted with a splint. With respect to treatment, she had physical therapy in 2012. Based on review of the record and interview and examination of the Veteran, the November 2017 VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. In the rationale, the examiner noted that “There is no diagnosis for the claimed condition.” This opinion is not probative, as it does not provide an opinion with respect to the de Quervain’s syndrome that was actually diagnosed during the VA examination. Thus, a new VA examination was necessary. The Veteran underwent a VA wrist conditions examination in June 2018. Based on review of the record and interview and examination of the Veteran, the VA examiner diagnosed wrist tendonitis with a date of diagnosis in May 1989. The VA examiner did not provide an etiology opinion. The Veteran underwent a VA wrist conditions examination in August 2020. Based on review of the record and interview and examination of the Veteran, the VA examiner diagnosed tendinitis with an onset date of May 1989 and de Quervain’s syndrome with an onset date of 2010. The examiner noted that the Veteran reported an onset date of 1988-1989. The “Veteran states that she started having left wrist issues while in service. She attributes the pain is related to picking up heavy items while in service.” In terms of current treatment, it was noted that she uses wrist splints daily for stabilization and paraffin baths as needed for pain. Based on review of the record and interview and examination of the Veteran, the examiner opined that the Veteran’s left wrist disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. As the rationale, the examiner noted that “During service, left wrist condition was acute only occurring in 1989.” The examiner found no evidence of chronicity of care, diagnosed as de Quervain’s tendinosis many years later. She noted that there are no current records in the clinical evidence to suggest current care for the left wrist. She concluded that the “Lack of chronicity is established due to the large gap in between time inservice that the condition occurred and currently. A nexus has not been established.” The Board finds that the August 2020 opinion is highly probative, as it was authored by an individual who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It is based on review of the record and interview and examination of the Veteran. The opinion cites to the facts of the Veteran’s case and pertinent medical principles, specifically noting that the Veteran’s in-service left wrist injury was acute and that there is no chronicity of care. The examiner essentially found that there is a medical reason to reject the proposition that the Veteran’s current disability had its onset in service; the condition would have required continuous medical treatment if the condition were a continuous disease process of symptoms noted in service. The only remaining contrary opinion comes from the Veteran herself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. In short, the Board finds that entitlement to service connection for a left wrist disability is not warranted. The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. 2. Entitlement to service connection for left thumb tendonitis is denied. The Veteran contends that her left thumb disability either began during service or was caused or aggravated by her left wrist disability. She has reported that “When I went to DCH hand therapy for both of my wrists,” the hand therapist “gave me these braces so I won’t have to move my thumb. It reminds me not to move my thumb.” (See Board hearing transcript, pages 9-10.) Service treatment records reflect that the Veteran’s upper extremities were clinically normal at the times of her August 1981 entrance and June 1989 separation examinations. Her June 1989 separation medical history report notes “Tendonitis to left wrist and thumb, first noted May 89, treated with medication and wrist brace, with some results.” June 1989 service treatment records reflect that the Veteran was evaluated and fit with a left thumb brace. The earliest post-service indications of left thumb tendonitis appear in a November 2010 private medical record. This record notes that the Veteran reported that she sought treatment for left wrist pain and that she was issued a thumb spica for her left thumb secondary to increased wrist pain. She continued to receive treatment in subsequent months. A January 2011 private medical record notes that the Veteran “was evaluated initially [in November 2010] after approximately a 15 year history of deQuervain’s tenosynovitis.” A November 2017 VA examination report diagnoses, in relevant, De Quervain’s tendinosis of the left thumb. It notes that the Veteran began having thumb pain in 1989. It was noted that left thumb pain increased and was treated with a splint due to diagnosis of left thumb tendinosis. With respect to current treatment, it was noted that the Veteran “Has had steroids shots in bilateral thumbs in 1990 and 94. Unable to take any analgesic. Had therapy in 2010. Pennsaid topical.” Based on review of the record and interview and examination of the Veteran, the VA examiner opined that the left thumb disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness.” The rationale is that “There is no diagnosis for the claimed condition.” This opinion is not probative, as it does not provide an opinion with respect to the tendinosis that was actually diagnosed during the VA examination. Thus, a new VA examination was necessary. The Veteran underwent a VA examination in August 2020. Based on review of the record and interview and examination of the Veteran, the examiner diagnosed de Quervain’s tendinosis and thumb tendonitis. With respect to history, the Veteran reported an onset of 1988-1989. It was noted that the “Veteran reports left hand injury since her time in service which required picking up heavy items.” She reported that “she was diagnosed with tendonitis while in service and placed in a thumb spica. She denies any further treatment in service.” It was noted that she uses paraffin baths and uses soft splints daily. Based on review of the record and interview and examination of the Veteran, the August 2020 VA examiner opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service, event, or illness. As a rationale, the examiner noted that “During service, left thumb condition was acute only in 1989.” The examiner noted that “There is no evidence of chronicity of care for the left wrist condition and left thumb condition, diagnosed as Dequervain’s tendinosis and Left thumb tendinosis, until many years later.” The examiner also noted that the records do not contain clinical evidence to suggest current care. The examiner stated that “Lack of chronicity is established due to the large gap in between time in service that the condition occurred and currently. A nexus has not been established.” The Board finds that the August 2020 opinion is highly probative, as it was authored by an individual who possesses the necessary education, training, or experience to provide competent medical evidence under 38 C.F.R. § 3.159 (a)(1). See Cox v. Nicholson, 20 Vet. App. 563 (2007). It is based on review of the record and interview and examination of the Veteran. The opinion cites to the facts of the Veteran’s case and pertinent medical principles, specifically noting that the Veteran’s in-service left thumb injury was acute and that there is no chronicity of care. The examiner essentially found that there is a medical reason to reject the proposition that the Veteran’s current disability had its onset in service; the condition would have required continuous medical treatment if the condition were a continuous disease process of symptoms noted in service. The only remaining contrary opinion comes from the Veteran herself. The Board recognizes that there are instances in which a layperson may be competent to offer testimony on medical matters, such as describing symptoms observable to the naked eye or even diagnosing simple conditions. See Jandreau v. Nicholson, 492 F.3d 1372 (Fed. Cir. 2007). The Board finds, however, that the questions posed by this claim are of such complexity as to require that individuals who provide competent medical evidence on this matter possess a level of expertise that a layperson simply does not possess. In short, entitlement to service connection for a left thumb disability must be denied on a direct basis. Finally, the August 2020 VA examination report also notes that the “Tendon sheath of the left thumb” is “[l]ikely partially related to the claimed [left wrist] condition.” To the extent that the appellant contends that her left thumb disability was caused or aggravated by her left wrist disability, because service connection for left wrist disability has been denied, service connection for a left thumb disability on a secondary basis must be denied as a matter of law. See Sabonis v. Brown, 6 Vet. App. 426, 430 (1994). The Board has considered the benefit-of-the-doubt doctrine. However, as the preponderance of the evidence is against the claim, the claim is not in equipoise. See 38 U.S.C. § 5107(b); 38 C.F.R. §§ 3.102, 4.3; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Accordingly, the claim must be denied. REASONS FOR REMAND 1. Entitlement to service connection for right ankle disability is remanded. The Veteran contends, in relevant part, that she has a current right ankle disability that was either caused or aggravated by her service-connected right foot disabilities. (See Board hearing transcript, page 11.) Service connection is in effect for right foot pes planus with degenerative joint disease of the right foot (previously rated as torn ligaments, right foot, under Diagnostic Code 5284) and for hammer toe, right foot (previously rated as status post broken fourth metatarsal, right foot, under Diagnostic Code 5010-5283). The Veteran underwent a VA examination in August 2020 and was diagnosed at that time with (1) right ankle tendonitis, (2) right ankle degenerative arthritis, and (3) acute right ankle sprain, resolved, in November 1983. The Board finds that a remand is necessary to obtain an addendum opinion that addresses the secondary theory of service connection. The matters are REMANDED for the following action: 1. Obtain all relevant VA and private treatment records not currently associated with the claims file, to include any VA medical records that were created since the Veteran’s records were last obtained. 2. Send the claims file to a qualified examiner to determine whether the Veteran’s right ankle disabilities were caused or aggravated by her service-connected right foot disabilities. The claims file must be made available to and reviewed by the examiner. The examiner should provide an opinion as to whether it is at least as likely as not (a 50 percent probability or greater) that the Veteran has a current right ankle disability that was caused OR aggravated by her service-connected right foot disabilities. In terms of current right ankle disability, the August 2020 VA examination report diagnoses current disabilities of (1) right ankle tendonitis and (2) right ankle degenerative arthritis. Service connection is in effect for (1) right foot pes planus with degenerative joint disease of the right foot and (2) hammer toe, right foot. A complete rationale for all opinions should be provided, including discussion of the facts of the Veteran’s case and pertinent medical principles. TANYA SMITH Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Elizabeth Jalley, 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.