Citation Nr: 21011757 Decision Date: 03/02/21 Archive Date: 03/02/21 DOCKET NO. 15-33 502 DATE: March 2, 2021 REMANDED Entitlement to service connection for a left thumb disability is remanded. REASONS FOR REMAND The Veteran had active service from February 1986 to February 1989. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a July 2013 rating decision issued by the Department of Veterans Affairs (VA) Regional Office (RO). In May 2017, the Veteran testified at a central office hearing before the undersigned Veterans Law Judge (VLJ). A copy of the transcript has been associated with the Veteran’s electronic claims folder. Entitlement to service connection for a left thumb disability is remanded. The Veteran contends that he is entitled to service connection for a left thumb disability because he injured it while playing basketball during service. See May 2017 Board Hearing Transcript, p. 9; November 2017 VA hand and finger conditions examination report. The Board notes that on the Veteran’s January 1985 entrance examination, the examiner noted that the Veteran had a history of a left thumb fracture 2 years prior – no residuals. The Veteran’s treatment records show that the Veteran was treated several times for right thumb symptoms. However, January 1989 service treatment records (STRs) indicate that the Veteran complained of left-hand problems secondary to trauma. At a November 2017 VA hand and finger conditions examination, the examiner noted that the Veteran had a diagnosis of osteochondrosis of the left side. The Veteran was afforded a VA examination in October 2019 where the examiner opined that the Veteran’s left thumb disability clearly and unmistakably preexisted service and was not aggravated by service. The examiner reasoned that the Veteran’s entrance examination listed a left thumb fracture with no residual issues; no service treatment records to demonstrate a left thumb fracture in service; and no objective evidence of an active thumb issue on examination. The Board finds that the October 2019 VA examination is inadequate for adjudication purposes. First, although the examiner states that a left thumb disability preexisted service based on the January 1985 entrance examination report, the examiner does not clarify if the Veteran indeed had a left thumb disability at the time of his entrance examination. Indeed, a finding of a left thumb fracture 2 years prior – no residuals – could be reasonably interpreted as no current disability. Second, the examiner does not acknowledge the January 1989 STR which showed complaints of trauma to the left hand. The Veteran has consistently contended that he injured his left thumb during an in-service sport activity. Third, the examiner does not acknowledge the 2017 VA examiner’s diagnosis of osteochondrosis of the left hand and the Veteran’s subjective complaints of left thumb pain. Based on these deficiencies in the October 2019 examination report, the Board finds that a remand is necessary to obtain an adequate medical opinion. The matters are REMANDED for the following action: Obtain an addendum opinion from the October 2019 VA examiner (or a suitable substitute). The Veteran’s electronic claims folder, including a copy of this remand, must be provided to the clinician. The clinician is requested to provide an opinion as to the following: (a) Opine as to whether it is clear and unmistakable (obvious, manifest, and undebatable) that a left thumb disability pre-existed active service. The examiner is requested to clarify if the January 1985 entrance examination report finding of a left thumb fracture 2 years prior – no residuals – constitutes a finding of a disability. (b) If a left thumb disability clearly and unmistakably preexisted service, the examiner must state whether it is clear and unmistakable (obvious, manifest, and undebatable) that a pre-existing left thumb disability WAS NOT aggravated (i.e., permanently worsened) during service; or whether it is clear and unmistakable (obvious, manifest, and undebatable) that any increase in service was due to the natural progress. (c) If a left thumb disability did not preexist service, opine whether it is at least as likely as not (50 percent probability or greater) that a left thumb disability was incurred in or is otherwise related to service. The clinician is requested to address the following: (i) January 1989 STRs indicate that the Veteran complained of left-hand problems secondary to trauma; (ii) The Veteran’s lay statements that he injured his left thumb while playing basketball during service; and (iii) November 2017 VA examination report which lists a diagnosis of osteochondrosis of the left side. A complete rationale for all opinions reached must be provided. Michael A. Pappas Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Baskerville, LaRita 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.