Citation Nr: 21014255 Decision Date: 03/11/21 Archive Date: 03/11/21 DOCKET NO. 14-03 088 DATE: March 11, 2021 ORDER Entitlement to service connection for a bilateral hand strain is denied. Entitlement to service connection for bilateral arm cramps is denied. FINDINGS OF FACT 1. The Veteran’s bilateral hand strain was not incurred in service and is not otherwise causally or etiologically related to service. 2. At no time during the pendency of the claim does the Veteran have a diagnosis of a disability manifested as bilateral arm cramps, and the record does not contain a recent diagnosis of such disability prior to the Veteran’s filing of a claim. CONCLUSIONS OF LAW 1. The criteria for entitlement to bilateral hand strain have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. 2. The criteria for entitlement to bilateral arm cramps have not been met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty in the United States Navy from January 1997 to January 2001. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a February 2012 rating decision issued by a Department of Veterans Affairs Regional Office (RO). The Veteran filed an original claim for disability benefits for bilateral hand strain and bilateral arm cramps in May 2010. The claims were denied by RO in February 2012 and the Veteran subsequently appealed the RO’s decision to the Board. The matter came before the Board in November 2018, whereupon it was remanded to allow for the Veteran to be provided with a VA examination. The matter returned to the Board in August 2020 and was remanded again to exam inadequacy. The Board finds that the Veteran has been provided with an VA examination pursuant to the Board’s 2020 remand directives, and that there has been substantial compliance with its remand. Stegall v. West, 11 Vet. App. 268 (1998). The matter is now again before the Board for adjudication. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires: (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); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Generally, to establish direct service connection 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 between the present disability and the disease or injury incurred or aggravated during service.” Davidson v. Shinseki, 581 F.3d 1313, 1315-16 (Fed. Cir. 2009); Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). For certain chronic diseases, such as arthritis, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. That presumption is rebuttable by probative evidence to the contrary. 38 C.F.R. §§ 3.307, 3.309. For those listed chronic conditions, a showing of continuity of symptoms affords an alternative route to service connection when the requirements for application of the presumption are not met. 38 C.F.R. § 3.303(b); Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). The threshold question in any claim seeking service connection is whether there is a current disability at any point during the appeal period. McClain v. Nicholson, 21 Vet. App. 319, 321 (2007). In the absence of proof of a current disability, service connection is not warranted. Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). The requirement of a current disability is satisfied if the veteran has a disability at the time she files her service connection claim or during the pendency of that claim, even if the disability resolves prior to adjudication of the claim. Id. Where there is an approximate balance of positive and negative evidence regarding any issue material to the determination of a matter, VA shall resolve reasonable doubt in favor of the claimant. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). 1. Entitlement to bilateral hand strain The Veteran contends that his bilateral hand strain is related to his service. Specifically, he contends that his bilateral hand strain resulted from prolonged usage of machinist tools while serving in the United States Navy. Service treatment records (STRs) document the Veteran being treated for several hand-related issues, namely a right thumb sprain in July 1997; a burn to the right hand in October 1997; and an issue with his left index finger in May 1998. A separation exam taken in October 2000, however revealed normal findings of the upper extremities, i.e. arms and hands, with full range of motion and painless use. The medical evidence is silent for any complaints, treatments, and/or diagnoses related to the hand from discharge from service until 2009, when the Veteran first sought treatment for hand-related symptoms. Then in June 2009, the Veteran presented for a visit with Dr. L. complaining of hand-related pain. Dr. L. conducted a “Finkelstein’s test” on the Veteran and diagnosed him with Dequervain’s tenosynovitis in the left wrist, a condition involving inflammation of the tendons controlling movement of the thumb and making it difficult to grip or otherwise make use of one’s hand. The Veteran exhibited pain in the left wrist, tenderness in the radial styloid, and thickening of the first dorsal department. Dr. L. noted that the Veteran had been suffering from wrist pain for the “past six months”, i.e. since early 2009. The Veteran was provided a VA examination for his hand in February 2011. The examiner diagnosed the Veteran with bilateral hand strain. The examiner noted the Veteran’s report that his hand pain began in service, possibly due to prolonged usage of machinist tools. The examiner then noted that the Veteran’s condition had been progressively worsening and he currently suffered from pain and decrease in strength in both hands. However, the examiner went on to opine that it was less likely than not that the Veteran’s bilateral hand strain was related to his service. The examiner’s rationale acknowledged that the Veteran had suffered three acute episodes of hand-related issues, i.e. a right thumb sprain in July 1997; a burn to the right hand in October 1997; and an issue with his left index finger in May 1998; all while in service. The examiner explained however that these issues were acute and temporary and resolved through treatment without any lingering residuals. The examiner found no evidence to support a chronic hand condition during the Veteran’s service or immediately after discharge. The examiner considered all evidence of record after thorough review of the claims file, including lay statements properly weighed and reported clear conclusions with supported data. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295 (2009); Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007). There is no contrary opinion of record. The Veteran was afforded another VA examination in December 2020. The examiner opined that the Veteran’s did not have any hand condition. Rather, the examiner opined, the Veteran’s condition was related to the wrist, specifically Dequervain’s tenosynovitis. The examiner acknowledged the Veteran’s contention that he suffered a blister on the right wrist and a right thumb sprain while in service. The examiner also considered the Veteran’s report of suffering from hand and arm symptoms including pain, tingling, and numbness that began during service, which the Veteran contended was the result of prolonged use of tool while working as a machinist mate in the Navy. However, the examiner explained that the wrist blister and thumb sprain were acute and temporary injuries that resolved and did not manifest as chronic or recurring conditions. Additionally, in regard to prolonged use of machine tools, the examiner noted that the record contained no evidence of any symptoms or treatment until June 2009, at which point the Veteran reported having suffered from symptoms for six months prior, i.e. early 2009. This would put an eight year gap after the Veteran’s discharge from service and his first report of symptoms. The examiner considered all evidence of record after thorough review of the claims file, including lay statements properly weighed and reported clear conclusions with supported data. See Nieves-Rodriguez v. Peake, supra; Stefl v. Nicholson, supra. There is no contrary opinion of record. The Board notes that an etiology opinion was also provided in December 2019. However, an August 2020 Board remand found that this opinion was inadequate because it did not discuss the Veteran’s in-service complaints and treatments. The Board notes that the Veteran has contended that his bilateral hand strain is the result of his service. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. Layno v. Brown, 6 Vet. App. 465, 469-70 (1994). Lay evidence may also be competent to establish medical etiology or nexus. Davidson v. Shinseki, 581 F.3d 1313, 1316 (Fed. Cir. 2009). However, "VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to." Waters v. Shinseki, 601 F.3d 1274, 1278 (2010). In the instant case, the Board finds that the question regarding the potential relationship between the Veteran's bilateral hand strain and any instance or event of his service to be complex in nature. Woehlaert v. Nicholson, 21 Vet. App. 456 (2007). Specifically, while the Veteran is competent to describe his current symptoms, the Board accords his statements regarding the etiology of his bilateral hand strain little probative value because he is not competent to opine on such a complex medical question. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issued. See Jones v. Brown, 7 Vet. App. 134, 137 (1994). In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship, and requires the administration and interpretation of diagnostic testing. In the instant case, there is no suggestion that the Veteran has had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinions of the Veteran are non-probative evidence. The Board finds that the first element for service connection, a “current disability”, is met for several reasons. The Veteran has been diagnosed with a bilateral hand strain upon VA examination in 2011. Additionally, the Veteran has a 2009 diagnosis for Dequervain’s tenosynovitis for the left wrist, supported by descriptions of pain, tenderness in the radial styloid, and thickening of the first dorsal department, all symptoms consistent with Dequervain’s tenosynovitis. Although the December 2020 examiner relied upon the 2009 diagnosis for Dequervain’s tenosynovitis and determined that it was not a hand-related disorder and rather was a wrist condition; the Board notes here that generally, the scope of a disability claim includes any disability that may reasonably be encompassed by the claimant’s description of the claim, reported symptoms, and any other information of record. See Brokowski v. Shinseki, 23 Vet. App. 79 (2009) (when a claimant makes a claim, he is seeking service connection for symptoms regardless of how those symptoms are diagnosed or labeled). Additionally, as stated above, the Veteran is competent to describe his observable symptoms, such as hand pain. Therefore, based on the 2009 diagnosis of Dequervain’s tenosynovitis for the left wrist; the 2011 diagnosis of a bilateral hand disability; and construing facts liberally in favor of the Veteran, the Board finds that the Veteran has a “current disability” for VA service connection purposes. To this end, the Board finds that the evidence does not establish an in-service incurrence of the Veteran’s disability. All probative medical opinions are unfavorable towards a finding of an in-service incurrence and any nexus between the Veteran’s current disability and his military service. The June 2009 visit that diagnosed the Veteran with Dequervain’s notes his condition beginning just six months prior to the visit, i.e. in early 2009, more than eight years after the Veteran’s separation from service. The Veteran has stated instead that his hand pain was continuous since his service. To be sure, the Veteran’s lay statement cannot be determined as not credible merely because it is unaccompanied by contemporaneous medical evidence; Buchanan v. Nicholson, 451 F.3d 1331, 1336-37 (Fed. Cir. 2006). However, the lack of contemporaneous medical evidence can be considered and weighed against a Veteran’s lay statements. Id. In the present matter, the Veteran did not seek any medical treatment between 1998 to 2009 for any hand-related condition. Additionally, his October 2000 separation exam found no hand-related issues. Further, the Veteran’s February 2011 examination, although diagnosing the Veteran with a bilateral hand strain, ultimately provided a negative nexus opinion concerning incurrence/etiology. The December 2020 examination provided a negative nexus opinion as well. Additionally, the Veteran’s lay statement, although competent to describe symptoms and helpful in determining a current disability, is not however probative in regard to the second and third elements of service connection, i.e. establishing an in-service incurrence that is causally related to the Veteran’s current disability. VA must consider lay evidence but may give it whatever weight it concludes the evidence is entitled to”. Waters v. Shinseki, supra. Specifically, where the determinative issue is one of medical causation, only those with specialized medical knowledge, training, or experience are competent to provide evidence on the issued. See Jones v. Brown, supra. In this regard, the question of causation involves a medical subject concerning an internal physical process extending beyond an immediately observable cause-and-effect relationship. In the instant case, there is no suggestion that the Veteran has had any medical training. As such, the question of etiology in this case may not be competently addressed by lay evidence, and the opinion of the Veteran is nonprobative evidence in regards to etiology. Thus, the Board lends greater probative weight to the medical opinions of record, which all are negative for any nexus. Here, the Veteran’s statements of in-service incurrence are contradicted by two VA medical opinions to the contrary. Both the February 2011 and December 2020 examiners provided negative nexus opinions stating that an in-service incurrence was less likely than not (less than 50 percent probability). Additionally, the Veteran albeit asserting that he self-treated with Motrin and ice, did not seek any medical treatment for his condition in the intervening eight years between discharge and 2009. A negative inference may be drawn from the absence of complaints for an extended period. See Maxson v. West, 12 Vet. App. 453, 459 (1999), aff’d sub nom. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Thus, the claim for service connection for a bilateral hand strain fails as the second and third elements, an in-service incurrence and a medical nexus, are not supported by the evidence of record. In reaching this decision, the Board has considered the applicability of the benefit of the doubt doctrine. However, the preponderance of the evidence is against the Veteran’s claim of entitlement to service connection for a bilateral hand strain. As such, that doctrine is not applicable in the instant claim, and his claim must be denied. 38 U.S.C. § 5107; 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. 2. Entitlement to bilateral arm cramps The Veteran contends that his bilateral arm cramps are related to his service. The February 2011 examination evaluated the Veteran’s hands but did not specifically test for arm conditions. However, the examiner did not note any pain shooting up into the Veteran’s arms from his hands. The examination only contains indicia of symptoms localized to the hands. The Veteran was provided an examination for his arm in December 2020. The examination revealed findings of normal range of motion and no functional loss. There was no evidence of pain, upon weight-bearing or otherwise. The examination overall revealed normal right and left arm findings. The examiner specifically opined that, for both left and right arms, “Vet has never been diagnosed with any elbow or forearm condition based on my historical review”. He also noted that the present examination did not reveal any current elbow/forearm pathology or disorder either. The Veteran denied having pain flareups in either arm. Upon a thorough review of the evidence, the Board finds that at no time since the filing of his claim and throughout its pendency has the Veteran had a current disability for VA compensation purposes. The Veteran has been evaluated at least three times for his arms and hands. Notably, the Veteran’s visit to Dr. L. in June 2009 did not diagnose an arm condition and does not contain indication of an arm disability. Additionally, the Veteran’s February 2011 and December 2020 VA examinations found no evidence of a past or present arm disability. Both examinations revealed normal findings of painless motion, normal function, and usage of the arms. The Board notes a current disability is always required in order to establish service connection. See Brammer v. Derwinski, supra. With regard to the claimed bilateral hand cramps there is not sufficient evidence to show that the Veteran has had a disability manifested as bilateral arm cramps during the appeal period. See McClain v. Nicholson, 21 Vet. App. 319 (2007). The Board acknowledges the United States Court of Appeals for Veterans Claims (Court’s) holding in Saunders but does not find a basis for determining that there is functional impairment related to a diagnosis of bilateral hand cramps. See Saunders v. Wilkie, 886 F.3d. 1356 (2018). In addition, the Veteran has not alleged manifestations of similar severity, frequency and duration as those VA has determined by regulation would cause impaired earning capacity in an average person. Wait v. Wilkie, 33 Vet. App. 8 (2020). The Board has considered the Veteran’s lay statements in support of his claim. Specifically, the Veteran reports experiencing excruciating pain shooting from his hands up to his arms, since 1997, while in-service. See Veteran's May 2010 Statement. The Veteran is competent to present his observations and symptoms of arm pain as a lay person. However, the Veteran cannot opine on whether his symptoms are attributable to an arm disability. Lay witnesses are competent to provide testimony or statements relating to symptoms or facts of events that the lay witness observed and is within the realm of his or her personal knowledge, but not competent to establish that which would require specialized knowledge or training, such as medical expertise. See Layno v. Brown, supra; See also Washington v. Nicholson, supra. As a service connection claim requires, at minimum, evidence of a current disability, the Veteran's claim for service connection for bilateral arm disability must be denied since he has not met this proof requirement. See Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992). A current disability means a disability shown by competent and credible evidence to exist. The evidence does not demonstrate to at least equipoise that the Veteran suffers from a current disability manifested by bilateral arm cramps. See Degmetich v. Brown, 104 F.2d 1328, 1332 (1997); McClain v. Nicholson, supra. Accordingly, the claim must be denied. As the preponderance of the evidence is against the Veteran's claim, the benefit of the doubt doctrine is not for application. See 38 U.S.C. § 5107, 38 C.F.R. § 3.102; Gilbert v. Derwinski, supra. KRISTY L. ZADORA Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board Kashif I. Ali, Associate 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.