Citation Nr: 21015771 Decision Date: 03/18/21 Archive Date: 03/18/21 DOCKET NO. 16-21 590 DATE: March 18, 2021 ORDER Entitlement to service connection for a left wrist disability, to include ganglion cyst is denied. REMANDED Entitlement to service connection for a right shoulder disability is remanded. Entitlement to service connection for a left shoulder disability is remanded. FINDING OF FACT The preponderance of the evidence is against finding that the Veteran’s left wrist disability, to include ganglion cyst, is etiologically related to a disease, injury, or event which occurred in service. CONCLUSION OF LAW The criteria for service connection for a left wrist disability, to include ganglion cyst, have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from August 1996 to August 1999. This matter comes before the Board of Veterans’ Appeals (Board) on appeal from a September 2013 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO). In November 2019, the Veteran testified at a videoconference hearing before the undersigned Veterans Law Judge (VLJ). A transcript of that proceeding has been associated with the record. The Board previously remanded the case in June 2020 for further development. The requested development as to the claim adjudicated below has been completed to the extent possible, and no further action is necessary to comply with the Board’s remand directives. Stegall v. West, 11 Vet. App. 268 (1998). Entitlement to service connection for a left wrist disability, to include ganglion cyst is denied. The Veteran is seeking to establish service connection for a left wrist disability, to include ganglion cyst. Specifically, the Veteran contends her left wrist disability manifested in service. The Board notes that the Veteran has been granted service connection for a right wrist disability, to include ganglion cyst. A veteran is entitled to VA disability compensation if there is a disability resulting from personal injury suffered or disease contracted in the line of duty in active service, or for aggravation of a preexisting injury suffered or disease contracted in the line of duty in active service. 38 U.S.C. § 1110. Generally, to establish a right to compensation for a present disability, a veteran must show: (1) a present disability; (2) an 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, the so-called “nexus” requirement. Shedden v. Principi, 381 F.3d 1163, 1167 (Fed. Cir. 2004). Service connection means the facts, shown by evidence, establish that a particular injury or disease resulting in disability was incurred coincident with service, or if preexisting such service, was aggravated by service. This may be accomplished by affirmatively showing inception or aggravation during service. 38 C.F.R. § 3.303(a). Service connection may be granted for disability shown after service, when all of the evidence, including that pertinent to service, shows that it was incurred in service. 38 C.F.R. § 3.303(d). Following a review of the record, the Board finds that the weight of the evidence does not support finding that the Veteran’s left wrist disability, to include ganglion cyst, is related to service. Reviewing the relevant evidence of record, service treatment records reflect treatment for a right wrist ganglion cyst. In August 1997, the Veteran presented with a mobile, nontender cyst noted on the dorsum of the right wrist. She complained of aching and painful movement and was assessed with a ganglion cyst. A June 1998 service treatment record noted a knot to the right wrist that hurt for two days. A ganglion cyst was noted. A March 1999 Report of Medical Examination upon separation noted a right wrist mass and the Veteran endorsed “wrist trouble” on the corresponding March 1999 Report of Medical History. A March 1999 service treatment record, dated the same day as the Reports of Medical Examination and History, noted “cyst in wrist (both).” In a May 1999 VA examination, the Veteran noted she had a right wrist cyst since 1996 but denied any history of a left wrist condition. The examiner indicated there was no pain on range of motion and strength was normal. The examiner noted that the Veteran was diagnosed with ganglion cyst of the right wrist prior to military service. No diagnosis was given for the Veteran’s left wrist. A June 1999 service treatment record indicated that the Veteran had a right dorsal wrist ganglion cyst that was causing pain and the inability to do pushups. The Veteran was placed on a physical profile because of a wrist cyst and contusion digit. A July 1999 service treatment record noted a right dorsal wrist ganglion cyst and right middle finger soft tissue injury. In a March 2013 VA examination, the Veteran reported her wrist conditions began in service during physical training and were painful with movements and push-ups. X-rays of the left wrist revealed no acute fracture or dislocation and surrounding soft tissue appeared normal. The impression was a normal left wrist series. The VA examiner diagnosed the Veteran with left wrist sprain and status post right wrist ganglion cyst with sprain. The examiner opined that the Veteran’s left wrist disability was less likely than not related to service, as there was no mention of left wrist pathology noted in medical records. In a March 2020 VA examination, the Veteran reported her wrist conditions began in 1998 to 1999 during physical training. It began as a lump in the wrist, pain, and decreased mobility. The VA examiner noted the claimed condition of left wrist ganglion cyst but indicated that the Veteran did not have a current diagnosis related to the claimed condition. The examiner opined that the Veteran’s left wrist disability was less likely than not related to service, as there was no ganglion cyst to service connect at that time. The examiner explained that the physical examination was benign for any active findings or residuals and “Enlistment, Reports of Medical and Separation evaluations” were benign for any left ganglion cyst related issues. In June 2020, the Board found that the March 2020 VA opinion was inadequate. The March 2020 examiner failed to acknowledge and provide an opinion for the Veteran’s left wrist strain, as diagnosed by the March 2013 VA examiner. Further, in support of his opinion, the March 2020 examiner explained there was no treatment for the left wrist during service; however, he failed to address the March 1999 service treatment record, reflecting a cyst on both of the Veteran’s wrists. Pursuant to the Board’s remand, a VA medical opinion was obtained in July 2020. The VA examiner reviewed the Veteran’s records and noted that it was “odd” that a March 1999 encounter documented a cyst in wrist (both), whereas her separation examination on the very same day was silent for a left wrist ganglion cyst. The examiner believed one of these exams were not accurate. The examiner explained that ganglion cysts were noncancerous lumps that most commonly developed along the tendons or joints of the wrists. The fluid-filled cysts could quickly appear, disappear, and change in size. In contrast, a left wrist sprain occurred when a ligament was stretched or torn. Wrist sprains were most often caused by a fall onto an outstretched hand. The examiner noted that this would stem from an acute injury or fall and not a cyst 14 years prior. He explained that the ganglion cyst and the wrist sprain were two separate entities. Further, there was no mention of pain in the March 1999 note that could even remotely connect a ganglion cyst to the sprain and there was a 14-year gap between the March 1999 notation and the March 2013 diagnosed left wrist strain. The examiner added that the Veteran’s March 1999 separation examination was silent for a left ganglion cyst condition. After review of the record, the Board finds that the weight of the evidence is against finding that the Veteran’s left wrist disability, to include ganglion cyst, is related to service. With regard to a left wrist ganglion cyst, the only mention of this condition is noted in a March 1999 service treatment record. The Board concurs with the March 2020 VA examiner that it is unusual the March 1999 record noted a cyst in both wrists, yet the separation examination conducted the same day only noted a right wrist ganglion cyst. Further, while multiple service treatment records reflect treatment for a right wrist ganglion cyst, the records are silent for treatment of any left wrist issues during service. In the May 1999 VA examination, the Veteran denied a history of a left wrist condition and the VA examiner only noted a diagnosis of right wrist ganglion cyst prior to service. Finally, post-service treatment records fail to reflect that the Veteran has been diagnosed with a left wrist ganglion cyst during the appeal period. Thus, for these reasons, the Board finds that service connection for a left wrist ganglion cyst is not warranted. With regard to left wrist strain, while the record shows the Veteran was diagnosed with this condition during the appeal period, service treatment records are silent for any complaints of, treatment for, or diagnosis of left wrist strain. The Veteran’s March 1999 separation examination failed to note any left wrist related issues. Furthermore, the Veteran denied a history of a left wrist condition on the May 1999 VA examination and the VA examiner did not make a diagnosis of wrist strain or any other left wrist condition. The first evidence of left wrist strain was made in 2013, during the Veteran’s VA examination. Finally, after noting the peculiarity of the March 1999 service treatment record indicating a cyst on both wrists, the July 2020 VA examiner opined that the Veteran’s wrist strain was not related to a ganglion cyst. She supported her opinion by explaining that ganglion cysts and wrist strain were two separate entities, there was no mention of left wrist pain in service that could connect a ganglion cyst and wrist sprain, and there was a 14 year gap between the March 1999 service treatment record and the March 2013 diagnosis of left wrist strain. The Board acknowledges the Veteran’s assertions that her left wrist disability, to include ganglion cyst, is related to service. However, the Board finds that the Veteran’s statements are less probative than the service treatment records, post-service treatment records, May 1999 VA examination, and July 2020 VA medical opinion. Further, the March 1999 note of “cyst in wrist (both)” is contrary to service treatment records that fail to reflect any treatment for a left wrist cyst, Reports of Medical Examination and History that do not indicate any left wrist issue, and the May 1999 VA examination in which the Veteran herself denied a history of a left wrist condition. Thus, the March 1999 notation is less probative than the evidence discussed above. For these reasons, the Board find that the weight of the evidence does not support a finding that the Veteran’s left wrist disability, to include ganglion cyst, is related to service. As a result, service connection for a left wrist disability, to include ganglion cyst, is not warranted. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine; however, as the preponderance of the evidence is against the claim, the doctrine is not applicable. 38 U.S.C. § 5107(b). REASONS FOR REMAND 1. Entitlement to service connection for a right shoulder disability is remanded. 2. Entitlement to service connection for a left shoulder disability is remanded. The Board notes that although the Veteran is advancing a theory of entitlement to service connection for bilateral shoulder disabilities on a direct basis, VA is obligated to develop and consider all theories of entitlement that are raised by the record or by the claimant. See Robinson v. Mansfield, 21 Vet. App. 545 (2008). VA must examine the record with a view towards ascertaining whether the veteran or the evidence raises consideration of any theory of entitlement, regardless of the specific disability claims. The evidence of record reflects a possible connection between the Veteran’s bilateral shoulder disability and her recently service-connected cervical spine disability. For example, an October 2012 treatment record noted that the Veteran described her cervicalgia as radiating down her bilateral shoulders. An April 2014 treatment record indicated neck pain that radiated to the shoulders. In September 2014, the Veteran reported shoulder pain and stiffness with right cervical rotation and left lateral tilt. A May 2018 treatment record noted pain at the base of the skull that went around the shoulder blades. In June and August 2018, the Veteran reported pain at the base of the skull and neck into the shoulders. As there is no opinion of record addressing secondary service connection, remand for an opinion on whether the Veteran’s bilateral shoulder disability is caused or aggravated by his service-connected cervical spine disability is warranted. The matters are REMANDED for the following action: 1. Obtain an addendum opinion from an appropriate VA examiner regarding the Veteran’s bilateral shoulder disability. The claims file and a copy of this remand must be made available to the examiner. The need for an additional examination of the Veteran is left to the discretion of the clinician selected to write the addendum opinion. The examiner should respond to the following: a) Is it as least as likely as not (50 percent probability or greater) that the Veteran’s left and right shoulder disability was caused by his service-connected cervical spine disability? Please provide an opinion for each shoulder and explain why or why not. b) Is it as least as likely as not (50 percent probability or greater) that the Veteran’s left and right shoulder disability is aggravated (worsened beyond its natural progression) by his service-connected cervical spine disability? Please provide an opinion for each shoulder and explain why or why not. The examination report must include a complete rationale for all opinions expressed. If the examiner feels that a requested opinion cannot be rendered without resorting to speculation, the examiner must state whether the need to speculate is caused by a deficiency in the state of general medical knowledge (i.e., no one could respond given medical science and the known facts) or by a deficiency in the record or the examiner (i.e., additional facts are required, or the examiner does not have the needed knowledge or training). 2. After completing the above, and any other development as may be indicated by any response received as a consequence of the actions taken in the preceding paragraphs, the Veteran’s claims should be readjudicated based on the entirety of the evidence. If any benefit sought remains denied, furnish the Veteran and her representative a supplemental statement of the case (SSOC) and return the case to the Board. KRISTI L. GUNN Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board L. Silverblatt, 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.