Citation Nr: 21022873 Decision Date: 04/19/21 Archive Date: 04/19/21 DOCKET NO. 17-66 947 DATE: April 19, 2021 ORDER Entitlement to service connection for a left wrist disability, to include chronic sprain, neurological symptoms assessed as possible disuse atrophy versus ulnar neuropathy, and possible scapholunate (SL) ligament tear, is granted. FINDING OF FACT The Veteran’s current left wrist disability, to include chronic sprain, neurological symptoms assessed as possible disuse atrophy versus ulnar neuropathy, and possible SL tear, was incurred during a period of active duty. CONCLUSION OF LAW The criteria for service connection for a left wrist disability, to include chronic sprain, neurological symptoms assessed as possible disuse atrophy versus ulnar neuropathy, and possible SL tear, are met. 38 U.S.C. §§ 1110, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran enlisted in the U.S. Army Reserve in February 2002. He had a period of active duty for training (ACDUTRA) from August 2002 to December 2002, and a period of active duty from February 2003 to August 2004. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from a February 2016 rating decision issued by a Department of Veterans Affairs (VA) Regional Office (RO) which, in pertinent part, denied service connection for left chronic wrist sprain (claimed as strained left wrist). In January 2017, the Veteran’s notice of disagreement was received by VA. In October 2017, the RO issued a Statement of the Case. In November 2017, the Veteran perfected a timely appeal via his submission of a VA Form 9. In November 2020, the Veteran testified at a Board telehearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is a part of the record. 1. Entitlement to service connection for left wrist disability is granted. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. § 3.303. The three-element test for service connection requires evidence of: (1) a current disability; (2) in-service incurrence or aggravation of a disease or injury; and (3) a causal relationship between the current disability and the in-service disease or injury. Shedden v. Principi, 381 F.3d 1163, 1166 -67 (Fed. Cir. 2004). The Veteran contends that his current left wrist disability is the result of an August 2003 injury he sustained while on active duty. At his November 2020 hearing, the Veteran testified credibly that in August 2003, during his period of active duty, he was attempting to change a flat tire on a forklift when the jack slipped and landed on his left hand pushing it backward. The Veteran testified his left wrist was immediately painful and he suspected he had sustained a significant injury. He testified that he immediately sought treatment at the infirmary. He recalled that the initial impression of the examiner was wrist strain but the examiner advised him that the type of injury he had sustained required further treatment at a hospital. The Veteran testified that because of the war, the hospital was busy and he was unable to get an appointment until the following month. During that month he was waiting for an appointment, his wrist remained swollen and painful. The Veteran testified that when he was seen at the hospital one month later, an X-ray study was performed and the results were negative. Nonetheless, the Veteran indicated that he continued to experience left wrist symptoms although he never sustained additional left wrist trauma. He indicated that in 2009, after his separation from active duty, he underwent an MRI in connection with his continued left wrist symptoms. As a result of the MRI, he was diagnosed as having a torn tendon in the left wrist. He testified that after conservative treatment such as physical and occupational therapy failed, he underwent surgery in 2017. At the hearing, the Veteran’s representative argued that, according to information from the Mayo Clinic, X-ray studies, such as the study of the Veteran’s left wrist performed in 2003 during active duty, were effective at identifying pathology of the bones but not pathology of softer tissues such as ligaments, tendons, and muscles; rather, MRI or CT scans were required to identify pathology of that nature. Thus, he argued that the Veteran’s tendon/ligament tear had been likely present during active duty, but that the X-ray study performed at that time had been insufficient to identify it. In pertinent part, the Veteran’s service treatment records confirm that in September 2003, X-ray studies of the left wrist were performed to rule out a fracture. It was noted that the Veteran had sustained an injury to his left wrist in August 2003 and since that time, he had been unable to pick up objects without experiencing pain. The studies were negative for a fracture. No additional imaging studies were performed. Subsequent service treatment records document that the Veteran nonetheless continued to experience left wrist symptoms which he consistently dated to the August 2003 injury. In November 2003, the Veteran was placed on a temporary physical profile for continued left wrist symptoms. Post-active duty service treatment records corresponding to the Veteran’s membership in the Reserve reflect consistent reports of left wrist pain since the August 2003 injury. For example, during a Periodic Health Assessment in February 2009, the Veteran reported that his left wrist had been injured by a jack snapping back in 2003 and he was experiencing ongoing left wrist pain. Based on the Veteran’s reported history and symptoms, the military clinician diagnosed the Veteran as having a possible split tear of the ulnotriquetral ligament. In 2012, the Veteran attended multiple physical therapy and occupational therapy sessions for his left wrist. This treatment did not resolve the Veteran’s pain in his left wrist. VA clinical records show that during a November 2012 neurology consultation, a VA physician noted the Veteran had left ulnar neuropathy. In December 2012, a VA physician noted the Veteran had a history of trauma to his left hand during active duty; the physician concluded that the Veteran had possible disuse atrophy of the left hand due to old trauma versus left ulnar neuropathy. In February 2013, it was noted that the Veteran had ulnar neuropathy following an injury in 2003 or 2004. A November 2012 VA primary care outpatient note states “patient also has chronic left wrist pain which resulted from an injury at Fort Dix in 2003 (working with a malfunctioning jack and forklift). X-ray wrist in 2003, negative for bone pathology. MRI not done. Patient complains of decreased grip strength of left hand for years.” In April 2017, the Veteran was evaluated by a VA orthopedic surgeon. It was noted that he had been diagnosed as having a left wrist SL tear and needed surgical evaluation. The Veteran reported that his left wrist pain first began in 2003 after a car jack axially loaded into his hyperextended left wrist. Immediately after the injury, X-rays were negative and he was placed in a removable splint. Over the last thirteen years, however, he had experienced continued left wrist pain which is exacerbated by participating in activities such as pushups and playing with his child. The Veteran also reported subjective weakness in his grip strength. The preoperative diagnosis was triangular fibrocartilage complex (TFCC) injury. The Veteran underwent arthroscopic TFCC debridement and repair. In connection with his claim of service connection for a left wrist disability, the Veteran was afforded a VA examination in January 2016. The VA examiner diagnosed chronic left wrist sprain and opined that the disability is less likely than not caused by or a result of service. The VA examiner reasoned that the September 2003 X-ray of the Veteran’s left wrist was normal there were no post-service treatment records documenting left wrist complaints until February 2009. The examiner indicated that left wrist symptoms complained about five plus years after service cannot reasonably be connected to active service when there are multiple other aging/occupational/daily activity factors in the intervening years. After considering the record in its entirety, the Board concludes that service connection for the Veteran’s left wrist disability is warranted. With respect to the first and second elements necessary to establish service connection, as set forth above, the clinical evidence of record unquestionably establishes that the Veteran has a current left wrist disability. Moreover, his service treatment records clearly establish that the Veteran sustained an injury to his left wrist while on a period of active duty, continued to experience pain and other symptoms in his left wrist for the remainder of that period of active service, and has continued to experience left wrist symptoms since discharge from active duty. With respect to the third element necessary to establish service connection, a nexus between the current disability and the in-service injury, the evidence is conflicting. As set forth above, in January 2016, a VA examiner provided a negative nexus opinion. The Board, however, finds that opinion to be of little probative value. First, the opinion did not address the significance of the Veteran’s injury not being a bone injury, the lack of a contemporaneous MRI, or whether the results of the September 2003 X-ray would have been able to address the full scope of the injury. Additionally, the VA examiner failed to address the post-service clinical evidence showing left wrist pathology beyond a chronic strain such as a possible ligament tear and disuse atrophy of left hand due to old trauma versus ulnar neuropathy. Finally, the VA examiner appeared to base the opinion on the absence of treatment records within two years of discharge from active duty but failed to consider the Veteran’s reports of continuous symptoms since the 2003 injury, including the significance, if any, of the Veteran being placed on a physical profile. The critical inquiry is continuity of symptomatology, not continuity of treatment and a medical opinion which relies solely on the absence of contemporaneous medical evidence and fails to consider whether lay statements present sufficient support of the etiology of the claimed disability is inadequate. See Buchanan v. Nicholson, 451 F.3d 1331, 1336 (Fed. Cir. 2006). (Continued on the next page)   On the other hand, as discussed above, the record on appeal contains multiple contemporaneous clinical notations linking the Veteran’s left wrist disability to the in-service injury. For example, treatment records corresponding to the Veteran’s service in the Reserve show that in February 2009, a military physician diagnosed the Veteran as having a possible split tear of the ulnotriquetral ligament. This diagnosis was based on a physical examination as well as consideration of the Veteran’s description of the August 2003 injury and his subsequent symptoms. Similarly, VA clinical records include a November 2012 VA primary care outpatient treatment record noting “chronic left wrist pain which resulted from an injury at Fort Dix in 2003.” In December 2012, a VA physician diagnosed possible disuse atrophy of the left hand due to old trauma versus left ulnar neuropathy. In February 2013, it was noted that the Veteran had ulnar neuropathy as a result of the in-service left wrist injury. Finally, in April 2017, the Veteran was diagnosed by a VA orthopedic surgeon as having a TFCC injury based on his described injury and subsequent symptoms. The Board has assigned this collective evidence considerable probative weight as these opinions were based on physical examinations coupled with full consideration of the Veteran’s description of his 2003 injury and subsequent symptoms. Upon review of the record, the Board therefore finds the evidence of record to be at least in relative equipoise as to whether the Veteran’s current left wrist disability, to include left chronic wrist sprain, neurological symptoms assessed as possible disuse atrophy versus ulnar neuropathy, and possible SL tear, is causally related to the August 2003 injury he sustained during active duty. Accordingly, after resolving all doubt in favor of the Veteran, the Board finds that service connection for left wrist disability is warranted. 38 U.S.C. § 5107; 38 C.F.R. § 3.102. K. Conner Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board S. Penn, 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.