Citation Nr: 21023365 Decision Date: 04/20/21 Archive Date: 04/20/21 DOCKET NO. 16-12 544A DATE: April 20, 2021 ORDER Service connection for a right wrist disorder claimed as secondary to service-connected right thumb fracture residuals is denied. FINDING OF FACT The Veteran’s right wrist disorder is not shown to be secondary to service-connected right thumb fracture residuals and is not otherwise related to active service. CONCLUSION OF LAW The criteria for service connection for a right wrist disorder, to include as secondary to service-connected right thumb fracture residuals have not been met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303, 3.310. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served on active duty from June 1965 to June 1969. This matter comes to the Board of Veterans’ Appeals (Board) on appeal from an October 2013 rating decision by the Regional Office (RO) of the Department of Veterans Affairs (VA). This case was previously before the Board in October 2018, on which occasion it was determined that the Veteran’s February 2016 substantive appeal for the issues of entitlement to service connection for a right wrist disability and an acquired psychiatric disorder was timely. The claims were subsequently reinstated as pending appeals. In December 2018 the RO granted service connection for an acquired psychiatric disorder. The remaining issue of entitlement to service connection for a right wrist disability was again remanded for further development in February 2019, December 2019 and October 2020. This matter is now returned to the Board. Right wrist disorder The Veteran contends that service connection is warranted for a right wrist disorder, including as secondary to service-connected right thumb fracture residuals. In an October 2012 statement in support of claim he alleged that the right wrist disorder resulted from the same in-service injury that resulted in a right thumb fracture and stated that “I injured my hand while serving... and I have had problems with my wrist since the injury.” Service connection is currently in effect for residuals of a right thumb fracture. Service connection may be granted for disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303. Such a determination requires a finding of current disability that is related to an injury or disease in service. Watson v. Brown, 4 Vet. App. 309 (1993); see also Brammer v. Derwinski, 3 Vet. App. 223, 225 (1992); Rabideau v. Derwinski, 2 Vet. App. 141, 143 (1992). Service connection may be granted for any disease diagnosed after discharge from service when all the evidence, including that pertinent to service, establishes that the disease was incurred in service. 38 C.F.R. § 3.303 (d). Service connection may be established under the provisions of 38 C.F.R. § 3.303 (b) when the evidence, regardless of its date, shows that a veteran had a chronic condition in service or during the applicable presumptive period. Certain chronic diseases, to include neurological disorders and psychosis, may be presumed to have been incurred or aggravated during service if they become disabling to a compensable degree within one year of separation from active duty. 38 U.S.C. §§ 1101, 1112; 38 C.F.R. §§ 3.307, 3.309. In addition, service connection solely on the basis of continuity of symptomatology can only be established for the chronic diseases specified at 38 C.F.R. § 3.309 (a). Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). With chronic disease shown as such in service (or within the presumptive period under § 3.307) so as to permit a finding of service connection, subsequent manifestations of the same chronic disease at any later date, however remote, are service connected, unless clearly attributable to intercurrent causes. Continuity of symptomatology is required only where the condition noted during service (or in the presumptive period) is not, in fact, shown to be chronic or where the diagnosis of chronicity may be legitimately questioned. When the fact of chronicity in service is not adequately supported, then a showing of continuity after discharge is required to support the claim. 38 C.F.R. § 3.303 (b). Service connection may be granted for a disability that is proximately due to, or aggravated by, service-connected disease or injury. 38 C.F.R. § 3.310. The question for the Board is whether the Veteran has a current disability, in this case a right wrist disorder (or residuals of) that was incurred in or aggravated by service or is proximately due to or the result of, or aggravated beyond its natural progress by service-connected disability of right thumb fracture residuals. In making all determinations, the Board must fully consider the lay assertions of record. If credible, competent lay evidence means any evidence not requiring that the proponent have specialized education, training, or experience. Lay evidence is competent if it is provided by a person who has knowledge of facts or circumstances and conveys matters that can be observed and described by a lay person. 38 C.F.R. § 3.159 (a). Thus, a layperson is competent to report on the onset and continuity of his symptomatology. See Kahana v. Shinseki, 24 Vet. App. 428, 438 (2011); Layno v. Brown, 6 Vet. App. 465, 470 (1994) (a veteran is competent to report on that of which he or she has personal knowledge). The June 1965 entrance examination disclosed normal findings of the upper extremities and the accompanying report of medical history denied any orthopedic issues. Service treatment records disclose that the Veteran fractured his right thumb in February 1968, with the injury noted as a comminuted fracture of the right first metacarpal bone. The Veteran was treated with a short arm cast of the right upper extremity but continued with right thumb symptoms of pain and a “sliding” sensation as reported in 1968. The records did not disclose any significant issues involving the wrist. The report of a June 1969 separation examination revealed normal upper extremities with no defects noted. Service connection is in effect for a right thumb fracture residuals per a February 2016 rating decision granting this disability. Service connection is also in effect for coronary artery disease associated with herbicide exposure per an October 2013 rating. Post-service medical treatment records are notably silent for any medical evidence that links any right wrist to service or to his service-connected right thumb disorder. Findings of minimal osteoarthritis of the right wrist along the radial/thumb base aspect are shown in a January 2016 X-ray of the right hand, which also diagnosed mild to moderate osteoarthritis of the thumb carpometacarpal joint and IP joints, as well as minimal chronic deformity of the metacarpal joint. No opinion addressing any possible relationship between these findings was given in the records. VA treatment records and examination reports include some evidence that the Veteran used a walker to ambulate at times, with some suggestion that this aggravated his wrist. This includes records from January 2014 and December 2014 which showed he ambulated with a walker, although a history given in a December 2013 indicated that prior to a September 2013 stroke he could not walk with a walker. He indicated that he had balance issues in a lay statement captured in a DBQ from September 2014 and in a January 2016, record suggesting possible balance issues due to stroke. In a January 2016 VA examination of his service connected cardiovascular disorder the findings included notation of functional limitations of this disorder including slow walking but there was no mention that a walker was used for this service-connected disability. The report of a September 2019 VA examination disclosed the Veteran’s contentions of right wrist arthritis secondary to his thumb residuals. Physical examination diagnosed arthritis, degenerative. Historically, he fractured the base of the right 1st metacarpal on February 22, 1968. He was found to have mild arthritic changes of the right wrist at his last examination. The Veteran reported no complaints of or treatment for the right wrist. There were no flares or loss of function of the right wrist. On examination his range of motion was all normal. There was no pain with weight bearing or localized tenderness or pain on palpation. There was no crepitus, and no loss of function or motion after 3 repetitions. (left wrist also examined). Muscle strength was a full 5/5. No reduction of muscle strength or atrophy was shown. There was no ankylosis. No scars or use of assistive devices were noted. X-ray showed minimal osteoarthritis of wrist along the radial/thumb base aspect. An opinion was given that this condition is less likely than not proximately due to or the result of the Veteran’s service connected condition. The rationale was that the Veteran denied any right wrist pain or loss of motion during the examination. The clinical examination was essentially normal for the right wrist. Radiological examination in 2016 showed mild degenerative joint disease DJD which was approximately 48 years after the right thumb injury. In the rationale it was noted that osteoarthritis (OA) is more common than any other joint disease and further it was noted that in the hand and wrist the most common site of OA is at the base of the thumb. It was further noted that as people age the risk of developing OA increases around 10 percent over the age of 60 years and over 90 percent of those over 90. Risk factors included increasing age, female gender, race, heavy labor. It was pointed out that the Veteran uses a walker and thus puts stress on the wrist and hand joints. Thus, the condition was less likely than not proximately due to or the result of his service connected disability. However, this examination did not address aggravation. In October 2020 an addendum opinion was obtained that addressed the question of aggravation. However, the rationale was inadequate, requiring that further opinion be obtained. The October 2020 negative opinion did confirm review of the claims file and recited the remand directives, as well as the prior (September 2019) examination’s opinions. The October 2020 examiner stated that as noted in the prior examination, the Veteran’s wrist arthritis is likely age related and not related to the injury. Also, the original examiner noted no pain or range of motion deficit in the wrist therefore the claimed right wrist is less likely than not proximately due to or the result of the Veteran’s fracture of the right first metacarpal base. Further, the examiner stated that the claimed right wrist disability was less likely than not proximately due to a service-connected disability but rather was due to age related arthritis. Regarding aggravation, the examiner further opined that the claimed right wrist disability was less likely than not aggravated beyond natural progression by a service-connected disability, to include residuals of a right thumb first metacarpal fracture. No rationale was given for this opinion. In November 2020 an addendum opinion was obtained to further clarify matters. The examiner confirmed review of the claims file including the STRs and medical literature. The examiner also recited the prior remand instructions, which included the October 2012 lay statements from the Veteran indicating that he had problems with his wrist since the initial hand injury in service and the January 2016 X-ray showing minimal right wrist OA along the radial/thumb aspect. The examiner further noted that the last VA examination of September 2019 essentially disclosed no complaints, full range of motion, normal strength and no functional disability bilaterally. The examiner stated that it was less likely than not that the Veteran’s right wrist disability had its initial manifestation during his military service. The examiner further opined that the claimed right wrist current disability was less likely than not incurred in or caused by the claimed in-service injury, event, or illness. The examiner further opined that the claimed right wrist current disability is less likely than not proximately due to or the result of the Veteran’s service connected disability. The examiner stated that the claimed right wrist disability which clearly and unmistakably did not have its initial manifestation during his military service, and was less likely than not aggravated by his service-connected right-thumb disability. The first carpometacarpal joint (CMCJ) is unique, it has only articulation between the trapezium and the base of the first metacarpal allowing extra motions for the thumb. The Veteran was first seen at VA in 1996 to present time. No limitations or treatment had been documented. The only part contributory to his military injury without doubt is noted on the X-ray in 2016 as right hand objective finding: “ Minimal chronic deformity of the first metacarpal base.” The arthritis noted in other parts of the right hand is age related. The examiner stated that no aggravation is found and thus no further opinion is needed regarding baseline prior to aggravation. Having reviewed the evidence the Board finds that the preponderance of the evidence is against a grant of service connection for a right wrist disability. Although a current disability of OA is shown by X-ray, there is no credible medical or lay evidence showing a right wrist disability of in-service onset or otherwise related to any in-service incident. The preponderance of the medical evidence is further against a finding that the right wrist OA was caused or aggravated by his service-connected right thumb disability. The Board accepts the findings and opinions detailed in the addendum VA opinions from October 2020 and November 2020, which provided clarification through detailed discussion of the factors causing OA including aging, discussion about the anatomical characteristics of the service connected thumb disability and discussion of the findings from the November 2019 VA examination showing essentially normal findings with no functional loss. The Board further notes that aside from the X-ray findings of OA in 2016, there is no medical evidence to suggest a current disability affecting his right wrist function. The opinions given in these addendums are based on an accurate medical history and provide an explanation that contains clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Although the Veteran believes his right disability was caused or aggravated by his service-connected right thumb disability or otherwise caused by the inservice incident resulting in the right thumb fracture, he is not competent to provide a nexus opinion regarding this issue. The issue is medically complex, as it requires knowledge of anatomical relationships. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24. Vet. App. 428 (2011). Consequently, the Board gives more probative weight to the VA medical examiner's opinions from October and November 2020. Thus, the Board finds that the claim of service connection for a right wrist disorder is not warranted on any basis, including as secondary to service connected residuals of a right thumb fracture. In reaching this conclusion, the Board has considered the applicability of the benefit-of-the-doubt doctrine. However, as the preponderance of the competent, probative evidence is against each claim, that doctrine is not applicable. See 38 U.S.C. § 5107 (b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49, 53-56 (1990). Eric S. Leboff Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board C. Eckart 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.