Citation Nr: 21024540 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 19-23 824 DATE: April 23, 2021 REMANDED The issue of entitlement to service connection for a right hand disability, to include carpal tunnel syndrome, is remanded. The issue of entitlement to service connection for a left hand disability, to include carpal tunnel syndrome, is remanded. The issue of entitlement to an initial evaluation in excess of 10 percent disabling for service-connected lumbar strain with thoracic spondylosis, claimed as low back condition, is remanded. The issue of entitlement to an initial evaluation in excess of 10 percent disabling for service-connected left knee patellofemoral syndrome with shin splints is remanded. The issue of entitlement to an initial evaluation in excess of 10 percent disabling for service-connected right knee patellofemoral syndrome with shin splints is remanded. The issue of entitlement to a total disability rating based on individual unemployability (TDIU) is remanded. REASONS FOR REMAND The Veteran served on active duty from August 2006 to April 2015. The issues of entitlement to service connection for right and left hand disabilities, to include carpal tunnel syndrome, have been expanded and recharacterized pursuant to Clemons v. Shinseki, 23 Vet. App. 1 (2009). The Board acknowledges an incomplete scan located on the electronic docket at February 5, 2020. The legible part of the scan shows that it is a VA form for Appointment of Individual as Claimant’s Representative. The Board notes that located on the electronic docket on the same date is a complete version of the same form, indicating the Veteran’s representative J.G.F. Thereafter, this representative is copied on correspondence to the Veteran (see, e.g., BVA Letter, April 2020), and he submitted documents on behalf of the Veteran (see, e.g., faxed VA Form 9, March 2020). Accordingly, the Board will proceed with J.G.F. as the Veteran’s representative of record. The Board will attempt to obtain a complete scan upon remand. 1. Entitlement to service connection for a right hand disability, to include carpal tunnel syndrome. 2. Entitlement to service connection for a left hand disability, to include carpal tunnel syndrome. The Board finds that additional development is needed prior to final adjudication of the issues on appeal. First, regarding the claimed hand disabilities, the Board acknowledges that the Veteran’s representative has requested that the Veteran be given a new examination. See NOD, June 2019. Upon review, the Board agrees that a new VA examination and opinion are warranted. The June 2018 VA examination for peripheral nerve conditions notes a diagnosis of carpal tunnel syndrome in both hands. The Veteran reported that while deployed in Afghanistan, “his vehicle was hit by an IED.” In attempting to exit the vehicle, “the door was slammed shut on him, injuring his head and hands.” He described that, since onset, the course of the condition “has been getting worse.” The June 2018 VA opinion states that “[t]here is no record of the injury that the veteran mentioned in his history, but even if it happened and was not mentioned in the record, it is unlikely that any crush injury would lead to carpal tunnel as it is an overuse injury and not due to blunt trauma.” However, the Veteran’s representative submitted evidence, citing the Arthritis Foundation, that “[i]njuries and trauma to the wrist, like a sprain or break, also can trigger this condition.” See NOD, June 2019. The Board asks that a new opinion address this contention. In addition, the June 2018 VA opinion states that a 2010 note indicates “one week of right wrist pain with a negative x-ray, but this is likely due to some wrist sprain as there is no mention of any numbness or tingling or pain in the fingers.” However, the Veteran’s representative cites the American Association of Neurological Surgeons for the contention that “wrist pain is a known symptom of carpal tunnel.” See NOD, June 2019. The Board also notes that a December 2010 service treatment record regarding the right wrist pain states “Pt states that it started hurting, no trauma.” Accordingly, the Board seeks clarification of the contention in the VA opinion that the Veteran’s wrist was sprained. The Board asks that the above be addressed upon remand. In addition to the above, the Board notes the following from the Veteran’s service treatment records and asks that it be considered in the new VA opinion. An August 2014 Report of Medical History shows that the Veteran indicated “[n]umbness or tingling,” “[s]wollen or painful joint(s),” “reoccurring wrist and shoulder pain,” and “tingling in fingers.” Another service treatment record notes “Joint Pain, Localized in The Wrist” as a chronic illness, dated December 2010. A service treatment record from December 2010 shows an appointment for right wrist pain. It states that the Veteran will be given a brace. No trauma was noted. A right wrist series report from December 2010 notes: “There is no evidence of fracture or dislocation. Alignment and joint spaces appear within normal limits. Boney mineralization appears normal. Soft tissues are grossly unremarkable.” The impression is noted as “[n]o evident bony abnormality involving the right wrist.” A September 2014 treatment record indicates that the Veteran reported tingling in his extremities. 3. Entitlement to an initial evaluation in excess of 10 percent disabling for service-connected lumbar strain with thoracic spondylosis, claimed as low back condition. 4. Entitlement to an initial evaluation in excess of 10 percent disabling for service-connected left knee patellofemoral syndrome with shin splints. 5. Entitlement to an initial evaluation in excess of 10 percent disabling for service-connected right knee patellofemoral syndrome with shin splints. The Board finds that new VA examinations are also needed for the service-connected disabilities on appeal. For the back disability, an examination is needed that notes where pain occurs in terms of degrees of range of motion. For example, the August 2018 VA examination report for the back indicates pain in initial range of motion testing on forward flexion, extension, right and left lateral flexion, and right and left lateral rotation. However, the point at which pain occurs, as expressed in degrees of range of motion, is needed. Accordingly, the Board asks that the Veteran be afforded a new VA examination. See Correia v. McDonald, 28 Vet. App. 158 (2016). In addition, the Board notes that the Veteran’s representative has also asked that the Veteran be provided a new VA examination for his back disability, specifically one to assess associated neurological conditions. See VA Form 9, July 2019. Accordingly, the Board asks that this be addressed upon remand. Similarly, regarding the August 2018 VA examination for the Veteran’s knees, the initial range of motion testing noted pain in flexion and extension for both knees. However, the point at which this pain begins, as expressed in terms of degrees of range of motion is needed. See Correia v. McDonald, 28 Vet. App. 158 (2016). 6. Entitlement to a TDIU. Finally, the issue of entitlement to a TDIU is intertwined with the remanded issues on appeal. Accordingly, remand is appropriate for this issue. The matters are REMANDED for the following action: 1. After securing any necessary consent forms from the Veteran, obtain any outstanding treatment records, to include any VA and/or private treatment records, pertaining to the issues on appeal. There is an incomplete scan located on the electronic docket at February 5, 2020. The legible part of the scan shows that it is a VA form for Appointment of Individual as Claimant’s Representative. Please provide a complete scan upon remand, if possible. All efforts should be documented in the claim file. If any records could not be obtained, this should be noted in the claim file. 2. Upon completion of the above, schedule the Veteran for the following VA examinations: Right and left hand/wrist A VA examination to clarify the diagnosis of his claimed right and left hand/wrist disabilities and to address the etiology of any diagnosed disability(ies). For each disability diagnosed, the examiner is asked to address whether it is at least as likely as not (i.e., a 50 percent or greater probability) that it was caused by the Veteran’s active duty service. The examiner is asked to specifically address: (a) The contention submitted, citing the Arthritis Foundation, that “[i]njuries and trauma to the wrist, like a sprain or break, also can trigger this condition.” See NOD, June 2019. (b) The contention submitted, citing the American Association of Neurological Surgeons, that “wrist pain is a known symptom of carpal tunnel” (see NOD, June 2019), and the December 2010 service treatment record regarding the right wrist pain which states that the “Pt states that it started hurting, no trauma.” (c) The following from the Veteran’s service treatment records: An August 2014 Report of Medical History shows that the Veteran indicated “[n]umbness or tingling,” “[s]wollen or painful joint(s),” “reoccurring wrist and shoulder pain,” and “tingling in fingers.” Another service treatment record that notes “Joint Pain, Localized in The Wrist” as a chronic illness, dated December 2010. A service treatment record from December 2010 that shows an appointment for right wrist pain. It states that the Veteran will be given a brace. No trauma was noted. A right wrist series report from December 2010 that notes: “There is no evidence of fracture or dislocation. Alignment and joint spaces appear within normal limits. Boney mineralization appears normal. Soft tissues are grossly unremarkable.” The impression is noted as “[n]o evident bony abnormality involving the right wrist.” A September 2014 treatment record that indicates that the Veteran reported tingling in his extremities. Back disability A VA examination to evaluate the current level of severity of his back disability. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner is asked specifically to provide range of motion testing (ROM) for active motion, passive motion, weight-bearing, and nonweight-bearing. In addition, the examiner must discuss pain for ROM movements on active, passive, and repetitive use testing. The examiner is asked to address the following questions: (a) Are any ROM movements painful on active, passive, and repetitive use testing? If yes, identify whether active, passive, and repetitive use. (b) If yes (there are painful movements), does the pain contribute to functional loss or additional limitation of ROM? Please further describe the functional loss or additional limitation of ROM. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. In addition, the examiner must discuss pain when used in weight-bearing or in nonweight-bearing. The examiner is asked to address the following questions: (a) Is there pain when the joint is used in weight-bearing or nonweight-bearing? If yes, identify whether weight-bearing or nonweight-bearing. (b) If yes (there is pain when used in weight-bearing or nonweight-bearing), does the pain contribute to functional loss or additional limitation of ROM? Please further describe these limitations. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. For all ranges and planes of motion where pain is noted, the exact point at which pain starts must be clearly noted. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups, as expressed in range of motion. To the extent possible, the examiner should identify any symptoms and functional impairments due to the back disability and discuss the effect of the Veteran’s back disability on any occupational functioning and activities of daily living. The examiner should address whether or not there are any neurologic disabilities, to include of the lower extremities, that is the result of the back disability. Finally, the examiner is asked to address the impact of the back disability on the Veteran’s employability. Knee disabilities A VA examination to evaluate the current level of severity of his knee disabilities. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. The examiner is asked specifically to provide range of motion testing (ROM) for both knees for active motion, passive motion, weight-bearing, and nonweight-bearing. Full ROM testing also must be conducted on the opposite joint unless the opposite joint is damaged, which includes any disorder that would make the joint in question abnormal. If the opposite joint is determined to be damaged, and no ROM on testing is conducted, this must be explained in the report. In addition, for both knees the examiner must discuss pain for ROM movements on active, passive, and repetitive use testing. The examiner is asked to address the following questions: (a) Are any ROM movements painful on active, passive, and repetitive use testing? If yes, identify whether active, passive, and repetitive use. (b) If yes (there are painful movements), does the pain contribute to functional loss or additional limitation of ROM? Please further describe the functional loss or additional limitation of ROM. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. In addition, for both knees the examiner must discuss pain when used in weight-bearing or in nonweight-bearing. The examiner is asked to address the following questions: (a) Is there pain when the joint is used in weight-bearing or nonweight-bearing? If yes, identify whether weight-bearing or nonweight-bearing. (b) If yes (there is pain when used in weight-bearing or nonweight-bearing), does the pain contribute to functional loss or additional limitation of ROM? Please further describe these limitations. (c) If no (the pain does not contribute to functional loss or additional limitation of ROM), explain why the pain does not contribute. For all ranges and planes of motion where pain is noted, the exact point at which pain starts must be clearly noted. The examiner must also attempt to elicit information regarding the severity, frequency, and duration of any flare-ups, and the degree of functional loss during flare-ups, as expressed in range of motion. To the extent possible, the examiner should identify any symptoms and functional impairments due to the knee disabilities and discuss the effect of the Veteran’s knee disabilities on any occupational functioning and activities of daily living. The examiner should state whether or not there is any neurologic disability, to include of the lower extremities, that is the result of the knee disabilities. Finally, the examiner is asked to address the impact of the back disability on the Veteran’s employability. The VA examiner should be given access to the claim file. The examiner should state that a review of the claim file was completed. The examiner must provide a comprehensive report including complete rationales for all opinions and conclusions reached, citing the objective medical findings leading to the conclusions. A detailed rationale is requested for all opinions provided.   3. If upon completion of the above action the issues are denied, the case should be returned to the Board after compliance with appellate procedures. E. I. VELEZ Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board K. Foster, 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.