Citation Nr: 21024597 Decision Date: 04/23/21 Archive Date: 04/23/21 DOCKET NO. 14-35 409A DATE: April 23, 2021 ORDER Service connection for a bilateral hand condition and joint pain is denied. FINDING OF FACT The claims file lacks evidence establishing an in-service injury, event, or illness causing the hand and joint pain. Additionally, medical examiners in the record state that the Veteran is not suffering from an undiagnosed illness, a medically unexplained chronic multi symptom illness, or a chronic diagnosed illness due to his service in the Persian Gulf War. CONCLUSION OF LAW The criteria for service connection for a bilateral hand condition and joint pain have not been met. 38 U.S.C. §§ 1110, 1117, 1131, 5107; 38 C.F.R. §§ 3.303, 3.304, 3.310, 3.317. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran served honorably in the United States Army from September 1981 to August 1992. The Veteran’s claim for joint pain in the bilateral hands was remanded by the Board in April 2018 for further development and for a VA examination. The Board again remanded the Veteran’s claim in July 2020, stating that substantial compliance with the Board’s April 2019 remand directives had not occurred and must be again remanded. The Board is now satisfied that there was substantial compliance with its remand orders and is prepared to adjudicate the issue at hand. See Dyment v. West, 13 Vet. App. 141, 146-147 (1999); Stegall v. West, 11 Vet. App. 268, 271 (1998). The Veteran provided sworn testimony in support of his appeal during a hearing before the undersigned Veterans Law Judge in May 2017. The hearing transcript has been associated with the file and has been reviewed. 1. Entitlement to service connection for a bilateral hand condition and joint pain The Veteran contends that his current bilateral hand disability and joint pain in the hands is causally related to his active military service and manifests as cramping and stiffness of his fingers. Under the relevant laws and regulations, service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by active service. 38 U.S.C. §§ 1110, 1131. Generally, the evidence 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. Shedden v. Principi, 381 F.3d 1163, 1166-67 (Fed. Cir. 2004). Service connection may also be granted for a Persian Gulf veteran with objective indications of a qualifying chronic disability that became manifest during active military, naval or air service in the Southwest Asia theater of operations during the Gulf War or to a degree of 10 percent or more not later than December 31, 2021. See 38 C.F.R. § 3.317 (a)(1). For purposes of 38 § C.F.R. § 3.317, there are three types of qualifying chronic disabilities: (1) an undiagnosed illness; (2) a medically unexplained chronic multi-symptom illness (MUCMI); and (3) a diagnosed illness that the Secretary determines in regulations prescribed under 38 U.S.C. § 1117(d) warrants a presumption of service connection. 38 U.S.C. § 1117(a)(1); 38 C.F.R. § 3.317(a)(1). An undiagnosed illness is defined as a condition that by history, physical examination and laboratory tests cannot be attributed to a known clinical diagnosis. In the case of claims based on undiagnosed illness under 38 U.S.C. § 1117 and 38 C.F.R. § 3.317, unlike those for direct service connection, there is no requirement that there be competent evidence of a nexus between the claimed illness and service. Gutierrez v. Principi, 19 Vet. App. 1, 8-9 (2004). Further, lay persons are competent to report objective signs of illness. Id. To determine whether the undiagnosed illness is manifested to a degree of 10 percent or more the condition must be rated by analogy to a disease or injury in which the functions affected, anatomical location or symptomatology are similar. See 38 C.F.R. § 3.317 (a)(5) (2018); see also Stankevich v. Nicholson, 19 Vet. App. 470 (2006). A medically unexplained chronic multi-symptom illness is one defined by a cluster of signs or symptoms, such as chronic fatigue syndrome, fibromyalgia, and functional gastrointestinal disorders (excluding structural gastrointestinal diseases), as well as any other illness that the Secretary determines meets the criteria in paragraph (a)(2)(ii) of this section for a medically unexplained chronic multi-symptom illness. A medically unexplained chronic multi-symptom illness means a diagnosed illness without conclusive pathophysiology or etiology that is characterized by overlapping symptoms and signs and has features such as fatigue, pain, disability out of proportion to physical findings, and inconsistent demonstration of laboratory abnormalities. Chronic multi-symptom illnesses of partially understood etiology and pathophysiology will not be considered medically unexplained. 38 C.F.R. § 3.317 (a)(2)(ii). For purposes of section 3.317, disabilities that have existed for six months or more and disabilities that exhibit intermittent episodes of improvement and worsening over a six-month period will be considered chronic. The six-month period of chronicity will be measured from the earliest date on which the pertinent evidence establishes that the signs or symptoms of the disability first became manifest. 38 C.F.R. § 3.317 (a)(4). Where the evidence does not warrant presumptive service connection, the United States Court of Appeals for the Federal Circuit (Federal Circuit) has determined that a Veteran is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994). Here, the Veteran had active service in Kuwait during the early 1990s. Therefore, he is considered a Persian Gulf veteran. 38 C.F.R. § 3.317(e). The evidence does not, however, show that the Veteran is entitled to service connection for a Gulf War illness. The Veteran’s service treatment records (STRs) are silent for any complaints, diagnosis, or treatment for a hand condition or joint pain in his hands and fingers. VA medical center notes dating back to 2002 show reports of hand cramping and joint pain in the fingers without any diagnosis. In July 2016, the Veteran attended a Gulf War examination. The exam is silent for any joint pain in his hands or fingers. The exam also states that the Veteran suffers no condition that can be connected to his service in the Gulf. The Veteran received a VA examination in December 2018 where the VA examiner stated that the finger joint pain and bilateral hand condition was not due to an undiagnosed illness or a medically unexplained chronic multi-symptom illness but did not diagnose the Veteran. Additionally, in the December 2020 VA medical addendum opinion, the examiner noted that the likely diagnosis of the Veteran is strain, which appears to be related to repetitive use. The examiner also stated that strain is unrelated to service in a particular theater of operations, including the Gulf War or Southwest Asia. Therefore, the Veteran is not service connected for his bilateral hand disability and finger joint pain through his service in the Gulf War and the showing of a qualifying chronic disability. As such, the December 2020 examination provided a likely diagnosis of a strain and both examiners clearly indicated that the symptoms were not indicative of a MUCMI. As such, service connection for joint and hand pain is not warranted under 38 C.F.R. § 3.317. The Veteran may still establish a service-connected condition by showing that he is directly service connected. The Veteran does have a current disability of joint pain in his hands and fingers. Although the December 2020 examination x-rays were negative for arthritis or degenerative joint disease of the hands and was negative for carpal tunnel syndrome, the record clearly reflects complaints of joint pain in the hands and fingers, which the December 2020 examiner believed to be strain from repetitive use. The record does not show any evidence that the Veteran suffered an in-service injury, event, or illness that led to the joint pain in his hands and fingers. The record also does not show any joint pain in the hands or fingers manifesting itself one year after the Veteran exited service. Furthermore, during the Board hearing in May 2017, the Veteran and his representative made no mention of the Veteran’s claimed hand condition or finger pain. The Board decision in July 2020 set out remand directives that ordered the VA to obtain all private treatment records for the Veteran. Subsequently the VA sent record requests to Carle Pain Clinic, Carle Physical Therapy, Baylor Scott & White Medical Center and Temple Clinic. None of the private medical records had any diagnosis, complaints or evidence of joint pain in either hand. The Veteran has made complaints throughout the VA medical records in 2002 and 2014 about finger joint pain, hand cramps and intermittent locking of his hands and fingers. The VA medical doctors have continually held that this is due to repetitive use and overuse by the Veteran and is not due to his active military service. The Veteran has also complained about a pain and tingling in his left arm down into his hand since 2014 in VA medical records. Doctors in the record have noted that the Veteran has upper left extremity radicular pain in the left arm and hand. However, radicular pain and joint pain are notably different. In the December 2018 examination the Veteran even reported that the finger joint pain onset has only been the last four to five years and there is no specific injury or trauma attributed to causing the onset. The 2020 examiner reviewed the record and concluded the condition was related to repetitive use and not related to service, to include service in Southwest Asia. In the absence of competent evidence that a bilateral joint pain in the hands and fingers exists which was caused by or aggravated by the Veteran’s military service, the criteria for establishing service connection for a hand disability has not been established. 38 C.F.R. § 3.303. Accordingly, the Board concludes that the preponderance of the evidence is against the claim for service connection for a bilateral hand disability, and the benefit-of-the-doubt rule enunciated in 38 U.S.C. § 5107(b) is not for application. Accordingly, service connection for a bilateral hand disability and joint pain is denied. H. SEESEL Veterans Law Judge Board of Veterans’ Appeals Attorney for the Board E.L. Aumiller, 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.