Citation Nr: 21026788 Decision Date: 05/04/21 Archive Date: 05/04/21 DOCKET NO. 15-04 177A DATE: May 4, 2021 ORDER Service connection for left upper extremity (LUE) carpal tunnel syndrome (claimed as peripheral neuropathy) is denied. Service connection right upper extremity (RUE) carpal tunnel syndrome (claimed as peripheral neuropathy) is denied. FINDINGS OF FACT 1. The Veteran has a current diagnosis of bilateral carpal tunnel syndrome. 2. The Veteran served in the Republic of Vietnam during the Vietnam Era and is presumed to have been exposed during such service to herbicide agents, to include Agent Orange. 3. Carpal tunnel syndrome is not on the presumptive list of diseases associated with herbicide exposure. 4. Symptoms of carpal tunnel syndrome were not chronic in service, were not continuous since service separation, and were not shown to a compensable degree within one year of service separation. 5. Carpal tunnel syndrome was not incurred in service and is not etiologically related to service, including herbicide exposure and exposure to chemicals during service. CONCLUSIONS OF LAW 1. The criteria for service connection for LUE carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1110, 1112, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. 2. The criteria for service connection for RUE carpal tunnel syndrome have not been met. 38 U.S.C. §§ 1110, 1112, 5103, 5103A, 5107; 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.307, 3.309. REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran, who is the Appellant, served on active duty from April 1970 to November 1971. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a May 2012 rating decision from the Regional Office (RO), which, in pertinent part, denied service connection bilateral upper extremity carpal tunnel syndrome. In May 2018, the Veteran testified at a Board videoconference hearing from the RO in Roanoke, Virginia, before the undersigned Veterans Law Judge in Washington, DC. The hearing transcript has been associated with the record. This matter was previously before the Board in October 2018 and August 2020. In August 2020, the Board remanded the issue on appeal for an addendum medical opinion that addressed whether the bilateral carpal tunnel syndrome is related to herbicide agent exposure. The Board finds that the Agency of Original Jurisdiction (AOJ) substantially complied with the August 2020 Board Remand directives. See Dyment v. West, 13 Vet. App. 141, 146-47 (1999) (remand not required under Stegall v. West, 11 Vet. App. 268 (1998), where the Board's remand instructions were substantially complied with), aff'd, Dyment v. Principi, 287 F.3d 1377 (Fed. Cir. 2002). The Board finds that the duties to notify and assist in this case have been fulfilled. Neither the Veteran nor the evidence has raised any specific contentions regarding the duties to notify or assist. Service Connection 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; 38 C.F.R. § 3.303(a). Generally, service connection for a disability requires evidence of: (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 in or aggravated by service. The Veteran is currently diagnosed with bilateral carpal tunnel syndrome, which is considered "organic diseases of the nervous system" recognized as a "chronic diseases" under 38 C.F.R. § 3.309(a); therefore, the presumptive provisions of 38 C.F.R. §§ 3.303(b), 3.307, and 3.309 apply to the claim for service connection for carpal tunnel syndrome of the upper extremities. Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In order to establish presumptive service connection for a disease associated with exposure to certain herbicide agents, unless there is affirmative evidence to establish that a veteran was not exposed to any such agent during that service, the Veteran must show the following: (1) that he served in the Republic of Vietnam during the period beginning on January 9, 1962, and ending on May 7, 1975; (2) that he suffered from a disease associated with exposure to certain herbicide agents enumerated under 38 C.F.R. § 3.309(e); and (3) that the disease process manifested to a degree of 10 percent or more within the specified time period prescribed in section 3.307(a)(6)(ii). 38 U.S.C. § 1116; 38 C.F.R. §§ 3.307(a)(6), 3.309(e). If a veteran was exposed to an herbicide agent during active service, presumptive service connection is warranted for several medical conditions. 38 C.F.R. § 3.309(e). "Service in the Republic of Vietnam" includes service in the waters offshore and service in other locations if the conditions of service involved duty or visitation in the Republic of Vietnam. 38 C.F.R. § 3.307(a)(6)(iii). In order to establish qualifying "service in Vietnam," a veteran must demonstrate actual duty or visitation in the Republic of Vietnam. Carpal tunnel syndrome is not listed as diseases for which presumptive service connection based on exposure to herbicides agents may be granted. 38 C.F.R. § 3.309(e). VA's Secretary has determined that a presumption of service connection based on exposure to herbicides used in the Republic of Vietnam during the Vietnam era is not warranted for any condition for which the Secretary has not specifically determined a presumption of service connection is warranted. See 68 Fed. Reg. 27, 630 (May 20, 2003). Notwithstanding the foregoing presumption provisions for herbicide exposure, a claimant is not precluded from establishing service connection with proof of direct causation. Combee v. Brown, 34 F.3d 1039, 1042 (Fed. Cir. 1994); see also Ramey v. Gober, 120 F.3d 1239, 1247-48 (Fed. Cir. 1997), aff'g Ramey v. Brown, 9 Vet. App. 40 (1996); Brock v. Brown, 10 Vet. App. 155, 160-61 (1997). 1. Service Connection for LUE Carpal Tunnel Syndrome 2. Service Connection for RUE Carpal Tunnel Syndrome The Veteran contends that service connection for carpal tunnel syndrome of the bilateral upper extremities is warranted due to exposure to chemicals such as gun cleaning solvents or herbicide agent exposure during service in Vietnam. The Veteran contends that numbness and tingling in the upper extremities was present within one year of service and have been remitting and relapsing since then. The Veteran testified that he reported neuropathy symptoms for years including during and after service. The Veteran asserts that he was referred to Salem VA Medical Center (VAMC) for symptoms following the service separation examination in November 1971, and he filed a claim at that time. The Veteran asserts that he sought treatment for numbness and tingling in the upper extremities at Salem VAMC in January 1972, but he asserts that the symptoms were overlooked, as there was no method of diagnosing or treating the condition at that time. See May 2018 Board Hearing Transcript; February 2015 VA Form 9; September 2011, April 2020, March 2021 correspondence. The evidence shows a current disability of bilateral carpal tunnel syndrome. See August 2012, November 2017 VA treatment records, September 2011 VA examination report. The Veteran served in the Republic of Vietnam from October 1970 to November 1971; therefore, in-service herbicide exposure is presumed. See DD Form 214; September 1968 service treatment record. However, carpal tunnel syndrome is not on the presumptive list of diseases associated with herbicide exposure. See 38 C.F.R. § 3.309(e). For this reason, the Veteran cannot benefit from the herbicide nexus presumption, regardless of whether he was exposed to herbicides in service. Turning to the theory of direct service connection, after reviewing all of the lay and medical evidence of record, the Board finds that the weight of the lay and medical evidence demonstrates that carpal tunnel syndrome, which began after service, is not otherwise related to active service, to include as due to exposure to chemicals or herbicide exposure in service. Regarding presumptive service connection, the Board finds that the weight of the evidence shows that symptoms of carpal tunnel syndrome were not chronic in service, were not continuous since service, and did not manifest to a compensable degree within one year of service. The weight of the evidence is against finding that symptoms of carpal tunnel syndrome were "chronic" in service. The service treatment records do not reflect any history, complaints, symptoms, diagnosis, or treatment of a neurological condition, to include carpal tunnel syndrome, during service. A June 1971 service treatment note shows that the Veteran presented with left shoulder pain, left-sided chest pain, and pain when he inhaled, but no neurological symptoms were reported, including numbness or tingling in the upper extremities. Examination revealed 5th through 6th costosternal pain, but no neurological deficits were noted. Diagnosis was viral myositis. Additionally, the upper extremities and neurologic system was described as normal upon clinical evaluation during the November 1971 service separation examination five months later. See June 1971, November 1971 service treatment records. The Board next finds that the weight of the evidence is against finding that symptoms of carpal tunnel syndrome were "continuous" since service separation. Post-service treatment notes are silent for complaints or symptoms of carpal tunnel syndrome for many years after service separation. Private treatment records dated from 1969 to October 1974 only show a complaint of left wrist pain after the Veteran fell and sprained his wrist, but no reports of neurological disturbance in the upper extremities. See July 1974, August 1974 private treatment records. The first mention of symptoms carpal tunnel syndrome in the upper extremities is in 2011, 40 years after service separation. Treatment notes from 2011 show that the Veteran reported problems with tingling and numbness in his arms and hands, but when providing a contemporaneous lay history for the purpose of treatment, he denied any prior history of neuropathy. Mild bilateral carpal tunnel syndrome was first diagnosed in 2012, 41 yrs after service separation. See March 2011, May 2011, August 2012 VA treatment records. This same evidence also shows that symptoms of bilateral upper extremity carpal tunnel syndrome did not manifest to a compensable degree within one year of service separation. The Board has considered the Veteran's contentions that symptoms of carpal tunnel syndrome began during service and were remitting and relapsing symptoms since service separations; however, these more recent assertions are inconsistent with, and outweighed by, other more contemporaneous lay and medical evidence of record, including histories presented for treatment purposes. Specifically, the Veteran now asserts that the military examiner referred him to Salem VAMC for treatment of carpal tunnel syndrome symptoms after his November 1971 service separation examination. The Veteran also asserted that he filed a claim upon leaving service and sought treatment at Salem VAMC in January 1972, but he contends that his symptoms were overlooked because there was no mechanism for diagnosing and treating carpal tunnel syndrome back then. As noted above, the service treatment records are silent for any neurological symptoms of carpal tunnel syndrome, and a review of the November 1971 service separation report shows that the upper extremities and neurological system were clinically normal during examination. Moreover, the military examiner annotated the Veteran's contemporaneous lay report that his medical condition was good, and there was no recommendation or referral noted for any neurological disorder. While the Veteran now asserts that he filed a claim for service connection upon separation from service, a review of the December 1971 Claim shows that the Veteran only claimed service connection for a bad cough, and he made no mention of any neurological symptoms in the upper extremities, to include numbness or tingling. Moreover, the RO has requested treatment records from Salem VAMC from November 1971, when the Veteran separated from service, through December 1972, which covers the period in January 1972 when the Veteran purportedly sought treatment for upper extremity neurological symptoms at Salem VAMC. The Salem VAMC responded that no treatment records were found during this period. See August 2012 Exchange of Beneficiary Information. The record does show that the Veteran presented to Salem VAMC in January 1972 for a VA examination. Contemporaneous lay reports made during the January 1972 VA examination indicate that the Veteran only reported problems with productive cough and feeling stopped up. There was no mention of neurological symptoms in the upper extremities. Additionally, the upper extremities and nervous system were again noted to be normal upon examination. See January 1972 VA examination report. To the extent that that the Veteran asserts that his symptoms were overlooked because there was no mechanism for diagnosing or treating carpal tunnel syndrome at that time, such a statement is merely speculative, as the Veteran is not shown to have the medical expertise or training to opine as to whether carpal tunnel syndrome was capable of clinical diagnosis and treatment in January 1972 when the Veteran asserts that he reported such symptoms. Such a statement is also factually baseless, as the Veteran himself did not even report symptoms in 1972 that pertain to carpal tunnel syndrome. Furthermore, the November 1971 service separation examination report, December 1971 Claim, and January 1972 VA examination report are revealing and highly probative in this matter, as each piece of evidence is notably silent for any contemporaneous lay report or clinical signs of neurological abnormalities in the upper extremities. Moreover, the fact that the Veteran filed a claim for respiratory symptoms in December 1971 following service separation, but the December 1971 claim and the January 1972 VA examination report are notably silent as to any specific neurological symptoms in the upper extremities, weighs against finding that any symptoms of carpal tunnel syndrome existed at that time, as they could easily have been reported or claimed at the same time the Veteran submitted the December 1971 claim for service connection for a bad cough and during the January 1972 VA examination, had such symptoms been present. Also weighing against finding continuous symptoms of carpal tunnel syndrome since service separation are the post-service records, which are silent for any complaints or symptoms of carpal tunnel syndrome for 40 years after service separation. Additionally, initial contemporaneous lay histories provided for the purpose of treatment are also silent as to any reports of symptoms of carpal tunnel syndrome during service or since service separation. A May 2011 treatment note shows that the Veteran denied any prior history of neuropathy despite reporting current symptoms of numbness and tingling in his arms and legs. Additionally, during an August 2012 consultation for neurological symptoms, the Veteran denied any prior treatment for numbness and tingling in his arm; this history is inconsistent with the Veteran's more recent assertions that he began seeking treatment for symptoms of carpal tunnel syndrome in 1972, within one year of service separation. See May 2011, August 2012 VA treatment records. Furthermore, the medical evidence of record does not indicate that any treating or examining physician of record has related the Veteran's bilateral carpal tunnel syndrome to service, to include chemical exposure to gun cleaning solvents or herbicide agent exposure during service. A VA medical opinion was provided in February 2021 addendum opinion, the VA examiner opined that it is less likely than not that the carpal tunnel syndrome is related to service. The examiner explained that the Veteran has a diagnosis of bilateral carpal tunnel syndrome established in 2011 with right carpal tunnel syndrome confirmed by EMG in 2012. The Veteran's medical history includes diagnoses of pre-diabetes and untreated hypothyroidism noted as part of his neurology evaluation for peripheral neuropathy. His occupational history is significant for 27 years as a pipefitter, job classification Heavy per DOT. The examiner noted that VA presumes veterans' early-onset peripheral neuropathy is related to their exposure to Agent Orange or other herbicides during service when the disease appears within one year of exposure to a degree of at least 10 percent disabling by VA's rating regulations. In this case, the Veteran's diagnosis of carpal tunnel syndrome was made 40 years after exposure to Agent Orange. Additionally, his post-military occupation as a pipefitter is typical of occupations associated with higher risk of carpal tunnel syndrome (Palmer 2007). Further, both pre-diabetes (Stino 2017) and hypothyroidism are associated with increased risk of peripheral neuropathy. The examiner reasoned that given the exceptionally long latency period from exposure to Agent Orange or other solvents during service and diagnosis of the claimed carpal tunnel syndrome condition, and the presence of several more plausible etiologies for peripheral neuropathy (occupation, pre-diabetes, and hypothyroidism) the Veteran's claimed bilateral carpal tunnel syndrome is less likely than not caused by or etiologically related to herbicide agent exposure during service in Vietnam or other cleaning solution exposures during service. See February 2021 VA examination report. (Continued on the next page) Considered in light of the records as a whole, the Board finds the February 2021 VA opinion to be of significant probative value, as it is based on an accurate history of the Veteran's medical condition, considers other risk factors for the development of carpal tunnel syndrome in this case, and is supported by a review of medical literature which does not support a probable causal relationship between the Veteran's carpal tunnel syndrome and active service, to include as to due to exposure to herbicides and gun cleaning solutions during service. There is no medical nexus opinion of record that supports an etiological relationship between the Veteran's carpal tunnel syndrome and service, to include exposure to herbicide agents or any other chemical exposure during service. Based on foregoing, the weight of the competent and credible evidence demonstrates no relationship between the current carpal tunnel syndrome of the bilateral upper extremities that began years after service, including exposure to herbicide agents or gun cleaning solutions during service. As the preponderance of the evidence is against service connection on all theories of service connection, the benefit of the doubt doctrine does not apply, and the claim for service connection for carpal tunnel syndrome must be denied. 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102. J. PARKER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Moore, Shanna 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.