Citation Nr: 21028053 Decision Date: 05/10/21 Archive Date: 05/10/21 DOCKET NO. 10-40 840A DATE: May 10, 2021 REMANDED The issue of entitlement to service connection for carpal tunnel syndrome of the right upper extremity, to include as secondary to service-connected disabilities, is remanded. The issue of entitlement to service connection for carpal tunnel syndrome of the left upper extremity, to include as secondary to service-connected disabilities, is remanded. REASONS FOR REMAND The appellant is a Veteran who had active military service from March 1966 to February 1968. This matter is before the Board of Veterans' Appeals (Board) on appeal from a September 2018 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO). These issues were previously before the Board in June 2020, when the Board remanded them to the Agency of Original Jurisdiction (AOJ) for further development. Although other issues previously on appeal in this case have involved a longer and more complex procedural history, the carpal tunnel issues currently on appeal were before the Board for the first time in June 2020 and have now returned from remand. The Board's June 2020 decision resolved other issues that were on appeal at that time, and furthermore remanded to the AOJ the additional issue of entitlement to service connection for a psychiatric disorder. During the processing of the remand, the AOJ issued a February 2021 rating decision granting entitlement to service connection for somatic symptom disorder with depression and anxious features, "an award of all benefits sought on appeal, and the appeal is considered satisfied in full." The issue is no longer a matter of controversy in appellate status, and is not before the Board at this time. 1. The issue of entitlement to service connection for carpal tunnel syndrome of the right upper extremity, to include as secondary to service-connected disabilities, is remanded. 2. The issue of entitlement to service connection for carpal tunnel syndrome of the left upper extremity, to include as secondary to service-connected disabilities, is remanded. As discussed in the Board's June 2020 remand, the May 2019 VA medical opinion addressing the carpal tunnel syndrome (CTS) claims finds: "The condition claimed is less likely than not (less than 50% probability) proximately due to or the result of the Veteran's service connected condition." The opinion contemplates the Veteran's contention that "his CTS is due to the frequent grasping of his walker, needed due to his dizziness from his Meniere's disease." The May 2019 VA medical opinion presents a rationale that recharacterizes the conclusion as: "it is less likely than not that this veteran's current CTS is secondary to his use of a walker." The Board's June 2020 remand explained that the May 2019 VA medical opinion does not appear to be adequate with regard to addressing whether the carpal tunnel syndrome may have been aggravated in severity by the service-connected Meniere's disease. The Board's June 2020 remand furthermore noted that a prior August 2018 VA medical opinion states that "it is less likely than not that this Veteran developed CTS due to 'Falls Caused By Service Connected Menieres.'" The rationale for that conclusion cited that "Meniere disease is not a recognized risk factor for the development of CTS." This opinion also does not appear to adequately contemplate aggravation in addressing the matter. It is noteworthy that another September 2018 VA medical opinion cited the Veteran's "frequent" falls "from his Meniere's" in concluding that "his current right shoulder injury is as likely as not caused secondarily to his SC for LABYRINTHITIS (30%-SC) /Meniere's disease." In the June 2020 remand, the Board sought development of a medical opinion that adequately addresses whether the Veteran's (a) frequent grasping / gripping of his walker, needed due to his dizziness from service-connected disability, and/or (b) frequent falls associated with service-connected disability have caused or aggravated his carpal tunnel syndrome in each or either arm / wrist. The resulting January 2021 VA medical opinion addressing the contention regarding frequent falls asserts that the "Bilateral Carpal Tunnel Syndrome" is "less likely than not due to frequent falls he has experienced due to dizziness and unsteadiness associated with his service-connected disabilities." However, the Board finds no adequate discussion of rationale is presented to support the VA examiner's conclusion. The VA medical opinion's rationale consists of language copied verbatim from an online fact-sheet regarding carpal tunnel syndrome, followed by the statement: "There is no medical literature to support a causal relationship between the two conditions. A nexus has not been established." With regard to aggravation, the VA examiner adds that: "There is no medical literature to support a causal relationship between the two conditions, or aggravation of the Bilateral Carpal Tunnel Syndrome by the service connected condition beyond its natural progression." However, the opinion does not include an adequate explanation allowing the Board to understand the basis for the conclusions. In particular, the Board notes that the fact-sheet language relied upon by the VA examiner as a rationale actually states: "Carpal tunnel syndrome is often the result of a combination of factors that increase pressure on the median nerve and tendons in the carpal tunnel .... Contributing factors include trauma or injury to the wrist that cause swelling, such as sprain...." The Veteran's theory of entitlement regarding frequent falls impacting his wrists / arms, events already medically indicated to have caused orthopedic disability in an upper extremity, appears to reasonably feature a potentially pertinent "trauma or injury to the wrist" as contemplated by the fact-sheet's discussion of factors that may cause or contribute to carpal tunnel syndrome. The VA examiner's rationale amounts to an assertion that "[t]here is no medical literature to support" the theory, but this assertion is not clearly consistent with the fact-sheet language the VA examiner otherwise relies upon to explain the conclusion. The VA examiner's rationale does not otherwise explain, or even suggest, a clear basis for the conclusion that the Veteran's carpal tunnel syndrome is unlikely to have been aggravated by the impact of frequent falls from his walker. The Veteran's theory of entitlement in this regard includes the plausible assertion that his frequent falls impact his wrists and cause injury to the carpal tunnels. The VA examiner does not address this theory, and the reliance upon the fact-sheet language actually appears to merely confirm the plausibility of the Veteran's theory of entitlement without any assessment of whether the Veteran's frequent falls are at least as likely as not to have caused stress / injury of a nature or degree that could cause or aggravate carpal tunnel syndrome. The Board finds that remand is necessary for an addendum / supplemental medical opinion with a more adequate discussion of rationale addressing the Veteran's contention that his carpal tunnel syndrome has been aggravated by frequent falls associated with service-connected disability. The Board notes that the VA examiner's rationale for responses to other inquiries are substantially identical to the rationale discussed above; the VA examiner's opinions are not accompanied by analyses tailored to the specifics of the Veteran's case, or the particulars of separate queries. Thus, the VA examiner's substantially identical discussion in response to the query regarding the Veteran's frequent grasping / gripping of his walker appears likewise inadequate. The Veteran's theory of entitlement in this regard includes the plausible assertion that his use of the walker stresses his wrists and causes injury to the carpal tunnels. The VA examiner does not address this theory, and the reliance on the fact-sheet language actually appears to merely confirm the plausibility of the Veteran's theory of entitlement without any assessment of whether the Veteran's use of the walker is at least as likely as not to have caused stress / injury of a nature or degree that could cause or aggravate carpal tunnel syndrome. The Board must seek a more adequate VA medical opinion on remand at this time. The Board furthermore notes that the June 2020 Board remand's directives included that "the clinician should comment on the relevant evidence of record. In particular, the clinician should comment upon the fact that a September 2018 VA medical opinion cited the Veteran's 'frequent' falls 'from his Meniere's' in concluding that he has suffered a right shoulder disability due to the frequency of significant falls." The resulting VA medical opinions of record do not comply with this directive. A remand by the Board confers on the Veteran claimant, as a matter of law, the right to compliance with the remand orders. See Stegall v. West, 11 Vet. App. 268, 271 (1998). Thus, the Board finds that the evidence currently of record is inadequate to resolve the claims of entitlement to service connection for carpal tunnel syndrome. Remand of the issues for a new / supplemental VA opinion is therefore warranted in order to more adequately address the matters. See 38 U.S.C. § 5103A; 38 C.F.R. § 3.159(c)(4); see also Barr v. Nicholson, 21 Vet. App. 303, 311 (2007) (once VA undertakes the effort to provide an examination when developing a service connection claim, even if not statutorily obligated to do so, it must provide one that is adequate for purposes of the determination being made). The matters are REMANDED for the following action: 1. Associate with the claims-file any outstanding pertinent treatment records, including any additional VA treatment records (such as those that may have been created since the last such update of the claims-file). 2. After the record is determined to be complete, refer the VA claims file to a medical professional with appropriate expertise to provide an opinion as to the nature and etiology of the Veteran's claimed carpal tunnel syndrome, bilaterally. (Should the clinician decide that an examination of the Veteran is required to address these questions, such should be scheduled -- or telehealth interview, review of the record, etc., if an in-person examination is not feasible). The Veteran's file should be made available for review by the clinician. The clinician should review the file and this fact should be noted in the accompanying medical report. The clinician is requested to review the claims file in its entirety. The clinician should then address the following: (a) Is it at least as likely as not that the Veteran's carpal tunnel syndrome has been caused by any service-connected disability, such as Meniere's disease or residuals of TBI? Please specifically address the Veteran's contentions (a) that his carpal tunnel syndrome has been caused by the extent to which he must grip his walker/other objects when rising to compensate for dizziness and unsteadiness associated with his service-connected disabilities, and (b) that his carpal tunnel syndrome has been caused by frequent falls he has experienced due to dizziness and unsteadiness associated with his service-connected disabilities. The clinician should take as fact that the Veteran has experienced frequent falls as a result of his service-connected Meniere's disease. (b) Is it at least as likely as not that the Veteran's carpal tunnel syndrome has been aggravated in severity (any increase in disability) by any service-connected disability, such as Meniere's disease or residuals of TBI? Please specifically address the Veteran's contentions (a) that his carpal tunnel syndrome has been aggravated by the extent to which he must grip his walker/other objects when rising to compensate for dizziness and unsteadiness associated with his service-connected disabilities, and (b) that his carpal tunnel syndrome has been aggravated by frequent falls he has experienced due to dizziness and unsteadiness associated with his service-connected disabilities. The clinician should take as fact that the Veteran has experienced frequent falls as a result of his service-connected Meniere's disease. If the Veteran's carpal tunnel syndrome has been aggravated by a service-connected disability, the clinician should also indicate the extent of such aggravation by identifying the baseline level of disability. This may be ascertained by the medical evidence of record and also by the Veteran's statements as to the nature, severity, and frequency of his observable symptoms over time. In providing the requested opinions, the clinician should comment on the relevant evidence of record. In particular, the clinician should comment upon the fact that a September 2018 VA medical opinion cited the Veteran's frequent falls from his Meniere's in concluding that he has suffered a right shoulder disability due to the frequency of significant falls. All examination findings/testing results (if any), along with complete, clearly-stated rationale for the conclusions reached, must be provided. In addressing the above, the clinician must consider and discuss the pertinent medical, periodical, and other objective evidence, and all lay assertions. The clinician is also advised that the Veteran is competent to report his symptoms and history, and such reports must be specifically acknowledged and considered in formulating any opinions. If the Veteran's assertions in any regard are discounted, the clinician should clearly so state and explain why. If the VA clinician is unable to offer an opinion without resorting to speculation, a thorough explanation as to why an opinion cannot be rendered should be provided. M. C. GRAHAM Veterans Law Judge Board of Veterans' Appeals Attorney for the Board A. Barone, 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.