Citation Nr: 21028736 Decision Date: 05/11/21 Archive Date: 05/11/21 DOCKET NO. 16-32 628 DATE: May 11, 2021 REMANDED Entitlement to service connection for a left wrist condition is remanded. Entitlement to service connection for a right wrist condition is remanded. REASONS FOR REMAND The Veteran served on active duty with the United States Army from November 2005 to December 2005 and from February 2006 to May 2006. The Veteran's service was under honorable conditions. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a December 2012 rating decision of a Department of Veterans Affairs (VA) Regional Office (RO), which, in pertinent part, denied entitlement to service connection for left and right wrist conditions. The Veteran timely perfected an appeal. See September 2013 Notice of Disagreement; May 2016 Statement of the Case; July 2016 VA Form 9. In September 2019, the Board remanded this matter for additional development. The Veteran contends that her bilateral wrist condition started during active service. Service treatment records show that the Veteran complained of bilateral wrist pain and that she was evaluated for carpal tunnel syndrome. An April 2006 service treatment record shows that the Veteran did not meet the criteria for carpal tunnel syndrome; however, the examining physician noted that the left median motor nerve was "borderline" with a latency of 4.1 ms, with normal being 4.2 ms or less. The physician indicated that the borderline left nerve latency "in conjunction with the right median motor being 3.8 and the ulnar nerves being fast...makes one suspicious that there is some slowing occurring in the left median motor nerve and that this may potentially progress to meeting criteria for carpal tunnel syndrome." The physician also noted "some component of tendonitis in the hand and wrist." Another April 2006 service treatment record reflects that the Veteran continued with carpal tunnel syndrome symptoms and that although the EMG/NCS did not show "operative CTS at this time," it was consistent with "early nerve root irritation." Post-service treatment records show that the Veteran complained of right wrist pain in October 2011 and that there was a suspicion of carpal tunnel syndrome. See October 2011 Private treatment Record. The Veteran was afforded a VA examination in December 2012. The examiner opined that the Veteran's bilateral wrist syndrome was not caused by military service because an in-service EMG study was negative for bilateral carpal tunnel syndrome. In the September 2019 remand, the Board found this opinion to be inadequate. A January 2013 VA new patient record shows that the Veteran reported chronic wrist pain since 2006. A March 2013 VA rheumatology note shows that the Veteran reported bilateral wrist pain and parasthesia since 2006. She was diagnosed with "probable idiopathic CTS." An April 2013 nerve conduction study showed "mild right median mononeuropathy at or around the wrist (carpal tunnel syndrome)" and "changes suggesting early CTS on the left." The Board notes that the actual results of the study are not included in the claims file. VA treatment records show that the Veteran underwent a right carpal tunnel release in December 2013 and a left carpal tunnel release in May 2014. The Veteran was afforded a VA examination in December 2019. The examiner noted that in-service tests did not show carpal tunnel syndrome and that the Veteran was not diagnosed with carpal tunnel syndrome until six years post-discharge. The examiner also noted that an in-service EMG was normal. The examiner opined that the Veteran current wrist pain and carpal tunnel (resolved) were "less likely as not due to her wrist tendonitis while in service." In an April 2020 addendum opinion, the December 2019 examiner again noted that the Veteran was evaluated for wrist pain during service but that EMGs "failed to show a nerve condition." The examiner indicated that "carpal tunnel syndrome was not diagnosed until six years post discharge and is independent of her prior complaint." The Board finds that the December 2019/April 2020 VA examination reports are not fully responsive to the Board's September 2019 remand instructions. See Stegall v. West, 11 Vet. App. 268 (1998). Specifically, the Board finds that these opinions are inadequate because they are conclusory and unsupported by any explanation of rationale. See Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) (holding that a medical opinion that contains only data and conclusions without any supporting analysis is accorded no weight). Moreover, although the examiner repeatedly noted that in-service tests did not confirm a diagnosis of carpal tunnel syndrome, the examiner did not discuss the significance of in-service findings showing early nerve root irritation that could progress to carpal tunnel syndrome. Thus, the examiner's conclusion that in-service EMGs "failed to show a nerve condition" appears to be inaccurate. See Reonal v. Brown, 5 Vet. App. 458, 461 (1993) (holding that the Board may reject a medical opinion based on an inaccurate factual basis). Finally, the examiner essentially based the negative nexus opinion on a lack of post-service treatment without considering the Veteran's lay statements of continuous symptoms since service. Relying on the absence of evidence in medical records to provide a negative opinion is contrary to established case law, and such opinions are therefore inadequate. See Dalton v. Nicholson, 21 Vet. App. 23 (2007). In light of the foregoing, the Board finds that an addendum opinion is necessary. See Bowling v. Principi, 15 Vet. App. 1, 12 (2001) (emphasizing the Board's duty to return an inadequate examination report "if further evidence or clarification of the evidence...is essential for a proper appellate decision"); 38 C.F.R. § 4.2 (noting that if the examination report does not contain sufficient detail, it is incumbent upon the rating board to return the report as inadequate for evaluation purposes). The matters are REMANDED for the following action: 1. Obtain and associate with the Veteran's claims file all outstanding VA treatment records documenting treatment for the issues on appeal, particularly including the VA EMG/NCS report referenced in an April 2013 VA treatment record. If no such records are located, that fact should be documented in the claims file. 2. After all available records have been associated with the claims file, obtain an addendum opinion regarding the etiology of the Veteran's diagnosed bilateral wrist condition. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. The claims file and a copy of this Remand must be made available to the reviewing examiner, and the examiner shall indicate in the addendum report that the claims file was reviewed. After reviewing the record and, if necessary, examining the Veteran, the examiner should render an opinion as to whether it is at least as likely as not (i.e., 50 percent probability or greater) that the Veteran's currently diagnosed bilateral wrist condition, to include carpal tunnel syndrome, was incurred in, caused by, or is otherwise related to, the Veteran's military service, to include the documented in-service bilateral wrist treatment. The examiner must carefully consider the Veteran's lay statements regarding the onset of her wrist symptoms and continuous nature of her symptoms since service. Specifically, the examiner must review and comment on the Veteran's long-standing complaints of wrist problems in service and since service and discuss whether they could have been symptoms of carpal tunnel syndrome, which was ultimately diagnosed in 2013. The examiner must also specifically discuss and comment on the Veteran's complete service treatment records, to include references to early nerve root irritation that could progress to carpal tunnel syndrome. If necessary, and to the extent possible, the examiner must reconcile his or her findings with these records. The examiner's report must reflect consideration of the Veteran's entire documented medical history and assertions and all lay evidence. If the examiner is unable to provide an opinion without resort to speculation, he or she should explain why this is so and what, if any, additional evidence would be necessary before an opinion could be rendered. The examiner must provide a thorough rationale for each opinion given. (Continued on the next page) 3. Following the completion of the foregoing, and any other development deemed necessary, the AOJ should readjudicate the Veteran's claim. If the claim is denied, supply the Veteran and her representative with a supplemental statement of the case and allow an appropriate period of time for response. Thereafter, the claims folder should be returned to the Board for further appellate review, if otherwise in order. B. MULLINS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board R. Kipper, 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.