Citation Nr: 21029789 Decision Date: 05/17/21 Archive Date: 05/17/21 DOCKET NO. 12-12 672 DATE: May 17, 2021 ORDER Entitlement to service connection for a right hand or finger disability is denied. FINDING OF FACT The preponderance of the evidence is against finding that a disability of the right hand or fingers began during active service or is otherwise related to an in-service injury or event. CONCLUSION OF LAW The criteria for service connection for a disability of the right hand and fingers are not met. 38 U.S.C. §§ 1110, 1131, 5107; 38 C.F.R. §§ 3.102, 3.303. REASONS AND BASES FOR FINDING AND CONCLUSION The Veteran had active service from September 1958 to September 1961. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a February 2012 rating decision issued by the Department of Veterans Affairs regional office (RO) in Hartford, Connecticut. The issue was previously before the Board in February 2015, January 2016, November 2017, December 2018, June 2020, and October 2020. It was also the subject of a December 2016 Memorandum Decision issued by the United States Court of Appeals for Veterans Claims (Court). Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. § 1110; 38 C.F.R. § 3.303(a). Service connection requires competent evidence showing: (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, 1167 (Fed. Cir. 2004); see also Caluza v. Brown, 7 Vet. App. 498 (1995). Service treatment records show that in July 1960, the Veteran sustained a laceration of his right little finger after it was smashed with a truck tailgate. It was treated with four stitches. A follow-up visit the same month indicated that the laceration was healing well. August 1960 service records noted the removal of sutures. Service treatment records also show that the Veteran sustained frostbite to his feet during service. Accordingly, the Board does not call into doubt the Veteran's credible reports of cold exposure during service. A September 1995 letter from a private treatment provider shows that the Veteran underwent treatment for his feet, telling his provider that his feet had been frozen many years ago when he was in the Army. At a September 2002 VA rheumatology consultation for the Veteran's ankles, the examiner noted frostbite of the distal extremities, as well as some radial deviation of the right hand and a hard nodule on the right index finger, which the veteran stated had reoccurred after he had surgery three years prior. At a rheumatology consultation in July 2007, it was noted that the Veteran had joint pain involving the neck, shoulders, elbows, wrists, fingers, knees, and hips. His symptoms, he noted, had been gradually progressive for the last 15 years and he said he had difficulty lifting pots and putting his shirt on over his head. Physical examination revealed joint pain and stiffness and nodules over his right index proximal interphalangeal joint. A July 2008 treatment note indicated that the Veteran had degenerative joint disease (DJD) in his hands, feet, and ankles, which caused changes to his hands, and a history of frostbite injury in service. At an August 2009 VA orthopedic consultation, the Veteran reported joint pain in his hands and worsening finger deformity. The examiner noted slight ulnar deviation of his fingers on both hands, prominent nodular swelling over the right thumb PIP joint, and prominent metacarpophalangeal (MCP) joints in the right hand. In September 2009, the Veteran received treatment for an apparent synovial cyst of the right index finger, and capsular thickening of the right second MCP joint and reducible ulnar drift were noted. A November 2010 VA rheumatology note indicated that a radiograph of the Veteran's right hand showed some mild osteoarthritic changes in his right thumb and little finger. The examiner noted capsular swelling in the right second MCP and several cystic nodules around the right index finger PIP joint with some mild tenderness on palpation and stated that there was apparent synovial or mucinous cysts of the right index finger. At an April 2012 Decision Review Officer (DRO) hearing, the Veteran testified that he believed the arthritis in his hands was caused by exposure to cold when he served in Germany. He stated that as a combat engineer he used his hands outdoors for prolonged periods and ungloved his right hand in order to use it, whereas he would put a glove on his left hand. He stated that while on duty one night he almost froze. He testified that he complained about his right hand in service and used medication but mostly received treatment for his feet, started having trouble with his hand when he returned home, and had two right hand operations after discharge. He said that he saw a private doctor in the 1970s and 1990s when he noticed knots on his hands which were later deemed to be arthritis. At an August 2012 VA rheumatology visit, the Veteran reported that loss of hand function and pain began 18 years prior. The examiner indicated that July 2012 X-rays of the hands and feet suggested inflammatory arthritis and areas of osteoarthritis. The examiner noted several non-tender nodules on the right index finger and shooting pain with wrist flexion. The examiner's impression was longstanding, non-inflammatory MCP joint flexion contractures of the index, middle, and ring fingers and hyperextension of PIP joints, with PIP joint nodules of "unclear etiology" because, although there was the appearance of rheumatoid arthritis, the condition was not behaving like rheumatoid arthritis since there was no stiffness and the Veteran had been seronegative on multiple prior draws. The examiner suggested Jaccoud's arthropathy as a differential diagnosis. At a January 2014 VA appointment, the Veteran reported that he was bothered by pains in both hands when he tried to grip objects or strap his seatbelt. He said his fingers felt numb at times. The Veteran underwent a VA hand and fingers examination in January 2018. The examiner reviewed the Veteran's medical history pertaining to his hand and finger treatment. The Veteran reported decreased grip strength of the right hand. Cysts were noted and the examiner noted a diagnosis of right-hand degenerative arthritis. The Veteran noted that the pain in his right hand was worse with cold weather. In a corresponding opinion, the examiner opined that the Veteran's right hand/fingers disability was less likely as not due to service. The rationale was that there was no evidence to support that the arthritis was related to service in light of an unremarkable discharge physical in 1961. Rather, the examiner opined that arthritis was more likely related to age and the Veteran's prior occupation. Because the examiner did not offer a detailed rationale, nor address the specific allegation of cold exposure during service, the Board, in its December 2018 Remand, requested that the Veteran undergo another examination, which took place in December 2019. The Veteran reported to the examiner that he initially had surgery on his right middle finger in the 1960s, later had a nodule removed, and was told that he had arthritis and that there was not much that could be done about it. He reported current symptoms of chronic pain which was worse in cold weather and with repetitive activity. The pain occurred daily and was relieved with rest and heat. The Veteran stated that he had less strength in his right hand and had trouble with cutting food and driving. After physical examination and interview of the Veteran, the examiner indicated that the condition was less likely than not incurred in or caused by service. The examiner reasoned that there was no evidence to support that the Veteran's arthritis was secondary to cold exposure in service, given the unremarkable separation examination in July 1961, and an unremarkable right-hand X-ray in June 2007. The examiner noted that the Veteran had been followed by a rheumatology provider and was noted to have laboratory readings suggestive of inflammatory arthritis, along with symmetrical presentation and multi joint involvement. The examiner added that patients with rheumatoid arthritis were genetically predisposed. The examiner added a medical description of the differences between arthritis and rheumatoid arthritis. A December 2019 VA rheumatology consultation note indicated that the Veteran had progressively worsening hand pain, with swelling after activity and stiffness. The Veteran said that cold weather made the problem worse. Physical examination was suggestive of osteoarthritis. There was no evidence of inflammation. In June 2020, the Board noted that the December 2019 examiner's negative opinion was based on a diagnosis of rheumatoid arthritis, without discussion of the fact that there were other potential diagnoses applicable to the right handsuch as osteoarthritis and Jaccoud's arthropathy. Therefore, because the opinion did not address evidence in the record calling that diagnosis into question, the Board requested that VA obtain another opinion. Accordingly, an addendum opinion was obtained in July 2020. The examiner concluded that the Veteran's prior injuries, age, and occupation as a plater for 34 years all likely contributed to his bilateral osteoarthritis, "with no medical evidence to support a link to service." The examiner noted injuries in 1971, 1975, and 1977, and noted that none of those injuries were reported in his August 2012 DRO testimony, when he asserted that cold exposure was the cause of the osteoarthritis in his right hand. Because the examiner did not adequately address the credible reports of cold exposure or how such exposure could or could not have contributed to the development of osteoarthritis, the Board again remanded the claim for additional opinion. In January 2021, another medical opinion was received. The reviewing clinician indicated a review of the prior VA examinations and all pertinent evidence and opined that the claimed condition was less likely than not incurred in or caused by the claimed in-service injury. By way of rationale, the examiner noted that review of the evidence and current medical literature suggested that it was less likely than not that the right hand and finger disability were due to cold exposure. The examiner did not dispute that the Veteran sustained cold exposure as reported, and also acknowledged that osteoarthritis was a possible complication of cold injury; however, the examiner also stated that such would typically present within months to years, rather than decades after the exposure, such as occurred in the Veteran's case. The examiner added that while initial consultation suggested that the Veteran had rheumatoid or inflammatory arthritis, more recent evaluations suggested bilateral hand osteoarthritis. The examiner noted that the mucinous cyst that was present on the right side was at least as likely as not part of the developing osteoarthritis of the right hand, which was starting to develop at the typical time/age that osteoarthritis would be likely to develop in the dominant hand due to use, rather than due to cold injury. Based on a review of all of the foregoing evidence, the Board finds that the preponderance of the evidence is against a finding that the Veteran's right hand and finger disability was incurred in service, to include as due to cold exposure therein. The Board finds that the most recent, January 2021 VA opinion is most probative on this question, insofar as a VA examiner stated that, based on a review of cited medical literature, osteoarthritis due to cold exposure would typically arise in a matter of months to years, rather than decades. The Board also finds the examiner's reasoning as to the conflicting diagnoses to be soundinsofar as the examiner noted that while initial consultations had suggested possible rheumatoid or inflammatory arthritis, more recent evaluations had shown osteoarthritis, a finding that is corroborated by the Veteran's VA treatment records. The Board adds that while it has found parts of the prior VA opinions to be inadequate, that nevertheless multiple prior VA examiners have attributed the Veteran's osteoarthritis to age and prior occupation, which is consistent with the findings by the January 2021 VA examiner. In sum, the January 2021 VA examiner addressed the questions as to the Veteran's primary diagnosis, addressed and considered the Veteran's lay reports of cold weather exposure, considered medical literature on the topic, and found that it was less likely than not that the Veteran's right hand/finger osteoarthritis was related to cold weather exposure in service, given the medical conclusion that osteoarthritis due to cold weather exposure would develop much sooner than it did in the Veteran. Thus, the opinion was based on an accurate medical history and provided explanations that contained clear conclusions and supporting data. Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008). Notably, over the course of the 10-year appeal period, no opinion evidence has been submitted suggesting that the Veteran's osteoarthritis in his right hand is related to his presumed cold weather exposure in Germany. In reaching its conclusions, the Board has also considered the Veteran's assertion that he has experienced hand and finger issues since his cold exposure during service. As noted above, the Board does not doubt the Veteran's credible reports of cold exposure during service; indeed, service treatment records show treatment for frostbite of the feet in service. However, the Board also finds that the Veteran's reports of continuity are largely not credible. In this regard, insofar as the Veteran is asserting that he has experienced right hand issues continuously since separation in 1961, the Board first notes that although the Veteran applied for disability benefits in December 1964, September 1969, July 1993, September 1995, July 2000, and March 2006, on none of those claims did he mention any right hand or finger issues, yet he filed many claims pertaining to arthritis in his feet due to in-service cold exposure. The Veteran has not articulated any reason as to why he did not file a claim for a right hand condition at any of those times if such disability had existed, and a reasonable person would assume that had the disability existed as the Veteran has so described, such would have been included on a claim form prior to July 2007, which is more than 40 years after separation from service. Another factor weighing against the Veteran's contentions is the evidence showing significant in-service and post-service treatment for his feet due to frostbite, but not for his hands. Indeed, VA and private treatment records as early as the 1960s show treatment for foot conditions that the Veteran contended were due to frostbite in service. It seems reasonable that in the course of seeking frostbite treatment for his feet, the Veteran would have indicated that he was experiencing similar symptoms in his hands. This timeline comports with the January 2021 VA examiner's opinion that the Veteran's osteoarthritis likely did not stem from the Veteran's in-service cold exposure because if it had, it would have onset within months or years following the exposure, not decades. In weighing credibility, VA may consider consistency with other evidence of record. Caluza v. Brown, 7 Vet. App. 498, 505 (1995). In this case, the Board finds that the record does not contain credible evidence of a continuity of right hand and finger symptoms from the time of the Veteran's discharge to the present. While the Veteran is competent to report the symptoms that he presently experiences, he is not competent to determine that his current right-hand disability is related to cold weather exposure in service. The issue is medically complex, requiring knowledge of the inner workings of the body. Therefore, it is outside the competence of the Veteran in this case because the record does not show that he has the medical training or credentials to make such a determination. Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007); see also Kahana v. Shinseki, 24 Vet. App. 428 (2011). Consequently., the Board affords higher probative weight to the VA opinions of record. For these reasons, the preponderance of the evidence is against the claim of entitlement to service connection for a disability of the right hand and fingers, diagnosed as osteoarthritis. As the preponderance of the evidence is against the claim, the benefit-of-the-doubt rule is not for application, and the claim must be denied. See 38 U.S.C. § 5107(b); 38 C.F.R. § 3.102; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). CHRISTOPHER A. WENDELL Acting Veterans Law Judge Board of Veterans' Appeals Attorney for the Board Polly Johnson, 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.