Citation Nr: 21041193 Decision Date: 07/08/21 Archive Date: 07/08/21 DOCKET NO. 18-06 595 DATE: July 8, 2021 REMANDED Entitlement to a rating higher than 10 percent for status post fracture, right wrist, (also claimed as right arm condition), is remanded. Entitlement to service connection for multiple sclerosis is remanded. REASONS FOR REMAND The Veteran served on active duty from September 1997 to September 2001. This matter comes before the Board of Veterans' Appeals (Board) on appeal from an April 2016 rating decision by a Department of Veterans' Affairs (VA) Regional Office (RO). In February 2021, the Veteran testified at a virtual hearing before the undersigned Veterans Law Judge. A copy of the hearing transcript is of record and has been reviewed. A remand is necessary to provide the Veteran with an adequate VA examination of his right wrist disability. In addition, it is necessary obtain an addendum medical opinion regarding the etiology of the Veteran's multiple sclerosis in view of the conflicting opinions of record. Right Wrist Disability The Veteran is service connected for status-post fracture, right wrist. He underwent a VA examination for wrist conditions in March 2016, at which time, he reported numbness, lack of strength, dropping objects, and difficulty lifting weight. The examiner noted that range of motion contributed to functional loss as it limited the Veteran with prolonged holding and carrying. Although the examiner noted the Veteran had a diagnosis of multiple sclerosis and supporting nerve studies, the examiner did not review the claims folder or e-folder and have all the diagnoses pertinent to the Veteran's right wrist/arm. At a March 2021 neurological examination, the Veteran reported weakness in his right hand and arm, and right arm numbness. That examiner noted the functional impact of the Veteran's peripheral neuropathy in the right arm was difficulty with lifting greater than 10 pounds with the right hand and right arm, with no functional limitation in a sedentary environment. The examiner stated there was no evidence of right upper extremity weakness and that the Veteran had claimed weakness in pain and right upper extremity, diagnosed as neuropathy and weakness secondary to multiple sclerosis. The Veteran has described symptoms of numbness and weakness in his right wrist/arm. The 2016 VA examiner stated these symptoms affected his range of motion of the right wrist. The VA examiners in 2016 and 2021 have attributed the same symptoms to his service-connected right wrist disability and nonservice-connected multiple sclerosis, right carpal tunnel syndrome, and nerve disorders. The examiners have both stated that these same symptoms have a functional impact on his ability to lift items, carry items, and pain. The Board is unable to discern which symptoms, functional loss, flare-ups, and loss of range of motion are solely attributable to his service-connected residuals of right wrist fracture. During the February 2021 Board hearing, the Veteran testified that symptoms of his right wrist disability increased in severity since the last VA examination in March 2016. Accordingly, a new VA examination is necessary. See Snuffer v. Gober, 10 Vet. App. 400, 403 (1997). Furthermore, the Board notes that the RO issued the statement of the case in December 2017. However, the 2021 VA examination report contains findings that are relevant to the increased rating for the right wrist disability, and was associated without the RO's issuance of a supplemental statement of the case (SSOC). Neither the Veteran nor his representative submitted a waiver of AOJ consideration. Therefore, the Board may not consider the VA-generated evidence in the first instance. 38 C.F.R. § 20.1304 (c) (2020). Multiple Sclerosis Service treatment records show that in December 1997, the Veteran was seen at Kaiser Permanente reporting that he was unable to extend his right wrist from falling. The diagnosis was probable radial nerve palsy. A therapy report dated January 1998 notes the Veteran injured his right wrist on December 26, 1997, that he fell asleep with his head on it, and was unable to extend his wrist when he woke a few hours later. He had tingling and weakness, but no numbness. The diagnosis was right radial nerve palsy. He was given a Futura splint to wear. A therapy treatment record later that month shows he was fit for full duty. In December 1998, the Veteran was seen for complaints of left shoulder pain for one and a half months. He described a sharp pain, not radiating, that was uncomfortable only when he lifted something. The diagnosis was rotator cuff/bursitis and was placed on light duty until January 1, 1999. In February 2000, at a surveillance examination for respiratory use, the Veteran reported no problems with numbness, tingling, weakness in hands or feet; and no problem with balance or coordination. In March 2001, the Veteran reported falling on his right hand while trying to keep himself from falling. He denied numbness, had no reduced range of motion and it hurt picking up things. X-ray of the right hand showed fracture of the 5th metatarsal; he was given a Volar splint to wear. The August 2001 report of separation from service notes right, 5th metacarpal fracture, February 2001, healed, and status post right ulnar neuropathy, 1998, well resolved. At a VA consultation in February 2002 following service, the Veteran reported associated weakness and stiffness, instability, fatigue and lack of endurance regarding his right wrist. With respect to his left shoulder, the Veteran reported feeling pain in the left shoulder around 1999 when he was picking something up. Since them, he gets a sharp pain when picking up thing and the joint pops when moving in a swinging motion. He reported working as a welder. No abnormalities were found on diagnostic studies of the right wrist, right hand or left shoulder. The diagnoses were status post fracture of the right hand with residual strain; peripheral neuropathy of the right wrist; and left shoulder strain. VA outpatient treatment records dating from 2004 to 2015, show that in June 2010, the Veteran sought treatment for complaints of right upper extremity weakness with numbness. He reported that he had right elbow trauma in 1998 in service, with subsequent right arm and hand weakness and neuropathy. He was now working as a welder and noticed right hand weakness and drop with heavy tools. He stated weakness was present all the time. Nerve conduction study was positive for median neuropathy. The examiner indicated "diagnosis may include tardy ulnar palsy but nerve conduction study of ulnar nerve within normal limits. Less likely, but may also consider radial nerve palsy, brachial neuritis, Hirayama's disease." In November 2011, the Veteran was seen for complaints of right shoulder and elbow pain. He had pain in the right forearm radiating up to his elbow, relieved with wrist extension, and numbness and tingling in thumb and index and third digits. It was indicated prior studies showed carpal tunnel syndrome. The diagnosis was rotator cuff tendonitis with carpal tunnel syndrome and secondary myofascial pain. The Veteran is shown to be diagnosed with relapsing and remitting multiple sclerosis in August 2013 per medical records from Fullerton Neurology and Headache Center. In October 2014, the neurologist noted right upper extremity weakness in 1998 probably first attack of multiple sclerosis, next symptoms in 2010, not diagnosed, diagnosis in 2013. In November 2014, the neurologist noted left leg weakness; right hand numbness, more likely ulnar neuropathy and not multiple sclerosis. In January 2016, his neurologist submitted a letter in which he noted the Veteran's complaint of numbness and weakness in his right hand while in the school of Infantry. He reported sought medical attention for chronic right upper extremity weakness at VA and was given possible diagnosis of radial nerve palsy, brachial neuritis or Hirayama's disease, but an MRI was never ordered. Fifteen years later he diagnosed multiple sclerosis by MRI and opined that it was medically probable that the initial symptoms that occurred in the military were caused by unrecognized multiple sclerosis. In December 2017, the Veteran underwent a VA examination for multiple sclerosis. The examiner opined that the right wrist cerebral nerve palsy was less likely than not incurred in or caused by the Veteran's multiple sclerosis. He reasoned that the median nerve was part of the peripheral nervous system while multiple sclerosis affects the central nervous system. In January 2018, the Veteran's neurologist submitted a subsequent statement disputing the VA examiner's opinion. He stated that the Veteran's symptoms were left sided, that "he initially had weakness of the left arm, and as I stated previously, it was thought to represent a left radial nerve palsy or brachial plexus neuropathy or a rare disorder termed Hirayama's. The electrodiagnostic study (EMG/NCV) did not show any abnormality in the left upper extremity." He went on to say that these were the first manifestation of multiple sclerosis which was diagnosed 15 years later. The Board notes that this last statement by the Veteran's neurologist indicating that the Veteran had left arm weakness and the EMG was of the left upper extremity is in direct contradiction to his January 2016 letter which stated it was the right upper extremity and to the actual VA treatment records in 2010 which showed it was the right upper extremity. An adequate medical opinion must be "accurate and fully descriptive," and based on an accurate factual premise and consideration of a veteran's prior medical history, Ardison v. Brown, 6 Vet. App. 405, 407 (1994). In addition, the opinion "must support its conclusions with an analysis that the Board can consider and weigh against contrary opinions." Stefl v. Nicholson, 21 Vet. App. 120, 124 (2007); see Nieves-Rodriguez v. Peake, 22 Vet. App. 295, 304 (2008) ("most of the probative value of a medical opinion comes from its reasoning"). An adequate medical examination report or opinion must also "sufficiently inform the Board of a medical expert's judgment on a medical question and the essential rationale for that opinion." Monzingo v. Shinseki, 26 Vet. App. 97, 106 (2012). On remand, an adequate opinion must be obtained. Accordingly, the matter is REMANDED for the following action: 1. Ensure that all outstanding VA treatment records are associated with the claims file. 2. Thereafter, provide the Veteran with a VA examination to help identify the current severity of the status-post fracture of the right wrist. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. All indicated studies, tests, and evaluations must be conducted, and all findings reported in detail. After a review of the record and examination of the Veteran, the examiner is asked to respond to the following: (a) Elicit from the Veteran all signs and symptoms attributed solely to the service-connected status-post fracture of the right wrist throughout the pendency of the appeal. The examiner is asked to differentiate any symptoms that are also due to other disorders of the right extremity. If any symptoms are due to both the service-connected and nonservice-connected disabilities, please describe the extent to which the symptom is attributable to the service-connected status post fracture of the right wrist. In doing so, obtain information from the Veteran (and the treatment records) as to the frequency, duration, characteristics, severity, or functional loss with any repetitive use or during any flare-ups. (b) Full range of motion testing must be performed where possible. The joint in question and the paired joint should be tested in (1) active motion, (2) passive motion, (3) in weight-bearing, and (4) in nonweight-bearing. If the examiner is unable to conduct the required testing or concludes that the required testing is not necessary in this case, he or she should clearly explain why that is so. If pain is found during the examination, the examiner should note when the pain begins. (c) In assessing functional loss, flare-ups and increased functional loss on repetitive use must be considered. The examiner must consider all procurable and ascertainable data and describe the extent of any pain, incoordination, weakened movement, and excess fatigability on use, and, to the extent possible, report functional impairment due to such factors in terms of additional degrees of limitation of motion. **If the examiner is unable to provide such an opinion without resort to speculation, the examiner must provide a rationale for this conclusion, with specific consideration of the instructions in the VA Clinician's Guide to estimate, "per [the] veteran," what extent, if any, flare-ups affect functional impairment. The examiner must include a discussion of any specific facts that cannot be determined if unable to opine without speculation. 3. Obtain a medical opinion from a neurologist regarding the likely nature and etiology of the Veteran's multiple sclerosis. The claims file and a copy of this remand will be made available to the examiner, who will acknowledge receipt and review of these materials. The need for another examination is left to the discretion of the medical professional offering the addendum opinion. the nature and etiology of the Veteran's multiple sclerosis. The examiner is asked to: (a) Detail the reported symptoms in service and thereafter, including the nature, onset, progression and severity of his reported symptoms. (b) Provide an opinion whether the Veteran's multiple sclerosis is at least as likely as not (50 percent or greater probability) related to his military service. Explain why or why not? (c) Did multiple sclerosis manifest within seven years of the Veteran's separation from service? **The opinion should specifically address all pertinent lay and medical evidence of record including, but not limited to: (i) the Veteran's contentions that his left and right extremity complaints in service were early manifestations of his multiple sclerosis; (ii) December 1997 probable diagnosis of radial nerve palsy; (iii) January 1998 therapy report diagnosis of right radial nerve palsy from report of December 1997 right wrist injury; (iv) December 1998 diagnosis was rotator cuff/bursitis; (v) February 2000 surveillance examination for respiratory use; (vi) March 2001 X-ray report of fracture of the 5th metatarsal; and (vi) August 2001 report of separation from service noting right, 5th metacarpal fracture, February 2001, healed, and status-post right ulnar neuropathy, 1998, well-resolved. A complete rationale should be provided for all opinions. 4. Then readjudicate the claims on appeal. S. B. MAYS Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Beach, 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.