Citation Nr: 21041638 Decision Date: 07/09/21 Archive Date: 07/09/21 DOCKET NO. 17-12 815 DATE: July 9, 2021 ORDER Service connection for a left wrist disability, to include degenerative arthritis and arthrodesis, claimed as carpal tunnel syndrome, is granted. Service connection for a right wrist disability, to include degenerative arthritis, claimed as carpal tunnel syndrome, is granted. Service connection for inguinal hernias is granted. REMANDED Entitlement to service connection for tinnitus. FINDINGS OF FACT 1. The Veteran's left wrist disability is related to service. 2. The Veteran's right wrist disability is related to service. 3. The Veteran's inguinal hernias are related to service. CONCLUSIONS OF LAW 1. The criteria for service connection for a left wrist disability, to include degenerative arthritis and arthrodesis, claimed as carpal tunnel syndrome, are met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 2. The criteria for service connection for a right wrist disability, to include degenerative arthritis and arthrodesis, claimed as carpal tunnel syndrome, are met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303, 3.307, 3.309 (2020). 3. The criteria for service connection for inguinal hernias are met. 38 U.S.C. §§ 1101, 1110, 1131, 5107 (2012); 38 C.F.R. §§ 3.102, 3.303 (2020). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS The Veteran served on active duty from February 1974 to August 1994. This appeal is before the Board of Veterans' Appeals (Board) from a November 2015 rating decision of the Department of Veterans Affairs (VA) Regional Office (RO) in Winston-Salem, North Carolina and an April 2016 rating decision from the RO in Columbia, South Carolina. In February 2021, the Veteran testified during a Board hearing before the undersigned Veterans Law Judge via videoconference. A transcript is included in the claims file. Service Connection Service connection may be granted for a disability resulting from disease or injury incurred in or aggravated by service. 38 U.S.C. §§ 1110, 1131; 38 C.F.R. § 3.303(a). Service connection requires: (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 connection may also be granted for any disease diagnosed after discharge when the evidence establishes that the disease was incurred in service. 38 C.F.R. § 3.303(d). Service connection is also warranted for a disability which is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a). Such secondary service connection is warranted for any increase in severity of a nonservice-connected disability that is proximately due to or the result of a service-connected disability. 38 C.F.R. § 3.310(b). For certain chronic diseases, including arthritis organic diseases of the nervous system such as carpal tunnel syndrome and tinnitus, a presumption of service connection arises if the disease is manifested to a degree of 10 percent within one year following discharge from service. 38 C.F.R. §§ 3.307(a)(3), 3.309(a). When a chronic disease is not shown to have manifested to a compensable degree within one year after service, under 38 C.F.R. § 3.303(b) for the showing of chronic disease in service, there is required a combination of manifestations sufficient to identify the disease entity and sufficient observation to establish chronicity at the time. When the fact of chronicity in service is not adequately supported, a showing of continuity after discharge is required to support a claim for such diseases; however, such continuity of symptomatology may only support a claim for those chronic diseases listed under 38 C.F.R. § 3.309(a). 38 C.F.R. § 3.303(b); see Walker v. Shinseki, 708 F.3d 1331 (Fed. Cir. 2013). In determining whether service connection is warranted for a disability, VA is responsible for determining whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a preponderance of the evidence is against the claim, in which case the claim is denied. 38 U.S.C. § 5107; Gilbert v. Derwinski, 1 Vet. App. 49 (1990). When there is an approximate balance of positive and negative evidence regarding any issue material to the determination, the benefit of the doubt is afforded the claimant. 1. Entitlement to service connection for a left wrist disability, to include degenerative arthritis and arthrodesis, claimed as carpal tunnel syndrome 2. Entitlement to service connection for a right wrist disability, to include degenerative arthritis, claimed as carpal tunnel syndrome The Veteran claims service connection for bilateral carpal tunnel syndrome. Service treatment records do not reflect any symptoms of or treatment for carpal tunnel syndrome, and no such abnormality was noted ath the Veteran's August 1994 separation examination. The Veteran underwent a general medical VA examination in October 1994. No carpal tunnel syndrome was noted. VA treatment records reflect that in March 2003 the Veteran reported pain on the underside of his left wrist when he reached or turned at a certain angle. He reported that his symptoms began two to three months prior. He denied tingling or any history of injury. X-rays showed degenerative joint disease. He began using a brace. In June 2006 he reported swelling in the left wrist. Private treatment records reflect that in August 2010 the Veteran reported that his wrist bothers him sometimes. No wrist diagnosis was given. VA treatment records reflect that in April 2012 the Veteran reported arthritis pain in his wrists to his nurse. The symptoms were not addressed by his physician. In June 2013 he reported decreased extension and some pain in his bilateral wrists. His physician diagnosed probable degenerative joint disease with no significant symptoms. Private treatment records reflect that in May 2015 he reported bilateral wrist pain on extension without numbness or tingling. He was referred for an orthopedic evaluation. In June 2015 he reported chronic progressive wrist pain in both wrists without any history of injury. In July 2015 his orthopedist diagnosed bilateral wrist and intercarpal arthritis, severe on the left and moderately severe on the right, and recommended surgery. In August 2015 he underwent left radial carpal joint arthrodesis with autograft. In his January 2016 notice of disagreement, the Veteran attributed his wrist disability to physical training over 20 years of active duty, specifically daily push-ups, crab walk, pull-ups, filling sandbags, digging ditches, lifting heavy objects and gear, climbing, and rappelling. Private treatment records reflect that in March 2016 the Veteran underwent right wrist proximal row carpectomy with dorsal capsular interposition arthroplasty and partial radial styloidectomy. He was diagnosed with posttraumatic degenerative arthritis of the right radiocarpal and intercarpal joints. In a November 2016 letter, the Veteran's private orthopedic surgeon stated that he had been treated for extensive arthritic conditions involving both wrists. The surgeon opined that the Veteran's duties and requirements while in the military more likely than not were a direct contributory factor to him developing severe bilateral wrist arthritis. In his March 2017 substantive appeal, the Veteran stated that he parachuted in service, which caused excessive use of the wrists. Push-ups were required to maintain upper body strength to control the parachute and hang from aircraft with up to 100 pounds of equipment as a jump master. He also reported working with tactical communication in service, laying telephone lines and cables and climbing poles to hang and splice cable. Private treatment records reflect that after his March 2016 surgeries, he continued reporting wrist pain that in December 2017 was diagnosed as probable right carpal tunnel syndrome. At his February 2021 hearing, the Veteran attributed his carpal tunnel syndrome to the rigors of service as described previously. In a March 2021 letter, the Veteran's private orthopedic surgeon opined that his wrist disabilities were more likely than not caused by, contributed to, or aggravated by his physical duties while in the military. This opinion was based on the rationale that the Veteran had twenty years of service with physical demands such as pushups, sit-ups, digging, filling sandbags, covering cable, marching in combat gear, running, and over two hundred parachute jumps. The Board finds that the evidence is at least in equipoise as to whether the Veteran's bilateral wrist disabilities are related to service. While he refers to his disability as carpal tunnel syndrome, such a diagnosis was only recently given in the right wrist and not at all in the left wrist. His claim, however, is broadly construed as a claim for all wrist disabilities. See Clemons v. Shinseki, 23 Vet. App. 1, 5 (2009). His private orthopedic surgeon has given a probative opinion indicating that his disabilities are related to his twenty years of physical activity in service. At the very least, such an opinion requires that the Veteran be provided with a VA examination. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). As there is no evidence in the record to contradict the opinion of the Veteran's surgeon supported by adequate rationale, remand for a VA opinion is not necessary. For these reasons, the Board finds that the evidence is at least in equipoise as to whether the Veteran's bilateral wrist disabilities are related to service, and service connection is therefore granted. 3. Entitlement to service connection for an inguinal hernia The Veteran claims service connection for an inguinal hernia. Service treatment records do not reflect any symptoms of or treatment for an inguinal hernia, and no such abnormality was noted ath the Veteran's August 1994 separation examination. The Veteran underwent a general medical VA examination in October 1994. The examiner stated that no hernia was present. Private treatment records reflect that in September 2001 the Veteran was noted to have mild laxity in the left inguinal canal. His physician noted that it was "certainly not a hernia at this point." His physician offered the same analysis in December 2002. In January 2005 his physician noted a little weakness in the left inguinal canal that had been fairly stable from last year. The physician stated that he would not be surprised if it eventually became a hernia. No hernia was found in January 2006. In February 2007 he was diagnosed with a new mild asymptomatic left inguinal hernia. In May 2008 he was noted to have some mild laxity in the left inguinal canal, but not what his physician would call a hernia at this point. In May 2009 his physician again predicted that the laxity would eventually develop into a hernia. In August 2010 he reported a little discomfort in the left inguinal region, and he was diagnosed with a very mild left inguinal hernia. The hernia was noted again in April 2011. He was referred to a surgeon where he reported pain with sneezing. He was diagnosed with bilateral inguinal hernias. He underwent a right laparoscopic herniorrhaphy in May 2011. In a March 2017 statement, the Veteran attributed his hernia to physical training, sit-ups, pull-ups, lifting cable reels from 50 to 100 pounds, marching with a rucksack, and parachute jumping with loads in excess of 100 pounds. In a May 2017 letter, the Veteran's private surgeon opined that his hernias most likely were caused by his active military duty. At his February 2021 hearing, the Veteran attributed his hernias to the rigors of service as described previously. In a March 2021 letter, the Veteran's private surgeon opened that his duties and requirements while in the military were more likely than not a direct contributory factor to developing a hernia. This opinion was based on the rationale that he was a paratrooper with over 200 jumps with full combat gear in excess of 100 pounds, as well as extensive marching in combat gear with 50-pound sacks, pushups, and sit-ups. The Board finds that the evidence is at least in equipoise as to whether the Veteran's inguinal hernias are related to service. His private surgeon has given a probative opinion indicating that his hernias are related to his twenty years of physical activity in service. This opinion is consistent with the medical record, which establishes a slowly growing hernia first detected seven years after separation, but not serious enough for treatment for another decade. At the very least, such an opinion requires that the Veteran be provided with a VA examination. McLendon v. Nicholson, 20 Vet. App. 79, 81 (2006); see 38 U.S.C. § 5103A(d)(2); 38 C.F.R. § 3.159(c)(4)(i). As there is no evidence in the record to contradict the opinion of the Veteran's surgeon supported by adequate rationale, remand for a VA opinion is not necessary. For these reasons, the Board finds that the evidence is at least in equipoise as to whether the Veteran's inguinal hernias are related to service, and service connection is therefore granted. REASONS FOR REMAND Entitlement to service connection for tinnitus The Veteran claims service connection for tinnitus. Service treatment records do not reflect any symptoms of or treatment for tinnitus, and no such abnormality was noted ath the Veteran's August 1994 separation examination. The Veteran underwent a general medical VA examination in October 1994. No tinnitus was noted. The Veteran underwent a VA examination in October 2015. He reported tinnitus that began within the prior few years. The examiner opined that the Veteran had a diagnosis of clinical hearing loss, and his or her tinnitus is at least as likely as not a symptom associated with hearing loss. This opinion was based on the rationale that tinnitus is known to be a symptom associated with hearing loss. The Veteran has not appealed his denial of service connection for hearing loss; nevertheless, the examiner opined that hearing loss was less likely than not related to service. This opinion as based on the rationale that hearing loss was more likely related to vertigo and possible hydrops or Meniere's disease, though such a diagnosis could only be made by an otolaryngologist. The examiner noted that there was no hearing loss at any time during military service or at separation. Private treatment records reflect that in October 2015 the Veteran presented to the emergency room reporting dizziness. At a November 2015 otolaryngology consultation, he reported bilateral ear fullness, fluid, pressure, and tinnitus, worse on the right for the prior two to three months. His hearing was grossly abnormal. He was diagnosed with sensorineural hearing loss with probable Meniere's disease. A January 2016 MRI of the head was normal. A February 2016 video-nystagmography test was consistent with a significant peripheral vestibular weakness in the right ear. His otolaryngologist maintained the diagnosis of Meniere's disease with tinnitus, asymmetric sensorineural hearing loss, and dizziness. In his January 2016 notice of disagreement, the Veteran reported that he was exposed to hazardous noise while on active duty for over 20 years. He stated that he has had ringing in his ears for many years that has become worse. In his March 2017 substantive appeal, the Veteran reported being exposed to loud noises in service, including indirect mortar fire, firing range, recoilless guns, generators, and airplanes and helicopters. Private treatment records reflect that in August 2017 the Veteran was treated for a progression of his symptoms. His otolaryngologist diagnosed Meniere's disease. At his February 2021 hearing, the Veteran attributed his current tinnitus to his experience in service as a mortarman. He described a number of incidents in which he injured his eardrums by mortars firing early. He stated that he was not given earplugs during these duties. The Board finds that remand is necessary to obtain a complete VA medical opinion regarding the Veteran's tinnitus. The October 2015 VA examiner opined that tinnitus was related to hearing loss, which in turn was related to a diagnosis of Meniere's disease. The examiner explicitly stated that diagnosis and presumably etiology of Meniere's disease required consultation with an otolaryngologist, but no such examination was scheduled. Such an examination is warranted where a Veteran who parachuted over 200 times in service claims a condition with an established connection to a vestibular disorder. As such, remand is necessary to provide the Veteran with a VA examination to determine whether the tinnitus may be due to service via for a vestibular disorder, to include Meniere's disease. The matter is REMANDED for the following action: 1. Obtain and associate with the claims file any additional medical evidence that may have come into existence but has not been associated with the record. 2. Schedule the Veteran for a VA examination for a vestibular disorder, to include Meniere's disease. The claims file must be reviewed by the examiner. Following a review of the claims file and any clinical examination results, the examiner should diagnose any relevant disorder exhibited by the Veteran. For each disability diagnosed, the examiner should offer an opinion as to whether it is at least as likely as not (i.e. 50 percent probability or more) that such disability is related to service, to include his history of parachuting. All opinions are to be accompanied by a rationale consistent with the evidence of record. A discussion of the pertinent evidence, relevant medical treatises, and generally accepted medical principles is requested. If the examiner cannot provide an opinion without resorting to speculation, he or she shall provide complete explanations stating why this is so. In so doing, the examiner shall explain whether any inability to provide a more definitive opinion is the result of a need for additional information, or that he or she has exhausted the limits of current medical knowledge in providing an answer to that particular question. 3. After completing the above, and any other development deemed necessary, readjudicate the appeal. If any benefit sought remains denied, return the appeal to the Board. JONATHAN B. KRAMER Veterans Law Judge Board of Veterans' Appeals Attorney for the Board J. Gallagher, 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.